UK FASHIoN: feasibility study of a randomised controlled trial of arthroscopic surgery for hip impingement compared with best conservative care

Acetabular retroversion and cam morphology are contributing risk factors for posterior hip dislocation independent of the trauma mechanism

INTRODUCTION

A high-energy trauma impact is generally considered the crucial factor causing native hip dislocation. However, femoroacetabular variations are assumed to contribute to low-energy posterior hip dislocations, especially in adolescent athletes. The study aimed to analyze the femoroacetabular morphology of adults who sustained traumatic posterior hip dislocations, comparing high-energy, sports-related, and low-energy trauma mechanisms.

MATERIALS AND METHODS

One hundred forty-one patients with traumatic posterior hip dislocations were analyzed and matched to a control group of 141 patients with high-energy trauma mechanisms without hip or pelvic injury, matched for age, gender, and Body Mass Index (BMI). The trauma mechanism was analyzed, and the femoroacetabular morphology and concomitant femoral head or posterior acetabular wall fractures were assessed using computed tomography (CT) scans. Acetabular version, coverage, and pincer morphology were evaluated by measuring the lateral center-edge angle, acetabular index, acetabular depth/width ratio, cranial and central acetabular version angles, and the anterior and posterior acetabular sector angles (AASA, PASA). The caput-collum-diaphyseal (CCD) angle and coronal and axial alpha angles were measured to detect cam morphology.

RESULTS

A high-energy trauma caused posterior hip dislocations in 79.4%, sports-related mechanisms in 7.8%, and a low-energy impact in 12.8%. Patients with high-energy and sports-related dislocations exhibited a higher disposition for acetabular retroversion (p < 0.001). However, the acetabular version in low-energy mechanisms did not differ from the control group (p ≥ 0.05). Acetabular retroversion was associated with isolated dislocation, while acetabular overcoverage correlated with concomitant posterior acetabular wall fractures (p < 0.05). Alpha angles were significantly increased in patients with hip dislocations, independent of the trauma mechanism (p < 0.001).

CONCLUSION

Acetabular retroversion contributes to posterior hip dislocation in high-energy and sports-related trauma mechanisms and decreases the likelihood of sustaining concomitant fractures. Acetabular morphology was subordinate to causing hip dislocation following a low-energy impact. Increased alpha angles were identified as a risk factor contributing to posterior hip dislocations, regardless of the trauma mechanism.

Feasibility of interdisciplinary evaluation in non-arthritic hip pain: A randomized trial

BACKGROUND

Physical therapy and orthopaedic surgery are two common treatments for non-arthritic hip pain. Interdisciplinary evaluation across these disciplines may produce a more supportive treatment-planning process; however, the feasibility of such an evaluation remains unknown.

HYPOTHESIS OBJECTIVE

To assess the feasibility of an interdisciplinary evaluation with an orthopaedic surgeon and physical therapist for non-arthritic hip pain.

STUDY DESIGN

Observational feasibility study of a randomized controlled trial.

METHODS

Participants were randomized to an interdisciplinary (surgeon + physical therapist) or standard (surgeon) evaluation in a hip preservation clinic. Recruitment rate was recorded. Retention rate was calculated for all variables of interest. Enrollment and refusal reasons were recorded as patient quotes and categorized by a single grader. Time spent in clinic was compared across groups using Mann Whitney U tests (P ≤ 0.05). Study clinicians were interviewed, and responses were categorized based on pre-determined themes.

RESULTS

Eighty-one percent of eligible patients enrolled over a 15-month recruitment period. Willingness(n = 16), urgency to resolve pain(n = 10), financial compensation(n = 1), interest in research(n = 42), physical therapy(n = 6), or multiple-provider care(n = 15) were participants' enrollment reasons; reason was not recorded for 22 participants. Time(n = 11), preference for single-provider care(n = 6), current physical therapy treatment(n = 1), and disinterest in physical therapy(n = 7) or research(n = 2) were refusal reasons of patients who did not enroll. Retention for primary variables of interest was 100% in both groups. Participants spent, on average, 23.5 min more time in clinic for the interdisciplinary evaluation compared to the standard (P < 0.001).

CONCLUSIONS

An interdisciplinary evaluation for patients with non-arthritic hip pain that included a physical therapist and orthopaedic surgeon in a hip preservation clinic was feasible and may better inform the treatment planning process.

Femoroacetabular Impingement and Groin Injuries Among Soccer Players

Groin injuries and femoroacetabular impingement are common among soccer players and can provide a challenge in diagnosis, as well as treatment. Nonoperative and operative measures are the 2 predominant treatments. This current review investigates the recent literature on groin and femoroacetabular impingement injuries in soccer players, as well as potential treatment modalities.

Arthroscopic Treatment of Femoroacetabular Impingement Syndrome: An Updated Review

Treatment strategies for femoroacetabular impingement (FAI) syndrome have evolved in tandem with increased comprehension of FAI's impact on hip joint health. Early intervention, including arthroscopic surgery, has gained popularity due to its potential to delay the progression of osteoarthritis. Arthroscopic surgery has demonstrated significant efficacy in treating FAI syndrome, with robust evidence from randomized controlled trials and systematic reviews supporting its use. Despite arthroscopic surgery's success, complications and reoperations are not uncommon. The incidence ranges from 1% to 31% and 4% to 13%, respectively. Adjunctive biologic treatments, such as bone marrow aspirate concentrates and platelet-rich plasma, have shown promise in chondral lesion management. However, robust evidence supporting their routine use in FAI syndrome is currently lacking. Among conservative treatment methods, intra-articular injections offer diagnostic and therapeutic benefits for FAI patients. While they may provide pain relief and aid in prognosis, their long-term efficacy remains a subject of debate. Comparative studies between conservative and arthroscopic treatments highlight the importance of personalized approaches in managing FAI syndrome. In conclusion, recent advancements in FAI syndrome management have illuminated various treatment modalities. Arthroscopic surgery stands as a pivotal intervention, offering substantial benefits in pain relief, function, and quality of life. However, careful patient selection and postoperative monitoring are crucial for optimizing outcomes. Adjunctive biologics and intra-articular injections show promise but require further investigation. Tailoring treatment to individual patient characteristics remains paramount in optimizing FAI syndrome management.

Squatting biomechanics following physiotherapist-led care or hip arthroscopy for femoroacetabular impingement syndrome: a secondary analysis from a randomised controlled trial

Background

Femoroacetabular impingement syndrome (FAIS) can cause hip pain and chondrolabral damage that may be managed non-operatively or surgically. Squatting motions require large degrees of hip flexion and underpin many daily and sporting tasks but may cause hip impingement and provoke pain. Differential effects of physiotherapist-led care and arthroscopy on biomechanics during squatting have not been examined previously. This study explored differences in 12-month changes in kinematics and moments during squatting between patients with FAIS treated with a physiotherapist-led intervention (Personalised Hip Therapy, PHT) and arthroscopy.

Methods

A subsample (n = 36) of participants with FAIS enrolled in a multi-centre, pragmatic, two-arm superiority randomised controlled trial underwent three-dimensional motion analysis during squatting at baseline and 12-months following random allocation to PHT (n = 17) or arthroscopy (n = 19). Changes in time-series and peak trunk, pelvis, and hip biomechanics, and squat velocity and maximum depth were explored between treatment groups.

Results

No significant differences in 12-month changes were detected between PHT and arthroscopy groups. Compared to baseline, the arthroscopy group squatted slower at follow-up (descent: mean difference -0.04 m∙s-1 (95%CI [-0.09 to 0.01]); ascent: -0.05 m∙s-1 [-0.11 to 0.01]%). No differences in squat depth were detected between or within groups. After adjusting for speed, trunk flexion was greater in both treatment groups at follow-up compared to baseline (descent: PHT 7.50° [-14.02 to -0.98]%; ascent: PHT 7.29° [-14.69 to 0.12]%, arthroscopy 16.32° [-32.95 to 0.30]%). Compared to baseline, both treatment groups exhibited reduced anterior pelvic tilt (descent: PHT 8.30° [0.21-16.39]%, arthroscopy -10.95° [-5.54 to 16.34]%; ascent: PHT -7.98° [-0.38 to 16.35]%, arthroscopy -10.82° [3.82-17.81]%), hip flexion (descent: PHT -11.86° [1.67-22.05]%, arthroscopy -16.78° [8.55-22.01]%; ascent: PHT -12.86° [1.30-24.42]%, arthroscopy -16.53° [6.72-26.35]%), and knee flexion (descent: PHT -6.62° [0.56- 12.67]%; ascent: PHT -8.24° [2.38-14.10]%, arthroscopy -8.00° [-0.02 to 16.03]%). Compared to baseline, the PHT group exhibited more plantarflexion during squat ascent at follow-up (-3.58° [-0.12 to 7.29]%). Compared to baseline, both groups exhibited lower external hip flexion moments at follow-up (descent: PHT -0.55 N∙m/BW∙HT[%] [0.05-1.05]%, arthroscopy -0.84 N∙m/BW∙HT[%] [0.06-1.61]%; ascent: PHT -0.464 N∙m/BW∙HT[%] [-0.002 to 0.93]%, arthroscopy -0.90 N∙m/BW∙HT[%] [0.13-1.67]%).

Conclusion

Exploratory data suggest at 12-months follow-up, neither PHT or hip arthroscopy are superior at eliciting changes in trunk, pelvis, or lower-limb biomechanics. Both treatments may induce changes in kinematics and moments, however the implications of these changes are unknown.

Trial registration details

Australia New Zealand Clinical Trials Registry reference: ACTRN12615001177549. Trial registered 2/11/2015.

Development and validation of a novel Barrett's oesophagus patient reported outcome measure (B-PROM)

BACKGROUND

Patients with Barrett's oesophagus (BO) carry significant cancer worry, burden of symptoms, and lack disease-specific knowledge. Currently there is no validated BO patient reported outcome measure (PROM) to measure these factors for use in clinical practice and research, hence the aim of this study was to devise a novel, validated BO-specific tool, B-PROM.

METHODS

Literature review, quantitative and qualitative research informed the initial item generation. The item bank was refined through a modified Delphi process between May and August 2021. The PROM was then tested through cognitive interviews and validated via multicentre testing between September 2021 and February 2023 with the aim to create a succinct tool which addresses the key important factors to BO patients and has strong psychometric properties.

FINDINGS

B-PROM covers key themes of disease-specific knowledge, trust in clinicians, burden of symptoms, cancer worry and burden of surveillance. Validation results from 387 participants (response rate 40.8%) showed 93.3% of participants completed >95% of B-PROM. All individual items scored a completion rate of >95%. Mean completion time was 5 mins 34s for a sample group. Nineteen items showed a ceiling effect, 3 items showed a floor effect. Internal consistency overall demonstrated a Cronbach Alpha of 0.846, while predetermined subsections showed Cronbach alphas of 0.335, 0.718, 0.736, and 0.896. Inter-item analysis found 2 pairs of items with strong correlation, with only 6 items correlating weakly. Item-total correlation showed 19 items correlated well. Exploratory Factor analysis (EFA) with principal component analysis produced 5 components with Eigenvalues >1 of which 4/5 had satisfactory Cronbach alphas. Test-retest reliability showed no significant differences across single and average measures (p ≤ 0.001).

INTERPRETATION

B-PROM is the first BO-specific PROM to be systematically evaluated. Validation findings show strong internal consistency, short completion time, low missingness and excellent test-retest reliability.

FUNDING

Medtronic Limited ISR-2016-1077.

A randomized controlled trial comparing conservative versus surgical treatment in patients with foot drop due to peroneal nerve entrapment: results of an internal feasibility pilot study

BACKGROUND

Based on the lack of literature to support any treatment strategy in patients with foot drop due to peroneal nerve entrapment, a prospective study randomizing patients between surgery and conservative treatment is warranted. Since studies comparing surgery to no surgery are often challenging, we first examined the feasibility of such a randomized controlled trial.

METHODS/DESIGN

An internal feasibility pilot study was conducted to assess several aspects of process, resource, management, and scientific feasibility. The main objective was the assessment of the recruitment rate. The criterion to embark on a full study was the recruitment of at least 14 patients in 6 participating centers within 6 months. Cross-over rate, blinding measures, training strategies, and trial assessments were evaluated. The trial was entirely funded by the KCE Trials public funding program of the Belgian Health Care Knowledge Centre (ID KCE19-1232).

RESULTS

The initial duration was prolonged due to the COVID-19 pandemic. Between April 2021 and October 2022, we included 19 patients of which 15 were randomized. Fourteen patients were treated as randomized. One drop-out occurred after randomization, prior to surgery. We did not document any cross-over or accidental unblinding. Training strategies were successful. Patients perceived the quality of life questionnaire as the least relevant assessment. Assessment of ankle dorsiflexion range of motion was prone to interobserver variability. All other trial assessments were adequate.

DISCUSSION

Recruitment of the anticipated 14 patients was feasible although slower than expected. The Short-Form Health Survey (SF-36) and assessment of ankle dorsiflexion range of motion will no longer be included in the full-scale FOOTDROP trial.

CONCLUSION

The FOOTDROP study is feasible.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier NCT04695834 . Registered 4 January 2021.

Are we doing the right surgical trials?

Cite this article: Bone Joint Res  2023;12(6):372–374.

Comparison of Walking Biomechanics After Physical Therapist-Led Care or Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Secondary Analysis From a Randomized Controlled Trial

BACKGROUND

Femoroacetabular impingement syndrome is characterized by chondrolabral damage and hip pain. The specific biomechanics used by people with femoroacetabular impingement syndrome during daily activities may exacerbate their symptoms. Femoroacetabular impingement syndrome can be treated nonoperatively or surgically; however, differential treatment effects on walking biomechanics have not been examined.

PURPOSE

To compare the 12-month effects of physical therapist-led care or arthroscopy on trunk, pelvis, and hip kinematics as well as hip moments during walking.

STUDY DESIGN

Secondary analysis of multi-centre, pragmatic, two-arm superiority randomized controlled trial subsample; Level of evidence, 1.

METHODS

A subsample of 43 participants from the Australian Full randomised controlled trial of Arthroscopic Surgery for Hip Impingement versus best cONventional (FASHIoN trial) underwent gait analysis and completed the International Hip Outcome Tool (iHOT-33) at both baseline and 12 months after random allocation to physical therapist-led care (personalized hip therapy; n = 22; mean age 35; 41% female) or arthroscopy (n = 21; mean age 36; 48% female). Changes in trunk, pelvis, and hip biomechanics were compared between treatment groups across the gait cycle using statistical parametric mapping. Associations between changes in iHOT-33 and changes in hip kinematics across 3 planes of motion were examined.

RESULTS

As compared with the arthroscopy group, the personalized hip therapy group increased its peak hip adduction moments (mean difference = 0.35 N·m/body weight·height [%] [95% CI, 0.05-0.65]; effect size = 0.72; P = .02). Hip adduction moments in the arthroscopy group were unchanged in response to treatment. No other between-group differences were detected. Improvements in iHOT-33 were not associated with changes in hip kinematics.

CONCLUSION

Peak hip adduction moments were increased in the personalized hip therapy group and unchanged in the arthroscopy group. No biomechanical changes favoring arthroscopy were detected, suggesting that personalized hip therapy elicits greater changes in hip moments during walking at 12-month follow-up. Twelve-month changes in hip-related quality of life were not associated with changes in hip kinematics.

Platelet-Rich Plasma Is Not Associated With Improved Outcomes Following Hip Femoroacetabular Impingement Surgery: Very Low-Quality Evidence Suggests Hyaluronic Acid and Cell-Based Therapies May Be Beneficial—A Systematic Review of Biological Treatments

Purpose

To examine the efficacy of biologic agents in the treatment of cartilage defects associated with femoroacetabular impingement (FAI).

Methods

PubMed, Ovid MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews were reviewed by 2 independent reviewers for eligible studies. We included randomized and nonrandomized control trials as well as uncontrolled case series and retrospective studies. Studies were excluded if they included injections of corticosteroids, papers that described technique only, review papers, and those not in the English language. Demographics, treatment type, outcome of treatment, and complications were extracted, whereas risk of bias and study quality were assessed independently using the risk of bias tool (ROB2) and effective public health practice project tool. A narrative synthesis was performed, and standardized mean differences were reported. Certainty of evidence was assessed using the GRADE approach.

Results

Eighteen studies consisting of 1,024 patients met the inclusion criteria. Three studies involved the use of platelet-rich plasma (PRP) as an adjuvant to surgery and were included in the meta-analysis. Three studies administered hyaluronic acid (HA) as a primary treatment. Twelve involved various cell-based methods of chondrocyte stimulation for cartilage defects associated with FAI, but heterogeneity did not allow for pooling. Low-quality evidence indicates PRP is not associated with improved outcomes following surgery (mean difference –1.42, 95% confidence interval –3.95 to 1.11, P = .27). Very-low-quality evidence suggests HA (standardized mean difference 1.15, 95% confidence interval 0.64-1.66, P < .001, Z = 4.39) and cell-based therapies may improve function and pain in patients with FAI.

Conclusions

Low-quality evidence indicates PRP is not associated with improved outcomes following hip FAI surgery, and very-low-quality evidence suggests HA and cell-based therapies may improve outcomes.

Level of Evidence

systematic review of Level I-V studies.

Arthroscopic hip surgery compared with personalised hip therapy in people over 16 years old with femoroacetabular impingement syndrome: UK FASHIoN RCT

BACKGROUND

Femoroacetabular impingement syndrome is an important cause of hip pain in young adults. It can be treated by arthroscopic hip surgery or with physiotherapist-led conservative care.

OBJECTIVE

To compare the clinical effectiveness and cost-effectiveness of hip arthroscopy with best conservative care.

DESIGN

The UK FASHIoN (full trial of arthroscopic surgery for hip impingement compared with non-operative care) trial was a pragmatic, multicentre, randomised controlled trial that was carried out at 23 NHS hospitals.

PARTICIPANTS

Participants were included if they had femoroacetabular impingement, were aged ≥ 16 years old, had hip pain with radiographic features of cam or pincer morphology (but no osteoarthritis) and were believed to be likely to benefit from hip arthroscopy.

INTERVENTION

Participants were randomly allocated (1 : 1) to receive hip arthroscopy followed by postoperative physiotherapy, or personalised hip therapy (i.e. an individualised physiotherapist-led programme of conservative care). Randomisation was stratified by impingement type and recruiting centre using a central telephone randomisation service. Outcome assessment and analysis were masked.

MAIN OUTCOME MEASURE

The primary outcome was hip-related quality of life, measured by the patient-reported International Hip Outcome Tool (iHOT-33) 12 months after randomisation, and analysed by intention to treat.

RESULTS

Between July 2012 and July 2016, 648 eligible patients were identified and 348 participants were recruited. In total, 171 participants were allocated to receive hip arthroscopy and 177 participants were allocated to receive personalised hip therapy. Three further patients were excluded from the trial after randomisation because they did not meet the eligibility criteria. Follow-up at the primary outcome assessment was 92% (N = 319; hip arthroscopy, n = 157; personalised hip therapy, n = 162). At 12 months, mean International Hip Outcome Tool (iHOT-33) score had improved from 39.2 (standard deviation 20.9) points to 58.8 (standard deviation 27.2) points for participants in the hip arthroscopy group, and from 35.6 (standard deviation 18.2) points to 49.7 (standard deviation 25.5) points for participants in personalised hip therapy group. In the primary analysis, the mean difference in International Hip Outcome Tool scores, adjusted for impingement type, sex, baseline International Hip Outcome Tool score and centre, was 6.8 (95% confidence interval 1.7 to 12.0) points in favour of hip arthroscopy (p = 0.0093). This estimate of treatment effect exceeded the minimum clinically important difference (6.1 points). Five (83%) of six serious adverse events in the hip arthroscopy group were related to treatment and one serious adverse event in the personalised hip therapy group was not. Thirty-eight (24%) personalised hip therapy patients chose to have hip arthroscopy between 1 and 3 years after randomisation. Nineteen (12%) hip arthroscopy patients had a revision arthroscopy. Eleven (7%) personalised hip therapy patients and three (2%) hip arthroscopy patients had a hip replacement within 3 years.

LIMITATIONS

Study participants and treating clinicians were not blinded to the intervention arm. Delays were encountered in participants accessing treatment, particularly surgery. Follow-up lasted for 3 years.

CONCLUSION

Hip arthroscopy and personalised hip therapy both improved hip-related quality of life for patients with femoroacetabular impingement syndrome. Hip arthroscopy led to a greater improvement in quality of life than personalised hip therapy, and this difference was clinically significant at 12 months. This study does not demonstrate cost-effectiveness of hip arthroscopy compared with personalised hip therapy within the first 12 months. Further follow-up will reveal whether or not the clinical benefits of hip arthroscopy are maintained and whether or not it is cost-effective in the long term.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN64081839.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 16. See the NIHR Journals Library website for further project information.

Controversial Issues in Arthroscopic Surgery for Femoroacetabular Impingement

Femoroacetabular impingement (FAI) is a common cause of painful hip in the young and middle-aged population. This condition frequently leads to a labral tear, damage of acetabular cartilage, and secondary arthritis of the hip. When nonsurgical managements are not effective, surgical procedures (open surgery and hip arthroscopy) are indicated. Due to its less invasiveness, hip arthroscopy has replaced open surgery during the last two decades. The effectiveness of arthroscopic surgery in pain relief for FAI syndrome has been well established. The procedure is also expected to slow or prevent further progression to hip arthritis. In this review, we provide the updated knowledge of arthroscopic procedures for the management of FAI syndrome.

The challenge of equipoise in trials with a surgical and non-surgical comparison: a qualitative synthesis using meta-ethnography

BACKGROUND

Randomised controlled trials in surgery can be a challenge to design and conduct, especially when including a non-surgical comparison. As few as half of initiated surgical trials reach their recruitment target, and failure to recruit is cited as the most frequent reason for premature closure of surgical RCTs. The aim of this qualitative evidence synthesis was to identify and synthesise findings from qualitative studies exploring the challenges in the design and conduct of trials directly comparing surgical and non-surgical interventions.

METHODS

A qualitative evidence synthesis using meta-ethnography was conducted. Six electronic bibliographic databases (Medline, Central, Cinahl, Embase and PsycInfo) were searched up to the end of February 2018. Studies that explored patients' and health care professionals' experiences regarding participating in RCTs with a surgical and non-surgical comparison were included. The GRADE-CERQual framework was used to assess confidence in review findings.

RESULTS

In total, 3697 abstracts and 49 full texts were screened and 26 published studies reporting experiences of patients and healthcare professionals were included. The focus of the studies (24/26) was primarily related to the challenge of recruitment. Two studies explored reasons for non-compliance to treatment allocation following randomisation. Five themes related to the challenges to these types of trials were identified: (1) radical choice between treatments; (2) patients' discomfort with randomisation: I want the best treatment for me as an individual; (3) challenge of equipoise: patients' a priori preferences for treatment; (4) challenge of equipoise: clinicians' a priori preferences for treatment and (5) imbalanced presentation of interventions.

CONCLUSION

The marked dichotomy between the surgical and non-surgical interventions was highlighted in this review as making recruitment to these types of trials particularly challenging. This review identified factors that increase our understanding of why patients and clinicians may find equipoise more challenging in these types of trials compared to other trial comparisons. Trialists may wish to consider exploring the balance of potential factors influencing patient and clinician preferences towards treatments before they start recruitment, to enable issues specific to a particular trial to be identified and addressed. This may enable trial teams to make more efficient considered design choices and benefit the delivery of such trials.

Undertaking pre-pilot work to gain an empathetic insight into participants' perspectives

BACKGROUND

Being an empathetic researcher can be crucial in understanding participants' perspectives. However, while the need for empathy is recognised in qualitative interview research, there is less acknowledgement of its value with other methods of collecting data. Researchers can face various challenges when the instruments and approaches used to collect data are new to them. The value of researchers acting as participants when undertaking pre-pilot work are not be underestimated. Aim To provide a reflective account of the pre-pilot work undertaken by the authors before their main study.

DISCUSSION

Pre-pilot work that involves the researchers as participants can develop cultural competence, as well as empathetic insight into participants' perspectives, thus enabling them to refine and strengthen their main study.

CONCLUSION

It takes time when planning research to incorporate appropriate pre-pilot work that assists personal training and learning. However, this can pay dividends in terms of the empathetic insight gained for the refinement of the proposed study. Pre-pilot work and a reflective approach can strengthen rigour, as well as assist in planning research and collecting data.

IMPLICATIONS FOR PRACTICE

Experienced researchers may be novices at using specific tools or methods of collecting data. Pre-pilot work enables a greater understanding and deeper appreciation of participants' perspectives.

Publication Trends and Hot Spots in Femoroacetabular Impingement Research: A 20-Year Bibliometric Analysis

BACKGROUND

Femoroacetabular impingement (FAI) has attracted increasing attention over the past few decades. We aim to evaluate FAI research and predict research hot spots quantitatively and qualitatively.

METHODS

The publications in FAI research between 2000 and 2019 were assimilated from the Web of Science Core Collection of Clarivate Analytics. The retrieved data were evaluated by the bibliometric method. Software CiteSpace 5.7.R1, VOSviewer 1.6.15, and the Online Analysis Platform of Literature Metrology (http://bibliometric.com/) were used to analyze and identify the hot spots and trends in this field.

RESULTS

A total of 2471 originals articles that fulfilled the study requirements were obtained. The number of manuscripts on FAI has experienced rapid growth, especially after 2009. The United States of America was the leading country for publication and to the collaboration network. FAI, osteoarthritis, hip arthroscopy, labral reconstruction, pathomorphology, outcome, rehabilitation, and joint cartilage are some of the high-frequency keywords in co-occurrence cluster analysis and cocited reference cluster analysis. Burst detection analysis of top keywords revealed that outcomes, instability, labral reconstruction, adolescent, and risk factor were newly emerged research hot spots.

CONCLUSION

The understanding of FAI has been improved significantly during the past two decades. Present studies focused on identifying the optimal method to treat labral pathology, outcome assessment of either surgeries or conservative managements, and predicting midterm and long-term outcomes. Together these studies exert critical implications for decision-making and management for FAI.

Arthroscopic Hip Surgery versus Conservative Therapy on Femoroacetabular Impingement Syndrome: A Meta-Analysis of RCTs

To determine the outcome and differences between arthroscopic hip surgery and conservative therapy in patients suffering from femoroacetabular impingement syndrome, we searched articles from PubMed, Embase, Cochrane, Web of Science and Clinicaltrials.gov using a Boolean search algorithm. Only randomized controlled trials comparing arthroscopic hip surgery and conservative therapy were included in this meta-analysis of femoroacetabular impingement syndrome management. Two authors determined eligibility, extracted the needed data and assessed the risk of bias of eligible studies independently. Then we meta-analyzed three articles to assess pooled estimate size (ES) and 95% confidence interval for Hip Outcome Score of activities of daily living (HOS ADL subscale), Hip Outcome Score sport (HOS sports subscale) and International Hip Outcome Tool (iHOT-33) analyses were performed by using STATA version 14.0 MP (STATA, College Station, TX, USA) with the principal summary measures are mean between group difference, sample size, and standard deviation. We collected 52 articles in total after removing duplicates and screened by titles and abstracts. A total of three RCTs were included finally. There was definite evidence of additional benefit of arthroscopic hip surgery against conservative therapy in the field of improving quality of life (three trials, 575 participants, ES = 2.109, 95% CI: 1.373 to 2.845, I2  = 42.8%, P = 0.000) and activity of daily living (two trials, 262 participants, ES = 9.220, 95% CI: 5.931 to 12.508, I2  = 16.5%, P = 0.000). However, no significant difference could be seen in sports function improvement (two trials, ES = 7.562, 95% CI: -2.957 to 18.082, I2  = 60.1%, P = 0.159). In conclusion, this meta-analysis suggests that arthroscopic hip surgery provided essential benefit compared with conservative therapy in improving activity of daily living and quality of life.

Nonsurgical Versus Surgical Management of Femoroacetabular Impingement: What Does the Current Best Evidence Tell Us

Controversy exists as to the management of femoroacetabular impingement (FAI). When nonsurgical management of symptomatic FAI fails, surgical management is generally indicated. However, many groups with a stake in patient care (particularly payors) have insisted on higher levels of evidence. Recently, there have been several Level I studies published, comparing physical therapy (PT) with hip arthroscopy in the management of symptomatic FAI. All of these studies have used outcomes tools developed and validated for patients with nonarthritic hip pain (the International Hip Outcome Tool). Most highest level evidence confirms that although patients with FAI do benefit from PT, patients who undergo surgical management for FAI with hip arthroscopy benefit more than those who undergo PT (mean difference in the International Hip Outcome Tool 6.8 [minimal clinically important difference 6.1], P = 0.0093). Future large prospective studies are needed to evaluate the effect on the outcomes when there is a delay in surgical management in symptomatic individuals, assess whether FAI surgery prevents or delays osteoarthritis, and determine the role of other advanced surgical techniques.

Conservative treatment for uncomplicated appendicitis in children: the CONTRACT feasibility study, including feasibility RCT

BACKGROUND

Although non-operative treatment is known to be effective for the treatment of uncomplicated acute appendicitis in children, randomised trial data comparing important outcomes of non-operative treatment with those of appendicectomy are lacking.

OBJECTIVES

The objectives were to ascertain the feasibility of conducting a multicentre randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of a non-operative treatment pathway with appendicectomy for the treatment of uncomplicated acute appendicitis in children.

DESIGN

This was a mixed-methods study, which included a feasibility randomised controlled trial, embedded and parallel qualitative and survey studies, a parallel health economic feasibility study and the development of a core outcome set.

SETTING

This study was set in three specialist NHS paediatric surgical units in England.

PARTICIPANTS

Children (aged 4-15 years) clinically diagnosed with uncomplicated acute appendicitis participated in the feasibility randomised controlled trial. Children, their families, recruiting clinicians and other health-care professionals involved in caring for children with appendicitis took part in the qualitative study. UK specialist paediatric surgeons took part in the survey. Specialist paediatric surgeons, adult general surgeons who treat children, and children and young people who previously had appendicitis, along with their families, took part in the development of the core outcome set.

INTERVENTIONS

Participants in the feasibility randomised controlled trial were randomised to a non-operative treatment pathway (broad-spectrum antibiotics and active observation) or appendicectomy.

MAIN OUTCOME MEASURES

The primary outcome measure was the proportion of eligible patients recruited to the feasibility trial.

DATA SOURCES

Data were sourced from NHS case notes, questionnaire responses, transcribed audio-recordings of recruitment discussions and qualitative interviews.

RESULTS

Overall, 50% (95% confidence interval 40% to 59%) of 115 eligible patients approached about the trial agreed to participate and were randomised. There was high acceptance of randomisation and good adherence to trial procedures and follow-up (follow-up rates of 89%, 85% and 85% at 6 weeks, 3 months and 6 months, respectively). More participants had perforated appendicitis than had been anticipated. Qualitative work enabled us to communicate about the trial effectively with patients and families, to design and deliver bespoke training to optimise recruitment and to understand how to optimise the design and delivery of a future trial. The health economic study indicated that the main cost drivers are the ward stay cost and the cost of the operation; it has also informed quality-of-life assessment methods for future work. A core outcome set for the treatment of uncomplicated acute appendicitis in children and young people was developed, containing 14 outcomes. There is adequate surgeon interest to justify proceeding to an effectiveness trial, with 51% of those surveyed expressing a willingness to recruit with an unchanged trial protocol.

LIMITATIONS

Because the feasibility randomised controlled trial was performed in only three centres, successful recruitment across a larger number of sites cannot be guaranteed. However, the qualitative work has informed a bespoke training package to facilitate this. Although survey results suggest adequate clinician interest to make a larger trial possible, actual participation may differ, and equipoise may have changed over time.

CONCLUSIONS

A future effectiveness trial is feasible, following limited additional preparation, to establish appropriate outcome measures and case identification. It is recommended to include a limited package of qualitative work to optimise recruitment, in particular at new centres.

FUTURE WORK

Prior to proceeding to an effectiveness trial, there is a need to develop a robust method for distinguishing children with uncomplicated acute appendicitis from those with more advanced appendicitis, and to reach agreement on a primary outcome measure and effect size that is acceptable to all stakeholder groups involved.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN15830435.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 10. See the NIHR Journals Library website for further project information.

Do currently prescribed exercises reflect contributing pathomechanics associated with femoroacetabular impingement syndrome? A scoping review

OBJECTIVE

Research reports limited, mixed evidence on the effectiveness of physiotherapy management in the treatment of femoroacetabular impingement (FAI) syndrome. The purpose of this review was to (1) identify what therapeutic exercises are being utilized in the non-surgical management of patients with FAI syndrome; (2) map the extent to which reported exercises reflect contributory pathomechanics associated with FAI syndrome.

DESIGN

Scoping Review.

METHODS

MEDLINE, PubMed, CINAHL, SPORTDiscus, and PEDRO electronic databases were searched for studies that implemented a non-surgical, exercise-based treatment approach in patients with FAI syndrome. Exercises were extracted and analyzed according to elements recognized as contributing to the pathomechanics associated with FAI syndrome.

RESULTS

24 studies fulfilled the inclusion criteria. 453 exercises were extracted. Uniplanar exercises accounted for 338/453 or 74.6% of all reported exercises whereas triplanar exercises accounted for 21/453 or 4.6% of all exercises. Non-weight bearing exercises accounted for 220/453 or 48.6% of all exercises.

CONCLUSION

The majority of therapeutic exercises were classified as sagittal, uniplanar exercises, utilizing a concentric exercise approach. These findings highlight that exercises utilizing triplanar, eccentric hip control, in a single limb weightbearing position are considerably underrepresented.

Surgery is no more effective than conservative treatment for Femoroacetabular impingement syndrome: Systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To summarize the effects of surgical treatment compared to conservative treatment in femoroacetabular impingement syndrome in the short, medium, and long term.

STUDY DESIGN

Systematic review.

METHODS

The following databases were searched on 14/09/2020: MEDLINE, EMBASE, CENTRAL, Web of Science, and PEDro. There were no date or language limits. The methodological quality assessment was performed using the PEDro scale and the quality of the evidence followed the GRADE recommendation. The outcomes pain, disability, and adverse effects were extracted.

RESULTS

Of 6264 initial studies, three met the full-text inclusion criteria. All studies were of good methodological quality. Follow up ranged from six months to two years, with 650 participants in total. The meta-analyses found no difference in disability between surgical versus conservative treatment, with a mean difference (MD) between groups of 3.91 points (95% CI -2.19 to 10.01) at six months, MD of 5.53 points (95% CI -3.11 to 14.16) at 12 months and 3.8 points (95% CI -6.0 to 13.6) at 24 months. The quality of the evidence (GRADE) varied from moderate to low across all comparisons.

CONCLUSION

There is moderate-quality evidence that surgical treatment is not superior to conservative treatment for femoroacetabular impingement syndrome in the short term, and there is low-quality evidence that it is not superior in the medium term.

LEVEL OF EVIDENCE

Therapy, level 1a.

REGISTRATION NUMBER

PROSPERO CRD42019134118.

Active monitoring, radical prostatectomy and radical radiotherapy in PSA-detected clinically localised prostate cancer: the ProtecT three-arm RCT

BACKGROUND

Prostate cancer is the most common cancer among men in the UK. Prostate-specific antigen testing followed by biopsy leads to overdetection, overtreatment as well as undertreatment of the disease. Evidence of treatment effectiveness has lacked because of the paucity of randomised controlled trials comparing conventional treatments.

OBJECTIVES

To evaluate the effectiveness of conventional treatments for localised prostate cancer (active monitoring, radical prostatectomy and radical radiotherapy) in men aged 50-69 years.

DESIGN

A prospective, multicentre prostate-specific antigen testing programme followed by a randomised trial of treatment, with a comprehensive cohort follow-up.

SETTING

Prostate-specific antigen testing in primary care and treatment in nine urology departments in the UK.

PARTICIPANTS

Between 2001 and 2009, 228,966 men aged 50-69 years received an invitation to attend an appointment for information about the Prostate testing for cancer and Treatment (ProtecT) study and a prostate-specific antigen test; 82,429 men were tested, 2664 were diagnosed with localised prostate cancer, 1643 agreed to randomisation to active monitoring (n = 545), radical prostatectomy (n = 553) or radical radiotherapy (n = 545) and 997 chose a treatment.

INTERVENTIONS

The interventions were active monitoring, radical prostatectomy and radical radiotherapy.

TRIAL PRIMARY OUTCOME MEASURE

Definite or probable disease-specific mortality at the 10-year median follow-up in randomised participants.

SECONDARY OUTCOME MEASURES

Overall mortality, metastases, disease progression, treatment complications, resource utilisation and patient-reported outcomes.

RESULTS

There were no statistically significant differences between the groups for 17 prostate cancer-specific (p = 0.48) and 169 all-cause (p = 0.87) deaths. Eight men died of prostate cancer in the active monitoring group (1.5 per 1000 person-years, 95% confidence interval 0.7 to 3.0); five died of prostate cancer in the radical prostatectomy group (0.9 per 1000 person-years, 95% confidence interval 0.4 to 2.2 per 1000 person years) and four died of prostate cancer in the radical radiotherapy group (0.7 per 1000 person-years, 95% confidence interval 0.3 to 2.0 per 1000 person years). More men developed metastases in the active monitoring group than in the radical prostatectomy and radical radiotherapy groups: active monitoring, n = 33 (6.3 per 1000 person-years, 95% confidence interval 4.5 to 8.8); radical prostatectomy, n = 13 (2.4 per 1000 person-years, 95% confidence interval 1.4 to 4.2 per 1000 person years); and radical radiotherapy, n = 16 (3.0 per 1000 person-years, 95% confidence interval 1.9 to 4.9 per 1000 person-years; p = 0.004). There were higher rates of disease progression in the active monitoring group than in the radical prostatectomy and radical radiotherapy groups: active monitoring (n = 112; 22.9 per 1000 person-years, 95% confidence interval 19.0 to 27.5 per 1000 person years); radical prostatectomy (n = 46; 8.9 per 1000 person-years, 95% confidence interval 6.7 to 11.9 per 1000 person-years); and radical radiotherapy (n = 46; 9.0 per 1000 person-years, 95% confidence interval 6.7 to 12.0 per 1000 person years; p < 0.001). Radical prostatectomy had the greatest impact on sexual function/urinary continence and remained worse than radical radiotherapy and active monitoring. Radical radiotherapy's impact on sexual function was greatest at 6 months, but recovered somewhat in the majority of participants. Sexual and urinary function gradually declined in the active monitoring group. Bowel function was worse with radical radiotherapy at 6 months, but it recovered with the exception of bloody stools. Urinary voiding and nocturia worsened in the radical radiotherapy group at 6 months but recovered. Condition-specific quality-of-life effects mirrored functional changes. No differences in anxiety/depression or generic or cancer-related quality of life were found. At the National Institute for Health and Care Excellence threshold of £20,000 per quality-adjusted life-year, the probabilities that each arm was the most cost-effective option were 58% (radical radiotherapy), 32% (active monitoring) and 10% (radical prostatectomy).

LIMITATIONS

A single prostate-specific antigen test and transrectal ultrasound biopsies were used. There were very few non-white men in the trial. The majority of men had low- and intermediate-risk disease. Longer follow-up is needed.

CONCLUSIONS

At a median follow-up point of 10 years, prostate cancer-specific mortality was low, irrespective of the assigned treatment. Radical prostatectomy and radical radiotherapy reduced disease progression and metastases, but with side effects. Further work is needed to follow up participants at a median of 15 years.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN20141297.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 37. See the National Institute for Health Research Journals Library website for further project information.

Mismatch between expectations and physical activity outcomes at six months following hip-arthroscopy: A qualitative study

OBJECTIVE

To explore factors influencing participation in physical activity for young to middle-aged patients at six months post-hip arthroscopy.

DESIGN

Qualitative study.

SETTING

Three specialist surgical centres in Australia.

PARTICIPANTS

Seventeen adults aged 18-50 years.

MAIN OUTCOME MEASURES

Individual semi-structured interviews were undertaken and transcribed verbatum. Inductive analysis of the data was undertaken, with themes identified through an iterative coding process.

RESULTS

Four key themes emerged from the analysis: 1) an evident mismatch between expectations and actual progress of physical activity during the first six months post-arthroscopy; 2) physical activity levels vary widely at six months post-operatively; 3) evidence of suboptimal psychological readiness to return to sport and an associated emotional toll; and 4) the influence of available support and information on post-operative physical activity.

CONCLUSIONS

This qualitative study has provided in-depth perspectives on recovery after hip arthroscopy. Clear opportunities exist to: 1) help patients develop realistic post-operative goals; 2) provide timely patient education and support; and 3) facilitate an effective transition to desired physical activity.

Total volume of cam deformity alone predicts outcome in arthroscopy for femoroacetabular impingement

PURPOSE

Rates for arthroscopic surgery for femoroacetabular impingement (FAI) are rising and there is growing concern related to the effectiveness and costs associated with this treatment. There is a general lack of consensus as to the criteria for surgical selection of patients. The purpose of this study was to determine whether patient outcome following arthroscopic surgery for FAI could be predicted based on the size and location of deformity. The specific questions were: (1) what is the morphology of FAI in terms of size and location of deformity in a cohort of patients selected for surgery? (2) Do morphological factors predict postoperative improvement in hip scores? (3) Do morphological factors predict preoperative hip scores? (4) Are there clusters of morphological factors which explain postsurgical improvement in hip scores?

MATERIALS AND METHODS

Computer tomography (CT) surgical plans of 90 hips in 79 patients who had undergone primary hip arthroscopy for FAI were retrospectively reviewed. Four parameters for the femur and acetabulum were created: total depth of deformity, maximal depth, extent and the position of maximal deformity. This data were compared with prospectively acquired preoperative and postoperative patient outcome data using generalised linear models.

RESULTS

The cohort comprised 33 males and 46 females aged 37.9 (18-61). The majority (74%) had mixed morphology, 23% isolated cam, and 3% isolated pincer. Overall, the bone depth was greatest and more extensive on the femur. Increased total additional cam deformity alone predicted poorer postoperative outcome (p = 0.045). None of the morphological factors were related to preoperative scores and there was no association between the meta-variables and postoperative outcome.

CONCLUSIONS

The results of this study indicate that a greater total volume of cam deformity led to poorer postoperative patient outcome scores at 1 year. This information provides the surgeon with more accurate patient-specific data for prediction of expected outcomes.

LEVEL OF EVIDENCE

Level III diagnostic.

Physical Activity Following Hip Arthroscopy in Young and Middle-Aged Adults: A Systematic Review

Background

Hip arthroscopy is a common surgical intervention for young and middle-aged adults with hip-related pain and dysfunction, who have high expectations for returning to physical activity following surgery. The purpose of this review was to evaluate the impact of hip arthroscopy on physical activity post-arthroscopy.

Methods

A systematic search of electronic databases was undertaken in identifying studies from January 1st 1990 to December 5th 2019. The search included English language articles reporting physical activity as an outcome following hip arthroscopy in adults aged 18-50 years. Quality assessment, data extraction and synthesis of included studies were undertaken.

Results

Full text articles (n = 234) were assessed for eligibility following screening of titles and abstracts (n = 2086), yielding 120 studies for inclusion. The majority (86%) of the studies were level 4 evidence. One study reported objective activity data. The most frequently occurring patient-reported outcome measure was the Hip Outcome Score-sport-specific subscale (HOS-SS, 84% of studies). Post--arthroscopy improvement was indicated by large effect sizes for patient-reported outcome measures (standard paired difference [95% confidence interval] −1.35[−1.61 to −1.09] at more than 2 years post-arthroscopy); however, the majority of outcome scores for the HOS-SS did not meet the defined level for a patient-acceptable symptom state.

Conclusion

The current level of available information regarding physical activity for post arthroscopy patients is limited in scope. Outcomes have focused on patients’ perceived difficulties with sport-related activities with a paucity of information on the type, quality and quantity of activity undertaken.

Level of Evidence

Level IV, systematic review of Level 2 through to Level 4 studies

Operative Versus Nonoperative Treatment of Femoroacetabular Impingement Syndrome: A Meta-analysis of Short-Term Outcomes

PURPOSE

To compare the outcomes of patients with femoroacetabular impingement (FAI) syndrome treated with hip arthroscopy versus those treated with physical therapy alone.

METHODS

The PubMed, Embase, and Cochrane Library databases were searched from inception to February 15, 2019. All randomized controlled trials (RCTs) that compared operative versus nonoperative treatment in the management of FAI for a minimum 6-month follow-up period were included. The primary outcome was the International Hip Outcome Tool 33. The CLEAR NPT (Checklist to Evaluate a Report of a Nonpharmacological Trial) was used to evaluate the methodologic quality of included studies.

RESULTS

Three RCTs (Level I) were included with a total of 650 patients (323 randomized to surgery and 327 randomized to physical therapy), follow-rate of 90% (583 patients, 295 operative and 288 nonoperative), and average of 11.5 months' follow-up. Regarding participation, 222 of 350 patients (63%) in the FAIT (Femoroacetabular Impingement Trial) study, 348 of 648 (54%) in the FASHIoN (Full UK RCT of Arthroscopic Surgery for Hip Impingement Versus Best Conservative Care) study, and 80 of 104 (77%) in the study by Mansell et al. agreed to participate. The mean age was 35 years, and 51.5% of patients were male patients. All 3 RCTs represented high methodologic quality and a low risk of bias. The frequency-weighted mean follow-up period was 10 months. A meta-analysis of the 3 randomized trials showed that patients treated with operative management had improved preoperative-to-postoperative change scores on the International Hip Outcome Tool 33 compared with the nonoperative group (standardized mean difference, 3.46; 95% confidence interval, 0.07-6.86; P < .05). One study reported on the achievement of clinically relevant outcomes at the individual level, with 51% of the operative group and 32% of the nonoperative group achieving the minimal clinically important difference and with 48% and 19%, respectively, achieving the patient acceptable symptomatic state for the Hip Outcome Score-Activities of Daily Living.

CONCLUSIONS

The results of this meta-analysis show that patients with FAI syndrome treated with hip arthroscopy have statistically superior hip-related outcomes in the short term compared with those treated with physical therapy alone.

LEVEL OF EVIDENCE

Level I, meta-analysis of Level I RCTs.

Danish Hip Arthroscopy Registry: predictors of outcome in patients with femoroacetabular impingement (FAI)

PURPOSE

Predictors of outcome after femoroacetabular impingement (FAI) surgery are not well-documented. This study presents data from the Danish Hip Arthroscopy Registry (DHAR) for such analyses. The purpose of this study was to identify predictors of poor outcome after FAI surgery in a Danish FAI population. The primary hypothesis was that older patients, patients with severe cartilage damage and female patients might have inferior outcome results compared with younger patients, patients with minor cartilage damage and male patients.

METHODS

Radiological and surgical data as well as patient-reported outcome measures (PROM) from FAI patients in DHAR between January 2012 and May 2015 were collected. PROMs consisting of Copenhagen Hip and Groin Outcome Score (HAGOS), quality of life (EQ-5D), Hip Sports Activity Scale (HSAS) and Numeric Rating Scale (NRS) pain scores were assessed. The patients were divided into three age groups (< 25, 25-39 and ≥ 40 years). Cartilage injuries were classified according to International Cartilage Repair Society (ICRS) (femoral side) and modified Becks (acetabular side) classifications. A non-parametric statistic method was used to analyze the differences between the preoperative and postoperative PROM values.

RESULTS

Data from 2054 FAI procedures in DHAR was collected. 53% of the procedures were done in female patients. All HAGOS sub-scales, EQ-5D, HSAS and NRS pain (rest and walk) demonstrated significant improvements in all age groups at follow-up. Comparison between age groups demonstrated poorer outcomes in both older age groups when compared with the < 25 years age group at 1- and 2-year follow-ups. Higher degrees of femoral and acetabular cartilage injury did have a negative influence on outcome at follow-up. Comparison between genders demonstrated lower preoperative outcomes in females and lower outcome score (HSAS) 1 and 2 years after FAI surgery.

CONCLUSIONS

Age above 25 and major cartilage injury might negatively affect the outcome of surgery, however, gender could not be identified as a negative predictor of clinical outcome after FAI surgery, but might negatively affect sports participation in females.

LEVEL OF EVIDENCE

III, prospective cohort study.

Facilitating trial recruitment: A qualitative study of patient and staff experiences of an orthopaedic trauma trial

Background

Qualitative research has been used to explore patients’ and healthcare professionals’ experiences of surgical randomised controlled trials (RCTs). From this research, reasons why patients accept or decline participation and barriers to engaging clinicians in trials have been identified. In a trauma setting, recruitment to surgical trials can be particularly difficult as patients may require urgent treatment and their ability to consider their options, ask questions and reach a decision may be hindered by the impact of their injury. Little research, however, has explored patients’ and healthcare professionals’ experiences of surgical RCTs in a trauma setting. This study aimed to understand patients’ and staff’s experiences of an orthopaedic trauma trial.

Methods

We carried out semi-structured interviews with 11 patients and 24 staff (10 surgeons and 14 research associates) participating in a UK multi-centre feasibility trial comparing intramedullary nails versus distal locking plates for fractures of the distal femur (TrAFFix). Interviews explored patients’ experience of TrAFFix and their reason for participating and staffs' experience of recruiting to TrAFFix and trauma trials more generally. Interviews were audio recorded and transcribed verbatim. Transcripts were analysed using thematic analysis.

Results

Three themes were identified. These were i) navigating research with patients after orthopaedic trauma, ii) knowing that it is the right decision and iii) making it work. These themes reflect: i) how research associates supported and guided patients through the consent process enabling them to participate, ii) the difficulty in engaging surgeons in a trial when individual equipoise and experience of the interventions are low despite the presence of community equipoise and iii) the way in which research teams worked together and encouraged the development of a research culture within the clinical teams in order to facilitate recruitment.

Conclusions

Our findings highlight the pivotal role of research associates (RAs) in facilitating trial recruitment. RAs supported patients to enable them to make a decision about participation and assisted in developing a research culture within the team by promoting studies and communicating research to clinical staff. Our findings also reinforce surgeons’ difficulty with equipoise and suggest that accepting community equipoise could facilitate recruitment.

NON-OPERATIVE MANAGEMENT OF INDIVIDUALS WITH NON-ARTHRITIC HIP PAIN: A LITERATURE REVIEW

BACKGROUND

Non-arthritic hip pain is defined as being related to pathologies of the intra-articular structures of the hip that can be symptomatic. A trial of non-operative management is commonly recommended before consideration of surgery for individuals with non-arthritic hip conditions. There is a need to describe a non-operative or conservative treatment plan for individuals with non-arthritic hip pain.

PURPOSE

The purpose of this literature review was to systematically examine the literature in order to identify and provide evidence for non-operative or conservative management of individuals with non-arthritic hip pain. A proposed home exercise program will be provided for individuals with non-arthritic hip pain.

STUDY DESIGN

Review of the Literature.

MATERIALS/METHODS

A literature search of PubMed, Medline, SPORTSDiscus, and CINAHL was conducted. Keywords included: "hip" AND "femoroacetabular impingement" OR "labral tear." Studies were included if they described non-operative management for individuals with non-arthritic hip pain. Studies were excluded if they recommended a trial of conservative treatment without specific management or interventions and/or activity modification without specific details for intervention.

RESULTS

A total of 49 studies met the eligibility criteria and were included in the review. Rehabilitation recommendations were identified from manuscripts including clinical trials, case series, discussion articles, or systematic reviews related to the non-operative or conservative management of non-arthritic hip pain. Rehabilitation interventions focused on patient education, activity modification, limitation of aggravating factors, an individualized physical therapy protocol, and use of a home exercise program.

CONCLUSIONS

Rehabilitation should address biomechanical deficiencies with neuromuscular training of the hip and lumbopelvic regions. While the current literature on non-operative management is limited, future randomized control trials will establish the effectiveness of specific physical therapy protocols for individuals with non-arthritic hip pain.

LEVEL OF EVIDENCE

3b.

Altered Walking and Muscle Patterns Reduce Hip Contact Forces in Individuals With Symptomatic Cam Femoroacetabular Impingement

BACKGROUND

Cam-type femoroacetabular impingement (FAI) is a causative factor for hip pain and early hip osteoarthritis. Although cam FAI can alter hip joint biomechanics, it is unclear what role muscle forces play and how they affect the hip joint loading. Purpose/Hypothesis: The purpose was to examine the muscle contributions and hip contact forces in individuals with symptomatic cam FAI during level walking. Patients with symptomatic cam FAI would demonstrate different muscle and hip contact forces during gait.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eighteen patients with symptomatic cam FAI were matched for age and body mass index with 18 control participants. Each participant's walking kinematics and kinetics were recorded throughout a gait cycle (ipsilateral foot-strike to ipsilateral foot-off) by use of a motion capture system and force plates. Muscle and hip contact forces were subsequently computed by use of a musculoskeletal modeling program and static optimization methods.

RESULTS

The FAI group walked slower and with shorter steps, demonstrating reduced joint motions and moments during contralateral foot-strike, compared with the control group. The FAI group showed reduced psoas major (median, 1.1 newtons per bodyweight [N/BW]; interquartile range [IQR], 1.0-1.5 N/BW) and iliacus forces (median, 1.2 N/BW; IQR, 1.0-1.6 N/BW), during contralateral foot-strike, compared with the control group (median, 1.6 N/BW; IQR, 1.3-1.6 N/BW, P = .004; and median, 1.5 N/BW; IQR, 1.3-1.6 N/BW, P = .03, respectively), which resulted in lower hip contact forces in the anterior ( P = .026), superior ( P = .02), and medial directions ( P = .038). The 3 vectors produced a resultant peak force at the anterosuperior aspect of the acetabulum for both groups, with the FAI group demonstrating a substantially lower magnitude.

CONCLUSION

FAI participants altered their walking kinematics and kinetics, especially during contralateral foot-strike, as a protective mechanism, which resulted in reduced psoas major and iliacus muscle force and anterosuperior hip contact force estimations.

CLINICAL RELEVANCE

Limited hip mobility not only is attributed to bone-on-bone impingement, caused by cam morphology, but could be attributed to musculature as well. Not only would the psoas major and iliacus be able to protect the hip joint during flexion-extension, athletic conditioning could further strengthen core muscles for improved hip mobility and pelvic balance.

Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): a multicentre randomised controlled trial

BACKGROUND

Femoroacetabular impingement syndrome is an important cause of hip pain in young adults. It can be treated by arthroscopic hip surgery, including reshaping the hip, or with physiotherapist-led conservative care. We aimed to compare the clinical effectiveness of hip arthroscopy with best conservative care.

METHODS

UK FASHIoN is a pragmatic, multicentre, assessor-blinded randomised controlled trial, done at 23 National Health Service hospitals in the UK. We enrolled patients with femoroacetabular impingement syndrome who presented at these hospitals. Eligible patients were at least 16 years old, had hip pain with radiographic features of cam or pincer morphology but no osteoarthritis, and were believed to be likely to benefit from hip arthroscopy. Patients with bilateral femoroacetabular impingement syndrome were eligible; only the most symptomatic hip was randomly assigned to treatment and followed-up. Participants were randomly allocated (1:1) to receive hip arthroscopy or personalised hip therapy (an individualised, supervised, and progressive physiotherapist-led programme of conservative care). Randomisation was stratified by impingement type and recruiting centre and was done by research staff at each hospital, using a central telephone randomisation service. Patients and treating clinicians were not masked to treatment allocation, but researchers who collected the outcome assessments and analysed the results were masked. The primary outcome was hip-related quality of life, as measured by the patient-reported International Hip Outcome Tool (iHOT-33) 12 months after randomisation, and analysed in all eligible participants who were allocated to treatment (the intention-to-treat population). This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN64081839, and is closed to recruitment.

FINDINGS

Between July 20, 2012, and July 15, 2016, we identified 648 eligible patients and recruited 348 participants: 171 participants were allocated to receive hip arthroscopy and 177 to receive personalised hip therapy. Three further patients were excluded from the trial after randomisation because they did not meet the eligibility criteria. Follow-up at the primary outcome assessment was 92% (319 of 348 participants). At 12 months after randomisation, mean iHOT-33 scores had improved from 39·2 (SD 20·9) to 58·8 (27·2) for participants in the hip arthroscopy group, and from 35·6 (18·2) to 49·7 (25·5) in the personalised hip therapy group. In the primary analysis, the mean difference in iHOT-33 scores, adjusted for impingement type, sex, baseline iHOT-33 score, and centre, was 6·8 (95% CI 1·7-12·0) in favour of hip arthroscopy (p=0·0093). This estimate of treatment effect exceeded the minimum clinically important difference (6·1 points). There were 147 patient-reported adverse events (in 100 [72%] of 138 patients) in the hip arthroscopy group) versus 102 events (in 88 [60%] of 146 patients) in the personalised hip therapy group, with muscle soreness being the most common of these (58 [42%] vs 69 [47%]). There were seven serious adverse events reported by participating hospitals. Five (83%) of six serious adverse events in the hip arthroscopy group were related to treatment, and the one in the personalised hip therapy group was not. There were no treatment-related deaths, but one patient in the hip arthroscopy group developed a hip joint infection after surgery.

INTERPRETATION

Hip arthroscopy and personalised hip therapy both improved hip-related quality of life for patients with femoroacetabular impingement syndrome. Hip arthroscopy led to a greater improvement than did personalised hip therapy, and this difference was clinically significant. Further follow-up will reveal whether the clinical benefits of hip arthroscopy are maintained and whether it is cost effective in the long term.

FUNDING

The Health Technology Assessment Programme of the National Institute of Health Research.

Anatomic Predictors of Sagittal Hip and Pelvic Motions in Patients With a Cam Deformity

BACKGROUND

As there is a high prevalence of patients with cam deformities and no ongoing hip dysfunction, understanding the biomechanical factors predicting the onset of symptoms and degenerative changes is critical. One such variable is how the spinopelvic parameters may influence hip and pelvic sagittal mobility. Hypothesis/Purpose: Pelvic incidence may predict sagittal hip and pelvic motions during walking and squatting. The purpose was to determine which anatomic characteristics were associated with symptoms and how they influenced functional hip and pelvic ranges of motion (ROMs) during walking and squatting.

STUDY DESIGN

Controlled laboratory study.

METHODS

Fifty-seven participants underwent computed tomography and were designated either symptomatic (n = 19, cam deformity with pain), asymptomatic (n = 19, cam deformity with no pain), or control (n = 19, no cam deformity or pain). Multiple femoral (cam deformity, neck angle, torsion), acetabular (version, coverage), and spinopelvic (pelvic tilt, sacral slope, pelvic incidence) parameters were measured from each participant's imaging data, and sagittal hip and pelvic ROMs during walking and squatting were recorded using a motion capture system.

RESULTS

Symptomatic participants had large cam deformities, smaller femoral neck-shaft angles, and larger pelvic incidence angles compared with the asymptomatic and control participants. Discriminant function analyses confirmed that radial 1:30 alpha angle (λ₁ = 0.386), femoral neck-shaft angle (λ₂ = 0.262), and pelvic incidence (λ₃ = 0.213) ( P < .001) were the best anatomic parameters to classify participants with their groups. Entering these 3 parameters into a hierarchical linear regression, significant regressions were achieved for hip ROM only when pelvic incidence was included for walking ( R² = 0.20, P = .01) and squatting ( R² = 0.14, P = .04). A higher pelvic incidence decreased walking hip ROM ( r = -0.402, P = .004). Although symptomatic participants indicated a trend of reduced squatting hip and pelvic ROMs, there were no significant regressions with the anatomic parameters.

CONCLUSION

A cam deformity alone may not indicate early clinical signs or decreased ROM. Not only was pelvic incidence a significant parameter to classify the participants, but it was also an important parameter to predict functional ROM. Symptomatic patients with a higher pelvic incidence may experience limited sagittal hip mobility.

CLINICAL RELEVANCE

Patients with symptomatic femoroacetabular impingement showed a higher pelvic incidence and, combined with a cam deformity and varus neck, can perhaps alter the musculature of their iliopsoas, contributing to a reduced sagittal ROM. With an early and accurate clinical diagnosis, athletes could benefit from a muscle training strategy to protect their hips.

Protocol for a multi-centre randomised controlled trial comparing arthroscopic hip surgery to physiotherapy-led care for femoroacetabular impingement (FAI): the Australian FASHIoN trial

BACKGROUND

Femoroacetabular impingement syndrome (FAI), a hip disorder affecting active young adults, is believed to be a leading cause of hip osteoarthritis (OA). Current management approaches for FAI include arthroscopic hip surgery and physiotherapy-led non-surgical care; however, there is a paucity of clinical trial evidence comparing these approaches. In particular, it is unknown whether these management approaches modify the future risk of developing hip OA. The primary objective of this randomised controlled trial is to determine if participants with FAI who undergo hip arthroscopy have greater improvements in hip cartilage health, as demonstrated by changes in delayed gadolinium-enhanced magnetic resonance imaging (MRI) of cartilage (dGEMRIC) index between baseline and 12 months, compared to those who undergo physiotherapy-led non-surgical management.

METHODS

This is a pragmatic, multi-centre, two-arm superiority randomised controlled trial comparing hip arthroscopy to physiotherapy-led management for FAI. A total of 140 participants with FAI will be recruited from the clinics of participating orthopaedic surgeons, and randomly allocated to receive either surgery or physiotherapy-led non-surgical care. The surgical intervention involves arthroscopic FAI surgery from one of eight orthopaedic surgeons specialising in this field, located in three different Australian cities. The physiotherapy-led non-surgical management is an individualised physiotherapy program, named Personalised Hip Therapy (PHT), developed by a panel to represent the best non-operative care for FAI. It entails at least six individual physiotherapy sessions over 12 weeks, and up to ten sessions over six months, provided by experienced musculoskeletal physiotherapists trained to deliver the PHT program. The primary outcome measure is the change in dGEMRIC score of a ROI containing both acetabular and femoral head cartilages at the chondrolabral transitional zone of the mid-sagittal plane between baseline and 12 months. Secondary outcomes include patient-reported outcomes and several structural and biomechanical measures relevant to the pathogenesis of FAI and development of hip OA. Interventions will be compared by intention-to-treat analysis.

DISCUSSION

The findings will help determine whether hip arthroscopy or an individualised physiotherapy program is superior for the management of FAI, including for the prevention of hip OA.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry reference: ACTRN12615001177549 . Trial registered 2/11/2015 (retrospectively registered).

The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement

The 2016 Warwick Agreement on femoroacetabular impingement (FAI) syndrome was convened to build an international, multidisciplinary consensus on the diagnosis and management of patients with FAI syndrome. 22 panel members and 1 patient from 9 countries and 5 different specialties participated in a 1-day consensus meeting on 29 June 2016. Prior to the meeting, 6 questions were agreed on, and recent relevant systematic reviews and seminal literature were circulated. Panel members gave presentations on the topics of the agreed questions at Sports Hip 2016, an open meeting held in the UK on 27-29 June. Presentations were followed by open discussion. At the 1-day consensus meeting, panel members developed statements in response to each question through open discussion; members then scored their level of agreement with each response on a scale of 0-10. Substantial agreement (range 9.5-10) was reached for each of the 6 consensus questions, and the associated terminology was agreed on. The term 'femoroacetabular impingement syndrome' was introduced to reflect the central role of patients' symptoms in the disorder. To reach a diagnosis, patients should have appropriate symptoms, positive clinical signs and imaging findings. Suitable treatments are conservative care, rehabilitation, and arthroscopic or open surgery. Current understanding of prognosis and topics for future research were discussed. The 2016 Warwick Agreement on FAI syndrome is an international multidisciplinary agreement on the diagnosis, treatment principles and key terminology relating to FAI syndrome.Author note The Warwick Agreement on femoroacetabular impingement syndrome has been endorsed by the following 25 clinical societies: American Medical Society for Sports Medicine (AMSSM), Association of Chartered Physiotherapists in Sports and Exercise Medicine (ACPSEM), Australasian College of Sports and Exercise Physicians (ACSEP), Austian Sports Physiotherapists, British Association of Sports and Exercise Medicine (BASEM), British Association of Sport Rehabilitators and Trainers (BASRaT), Canadian Academy of Sport and Exercise Medicine (CASEM), Danish Society of Sports Physical Therapy (DSSF), European College of Sports and Exercise Physicians (ECOSEP), European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA), Finnish Sports Physiotherapist Association (SUFT), German-Austrian-Swiss Society for Orthopaedic Traumatologic Sports Medicine (GOTS), International Federation of Sports Physical Therapy (IFSPT), International Society for Hip Arthroscopy (ISHA), Groupo di Interesse Specialistico dell'A.I.F.I., Norwegian Association of Sports Medicine and Physical Activity (NIMF), Norwegian Sports Physiotherapy Association (FFI), Society of Sports Therapists (SST), South African Sports Medicine Association (SASMA), Sports Medicine Australia (SMA), Sports Doctors Australia (SDrA), Sports Physiotherapy New Zealand (SPNZ), Swedish Society of Exercise and Sports Medicine (SFAIM), Swiss Society of Sports Medicine (SGMS/SGSM), Swiss Sports Physiotherapy Association (SSPA).

Personalised Hip Therapy: development of a non-operative protocol to treat femoroacetabular impingement syndrome in the FASHIoN randomised controlled trial

INTRODUCTION

Femoroacetabular impingement (FAI) syndrome is increasingly recognised as a cause of hip pain. As part of the design of a randomised controlled trial (RCT) of arthroscopic surgery for FAI syndrome, we developed a protocol for non-operative care and evaluated its feasibility.

METHODS

In phase one, we developed a protocol for non-operative care for FAI in the UK National Health Service (NHS), through a process of systematic review and consensus gathering. In phase two, the protocol was tested in an internal pilot RCT for protocol adherence and adverse events.

RESULTS

The final protocol, called Personalised Hip Therapy (PHT), consists of four core components led by physiotherapists: detailed patient assessment, education and advice, help with pain relief and an exercise-based programme that is individualised, supervised and progressed over time. PHT is delivered over 12-26 weeks in 6-10 physiotherapist-patient contacts, supplemented by a home exercise programme. In the pilot RCT, 42 patients were recruited and 21 randomised to PHT. Review of treatment case report forms, completed by physiotherapists, showed that 13 patients (62%) received treatment that had closely followed the PHT protocol. 13 patients reported some muscle soreness at 6 weeks, but there were no serious adverse events.

CONCLUSION

PHT provides a structure for the non-operative care of FAI and offers guidance to clinicians and researchers in an evolving area with limited evidence. PHT was deliverable within the National Health Service, is safe, and now forms the comparator to arthroscopic surgery in the UK FASHIoN trial (ISRCTN64081839).

TRIAL REGISTRATION NUMBER

ISRCTN 09754699.

Hip arthroscopy results in improved patient reported outcomes compared to non-operative management of waitlisted patients

Hip arthroscopy (HA) is an established treatment option to address intra-articular pathology of the hip. However, some clinicians encourage non-operative management (NOM). Non-operative management may include active measures such as physiotherapy and intra-articular steroid injections, or NOM may involve so called watchful waiting with no active intervention. These approaches, along with surgery have been detailed recently in the Warwick Agreement, a Consensus Statement regarding diagnosis and treatment of Femoroacetabular Impingement Syndrome The aim of this study is to compare the change in clinical outcome scores of waitlisted patients with intra-articular hip pathology who receive no active treatment with matched controls that have undergone HA. Patients less than 60 years of age were identified from a HA waiting list in a single hospital in the Australian public hospital system. Patient reported outcomes (PRO) were collected whilst patients waited for surgery. During this waiting period no specific treatment was offered. A separate group of patients who had previously undergone HA were matched based on age, sex, body mass index and baseline non-arthritic hip scores (NAHS). The groups were compared using the NAHS as the primary outcome measures. Modified Harris Hip Scores were also collected and compared. Thirty-six patients were included in each group, with a mean follow up of 19 months (12–36). There were no significant differences in age, sex, BMI and NAHS between groups at baseline. At final follow up, mean NAHS scores after HA were significantly higher than scores after NOM, 82.1 (36.4–100.0) versus 48.9 (11.3–78.8), respectively (P < 0.001) with a large effect size for mean change in scores between groups (d = 1.77, 95% CI 1.21–2.30). Mean mHHS after HA were significantly higher than scores after NOM, 84.3 (15.4–100.0) versus 48.1 (21.0–66.0) respectively (P < 0.001), with a large effect size for mean change in scores between groups (d = 1.92, 95% CI 1.34–2.46). HA may lead to significant improvements in PRO when compared to non-operative management of waitlisted patients with intra-articular pathology of the hip at 18 months follow-up.

The feasibility of conducting a randomised controlled trial comparing arthroscopic hip surgery to conservative care for patients with femoroacetabular impingement syndrome: the FASHIoN feasibility study

To determine whether it was feasible to perform a randomized controlled trial (RCT) comparing arthroscopic hip surgery to conservative care in patients with femoroacetabular impingement (FAI). This study had two phases: a pre-pilot and pilot RCT. In the pre-pilot, we conducted interviews with clinicians who treated FAI and with FAI patients to determine their views about an RCT. We developed protocols for operative and conservative care. In the pilot RCT, we determined the rates of patient eligibility, recruitment and retention, to investigate the feasibility of the protocol and we established methods to assess treatment fidelity. In the pre-pilot phase, 32 clinicians were interviewed, of which 26 reported theoretical equipoise, but in example scenarios 7 failed to show clinical equipoise. Eighteen patients treated for FAI were also interviewed, the majority of whom felt that surgery and conservative care were acceptable treatments. Surgery was viewed by patients as a 'definitive solution'. Patients were motivated to participate in research but were uncomfortable about randomization. Randomization was more acceptable if the alternative was available at the end of the trial. In the pilot phase, 151 patients were assessed for eligibility. Sixty were eligible and invited to take part in the pilot RCT; 42 consented to randomization. Follow-up was 100% at 12 months. Assessments of treatment fidelity were satisfactory. An RCT to compare arthroscopic hip surgery with conservative care in patients with FAI is challenging but feasible. Recruitment has started for a full RCT.

Protocol for a multicentre, parallel-arm, 12-month, randomised, controlled trial of arthroscopic surgery versus conservative care for femoroacetabular impingement syndrome (FASHIoN)

INTRODUCTION

Femoroacetabular impingement (FAI) syndrome is a recognised cause of young adult hip pain. There has been a large increase in the number of patients undergoing arthroscopic surgery for FAI; however, a recent Cochrane review highlighted that there are no randomised controlled trials (RCTs) evaluating treatment effectiveness. We aim to compare the clinical and cost-effectiveness of arthroscopic surgery versus best conservative care for patients with FAI syndrome.

METHODS

We will conduct a multicentre, pragmatic, assessor-blinded, two parallel arm, RCT comparing arthroscopic surgery to physiotherapy-led best conservative care. 24 hospitals treating NHS patients will recruit 344 patients over a 26-month recruitment period. Symptomatic adults with radiographic signs of FAI morphology who are considered suitable for arthroscopic surgery by their surgeon will be eligible. Patients will be excluded if they have radiographic evidence of osteoarthritis, previous significant hip pathology or previous shape changing surgery. Participants will be allocated in a ratio of 1:1 to receive arthroscopic surgery or conservative care. Recruitment will be monitored and supported by qualitative intervention to optimise informed consent and recruitment. The primary outcome will be pain and function assessed by the international hip outcome tool 33 (iHOT-33) measured 1-year following randomisation. Secondary outcomes include general health (short form 12), quality of life (EQ5D-5L) and patient satisfaction. The primary analysis will compare change in pain and function (iHOT-33) at 12 months between the treatment groups, on an intention-to-treat basis, presented as the mean difference between the trial groups with 95% CIs. The study is funded by the Health Technology Assessment Programme (13/103/02).

ETHICS AND DISSEMINATION

Ethical approval is granted by the Edgbaston Research Ethics committee (14/WM/0124). The results will be disseminated through open access peer-reviewed publications, including Health Technology Assessment, and presented at relevant conferences.

TRIAL REGISTRATION NUMBER

ISRCTN64081839; Pre-results.

A new simple six-step model to promote recruitment to RCTs was developed and successfully implemented

OBJECTIVES

How a randomized controlled trial (RCT) is explained to patients is a key determinant of recruitment to that trial. This study developed and implemented a simple six-step model to fully inform patients and to support them in deciding whether to take part or not.

STUDY DESIGN AND SETTING

Ninety-two consultations with 60 new patients were recorded and analyzed during a pilot RCT comparing surgical and nonsurgical interventions for hip impingement. Recordings were analyzed using techniques of thematic analysis and focused conversation analysis.

RESULTS

Early findings supported the development of a simple six-step model to provide a framework for good recruitment practice. Model steps are as follows: (1) explain the condition, (2) reassure patients about receiving treatment, (3) establish uncertainty, (4) explain the study purpose, (5) give a balanced view of treatments, and (6) Explain study procedures. There are also two elements throughout the consultation: (1) responding to patients' concerns and (2) showing confidence. The pilot study was successful, with 70% (n = 60) of patients approached across nine centers agreeing to take part in the RCT, so that the full-scale trial was funded.

CONCLUSION

The six-step model provides a promising framework for successful recruitment to RCTs. Further testing of the model is now required.