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. 2022 Feb;26(16):1–236. doi: 10.3310/FXII0508

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

Damian R Griffin, Edward J Dickenson, Felix Achana, James Griffin, Joanna Smith, Peter Dh Wall, Alba Realpe, Nick Parsons, Rachel Hobson, Jeremy Fry, Marcus Jepson, Stavros Petrou, Charles Hutchinson, Nadine Foster, Jenny Donovan
PMCID: PMC8919110  PMID: 35229713

Abstract

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.

Plain language summary

In some people, the ball and the socket of the hip joint develop so that they do not fit together properly. This is called hip impingement, and is an important cause of hip and groin pain in young and middle-aged adults. Treatments include physiotherapy and surgery. Physiotherapy typically involves a programme of 6–10 outpatient consultations that aim to strengthen the muscles around the hip: we called this personalised hip therapy. Surgery can be carried out by a keyhole operation, called a hip arthroscopy, which aims to reshape the hip to prevent impingement. Surgery is normally followed by some physiotherapy. We performed a research study to compare the results of hip arthroscopy and personalised hip therapy in people with hip impingement. A total of 348 people with painful hip impingement in 23 hospitals in the UK agreed to take part. About half were treated with hip arthroscopy and half with personalised hip therapy. We used questionnaires to ask participants about pain in the hip and their ability to do everyday things at 6 months and 1 year after entering the study. At 2 and 3 years, we asked if patients required any additional treatments. We found that both groups improved, but those treated with hip arthroscopy improved a moderate amount more than those treated with personalised hip therapy. However, these improvements were not cost-effective compared with personalised hip therapy at 1 year. We need to see whether or not this difference continues after several years, but the results, so far, suggest that if a person has painful hip impingement, then hip arthroscopy offers greater improvements than personalised hip therapy.

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References

  1. Griffin DR, Dickenson EJ, Wall PD, Donovan JL, Foster NE, Hutchinson CE, et al. Protocol for a multi-centre, parallel-arm, 12-month, randomised controlled trial of arthroscopic surgery versus conservative care for femoroacetabular impingement syndrome (FASHIoN). BMJ Open 2016;6:e012453. https://doi.org/10.1136/bmjopen-2016-012453 doi: 10.1136/bmjopen-2016-012453. [DOI] [PMC free article] [PubMed]
  2. Griffin DR, Dickenson EJ, Wall PDH, Realpe A, Adams A, Parsons N, et al. 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. J Hip Preserv Surg 2016;3:304–11. https://doi.org/10.1093/jhps/hnw026 doi: 10.1093/jhps/hnw026. [DOI] [PMC free article] [PubMed]
  3. Griffin D, Wall P, Realpe A, Adams A, Parsons N, Hobson R, et al. UK FASHIoN: feasibility study of a randomised controlled trial of arthroscopic surgery for hip impingement compared with best conservative care. Health Technol Assess 2016;20(32). https://doi.org/10.3310/hta20320 doi: 10.3310/hta20320. [DOI] [PMC free article] [PubMed]
  4. Wall PDH. Treatments for Femoroacetabular Impingement. PhD thesis. Coventry: University of Warwick; 2013.
  5. Wall PD, Dickenson EJ, Robinson D, Hughes I, Realpe A, Hobson R, et al. Personalised hip therapy: development of a non-operative protocol to treat femoroacetabular impingement syndrome in the FASHIoN randomised controlled trial. Br J Sports Med 2016;50:1217–23. https://doi.org/10.1136/bjsports-2016-096368 doi: 10.1136/bjsports-2016-096368. [DOI] [PMC free article] [PubMed]
  6. Griffin DR, Dickenson EJ, Wall PDH, Achana F, Donovan JL, Griffin J, et al. Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): a multicentre randomised controlled trial. Lancet 2018;391:2225–35. https://doi.org/10.1016/S0140-6736(18)31202-9 doi: 10.1016/S0140-6736(18)31202-9. [DOI] [PMC free article] [PubMed]
  7. Ganz R, Parvizi J, Beck M, Leunig M, Nötzli H, Siebenrock KA. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res 2003;417:112–20. https://doi.org/10.1097/01.blo.0000096804.78689.c2 doi: 10.1097/01.blo.0000096804.78689.c2. [DOI] [PubMed]
  8. Lavigne M, Parvizi J, Beck M, Siebenrock KA, Ganz R, Leunig M. Anterior femoroacetabular impingement: part I. Techniques of joint preserving surgery. Clin Orthop Relat Res 2004;418:61–6. https://doi.org/10.1097/00003086-200401000-00011 doi: 10.1097/00003086-200401000-00011. [DOI] [PubMed]
  9. Ganz R, Leunig M, Leunig-Ganz K, Harris WH. The etiology of osteoarthritis of the hip: an integrated mechanical concept. Clin Orthop Relat Res 2008;466:264–72. https://doi.org/10.1007/s11999-007-0060-z doi: 10.1007/s11999-007-0060-z. [DOI] [PMC free article] [PubMed]
  10. Hack K, Di Primio G, Rakhra K, Beaulé PE. Prevalence of cam-type femoroacetabular impingement morphology in asymptomatic volunteers. J Bone Joint Surg Am 2010;92:2436–44. https://doi.org/10.2106/JBJS.J.01280 doi: 10.2106/JBJS.J.01280. [DOI] [PubMed]
  11. Gosvig KK, Jacobsen S, Sonne-Holm S, Gebuhr P. The prevalence of cam-type deformity of the hip joint: a survey of 4151 subjects of the Copenhagen osteoarthritis study. Acta Radiol 2008;49:436–41. https://doi.org/10.1080/02841850801935567 doi: 10.1080/02841850801935567. [DOI] [PubMed]
  12. Montgomery SR, Ngo SS, Hobson T, Nguyen S, Alluri R, Wang JC, Hame SL. Trends and demographics in hip arthroscopy in the United States. Arthroscopy 2013;29:661–5. https://doi.org/10.1016/j.arthro.2012.11.005 doi: 10.1016/j.arthro.2012.11.005. [DOI] [PubMed]
  13. Botser IB, Smith TW, Nasser R, Domb BG. Open surgical dislocation versus arthroscopy for femoroacetabular impingement: a comparison of clinical outcomes. Arthroscopy 2011;27:270–8. https://doi.org/10.1016/j.arthro.2010.11.008 doi: 10.1016/j.arthro.2010.11.008. [DOI] [PubMed]
  14. Matsuda DK, Carlisle JC, Arthurs SC, Wierks CH, Philippon MJ. Comparative systematic review of the open dislocation, mini-open, and arthroscopic surgeries for femoroacetabular impingement. Arthroscopy 2011;27:252–69. https://doi.org/10.1016/j.arthro.2010.09.011 doi: 10.1016/j.arthro.2010.09.011. [DOI] [PubMed]
  15. National Institute for Health and Care Excellence (NICE). Arthroscopic Femoro-Acetabular Surgery for Hip Impingement Syndrome. Interventional Procedures Guidance [IPG408]. London: NICE; 2011.
  16. Wall PD, Brown JS, Parsons N, Buchbinder R, Costa ML, Griffin D. Surgery for treating hip impingement (femoroacetabular impingement). Cochrane Database Syst Rev 2014;9:CD010796. https://doi.org/10.1002/14651858.CD010796.pub2 doi: 10.1002/14651858.CD010796.pub2. [DOI] [PMC free article] [PubMed]
  17. Britton A, McKee M, Black N, McPherson K, Sanderson C, Bain C. Choosing between randomised and non-randomised studies: a systematic review. Health Technol Assess 1997;2(13). https://doi.org/10.3310/hta2130 doi: 10.3310/hta2130. [DOI] [PubMed]
  18. Ross S, Grant A, Counsell C, Gillespie W, Russell I, Prescott R. Barriers to participation in randomised controlled trials: a systematic review. J Clin Epidemiol 1999;52:1143–56. https://doi.org/10.1016/S0895-4356(99)00141-9 doi: 10.1016/S0895-4356(99)00141-9. [DOI] [PubMed]
  19. Ergina PL, Cook JA, Blazeby JM, Boutron I, Clavien PA, Reeves BC, et al. Challenges in evaluating surgical innovation. Lancet 2009;374:1097–104. https://doi.org/10.1016/S0140-6736(09)61086-2 doi: 10.1016/S0140-6736(09)61086-2. [DOI] [PMC free article] [PubMed]
  20. Wall PD, Fernandez M, Griffin DR, Foster NE. Nonoperative treatment for femoroacetabular impingement: a systematic review of the literature. PM R 2013;5:418–26. https://doi.org/10.1016/j.pmrj.2013.02.005 doi: 10.1016/j.pmrj.2013.02.005. [DOI] [PubMed]
  21. NHS Berkshire West Clinical Commissioning Group. Thames Valley Priorities Committee Commissioning Policy Statement: Policy No. TVPC33 – Surgical Treatment Of Femoro Acetabular Hip Impingement (FAI) (Open or Arthroscopic). London: NHS Berkshire West Clinical Commissioning Group; 2018.
  22. Fransen M, McConnell S. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev 2008;4:CD004376. https://doi.org/10.1002/14651858.CD004376.pub2 doi: 10.1002/14651858.CD004376.pub2. [DOI] [PubMed]
  23. Hayden JA, van Tulder MW, Malmivaara AV, Koes BW. Meta-analysis: exercise therapy for nonspecific low back pain. Ann Intern Med 2005;142:765–75. https://doi.org/10.7326/0003-4819-142-9-200505030-00013 doi: 10.7326/0003-4819-142-9-200505030-00013. [DOI] [PubMed]
  24. Chartered Society of Physiotherapy. Frontline Magazine. URL: www.csp.org.uk/news/frontline-magazine (accessed 23 September 2021).
  25. Palmer AJ, Thomas GE, Pollard TC, Rombach I, Taylor A, Arden N, et al. The feasibility of performing a randomised controlled trial for femoroacetabular impingement surgery. Bone Joint Res 2013;2:33–40. https://doi.org/10.1302/2046-3758.22.2000137 doi: 10.1302/2046-3758.22.2000137. [DOI] [PMC free article] [PubMed]
  26. Donovan JL, Lane JA, Peters TJ, Brindle L, Salter E, Gillatt D, et al. Development of a complex intervention improved randomization and informed consent in a randomized controlled trial. J Clin Epidemiol 2009;62:29–36. https://doi.org/10.1016/j.jclinepi.2008.02.010 doi: 10.1016/j.jclinepi.2008.02.010. [DOI] [PubMed]
  27. Wade J, Donovan JL, Lane JA, Neal DE, Hamdy FC. It’s not just what you say, it’s also how you say it: opening the ‘black box’ of informed consent appointments in randomised controlled trials. Soc Sci Med 2009;68:2018–28. https://doi.org/10.1016/j.socscimed.2009.02.023 doi: 10.1016/j.socscimed.2009.02.023. [DOI] [PubMed]
  28. Realpe A, Adams A, Wall P, Griffin D, Donovan JL. A new simple six-step model to promote recruitment to RCTs was developed and successfully implemented. J Clin Epidemiol 2016;76:166–74. https://doi.org/10.1016/j.jclinepi.2016.02.002 doi: 10.1016/j.jclinepi.2016.02.002. [DOI] [PMC free article] [PubMed]
  29. Quintana JM, Escobar A, Bilbao A, Arostegui I, Lafuente I, Vidaurreta I. Responsiveness and clinically important differences for the WOMAC and SF-36 after hip joint replacement. Osteoarthritis Cartilage 2005;13:1076–83. https://doi.org/10.1016/j.joca.2005.06.012 doi: 10.1016/j.joca.2005.06.012. [DOI] [PubMed]
  30. Wamper KE, Sierevelt IN, Poolman RW, Bhandari M, Haverkamp D. The Harris hip score: do ceiling effects limit its usefulness in orthopedics? A systematic review. Acta Orthop 2010;81:703–7. https://doi.org/10.3109/17453674.2010.537808 doi: 10.3109/17453674.2010.537808. [DOI] [PMC free article] [PubMed]
  31. Mohtadi NG, Griffin DR, Pedersen ME, Chan D, Safran MR, Parsons N, et al. The development and validation of a self-administered quality-of-life outcome measure for young, active patients with symptomatic hip disease: the International Hip Outcome Tool (iHOT-33). Arthroscopy 2012;28:595–605. https://doi.org/10.1016/j.arthro.2012.03.013 doi: 10.1016/j.arthro.2012.03.013. [DOI] [PubMed]
  32. Christensen CP, Althausen PL, Mittleman MA, Lee J, McCarthy JC. The nonarthritic hip score: reliable and validated. Clin Orthop Relat Res 2003;406:75–83. https://doi.org/10.1097/00003086-200301000-00013 doi: 10.1097/00003086-200301000-00013. [DOI] [PubMed]
  33. Phillips L, Mohtadi N, Chan D. The responsiveness and minimal clinically important difference (MCID) of the MAHORN Quality of Life Tool. Arthroscopy 2011;27:e23. https://doi.org/10.1016/j.arthro.2010.11.053 doi: 10.1016/j.arthro.2010.11.053. [DOI]
  34. Harris-Hayes M, McDonough CM, Leunig M, Lee CB, Callaghan JJ, Roos EM. Clinical outcomes assessment in clinical trials to assess treatment of femoroacetabular impingement: use of patient-reported outcome measures. J Am Acad Orthop Surg 2013;21:39–46. https://doi.org/10.5435/JAAOS-21-07-S39 doi: 10.5435/JAAOS-21-07-S39. [DOI] [PMC free article] [PubMed]
  35. World Medical Association. Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA 2013;310:2191–4. https://doi.org/10.1001/jama.2013.281053 doi: 10.1001/jama.2013.281053. [DOI] [PubMed]
  36. Nötzli HP, Wyss TF, Stoecklin CH, Schmid MR, Treiber K, Hodler J. The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement. J Bone Joint Surg Br 2002;84:556–60. https://doi.org/10.1302/0301-620x.84b4.12014 doi: 10.1302/0301-620x.84b4.12014. [DOI] [PubMed]
  37. Nepple JJ, Prather H, Trousdale RT, Clohisy JC, Beaulé PE, Glyn-Jones S, et al. Diagnostic imaging of femoroacetabular impingement. J Am Acad Orthop Surg 2013;21:S20–6. https://doi.org/10.5435/JAAOS-21-07-S20 doi: 10.5435/JAAOS-21-07-S20. [DOI] [PubMed]
  38. Tönnis D, Heinecke A. Current concepts review – acetabular and femoral anteversion: relationship with osteoarthritis of the hip. J Bone Joint Surg Am 1999;81:1747–70. https://doi.org/10.2106/00004623-199912000-00014 doi: 10.2106/00004623-199912000-00014. [DOI] [PubMed]
  39. Philippon MJ, Briggs KK, Yen YM, Kuppersmith DA. Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: minimum two-year follow-up. J Bone Joint Surg Br 2009;91:16–23. https://doi.org/10.1302/0301-620X.91B1.21329 doi: 10.1302/0301-620X.91B1.21329. [DOI] [PubMed]
  40. Donovan JL, Paramasivan S, de Salis I, Toerien M. Clear obstacles and hidden challenges: understanding recruiter perspectives in six pragmatic randomised controlled trials. Trials 2014;15:5. https://doi.org/10.1186/1745-6215-15-5 doi: 10.1186/1745-6215-15-5. [DOI] [PMC free article] [PubMed]
  41. Emara K, Samir W, Motasem el H, Ghafar KA. Conservative treatment for mild femoroacetabular impingement. J Orthop Surg 2011;19:41–5. https://doi.org/10.1177/230949901101900109 doi: 10.1177/230949901101900109. [DOI] [PubMed]
  42. Walters SJ, Brazier JE. Comparison of the minimally important difference for two health state utility measures: EQ-5D and SF-6D. Qual Life Res 2005;14:1523–32. https://doi.org/10.1007/s11136-004-7713-0 doi: 10.1007/s11136-004-7713-0. [DOI] [PubMed]
  43. Oppe M, Devlin NJ, van Hout B, Krabbe PF, de Charro F. A program of methodological research to arrive at the new international EQ-5D-5L valuation protocol. Value Health 2014;17:445–53. https://doi.org/10.1016/j.jval.2014.04.002 doi: 10.1016/j.jval.2014.04.002. [DOI] [PubMed]
  44. Ostendorf M, van Stel HF, Buskens E, Schrijvers AJ, Marting LN, Verbout AJ, Dhert WJ. Patient-reported outcome in total hip replacement. A comparison of five instruments of health status. J Bone Joint Surg Br 2004;86:801–8. https://doi.org/10.1302/0301-620x.86b6.14950 doi: 10.1302/0301-620x.86b6.14950. [DOI] [PubMed]
  45. Jenkinson C, Layte R. Development and testing of the UK SF-12. J Health Serv Res Policy 1997;2:14–18. https://doi.org/10.1177/135581969700200105 doi: 10.1177/135581969700200105. [DOI] [PubMed]
  46. Brazier JE, Roberts J. The estimation of a preference-based measure of health from the SF-12. Med Care 2004;42:851–9. https://doi.org/10.1097/01.mlr.0000135827.18610.0d doi: 10.1097/01.mlr.0000135827.18610.0d. [DOI] [PubMed]
  47. Foster NE, Thomas E, Barlas P, Hill JC, Young J, Mason E, Hay EM. Acupuncture as an adjunct to exercise based physiotherapy for osteoarthritis of the knee: randomised controlled trial. BMJ 2007;335:436. https://doi.org/10.1136/bmj.39280.509803.BE doi: 10.1136/bmj.39280.509803.BE. [DOI] [PMC free article] [PubMed]
  48. van den Brink M, van den Hout W, Stiggelbout A, Kievit J, van de Velde C. Self-reports of Health Care Utilization: Can a Questionnaire Replace a Diary. International Society for Technology Assessment in Health Care (ISTAHC), 16th Annual Meeting, The Hague, 18–21 June 2000. doi: 10.1017/s0266462305050397. [DOI] [PubMed]
  49. Amstutz H, Thomas B, Jinnah R, Kim W, Grogan T, Yale C. Treatment of primary osteoarthritis of the hip. A comparison of total joint and surface replacement arthroplasty. J Bone Joint Surg Am 1984;66:228–41. https://doi.org/10.2106/00004623-198466020-00010 doi: 10.2106/00004623-198466020-00010. [DOI] [PubMed]
  50. Ng VY, Arora N, Best TM, Pan X, Ellis TJ. Efficacy of surgery for femoroacetabular impingement: a systematic review. Am J Sports Med 2010;38:2337–45. https://doi.org/10.1177/0363546510365530 doi: 10.1177/0363546510365530. [DOI] [PubMed]
  51. Husereau D, Drummond M, Petrou S, Carswell C, Moher D, Greenberg D, et al. Consolidated Health Economic Evaluation Reporting Standards (CHEERS) – explanation and elaboration: a report of the ISPOR Health Economic Evaluation Publication Guidelines Good Reporting Practices Task Force. Value Health 2013;16:231–50. https://doi.org/10.1016/j.jval.2013.02.002 doi: 10.1016/j.jval.2013.02.002. [DOI] [PubMed]
  52. Curtis L. Unit Costs of Health and Social Care 2016. Canterbury: PSSRU, University of Kent; 2016.
  53. NHS Digital. Prescription Cost Analysis, England – 2016. URL: www.content.digital.nhs.uk/catalogue/PUB23631 (accessed April 2017).
  54. ISD Scotland. Theatres: Costs – Detailed Tables. URL: www.isdscotland.org/Health-Topics/Finance/Costs/Detailed-Tables/Theatres.asp (accessed April 2017).
  55. NHS Scotland. Scottish Health Service Costs Book User Manual June 2016 Version: 3.0. Edinburgh: NHS Scotland; 2016.
  56. NHS Supply Chain. NHS Supply Chain Catalogue 2016. URL: www.supplychain.nhs.uk/clinical-and-consumables/ (accessed April 2017).
  57. Department of Health and Social Care. National Reference Costs 2014 to 2015. URL: www.gov.uk/government/publications/nhs-reference-costs-2014-to-2015 (accessed 4 October 2021).
  58. Joint Formulary Committee. British National Formulary. 71 ed. London: BMJ Group and Pharmaceutical Press; 2016.
  59. EuroQol Group. EuroQol – a new facility for the measurement of health-related quality of life. Health Policy 1990;16:199–208. https://doi.org/10.1016/0168-8510(90)90421-9 doi: 10.1016/0168-8510(90)90421-9. [DOI] [PubMed]
  60. Herdman M, Gudex C, Lloyd A, Janssen M, Kind P, Parkin D, et al. Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Qual Life Res 2011;20:1727–36. https://doi.org/10.1007/s11136-011-9903-x doi: 10.1007/s11136-011-9903-x. [DOI] [PMC free article] [PubMed]
  61. Tarlov AR, Ware JE, Greenfield S, Nelson EC, Perrin E, Zubkoff M. The Medical Outcomes Study. An application of methods for monitoring the results of medical care. JAMA 1989;262:925–30. https://doi.org/10.1001/jama.262.7.925 doi: 10.1001/jama.262.7.925. [DOI] [PubMed]
  62. Kind P, Dolan P, Gudex C, Williams A. Variations in population health status: results from a United Kingdom national questionnaire survey. BMJ 1998;316:736–41. https://doi.org/10.1136/bmj.316.7133.736 doi: 10.1136/bmj.316.7133.736. [DOI] [PMC free article] [PubMed]
  63. van Hout B, Janssen MF, Feng YS, Kohlmann T, Busschbach J, Golicki D, et al. Interim scoring for the EQ-5D-5L: mapping the EQ-5D-5L to EQ-5D-3L value sets. Value Health 2012;15:708–15. https://doi.org/10.1016/j.jval.2012.02.008 doi: 10.1016/j.jval.2012.02.008. [DOI] [PubMed]
  64. Devlin NJ, Shah KK, Feng Y, Mulhern B, van Hout B. Valuing health-related quality of life: an EQ-5D-5L value set for England. Health Econ 2018;27:7–22. https://doi.org/10.1002/hec.3564 doi: 10.1002/hec.3564. [DOI] [PMC free article] [PubMed]
  65. Ramsey SD, Willke RJ, Glick H, Reed SD, Augustovski F, Jonsson B, et al. Cost-effectiveness analysis alongside clinical trials II – an ISPOR Good Research Practices Task Force report. Value Health 2015;18:161–72. https://doi.org/10.1016/j.jval.2015.02.001 doi: 10.1016/j.jval.2015.02.001. [DOI] [PubMed]
  66. Faria R, Gomes M, Epstein D, White IR. A guide to handling missing data in cost-effectiveness analysis conducted within randomised controlled trials. PharmacoEconomics 2014;32:1157–70. https://doi.org/10.1007/s40273-014-0193-3 doi: 10.1007/s40273-014-0193-3. [DOI] [PMC free article] [PubMed]
  67. National Institute of Health and Care Excellence (NICE). Guide to the Methods of Technology Appraisal 2013. London: NICE; 2013. [PubMed]
  68. Claxton K, Martin S, Soares M, Rice N, Spackman E, Hinde S, et al. Methods for the estimation of the National Institute for Health and Care Excellence cost-effectiveness threshold. Health Technol Assess 2015;19(14). https://doi.org/10.3310/hta19140 doi: 10.3310/hta19140. [DOI] [PMC free article] [PubMed]
  69. Glick HA, Doshi JA, Sonnad SS, Polsky D. Economic Evaluation in Clinical Trials. Oxford: Oxford University Press; 2014. https://doi.org/10.1093/med/9780199685028.001.0001 doi: 10.1093/med/9780199685028.001.0001. [DOI]
  70. Sculpher MJ, Claxton K, Drummond M, McCabe C. Whither trial based economic evaluation for health care decision making? Health Econ 2006;15:677–87. doi: 10.1002/hec.1093. [DOI] [PubMed]
  71. Donovan JL, Rooshenas L, Jepson M, Elliott D, Wade J, Avery K, et al. Optimising recruitment and informed consent in randomised controlled trials: the development and implementation of the Quintet Recruitment Intervention (QRI). Trials 2016;17:283. https://doi.org/10.1186/s13063-016-1391-4 doi: 10.1186/s13063-016-1391-4. [DOI] [PMC free article] [PubMed]
  72. de Salis I, Tomlin Z, Toerien M, Donovan J. Qualitative research to improve RCT recruitment: issues arising in establishing research collaborations. Contemp Clin Trials 2008;29:663–70. https://doi.org/10.1016/j.cct.2008.03.003 doi: 10.1016/j.cct.2008.03.003. [DOI] [PubMed]
  73. Mills N, Donovan JL, Wade J, Hamdy FC, Neal DE, Lane JA. Exploring treatment preferences facilitated recruitment to randomised controlled trials. J Clin Epidemiol 2011;64:1127–36. https://doi.org/10.1016/j.jclinepi.2010.12.017 doi: 10.1016/j.jclinepi.2010.12.017. [DOI] [PMC free article] [PubMed]
  74. Paramasivan S, Huddart R, Hall E, Lewis R, Birtle A, Donovan JL. Key issues in recruitment to randomised controlled trials with very different interventions: a qualitative investigation of recruitment to the SPARE trial (CRUK/07/011). Trials 2011;12:78. https://doi.org/10.1186/1745-6215-12-78 doi: 10.1186/1745-6215-12-78. [DOI] [PMC free article] [PubMed]
  75. Paramasivan S, Strong S, Wilson C, Campbell B, Blazeby JM, Donovan JL. A simple technique to identify key recruitment issues in randomised controlled trials: Q-QAT – Quanti-Qualitative Appointment Timing. Trials 2015;16:88. https://doi.org/10.1186/s13063-015-0617-1 doi: 10.1186/s13063-015-0617-1. [DOI] [PMC free article] [PubMed]
  76. Strong S, Paramasivan S, Mills N, Wilson C, Donovan JL, Blazeby JM. ‘The trial is owned by the team, not by an individual’: a qualitative study exploring the role of teamwork in recruitment to randomised controlled trials in surgical oncology. Trials 2016;17:212. https://doi.org/10.1186/s13063-016-1341-1 doi: 10.1186/s13063-016-1341-1. [DOI] [PMC free article] [PubMed]
  77. Department of Health and Social Care. National Reference Costs 2015 to 2016. URL: www.gov.uk/government/publications/nhs-reference-costs-2015-to-2016 (accessed April 2017).
  78. Mansell NS, Rhon DI, Meyer J, Slevin JM, Marchant BG. Arthroscopic surgery or physical therapy for patients with femoroacetabular impingement syndrome: a randomized controlled trial with 2-year follow-up. Am J Sports Med 2018;46:1306–14. https://doi.org/10.1177/0363546517751912 doi: 10.1177/0363546517751912. [DOI] [PubMed]
  79. Weber AE, Harris JD, Nho SJ. Complications in hip arthroscopy: a systematic review and strategies for prevention. Sports Med Arthrosc Rev 2015;23:187–93. https://doi.org/10.1097/JSA.0000000000000084 doi: 10.1097/JSA.0000000000000084. [DOI] [PubMed]
  80. Nakano N, Lisenda L, Jones TL, Loveday DT, Khanduja V. Complications following arthroscopic surgery of the hip: a systematic review of 36 761 cases. Bone Joint J 2017;99–B:1577–83. https://doi.org/10.1302/0301-620X.99B12.BJJ-2017-0043.R2 doi: 10.1302/0301-620X.99B12.BJJ-2017-0043.R2. [DOI] [PubMed]
  81. Agricola R, Heijboer M, Bierma-Zeinstra S, Verhaar J, Weinans H, Waarsing E. Cam impingement causes end-stage osteoarthritis of the hip: a nationwide prospective study (CHECK). HIP Int 2012;22:443. https://doi.org/10.1136/annrheumdis-2012-201643 doi: 10.1136/annrheumdis-2012-201643. [DOI]
  82. Walters SJ, Bonacho Dos Anjos Henriques-Cadby I, Bortolami O, Flight L, Hind D, Jacques RM, et al. Recruitment and retention of participants in randomised controlled trials: a review of trials funded and published by the United Kingdom Health Technology Assessment Programme. BMJ Open 2017;7:e015276. https://doi.org/10.1136/bmjopen-2016-015276 doi: 10.1136/bmjopen-2016-015276. [DOI] [PMC free article] [PubMed]
  83. Foster NE, Healey EL, Holden MA, Nicholls E, Whitehurst DG, Jowett S, et al. A multicentre, pragmatic, parallel group, randomised controlled trial to compare the clinical and cost-effectiveness of three physiotherapy-led exercise interventions for knee osteoarthritis in older adults: the BEEP trial protocol (ISRCTN: 93634563). BMC Musculoskelet Disord 2014;15:254. https://doi.org/10.1186/1471-2474-15-254 doi: 10.1186/1471-2474-15-254. [DOI] [PMC free article] [PubMed]
  84. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M, Medical Research Council Guidance. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ 2008;337:a1655. https://doi.org/10.1136/bmj.a1655 doi: 10.1136/bmj.a1655. [DOI] [PMC free article] [PubMed]
  85. Hay EM, Foster NE, Thomas E, Peat G, Phelan M, Yates HE, et al. Effectiveness of community physiotherapy and enhanced pharmacy review for knee pain in people aged over 55 presenting to primary care: pragmatic randomised trial. BMJ 2006;333:995. https://doi.org/10.1136/bmj.38977.590752.0B doi: 10.1136/bmj.38977.590752.0B. [DOI] [PMC free article] [PubMed]
  86. Villar Bajwa Protocol. URL: www.villarbajwa.com/pdfs/Rehabilitation%20protocol%20following%20Hip%20Arthroscopy%20(May%202010).pdf (accessed 20 February 2021).
  87. Shepherd J, Jones J, Frampton G, Bryant J, Baxter L, Cooper K. Clinical effectiveness and cost-effectiveness of depth of anaesthesia monitoring (E-Entropy, Bispectral Index and Narcotrend): a systematic review and economic evaluation. Health Technol Assess 2013;17(34). https://doi.org/10.3310/hta17340 doi: 10.3310/hta17340. [DOI] [PMC free article] [PubMed]
  88. Joint Formulary Committee. British National Formulary. 72 ed. London: BMJ Group and Pharmaceutical Press; 2017.
  89. Curtis L. Unit Costs of Health and Social Care 2014. Canterbury: PSSRU, University of Kent; 2014.
  90. Curtis L. Unit Costs of Health and Social Care 2015. Canterbury: PSSRU, University of Kent; 2015.
  91. NHS Foundation Trust. Sensory Equipment Supplier Information. URL: www.swft.nhs.uk/download_file/223/185 (accessed 8 March 2017).
  92. South & West Devon Formulary and Referral. 18.2 Catheters. URL: https://southwest.devonformularyguidance.nhs.uk/formulary/chapters/continence-formulary/catheters (accessed 20 February 2021).
  93. The Physiotherapy Centre. URL: www.thephysiocentre.co.uk/how_much/ (accessed 30 November 2016).
  94. amazon.co.uk. Faithfull FAILITPICK Litter Picker, Pick Up Grabber Tool 87 cm (34 in). URL: www.amazon.co.uk/product-reviews/B004EK3NOC (accessed 4 October 2021).
  95. Sports Direct. Adidas Galaxy Elite Trainers. URL: www.sportsdirect.com/adidas-galaxy-elite-trainers-ladies-271462?colcode=27146203 (accessed 20 February 2021).
  96. Sports Direct. Slazenger Gel Insoles. URL: www.sportsdirect.com/dunlop-gel-insole-mens-750268?colcode=75026890 (accessed 20 February 2021).
  97. Sports Direct. Character Umbrella. URL: www.sportsdirect.com/character-umbrella-infants-750143?colcode=75014393unknown (accessed 20 February 2021).
  98. amazon.co.uk. Oypla Kneeling Orthopaedic Ergonomic Posture Office Stool Chair Seat. URL: www.amazon.co.uk/Oypla-Kneeling-Orthopaedic-Ergonomic-Posture/dp/B00YS8NLJC/ref=sr_1_1?dchild=1%26keywords=Oypla+Kneeling+Orthopaedic+Ergonomic+Posture+Office+Stool+Chair+Seat%26qid=1633348842%26sr=8-1 (accessed 20 February 2021).
  99. amazon.co.uk. Lexington Office Chair – Black Computer Chair – Desk Chair – Gas Lift – Adjustable Seat – Mesh Design. URL: amazon.co.uk (accessed 20 February 2021).
  100. amazon.co.uk. Foam Bed Wedge with Quilted Cover Multi-Purpose Cushion for Back, Neck & Leg Support. URL: amazon.co.uk (accessed 20 February 2021).
  101. amazon.co.uk. YAHILL® 1pc or 2 pcs Folding Trekking Pole Collapsible Climbing Stick Ultralight Adjustable, Alpenstocks with EVA Foam Handle, for Traveling Hiking Camping Climbing Backpacking Walking. URL: www.amazon.co.uk/Collapsible-Ultralight-Adjustable-Alpenstocks-Backpacking/dp/B0140KEYUM/ref=sr_1_7?ie=UTF8%26qid=1485185655%26sr=8-7%26keywords=Trekking+pole (accessed 20 February 2021).

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