VIDEO

Abstract

Osteochondroplasty and Labral Repair

for the Treatment of Young Adults
With Femoroacetabular Impingement
A Randomized Controlled Trial
Femoroacetabular Impingement Randomized Controlled Trial (FIRST) Investigators*
Investigation performed at McMaster University, Hamilton, Ontario, Canada

Background: Femoroacetabular impingement (FAI) is a condition known to cause hip pain in young adults.
Purpose: To evaluate the efficacy of the surgical correction of FAI via arthroscopic osteochondroplasty with or without labral
repair compared with arthroscopic lavage of the hip joint with or without labral repair.
Study Design: Randomized controlled trial; Level of evidence, 1.
Methods: A total of 220 male and female participants aged 18 to 50 years with nonarthritic FAI suitable for surgical treatment
were recruited for the trial at 10 clinical centers in Canada, Finland, and Denmark between October 2012 and November
2017, of whom 214 were included in the final analysis. In the osteochondroplasty group, cam- and/or pincer-type lesions were
resected using fluoroscopic guidance. In the lavage group, the joint was washed out with 3 L of normal saline. Surgeons were
instructed to repair the labrum in both groups if it was mechanically unstable once probed, showing visible displacement or chon-
drolabral separation. The primary outcome was patient-reported pain (using the 100-point visual analog scale [VAS]) at 12
months. Secondary outcomes included hip function (Hip Outcome Score [HOS] and International Hip Outcome Tool), physical
and mental health (12-Item Short Form Health Survey), and health utility (EuroQol–5 Dimensions) at 12 months as well as any re-
operations and other hip-related adverse events at 24 months.
Results: At 12 months, there was no difference in pain (VAS) between the groups (mean difference [MD], 0.11 [95% CI, –7.22 to
7.45]; P = .98). Also, 88.3% (189/214) of participants had a labral tear, of which 60.3% were repaired. For the secondary out-
comes, there were no significant differences between treatment groups, with the exception of the HOS activities of daily living
domain in which lavage showed significant improvement compared with osteochondroplasty (MD, –5.03 [95% CI, –10.40 to
–0.03]; P = .049). By 24 months, there were significantly fewer reoperations reported in the osteochondroplasty group (8/105)
than the lavage group (19/104) (odds ratio, 0.37 [95% CI, 0.15-0.89]; P = .026). The primary reasons for a reoperation included
hip pain (15/27; 55.6%) and a reinjury of the labrum (11/27; 40.7%).
Conclusion: Both the osteochondroplasty and the lavage groups with or without labral repair for FAI had significantly improved
pain or function significantly at 1 year. By 2 years, the reoperation rate was significantly lower in the osteochondroplasty group.
Registration: NCT01623843 (ClinicalTrials.gov identifier)
Keywords: osteochondroplasty; lavage; femoroacetabular impingement; randomized controlled trial

Femoroacetabular impingement (FAI) is a clinical entity
that causes hip pain in the young adult. It is characterized
by a clinical presentation of hip pain, limitation in hip
motion, and abnormal morphology on imaging of the hip
joint.11 Although FAI was originally described in 1936,28
in 2003 Ganz et al10 proposed a theory in which FAI causes
The American Journal of Sports Medicine
2021;49(1):25–34
DOI: 10.1177/0363546520952804
Ó 2020 The Author(s)
hip pain and dysfunction with the subsequent development
of primary osteoarthritis. It is proposed that abnormal
bony morphology, such as an enlarged femoral head-neck
junction (cam type) or a prominent acetabular rim (pincer
type), is associated with FAI, causes impingement, and
ultimately leads to osteoarthritis.1,10 Most patients with
FAI have a combination of cam- and pincer-type bone
deformities, which is known as the mixed subtype.3 With
hip movements, especially rotation, abnormal bony mor-
phology causes impingement, or increased contact between
bony surfaces, leading to joint damage such as cartilage
and labral tears.

25
26 FIRST Investigators The American Journal of Sports Medicine

The diagnosis and treatment of FAI have dramatically Patients

increased in recent times across the globe.4,16 Initially,
open surgical hip dislocation was the gold standard of
treatment9; however, arthroscopic surgery is now more
common and increasingly utilized to treat this condition.
The principles of surgical treatment involve correcting
FAI-associated deformities noted on the femoral head-
neck and acetabulum (osteochondroplasty) while concur-
rently treating any other obvious lesions in the hip joint
such as labral tears or cartilage damage.23
Despite the increase in FAI surgery and promising ini-
tial results, there are very few high-level trials evaluating
the efficacy of the surgical correction of FAI. There have
been 3 trials that recently compared surgical interventions
to physical therapy (nonoperative care), 2 of which found
surgery to be superior to physical therapy.12,18,22 However,
given the inability to blind patients to treatment groups,
limited clinical follow-ups, and high crossover rates across
treatment groups, there remains uncertainty about the
efficacy of surgical treatment despite these studies. More-
over, FAI morphology has been noted to be present in large
portions of asymptomatic populations, prompting ques-
tions about the need for osteochondroplasty to change the
shape of the hip joint.8 We conducted an international,
multicenter randomized controlled trial to evaluate the
efficacy of surgical correction of FAI via arthroscopic osteo-
chondroplasty compared with arthroscopic washout or
lavage of the hip joint with or without labral repair in
both groups if indicated.
We recruited 220 patients at 10 clinical sites in Canada,
Finland, and Denmark. The initial pilot study recruited
50 patients from October 2012 to December 2013, who
were then rolled into the definitive trial. After obtaining
definitive trial funding, the remaining 170 patients were
recruited from October 2014 to November 2017. Eligible
patients had failed results with a documented period of
nonoperative management including hip-focused physical
therapy (for at least 6 months), were between the ages of
18 and 50 years with cam- or mixed-type FAI diagnosed
using radiography and/or magnetic resonance imaging,
and obtained temporary pain relief from a diagnostic
intra-articular hip injection (see detailed eligibility criteria
in Appendix 1, available in the online version of this arti-
cle). All patients provided written informed consent.
Randomization and Masking
Eligible patients were randomized to undergo either
arthroscopic osteochondroplasty or arthroscopic lavage
with or without labral repair using site and impingement
subtype (cam or mixed type) as stratification variables.
We used a centralized, 24-hour, internet-based randomiza-
tion system to allocate patients to the study groups.
Patients, outcome assessors, and data analysts were
blinded throughout the trial.

METHODS Interventions and Trial Procedures

Study Design In the osteochondroplasty group, cam- and/or pincer-type

We performed a parallel, multicenter, blinded randomized
controlled trial comparing arthroscopic osteochondroplasty
with arthroscopic lavage with or without labral repair for
the treatment of FAI in adults aged 18 to 50 years. The tri-
al methods have been published previously.7 The trial was
centrally coordinated at 1 center in Canada, and 9 addi-
tional academic centers in Canada, Finland, and Denmark
recruited patients for the study. All participating sites
obtained ethics approval. A blinded, independent adjudica-
tion committee evaluated surgical quality, and all reopera-
tions and hip-related complications were reported during
the trial. An independent data and safety monitoring com-
mittee met once or twice annually to review accumulated
safety and efficacy data.
lesions were resected using fluoroscopic guidance. In the
lavage group, no osteochondroplasty was performed after
lavaging the joint with 3 L of normal saline.7 In both
groups, significant and obvious labral tears and cartilage
damage were addressed with repair or debridement as
defined by the steering committee.2,23 Surgeons were
instructed to repair the labrum in both groups if it was
mechanically unstable on probing with visible displace-
ment or chondrolabral separation. This was required by
all site ethics boards before the trial began. Therefore, it
is important to note for the remainder of this article that
when referring to the ‘‘osteochondroplasty’’ group, we
mean that osteochondroplasty was performed with labral
repair only if deemed necessary according to the previously
mentioned a priori criteria. Congruently, when referring to

*Address correspondence to Olufemi R. Ayeni, MD, MSc, PhD, Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1200
Main Street West, 4E15, Hamilton, ON L8N 3Z5, Canada (email: ayenif@mcmaster.ca).
All authors are listed in the Authors section at the end of this article and in the Appendix, available in the online version of this article.
Submitted April 13, 2020; accepted July 14, 2020.
One or more of the authors has declared the following potential conflict of interest or source of funding: Research grants were received from the Cana-
dian Institutes of Health Research (principal investigators: O.R.A., M.B.), American Orthopaedic Society for Sports Medicine (principal investigator: O.R.A.),
Canadian Orthopaedic Foundation (principal investigators: O.R.A., M.B.), McMaster Surgical Associates (principal investigators: O.R.A., M.B.), and Ham-
ilton Health Sciences Department of Surgery (principal investigator: O.R.A.). M.B. was also funded, in part, by the Canada Research Chair in Musculoskel-
etal Trauma (McMaster University), which is unrelated to the present study. V.M. receives consulting fees from Stryker and has received education
payments from Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent inves-
tigation on the OPD and disclaims any liability or responsibility relating thereto.
AJSM Vol. 49, No. 1, 2021
the ‘‘lavage’’ group, we mean that the hip joint was lavaged
with labral repair only if deemed necessary according to
the same a priori criteria.
Surgeon investigators were eligible to participate in this
trial if they had advanced training in hip arthroscopic sur-
gery, a focused practice managing FAI, and an annual min-
imum of 30 FAI surgical cases.14 Incidentally, the surgeons
involved in the trial performed a median of 100 cases per
year. Further standardization of the surgical procedure
was facilitated by a review of a video of the proposed
technique.2
We standardized postoperative pain management, pro-
tected weightbearing, and physical therapy (Appendix 2,
available online). Patients were followed at 2 weeks, 6 weeks,
3 months, 6 months, and 12 months after surgery for all pri-
mary and secondary outcomes. Patients were followed to 24
months after surgery for adverse events including reopera-
tions and other nonoperatively treated hip-related complica-
tions. The full trial recruitment and follow-up process is
shown in Appendix 3 (available online).
Study Outcomes
The primary outcome was pain, defined using the 100-
point visual analog scale (VAS), at 12 months24, where
‘‘alleviation of pain’’ has been previously described as the
‘‘top reason’’ that patients seek surgical interventions for
FAI.17 Secondary outcomes included hip function (as mea-
sured by the Hip Outcome Score [HOS] and International
Hip Outcome Tool [iHOT-12]),13,26 generic physical and
mental health (as measured by the 12-Item Short Form
Health Survey [SF-12]),30 and health utility (as measured
by the EuroQol–5 Dimensions [EQ-5D])6 at 12 months.
The adjudication committee evaluated all reoperations
to determine if they met the criteria for a study event
and if the event was warranted; additionally, they classi-
fied the reasons for a reoperation for the randomized hip.
Other hip-related, nonsurgically treated adverse events
were also adjudicated by the committee such as hip insta-
bility, hip tendinopathy, hip osteoarthritis (that developed
after surgery), and infection (superficial or deep). More-
over, it evaluated the quality of each osteochondroplasty
procedure based on preoperative and postoperative imag-
ing (Appendix 4, available online).
Statistical Analysis
Sample Size Calculation. The trial was powered to detect
a minimal clinically important improvement (MCII) for the
VAS pain score (ie, 13 points) between interventions.21 To
achieve 80% study power and with a 2-sided type I error
rate (5%), 73 patients per study arm were required for the
primary outcome. For the secondary outcomes, a 2-tailed
type I error rate was set to 1% to account for multiple com-
parisons and again considered the MCII for the SF-12, the
HOS, and the iHOT-12 in which the value was at least
half the standard deviation, equivalent to a 4-point differ-
ence in the score.20,21,31 Specifying an alpha level of .01
and a beta of 0.20 (study power = 0.80), we required, at
Osteochondroplasty for the Treatment of FAI 27
the least, a sample of 192 patients (96 per group) to ensure
the detection of a half–standard deviation mean difference
(MD) for the SF-12 between interventions. We were also
powered for the HOS and iHOT-12 at this sample size. To
account for potential loss to follow-up (5%) and potential
crossovers (5%), the total sample size was 220 patients.
Primary Outcome Analysis. We adhered to the pub-
lished statistical analysis plan when conducting the final
analyses.27 Briefly, the primary analysis compared pain
scores (VAS) using multiple linear regression, with change
in the VAS score from baseline to 12 months as the depen-
dent variable and treatment, baseline VAS score, impinge-
ment subtype, and clinical center as the independent
variables. Assuming the data would be missing at random,
multiple imputation stratified by trial arm was used to
enable the planned intention-to-treat analysis. The multiple
imputation step included the following demographic and
prognostic variables for which there were complete data:
impingement subtype, clinical site, age, any comorbidities,
onset of symptoms, severity of impingement, sex, Tönnis
and Heinecke preoperative classification,29 smoking status,
body mass index, baseline sports activity, presence of labral
tears at surgery, and labral repair or resection. A per-proto-
col analysis was not performed, given that the crossover
rate was less than 1% (2 crossovers total, with 1 for each
group). Residuals were examined to assess the model
assumptions for the multiple linear regression model.
Secondary Outcome Analysis. Similar to the primary
analysis, multiple linear regression was performed, includ-
ing treatment, baseline score, impingement subtype, and
center as independent variables for the SF-12, iHOT,
HOS, and EQ-5D. The effect of randomized group on the
reoperation rate at 24 months was analyzed using logistic
regression that included treatment and impingement
subtype as independent variables. Other nonoperatively
treated, hip-related adverse events were presented by ran-
domized group at 24 months. Complete case analyses were
performed for all secondary outcomes.
Sensitivity and Subgroup Analyses. A sensitivity analy-
sis of center effects and missing data (ie, complete cases
only) was performed for the primary outcome. We also per-
formed an analysis adjusting for age (\40 vs 40 years),
any comorbidities reported at baseline, onset of symptoms
(acute, subacute, insidious, traumatic, or nontraumatic),
and presence of labral tears at initial surgery to address
any potential baseline imbalance between the randomized
groups. There were 6 subgroups identified a priori, which
were analyzed in the primary model described above to
assess whether the magnitude of the treatment effect
was significantly different between subgroups for the pri-
mary outcome (Appendix 5, available online).27
The primary analyses were first conducted using
blinded treatment groups (ie, treatment X and Y) by
a blinded data analyst (D.H.-A.). Interpretations for the
effect of the surgical interventions were developed and
documented based on the blinded X versus Y treatment.15
The randomization code was then broken, the applicable
a priori interpretation was selected, and the article was
drafted (Appendix 6, available online). All analyses were
conducted with SAS version 9.4 (SAS Institute).
28 FIRST Investigators The American Journal of Sports Medicine

impingement was predominantly mild to moderate (37.9%

Eligible Patients
N = 383
[81/214] and 53.7% [115/214], respectively). Baseline char-
acteristics were similar in the randomized study groups
(Table 1). There was a relatively equal proportion of partial
Randomized Excluded Missed
(42.1%; 90/214) and complete (46.3%; 99/214) labral tears
N = 220 N = 185 N=2 found at surgery, and of these, 60.3% were repaired (Table
2). Hip range of motion and radiographic/magnetic reso-
nance imaging measurements, in general, showed improve-
Allocated to Arthroscopic Allocated to ment from baseline to 12 months (Appendix 8, available
Osteochondroplasty Arthroscopic Lavage
N = 110 N = 110 online). In the osteochondroplasty group, among 78 patients
who had both baseline and 12-month measurements, there
was a mean alpha angle correction of 11.5° (95% CI, 8.3°-
Ineligible post- Ineligible post-
randomization randomization 14.7°). As per the adjudication committee, surgical correc-
N=2 N=4 tion was deemed ‘‘acceptable’’ in 83 of 100 (83.0%) patients
in the osteochondroplasty group with complete preoperative
VAS not requested VAS not requested and postoperative imaging available (10 were deemed
as part of pilot* as part of pilot*
‘‘unacceptable,’’ and 7 were deemed ‘‘unable to assess’’
N = 19 N=8
because of inadequate imaging views).
While pain scores improved across both groups, arthro-
Analyzed in Primary Analyzed in Primary scopic osteochondroplasty did not significantly improve pain
Analysis Analysis
N = 89 N = 98 at 12 months compared with arthroscopic lavage (MD, 0.11
[95% CI, –7.22 to 7.45]; P = .98) (Appendix 9, available
online). The 95% CI around this estimate also did not surpass
Final Patient Status: Final Patient Status:
Included in complete case Included in complete case
the MCII for pain. Both treatments, however, resulted in sta-
analysis (n = 74) analysis (n = 80) tistically significant and clinically important improvements
Unable to locate (n = 4) Unable to locate (n = 7)
Missed completing VAS (n = 1) Missed completing VAS (n = 1)
in pain at 12 months (osteochondroplasty group’s mean
VAS completed outside 12M VAS completed outside 12M change in VAS score from baseline, 37.0 [95% CI, 30.5-
window (n = 8) window (n = 8)
Missing baseline VAS (n = 1) Missing baseline VAS (n = 2)
43.6]; lavage group’s mean change in VAS score from base-
Died (n = 1) Died (n = 0) line, 32.6 [95% CI, 26.1-39.0]). Adjusted analyses yielded sim-
ilar results (Appendix Table A1, available online).
Figure 1. Participant flow diagram. *Partway into the pilot There were no significant differences between osteo-
study, the principal investigator, co-investigators, and femo- chondroplasty and lavage for the SF-12 physical and men-
roacetabular impingement experts met for an investigators’ tal component summary scores, the EQ-5D index and VAS
meeting and collectively decided to amend the primary out- scores, the iHOT scores, and the HOS sport domain scores
come to pain (via the visual analog scale [VAS]) at 12 months. at 12 months. However, arthroscopic lavage significantly
improved HOS activities of daily living domain scores com-
pared with osteochondroplasty (MD, –5.03 [95% CI, –10.40
RESULTS to –0.03]; P = .049). Nonoperatively treated, hip-related
adverse events were not significantly different between
We enrolled 220 patients of the 407 screened across all par- the osteochondroplasty and lavage groups at 24 months
ticipating clinical sites from October 26, 2012, to November 9, (15/105 vs 13/104, respectively; odds ratio, 1.18 [95% CI,
2017. A total of 110 patients each were randomized to undergo 0.53-2.62]; P = .695). However, the reoperation rate was
arthroscopic osteochondroplasty and arthroscopic lavage, significantly lower in the osteochondroplasty group com-
respectively. Of these, 6 patients were found to be ineligible: pared with the lavage group at 24 months (8/105 vs 19/
2 patients decided against surgery, 2 patients were found to 104, respectively; odds ratio, 0.37 [95% CI, 0.15-0.89]; P =
have neither cam- nor mixed-type FAI on arthroscopic explo- .026) (Appendix 9, available online). The primary reasons
ration, 1 patient was older than 50 years, and 1 patient did for a reoperation included hip pain (15/27; 55.6%) and
not undergo documented physical therapy for the hip before a reinjury of the labrum (11/27; 40.7%). There were no sta-
surgery. The VAS (primary outcome) was not completed for tistically significant subgroup effects (Appendix Figure A1,
57 patients for the reasons described in Figure 1. We achieved available online).
a 72% follow-up rate for the primary outcome and a 94% fol-
low-up rate for any outcome at 12 months (Appendix 7, avail-
able online). We achieved a 97% follow-up rate for adverse DISCUSSION
event outcomes at 24 months.
The majority of patients were White men with a mean The findings of this trial suggest that the correction of FAI
age of 36.0 years (range, 18-50 years). The majority of morphology through osteochondroplasty was superior to
patients had groin pain, an insidious onset of FAI symp- lavage with or without labral repair based on the reopera-
toms, a Tönnis and Heinecke classification of grade 0 or 1, tion rate at 2 years. There were no differences in the effect
and an anterior labral tear. The most common impinge- between groups for the primary outcome of pain and the
ment type was cam (58.4%; 125/214), and the severity of secondary outcomes of hip function, health utility, and
AJSM Vol. 49, No. 1, 2021 Osteochondroplasty for the Treatment of FAI 29

TABLE 1
Patient Demographics and Hip Characteristicsa

Osteochondroplasty (n = 108) Lavage (n = 106) Total (N = 214)

Demographics
Age, mean 6 SD, y 36.7 6 8.2 35.4 6 8.8 36.0 6 8.5
Sex
Male 66 (61.1) 67 (63.2) 133 (62.1)
Female 42 (38.9) 39 (36.8) 81 (37.9)
Ethnicity
White 100 (92.6) 95 (89.6) 195 (91.1)
Asian 3 (2.8) 4 (3.8) 7 (3.3)
Mixed race 1 (0.9) 4 (3.8) 5 (2.3)
Native 4 (3.7) 0 (0.0) 4 (1.9)
Black 0 (0.0) 3 (2.8) 3 (1.4)
Hispanic 0 (0.0) 0 (0.0) 0 (0.0)
Smoking history
Never smoked 80 (74.1) 84 (79.2) 164 (76.6)
Current smoker 19 (17.6) 16 (15.1) 35 (16.4)
Former smoker 9 (8.3) 6 (5.7) 15 (7.0)
Alcohol consumption
No alcohol 25 (23.1) 26 (24.5) 51 (23.8)
.0-2 drinks/wk 46 (42.6) 48 (45.3) 94 (43.9)
.2-5 drinks/wk 22 (20.4) 18 (17.0) 40 (18.7)
.5-10 drinks/wk 9 (8.3) 8 (7.5) 17 (7.9)
.10 drinks/wk 5 (4.6) 4 (3.8) 9 (4.2)
Yes, but missing number of drinks/wk 1 (0.9) 2 (1.9) 3 (1.4)
Treatment modalities
Physical therapy 108 (100.0) 106 (100.0) 214 (100.0)
Hip injection 107 (99.1) 105 (99.1) 212 (99.1)
Nonsteroidal anti-inflammatory drugs 68 (63.0) 71 (67.0) 139 (65.0)
Massage 5 (4.6) 7 (6.6) 12 (5.6)
Chiropractic 4 (3.7) 5 (4.7) 9 (4.2)
Acupuncture 3 (2.8) 3 (2.8) 6 (2.8)
Ultrasound 1 (0.9) 0 (0.0) 1 (0.5)
Comorbidities
None 58 (53.7) 52 (49.1) 110 (51.4)
Back pain 21 (19.4) 19 (17.9) 40 (18.7)
Depression 9 (8.3) 16 (15.1) 25 (11.7)
Previous lower extremity injury 13 (12.0) 6 (5.7) 19 (8.9)
Osteoarthritis/degenerative arthritis 5 (4.6) 4 (3.8) 9 (4.2)
High blood pressure 4 (3.7) 5 (4.7) 9 (4.2)
Ulcers/stomach disease 4 (3.7) 4 (3.8) 8 (3.7)
Diabetes 1 (0.9) 4 (3.8) 5 (2.3)
Anemia or other blood disease 1 (0.9) 3 (2.8) 4 (1.9)
Lung disease 0 (0.0) 3 (2.8) 3 (1.4)
Rheumatoid arthritis 1 (0.9) 2 (1.9) 3 (1.4)
Heart disease 2 (1.9) 1 (0.9) 3 (1.4)
Thyroid disease 2 (1.9) 1 (0.9) 3 (1.4)
Cancer 0 (0.0) 2 (1.9) 2 (0.9)
Hypothyroidism 0 (0.0) 2 (1.9) 2 (0.9)
Migraine 2 (1.9) 0 (0.0) 2 (0.9)
Hyperthyroidism 0 (0.0) 2 (1.9) 2 (0.9)
Dyslipidemia 1 (0.9) 1 (0.9) 2 (0.9)
Asthma 1 (0.9) 0 (0.0) 1 (0.5)
Crohn disease 0 (0.0) 1 (0.9) 1 (0.5)
Otherb 4 (3.7) 6 (5.7) 10 (4.7)
Body mass index
Underweight (\18.5 kg/m2) 4 (3.7) 1 (0.9) 5 (2.3)
Normal weight (18.5 to \25 kg/m2) 35 (32.4) 37 (34.9) 72 (33.6)
Overweight (25 to \30 kg/m2) 46 (42.6) 31 (29.2) 77 (36.0)
Obese (30 to \40 kg/m2) 22 (20.4) 35 (33.0) 57 (26.6)
Morbidly obese (40 kg/m2) 1 (0.9) 2 (1.9) 3 (1.4)

(continued)
30 FIRST Investigators The American Journal of Sports Medicine

TABLE 1
(continued)

Osteochondroplasty (n = 108) Lavage (n = 106) Total (N = 214)

Weightbearing status
Nonweightbearing 5 (4.6) 1 (0.9) 6 (2.8)
Partial weightbearing 11 (10.2) 9 (8.5) 20 (9.3)
Full weightbearing 92 (85.2) 96 (90.6) 188 (87.9)
Baseline sports activity
None 22 (20.4) 18 (17.0) 40 (18.7)
Light 28 (25.9) 31 (29.2) 59 (27.6)
Moderate 37 (34.3) 43 (40.6) 80 (37.4)
Vigorous 21 (19.4) 14 (13.2) 35 (16.4)
Hip characteristics
Affected hip
Left 46 (42.6) 50 (47.2) 96 (44.9)
Right 62 (57.4) 56 (52.8) 118 (55.1)
Location of hip pain
Groin only 67 (62.0) 58 (54.7) 125 (58.4)
Groin and lateral 18 (16.7) 15 (14.2) 33 (15.4)
Groin, lateral, and posterior 11 (10.2) 13 (12.3) 24 (11.2)
Groin and posterior 5 (4.6) 10 (9.4) 15 (7.0)
Lateral only 5 (4.6) 8 (7.5) 13 (6.1)
Posterior only 1 (0.9) 2 (1.9) 3 (1.4)
Lateral and posterior 1 (0.9) 0 (0.0) 1 (0.5)
Onset of symptoms
Insidious 50 (46.3) 47 (44.3) 97 (45.3)
Subacute 18 (16.7) 22 (20.8) 40 (18.7)
Nontraumatic 14 (13.0) 13 (12.3) 27 (12.6)
Traumatic 11 (10.2) 15 (14.2) 26 (12.1)
Acute 15 (13.9) 9 (8.5) 24 (11.2)
Tönnis and Heinecke classification
Grade 0 47 (43.5) 51 (48.1) 98 (45.8)
Grade 1 56 (51.9) 41 (38.7) 97 (45.3)
Grade 2 5 (4.6) 13 (12.3) 18 (8.4)
Grade 3 0 (0.0) 1 (0.9) 1 (0.5)
Labral tears
None 16 (14.8) 15 (14.2) 31 (14.5)
Anterior only 78 (72.2) 84 (79.2) 162 (75.7)
Superior/lateral only 7 (6.5) 4 (3.8) 11 (5.1)
Anterior and superior/lateral 5 (4.6) 2 (1.9) 7 (3.3)
Posterior only 2 (1.9) 1 (0.9) 3 (1.4)
Herniation pits
Yes 28 (25.9) 16 (15.1) 44 (20.6)
No 80 (74.1) 90 (84.9) 170 (79.4)
Impingement subtype
Mixed 44 (40.7) 45 (42.5) 89 (41.6)
Cam 64 (59.3) 61 (57.5) 125 (58.4)
Impingement severity
Severe (alpha angle 83°) 12 (11.1) 6 (5.7) 18 (8.4)
Moderate (alpha angle 60°-82°) 54 (50.0) 61 (57.5) 115 (53.7)
Mild (alpha angle \60°) 42 (38.9) 39 (36.8) 81 (37.9)

a
Data are shown as n (%) unless otherwise indicated.
b
Whiplash, myasthenia gravis, reflux, herpes, polycystic ovary syndrome, Arnold-Chiari malformation, vertigo, irritable bowel syndrome,
clogged artery, and anxiety.

health-related quality of life, with the exception of a slight
improvement in activities of daily hip function in the
lavage group at 1 year. In both treatment groups, more
than 85% of patients had a labral tear diagnosed at index
surgery. It remains to be determined if the cause of the lab-
ral abnormality is FAI morphology or other relevant
factors such as activity profile and load on the hip (eg,
body mass index).
Although pain reduction is among the most relevant
outcomes for patients undergoing surgery for FAI, a lower
reoperation rate is always an important consideration.
There was a significant majority of reoperations that
AJSM Vol. 49, No. 1, 2021 Osteochondroplasty for the Treatment of FAI 31

TABLE 2
Surgical and Postoperative Management Characteristicsa

Osteochondroplasty (n = 108) Lavage (n = 106) Total (N = 214)

Surgical characteristics
Duration of procedure, min n = 98 n = 95 n = 193
Mean 6 SD 88.5 6 32.7 56.1 6 25.2 72.6 6 33.4
Median (IQR) 90 (60-115) 52 (35-70) 65 (45-90)
Duration of traction, min n = 100 n = 96 n = 196
Mean 6 SD 48.0 6 21.1 39.2 6 24.5 43.7 6 23.2
Median (IQR) 50 (37-60) 40 (21-51) 45 (30-60)
Total saline used in procedure, L n = 106 n = 92 n = 198
Mean 6 SD 12.2 6 6.4 8.8 6 5.4 10.6 6 6.2
Median (IQR) 12 (10-15) 9 (6-10) 10 (7-14)
Type of surgical preparation solution
Chlorhexidine 74 (68.5) 85 (80.2) 159 (74.3)
Alcohol 21 (19.4) 15 (14.2) 36 (16.8)
Iodine 14 (13.0) 7 (6.6) 21 (9.8)
Labral tears
None 10 (9.3) 15 (14.2) 25 (11.7)
Partial 42 (38.9) 48 (45.3) 90 (42.1)
Complete 56 (51.9) 43 (40.6) 99 (46.3)
Labral treatment
Repair 79 (73.1) 50 (47.2) 129 (60.3)
Resection 20 (18.5) 20 (18.9) 40 (18.7)
Neither 9 (8.3) 36 (34.0) 45 (21.0)
Labral injection
No 49 (45.4) 52 (49.1) 101 (47.2)
Yes, focal 33 (30.6) 25 (23.6) 58 (27.1)
Yes, diffuse 26 (24.1) 29 (27.4) 55 (25.7)
Outerbridge intraoperative cartilage classification n = 107 n = 106 n = 213
Grade 0 21 (19.6) 20 (18.9) 41 (19.2)
Grade 1 32 (29.9) 37 (34.9) 69 (32.4)
Grade 2 31 (29.0) 26 (24.5) 57 (26.8)
Grade 3 12 (11.2) 13 (12.3) 25 (11.7)
Grade 4 11 (10.3) 10 (9.4) 21 (9.9)
Beck intraoperative cartilage classification n = 107 n = 106 n = 213
Grade 0 23 (21.5) 18 (17.0) 41 (19.2)
Grade 1 29 (27.1) 38 (35.8) 67 (31.5)
Grade 2 30 (28.0) 28 (26.4) 58 (27.2)
Grade 3 15 (14.0) 14 (13.2) 29 (13.6)
Grade 4 10 (9.3) 8 (7.5) 18 (8.5)
Beck intraoperative labral classification n = 107 n = 105 n = 212
Grade 0 7 (6.5) 13 (12.4) 20 (9.4)
Grade 1 30 (28.0) 35 (33.3) 65 (30.7)
Grade 2 35 (32.7) 37 (35.2) 72 (34.0)
Grade 3 26 (24.3) 19 (18.1) 45 (21.2)
Grade 4 9 (8.4) 1 (1.0) 10 (4.7)
Capsulotomy performed
Partial 87 (80.6) 77 (72.6) 164 (76.6)
Complete 20 (18.5) 21 (19.8) 41 (19.2)
No 1 (0.9) 8 (7.5) 9 (4.2)
Capsular closure performed
Yes 33 (30.6) 14 (13.2) 47 (22.0)
No 75 (69.4) 92 (86.8) 167 (78.0)
No. of anchors used for labral repair
Not applicable (no repair) 29 (26.9) 56 (52.8) 85 (39.7)
0 5 (4.6) 2 (1.9) 7 (3.3)
1 7 (6.5) 8 (7.5) 15 (7.0)
2 30 (27.8) 21 (19.8) 51 (23.8)
3 19 (17.6) 10 (9.4) 29 (13.6)
4 10 (9.3) 8 (7.5) 18 (8.4)
5 4 (3.7) 1 (0.9) 5 (2.3)
6 4 (3.7) 0 (0.0) 4 (1.9)

(continued)
32 FIRST Investigators The American Journal of Sports Medicine

TABLE 2
(continued)

Osteochondroplasty (n = 108) Lavage (n = 106) Total (N = 214)

Postoperative characteristics
Antibiotic prophylaxis
No 106 (98.1) 104 (98.1) 210 (98.1)
Yes 2 (1.9) 2 (1.9) 4 (1.9)
Cefazolin 1 (0.9) 2 (1.9) 3 (1.4)
Cefuroxime 1 (0.9) 0 (0.0) 1 (0.5)
Thromboprophylaxis
No 84 (77.8) 79 (74.5) 163 (76.2)
Yes 24 (22.2) 27 (25.5) 51 (23.8)
Mechanical 19 (17.6) 20 (18.9) 39 (18.2)
Aspirin 5 (4.6) 7 (6.6) 12 (5.6)
Warfarin 1 (0.9) 0 (0.0) 1 (0.5)
Patient discharge location
Home 108 (100.0) 106 (100.0) 214 (100.0)
Weightbearing status at discharge
Nonweightbearing 45 (41.7) 40 (37.7) 85 (39.7)
Full weightbearing 40 (37.0) 42 (39.6) 82 (38.3)
Partial weightbearing 23 (21.3) 24 (22.6) 47 (22.0)
Patient aids at discharge
2 crutches 95 (88.0) 100 (94.3) 195 (91.1)
Wheelchair 17 (15.7) 10 (9.4) 27 (12.6)
Walker 3 (2.8) 2 (1.9) 5 (2.3)
Protective weightbearing for 2 wk 1 (0.9) 0 (0.0) 1 (0.5)
None 1 (0.9) 0 (0.0) 1 (0.5)

a
Some patients received more than one type of surgical prep solution and thromboprophylaxis. Data are shown as n (%) unless otherwise
indicated. IQR, interquartile range.

occurred in the lavage group and no significant differences
in other nonoperative interventions for adverse events.
This trend in reoperations was also present at the 1-year
mark but reached statistical significance at 2 years. Previ-
ous investigations have documented a need for 2-year
follow-up after FAI surgery to capture a more robust revi-
sion surgery rate.25 It follows that osteochondroplasty to
correct impingement-related lesions is an important part
of FAI management to minimize the recurrence of FAI-
related symptoms such as hip pain as well as mitigate
the risk of developing osteoarthritis later in life.
Of all questionnaire-based outcomes, there was only 1
significant finding, with improved HOS activities of daily
living domain scores (P = .049) in the lavage group, and
the 95% CI did not include the MCII. However, this was
not found with other hip-specific measures including the
HOS sport domain or iHOT-12. Interestingly, prognostic
factors that were analyzed in the subgroup analyses
including sex, severity of impingement, cartilage status,
and labral treatment did not substantially affect the treat-
ment effect.
The present trial had several strengths. We used con-
cealed randomization and blinded the patients, outcome
assessors, and data analysts throughout the trial (up to
and including the 2-year follow-up). We limited interpreta-
tion bias by drafting concluding statements for all possible
outcomes a priori and conducting blinded analyses. There
was standardization of the surgical technique and postop-
erative rehabilitation, and we employed strict surgeon
expertise criteria. Unlike previous FAI trials that relied
on subjective opinion,12,22 all decision rules for defining
surgical correction and other hip-related adverse events
were adapted from objective criteria presented in the cur-
rent literature, informed by the expert adjudication com-
mittee, and finalized before the start of adjudication.
Finally, patient-important outcomes in a multicenter inter-
national trial were used for generalizable results with high
external validity.
This trial also had some limitations. We did not capture
data for 27% of the enrolled patients at 12 months for the
primary outcome mainly because the VAS score was not
collected at this time point for part of the pilot study.
The initial sample size calculations accounted for losses,
and a 72% follow-up rate was still well above the a priori
calculated sample size needed for the primary outcome.
In addition, we conducted sensitivity analyses to ensure
the robustness of any significant findings, and the multiple
imputation analysis accounts for any differences among
patients who did and did not complete follow-up. We did
achieve a very high follow-up rate for the adverse event
secondary outcomes at 24 months. Not surprisingly, there
was a high rate of labral abnormalities in the study popu-
lation. Of those undergoing a reoperation, there was
a higher percentage of labral repair procedures in the
osteochondroplasty group (7/8; 87.5%) than in the lavage
group (10/19; 52.6%) at index surgery. Therefore, it is diffi-
cult to know if differences in treatment of the labrum also
contributed significantly to the reoperation rate.
AJSM Vol. 49, No. 1, 2021
The decision and timing for a reoperation can be a com-
plex process involving patient- and surgeon-related factors
that could potentially introduce bias. However, all study-
related adverse events were adjudicated using established
decision rules to review clinical information and minimize
this potential. In addition, both groups had similar rates of
nonoperatively treated adverse events, which suggests
that one group was not preferentially treated with a reoper-
ation. Finally, while 10 of the 100 osteochondroplasty pro-
cedures were found to be ‘‘unacceptable,’’ and 7 were
deemed ‘‘unable to assess’’ according to the adjudication
committee, this means that 83.0% of procedures were of
high fidelity. This is consistent with the 87% fidelity rate
in the UK FASHIoN trial.12
As FAI surgery continues to evolve, new paradigms and
considerations such as capsule management, version anal-
ysis, and spinopelvic morphology analysis may affect the
understanding and treatment of these patients.5,19 Future
long-term follow-up studies will help determine if those
with FAI morphology develop degenerative changes earlier
than those who had FAI correction.
In conclusion, at 1 year, both study groups improved
significantly after a surgical intervention. At 2 years, the
reoperation rate was significantly higher in the lavage
group. Therefore, arthroscopic osteochondroplasty was
a more effective surgical treatment for FAI at 2 years after
surgery.
AUTHORS
Writing Committee: Olufemi R. Ayeni, MD, MSc, PhD, FRCSC
(Chair; McMaster University); Jon Karlsson, MD, PhD (Univer-
sity of Gothenburg); Diane Heels-Ansdell, MSc (McMaster Univer-
sity); Lehana Thabane, PhD (McMaster University); Volker
Musahl, MD (University of Pittsburgh); Nicole Simunovic, MSc
(McMaster University); Andrew Duong, MSc (McMaster University);
and Mohit Bhandari, MD, PhD, FRCSC (McMaster University).
Steering Committee: Olufemi R. Ayeni, MD, MSc, PhD, FRCSC
(Chair; McMaster University); Mohit Bhandari, MD, PhD, FRCSC
(Co-chair; McMaster University); Asheesh Bedi, MD (University
of Michigan); Teppo Järvinen, MD (University of Helsinki); Volker
Musahl, MD (University of Pittsburgh); Douglas Naudie, MD,
FRCSC (University of Western Ontario); Matti Seppänen, MD
(University of Turku); Gerard Slobogean, MD, MPH, FRCSC
(University of Maryland, Baltimore); and Lehana Thabane, PhD
(McMaster University).
Methods Center (McMaster University): Olufemi R. Ayeni,
MD, MSc, PhD, FRCSC (Principal Investigator); Nicole Simu-
novic, MSc (Research Manager); Andrew Duong, MSc, Matthew
Skelly, BSc, Ajay Shanmugaraj, BSc, and Sarah Crouch, BSc (Pro-
ject Management); Sheila Sprague, MSc, PhD (Research Method-
ologist); Diane Heels-Ansdell, MSc (Statistical Analysis); and Lisa
Buckingham, BSc (Data Management).
Data and Safety Monitoring Committee: Tim Ramsay, PhD
(Chair; Ottawa Hospital Research Institute); John Lee, MD,
MSc, FRCSC (University of Toronto); and Petteri Kousa, MD
(Sports Clinic Hospital Dextra).
Adjudication Committee: Sasha Carsen, MD, MBA, FRCSC
(Chair; University of Ottawa); Hema Choudur, MBBS, FRCPC
(Hamilton Health Sciences); Yan Sim, MD (McMaster University);
and Kelly Johnston, MD, FRCSC (University of Calgary).
Osteochondroplasty for the Treatment of FAI 33
Participating Clinical Sites Canada: McMaster University
Medical Centre (Hamilton, ON)–Olufemi R. Ayeni, MD, PhD,
FRCSC; Sarah Crouch, BSc (Pharm); Andrew Duong, MSc; Ajay
Shanmugaraj, BSc; Nicole Simunovic, MSc; Matthew Skelly,
BSc; Sheila Sprague, PhD. Dalhousie University (Halifax, NS)–
Ivan Wong, MD, FRCSC, Dip. Sports Medicine, MACM; Ryland
Murphy, BSc; Sara Sparavalo, MASc. St Michael’s Hospital
(Toronto, ON)–Daniel Whelan, MD, MSc, FRCSC; Ryan Khan, BA,
CCRP. Kingston Health Sciences Centre (Kingston, ON)–Gavin
C.A. Wood, MBChB, FRCS; Fiona Howells, BPharm; Heather Grant,
MSc. London Health Sciences Centre (London, ON)–Douglas
Naudie, MD, MSc, FRCSC; Bryn Zomar, MSc; Michael Pollock,
MSc. Fowler Kennedy Sport Medicine Clinic (London, ON)–Kevin
Willits, MD, FRCSC; Andrew Firth, MSc; Stacey Wanlin; Alliya
Remtulla, MSc; Nicole Kaniki, PhD. CHU de Québec-Université
Laval (Quebec City, QC)–Etienne L. Belzile, MD; Sylvie Turmel, RN.
International: Odense University Hospital (Odense, Den-
mark)–Uffe Jørgensen, MD, Dr. Med Sci; Annie Gam-Pedersen,
RN. Tays Hatanpää (Tampere University Hospital, Tampere, Fin-
land)–Raine Sihvonen, MD, PhD; Marko Raivio, MD; Pirjo Toivo-
nen, PT. Turku University Hospital (Turku, Finland)–Matti
Seppaänen, MD; Mari Pirjetta Routapohja, RN.
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