Amateur and Recreational Athletes Return to Sport at a High Rate Following Hip Arthroscopy for Femoroacetabular Impingement

Outcomes of Flexibility Sport Athletes With Borderline Hip Dysplasia After Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Propensity-Matched Analysis at Minimum 2-Year Follow-up

BACKGROUND

Hip arthroscopy has proved successful in treating femoroacetabular impingement syndrome (FAIS) in patients with and without borderline hip dysplasia (BHD). Despite a high prevalence of BHD in patients who participate in sports with high flexibility requirements, a paucity of literature evaluates the efficacy of hip arthroscopy in treating FAIS in flexibility sport athletes with BHD.

PURPOSE

To compare minimum 2-year patient-reported outcomes (PROs) and achievement of clinically significant outcomes in flexibility sport athletes with BHD undergoing primary hip arthroscopy for FAIS with capsular plication with results in flexibility sport athletes without dysplasia.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected for patients undergoing primary hip arthroscopy for FAIS with BHD, defined as a lateral center-edge angle of 18° to 25°, who reported participation in a sport with a high flexibility requirement, including dance, gymnastics, figure skating, yoga, cheerleading, and martial arts, according to previous literature. These patients were matched 1:2 to flexibility sport athletes without dysplasia, controlling for age, sex, and body mass index. Preoperative and minimum 2-year postoperative PROs were collected and compared between groups. Cohort-specific minimal clinically important difference and patient acceptable symptom state achievement was compared between groups.

RESULTS

In total, 52 flexibility sport athletes with BHD were matched to 104 flexibility sport athletes without BHD. Both groups showed similar sport participation (P = .874) and a similar level of competition (P = .877). Preoperative lateral center-edge angle (22.2°± 1.6° vs 31.5°± 3.9°; P < .001) and Tönnis angle (10.9°± 3.7° vs 5.8°± 4.4°; P < .001) differed between groups. Capsular plication was performed in all cases. Both groups achieved significant improvement in all PROs (P < .001) with no differences in postoperative PROs between groups (P≥ .147). High minimal clinically important difference (BHD group: 95.7%; control group: 94.8%) and patient acceptable symptom state (BHD group: 71.7%; control group: 72.2%) achievement for any PRO was observed with no differences between groups (P≥ .835).

CONCLUSION

Flexibility sport athletes with BHD achieved similar outcomes as those of flexibility sport athletes without BHD after hip arthroscopy for FAIS with capsular plication.

Return-to-Sport Rates After Hip Arthroscopy for Femoroacetabular Impingement Syndrome in Flexibility Sports Athletes: A Systematic Review

CONTEXT

Femoroacetabular impingement syndrome (FAIS) is a common cause of hip pain in young adults. Flexibility athletes represent an interesting subset due to the extreme range of motion requirements of their sport.

OBJECTIVE

The objective of this review was to provide a summary of the outcomes of hip arthroscopy for FAIS in patients who participate in flexibility sports.

DATA SOURCES

Three online databases (Medline, Embase, and PubMed) were searched from database inception (1946, 1974, and 1966, respectively) to January 10, 2023.

STUDY SELECTION

Studies were screened for literature addressing surgical outcomes for flexibility athletes undergoing hip arthroscopy for FAIS.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Various patient-reported outcomes that evaluated the efficacy of hip arthroscopy in this patient population were abstracted and presented in descriptive and analytical format. Abstraction was performed by 2 reviewers.

RESULTS

Overall, a total of 8 Level 3 or 4 studies and 295 patients (312 hips) were included in this review. The pooled standardized mean differences for the Visual Analog Scale for pain score, Modified Harris Hip Score, Hip Outcome Score - Activity of Daily Living scale, and Hip Outcome Score - Sport-Specific Subscale all demonstrated significant improvement after undergoing arthroscopy for FAIS between 12 and 116 months (N = 175, -1.97, 95% CI -2.5 to -1.4, P < 0.01, I2 = 76%; N = 211, 1.82, 95% CI 1.49 to 2.16, P < 0.01, I2 = 52%; N = 164, 1.75, 95% CI 1.42 to 2.05, P < 0.01, I2 = 28%; N = 211, 1.71, 95% CI 1.38 to 2.04, P < 0.01, I2 = 52%, respectively). Across 289 patients, 75.6% to 98% returned to sport at a similar or higher level than presurgery.

CONCLUSION

This review demonstrates a trend of improvement in patient-reported pain, function, quality of life, and return to sport at a minimum of 12 months among flexibility athletes after hip arthroscopy to treat FAIS.

Association of Changes in Hip and Knee Kinematics During a Single-Leg Squat With Changes in Patient-Reported Outcomes at 6 Months and 1 Year After Hip Arthroscopy

BACKGROUND

Previous studies have demonstrated alterations in squat kinematics in patients with femoroacetabular impingement syndrome (FAIS). Little is known about the effects of arthroscopic hip surgery on biomechanics during a single-leg squat (SLS) in these patients.

PURPOSE/HYPOTHESIS

The purpose of this study was to determine if (1) lower extremity dynamic range of motion (ROM) during an SLS task improves after hip arthroscopy for FAIS and (2) correlations exist between changes in patient-reported outcomes (PROs) and changes in lower extremity dynamic ROM during an SLS after hip arthroscopy for FAIS. It was hypothesized that dynamic hip ROM would improve after hip arthroscopy and that hip dynamic ROM would be associated with changes in PRO scores at both 6 months and 1 year.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Patients with FAIS performed 3 SLSs that were analyzed using a 20-camera motion capture system. Dynamic ROMs were calculated in 3 planes for the hip, knee, ankle, and pelvic segments. Squat depth was calculated as the change in vertical center of mass during the squat cycle. PROs including the Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports (HOS-Sports), International Hip Outcome Tool-12, and visual analog scale for pain scores were collected preoperatively and at the time of postoperative testing. Paired-samples t tests were used to compare kinematic variables pre- and postoperatively. Correlations were used to compare changes in PROs with changes in kinematics. All statistical analysis was performed using SPSS Version 26.

RESULTS

Fifteen patients were tested preoperatively and at a mean of 9 months postoperatively. All PRO measures improved postoperatively at 6 months and 1 year. Squat depth and sagittal plane hip and knee dynamic ROMs were significantly improved postoperatively. Positive correlations existed between changes in (1) hip ROM with the 6-month HOS-ADL score (r = 0.665) and (2) knee ROM with the 6 month (r = 0.590) and 1-year (r = 0.565) HOS-Sports scores.

CONCLUSION

Dynamic sagittal plane hip and knee ROMs improve after hip arthroscopy for FAIS. These improvements demonstrate strong correlations with improvements in some but not all postoperative PROs.

CLINICAL RELEVANCE

The current study sought to better understand the role of dynamic movement in the diagnosis and treatment of FAIS. These findings indicate that dynamic ROM and squat depth can, similarly to PROs, serve as biomarkers for patient function both before and after hip arthroscopic surgery.

Incidence of Venous Thromboembolism After Hip Arthroscopy Is Low With or Without Prophylaxis but Risk Factors Include Oral Contraceptive Use, Obesity, and Malignancy

PURPOSE

To determine the incidence of and risk factors for symptomatic venous thromboembolism (VTE) after hip arthroscopy (HA) and thromboprophylaxis prescription utilization for this procedure.

METHODS

The PearlDiver Mariner database was queried using Current Procedural Terminology codes to identify adult patients (aged ≥ 18 years) who underwent HA between 2010 and 2020. Patient demographic information, including age, oral contraceptive use, and medical comorbidities, as well as perioperative thromboprophylaxis utilization, was recorded using International Classification of Diseases codes and National Drug Codes. The incidence of postoperative VTE within 90 days was determined. Multivariate logistic regression was used to identify predictors of perioperative thromboprophylaxis utilization and risk factors for VTE.

RESULTS

The queried records identified 60,181 patients who met the inclusion criteria. Of these patients, 367 (0.6%) experienced VTE, including deep venous thrombosis (0.5%) and/or pulmonary embolism (0.2%). Approximately 2.1% of patients used thromboprophylaxis, including aspirin (1.1%), low-molecular-weight heparin (0.9%), and oral factor Xa inhibitors (0.1%). Oral contraceptive pill use (adjusted odds ratio [aOR], 2.16; 95% confidence interval [CI], 1.34-3.46), obesity (aOR, 1.37; 95% CI, 1.05-1.79), and a history of malignancy (aOR, 1.69; 95% CI, 1.12-2.54) were associated with increased odds of experiencing VTE. Perioperative thromboprophylaxis (aOR, 0.52; 95% CI, 0.19-1.39) was not significantly associated with decreased odds of experiencing VTE. However, obesity (aOR, 1.17; 95% CI, 1.00-1.38) and hypertension (aOR, 1.17; 95% CI, 1.02-1.36) were associated with increased odds of thromboprophylaxis prescription utilization.

CONCLUSIONS

Although the overall risk of symptomatic VTE after HA remains low, oral contraceptive use, obesity, and a history of malignancy are associated with increased odds of thromboembolic events within 90 days. Routine thromboprophylaxis after HA may not be indicated in all patients but can be considered based on patient-specific risk factors.

LEVEL OF EVIDENCE

Level III, retrospective prognostic comparative trial.

Does Femoral Osteoplasty Improve Long-term Clinical Outcomes and Survivorship of Hip Arthroscopy? A 15-Year Minimum Follow-up Study

BACKGROUND

Although femoral osteoplasty is common practice in treating cam-type femoroacetabular impingement (FAI), long-term data are lacking that support the ability of this procedure to optimize outcomes and alter natural history.

PURPOSE

To compare long-term clinical outcomes and survivorship of treatment for symptomatic FAI via arthroscopic correction of labral or chondral pathology with and without femoral osteoplasty.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective cohort study was performed across 2 consecutive cohorts of patients with isolated cam-type FAI who underwent hip arthroscopic treatment of labral or chondral pathology without femoral osteoplasty (HS group) or with femoral osteoplasty (HS-OST group). These unique cohorts were established at a distinct transition time in our practice before and after adoption of femoral osteoplasty for treatment of FAI. Clinical outcomes were measured using the modified Harris Hip Score (mHHS). Kaplan-Meier analysis was used to assess for total hip arthroplasty (THA)-free and reoperation-free survivorship.

RESULTS

The final HS group included 17 hips followed for 19.7 ± 1.2 years, and the final HS-OST group included 23 hips followed for 16.0 ± 0.6 years. No significant patient or morphological differences were found between groups. Compared with the HS group, the HS-OST group had significantly higher final mHHS (82.7 vs 64.7 for HS-OST vs HS, respectively; P = .002) and mHHS improvement (18.4 vs 6.1; P = .02). The HS-OST group also had significantly greater 15-year THA-free survivorship versus the HS group (78% vs 41%, respectively; P = .02) and reoperation-free survivorship (78% vs 29%; P = .003).

CONCLUSION

This study demonstrated superior long-term clinical outcomes and survivorship with combined arthroscopy and femoral osteoplasty compared with hip arthroscopy alone. These long-term data strongly support the practice of femoral osteoplasty in patients with cam FAI morphologies and suggest that this treatment alters the natural history of FAI at long-term follow-up.

Elite Female Athletes Demonstrate a Comparable Improvement in Midterm Patient-Reported Outcome Scores and Rate of Return to Sport Compared With Elite Male Athletes After Hip Arthroscopic Surgery: A Sex-Based Comparison in Professional and Collegiate Athletes

BACKGROUND

Few studies have compared outcomes, return to sport (RTS), and continuation of sport (CTS) after primary hip arthroscopic surgery between matched groups of male and female athletes with a minimum 5-year follow-up.

PURPOSE

(1) To report minimum 5-year patient-reported outcome (PRO) scores as well as RTS and CTS rates for elite female athletes undergoing hip arthroscopic surgery for femoroacetabular impingement syndrome (FAIS) and (2) to compare clinical results with those of a matched control group of elite male athletes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed for elite (collegiate or professional) female athletes who underwent primary hip arthroscopic surgery for FAIS between March 2009 and March 2016. Inclusion criteria were preoperative and minimum 5-year scores for the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sport Specific Subscale, and visual analog scale for pain. Exclusion criteria were Tönnis grade >1, hip dysplasia, previous ipsilateral hip surgery/conditions, and those unwilling to participate. Rates of achieving the minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), and maximum outcome improvement satisfaction threshold (MOIST) were recorded in addition to RTS. CTS was also recorded and defined as athletes reporting continued sport activity at a minimum 5-year follow-up after initially reporting returning to sport. Elite female athletes were propensity matched in a 1:1 ratio to elite male athletes for comparison.

RESULTS

A total of 81 hips in elite female athletes that underwent primary hip arthroscopic surgery met the inclusion criteria, and follow-up was available for 65 hips (80.2%) at a mean of 67.6 ± 6.5 months, with a mean age of 24.3 ± 6.8 years. Female athletes demonstrated significant improvements in all recorded PRO scores; achieved the MCID, PASS, and MOIST at high rates; returned to sport at a rate of 80.4%; and continued sport at a rate of 97.1%. Female athletes demonstrated lower preoperative PRO scores compared with male athletes, but postoperative PRO scores; improvements in scores; rates of achieving the MCID, PASS, MOIST; and RTS and CTS rates were similar between female and male athletes.

CONCLUSION

Elite female athletes undergoing primary hip arthroscopic surgery for FAIS demonstrated favorable PRO scores and high RTS and CTS rates at a minimum 5-year follow-up. These results were comparable with those of a propensity-matched control group of elite male athletes.

Criteria for Return to Play After Hip Arthroscopy in the Treatment of Femoroacetabular Impingement: A Systematic Review

BACKGROUND

Femoroacetabular impingement (FAI) is a common pathology in athletes that often requires operative management in the form of hip arthroscopy.

PURPOSE

To systematically review the rates and level of return to play (RTP) and the criteria used for RTP after hip arthroscopy for FAI in athletes.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of the literature, based on the PRISMA guidelines, was performed using PubMed, Embase, and Scopus databases. Studies reporting outcomes after the use of hip arthroscopy for FAI were included. Outcomes analyzed were RTP rate, RTP level, and criteria used for RTP. Statistical analysis was performed using SPSS software.

RESULTS

Our review found 130 studies, which included 14,069 patients (14,517 hips) and had a mean methodological quality of evidence (MQOE) of 40.4 (range, 5-67). The majority of patients were female (53.7%), the mean patient age was 30.4 years (range, 15-47 years), and the mean follow-up was 29.7 months (range, 6-75 months). A total of 81 studies reported RTP rates, with an overall RTP rate of 85.4% over a mean period of 6.6 months. Additionally, 49 studies reported the rate of RTP at preinjury level as 72.6%. Specific RTP criteria were reported in 97 studies (77.2%), with time being the most commonly reported item, which was reported in 80 studies (69.2%). A total of 45 studies (57.9%) advised RTP at 3 to 6 months after hip arthroscopy.

CONCLUSION

The overall rate of reported RTP was high after hip arthroscopy for FAI. However, more than one-fourth of athletes who returned to sports did not return at their preinjury level. Development of validated rehabilitation criteria for safe return to sports after hip arthroscopy for FAI could potentially improve clinical outcomes while also increasing rates of RTP at preinjury levels.

Determining Clinically Meaningful Thresholds for the Hip Outcome Score Sport-Specific Subscale in Athletes Undergoing Hip Arthroscopy for Femoroacetabular Impingement Syndrome

BACKGROUND

The minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), substantial clinical benefit (SCB), and maximum outcome improvement (MOI) satisfaction threshold for the Hip Outcome Score Sport-Specific Subscale (HOS-SSS) have not been established in athletes undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

PURPOSE

To determine threshold MCID, PASS, SCB, and MOI satisfaction threshold values for the HOS-SSS in athletes undergoing hip arthroscopy for FAIS at minimum 2-year follow-up.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 3.

METHODS

Anchor questions were administered to recreational, organized amateur, high school, college, and professional athletes who underwent primary hip arthroscopy for FAIS between May 2015 and March 2019. Patients were included if they were younger than 50 years, answered the anchor questions, and had preoperative and minimum 2-year follow-up for the HOS-SSS, modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), and visual analog scale (VAS) for pain. Exclusion criteria were Tönnis grade >1, hip dysplasia (lateral center-edge angle <18°), and previous ipsilateral hip surgery or conditions. Receiver operating characteristic (ROC) analysis was used to determine PASS, SCB, and MOI satisfaction for the HOS-SSS. Two distribution methods were used to calculate MCID for HOS-SSS.

RESULTS

A total of 225 athletes who underwent primary hip arthroscopy met the inclusion criteria. Of those athletes, 200 (88.9%) who had minimum 2-year follow-up and information regarding return to sport (RTS) were included. The cohort included 124 (62.0%) women and 76 (38.0%) men with a mean ± standard deviation age of 29.4 ± 10.4 years, body mass index of 25.6 ± 5.4, and follow-up of 29.5 ± 5.1 months. Athletes experienced significant improvements in HOS-SSS, mHHS, NAHS, and VAS from preoperative to latest postoperative follow-up (P < .001), and mean satisfaction was 8.2. The RTS rate was 83.7%. ROC analysis determined that the PASS, MOI satisfaction threshold, SCB absolute score, SCB change score, and MCID (baseline/change score methods) for the HOS-SSS were 77.0, 44.6%, 92.7, 30.6, and 10.6, respectively, with athletes achieving thresholds at high rates (80.0%, 80.5%, 45.0%, 54.0%, and 79.5%, respectively).

CONCLUSION

This study identified values for the HOS-SSS that can be used to define clinically meaningful outcomes in athletes after primary hip arthroscopy for FAIS. The PASS, MOI satisfaction threshold, SCB absolute score, SCB change score, and MCID for the HOS-SSS at minimum 2-year follow-up in athletes after primary hip arthroscopy were 77.0, 44.6%, 92.7, 30.6, and 10.6, respectively.

Earlier Treatment Yields Superior Outcomes in Competitive Athletes Undergoing Primary Hip Arthroscopy

PURPOSE

To report minimum 2-year patient-reported outcome scores (PROs) and return to sport (RTS) for competitive athletes undergoing primary hip arthroscopy for femoroacetabular impingement syndrome within 1 year of symptom onset and to compare these results with a propensity-matched control group of competitive athletes with symptoms for over 1 year.

METHODS

Data on professional, collegiate, high-school, and organized amateur athletes who underwent primary hip arthroscopy within 1 year of symptom onset between April 2008 and November 2017 were collected. RTS and minimum 2-year PROs were collected for the modified Harris Hip Score (mHHS), Non-arthritic Hip Score (NAHS), Hip Outcome Score-Sport Specific Subscale (HOS-SSS), International Hip Outcome Tool (iHOT-12), and visual analog pain scale (VAS). Rates of achieving minimal clinically important difference (MCID) were also evaluated. These patients were propensity-matched to a control group of competitive athletes with symptoms for over one year for comparison.

RESULTS

Fifty competitive athletes (51 hips, 54.9% female) were included in the study group with a mean follow-up of 70.9 ± 29.1 months and age of 23.6 ± 11.3 years. They demonstrated significant improvement from preoperative to latest follow-up for all recorded PROs (P < .001) and RTS at a rate of 72.9%. When outcomes were compared to the control group, the study group demonstrated similar preoperative scores for all PROs but significantly better minimum 2-year postoperative scores for NAHS (93.8 vs 85.1, P = .0001), HOS-SSS (89.1 vs 77.2, P = .001), iHOT-12 (87.7 vs 76.4, P = 0.011), and VAS (1.5 vs 2.4, P = 0.027). Rates of achieving MCID for HOS-SSS and mHHS were comparable between groups. Further, RTS rates were similar between groups (P = .301).

CONCLUSION

Competitive athletes undergoing primary hip arthroscopy with symptoms for less than 1 year demonstrated superior 2-year PROs compared to a propensity-matched control group with symptoms for over 1 year, but the rates achieving MCID and RTS were similar between groups.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Outcomes and Return-to-Sport Rates for Elite Athletes With Femoral Retroversion Undergoing Hip Arthroscopy: A Propensity-Matched Analysis With Minimum 2-Year Follow-up

Background:

Return to sports (RTS) and patient-reported outcomes (PROs) for elite athletes with femoral version abnormalities undergoing hip arthroscopy have not been well established.

Purposes:

To (1) report minimum 2-year PROs and RTS rates in elite athletes with femoral retroversion who underwent primary hip arthroscopy and (2) compare clinical results to those of a propensity-matched control group of elite athletes with normal femoral version who underwent primary hip arthroscopy.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Data were prospectively collected and retrospectively reviewed for elite (professional and collegiate) athletes with femoral version <5°, as measured on magnetic resonance imaging scans, who underwent hip arthroscopy for femoroacetabular impingement syndrome between March 2010 and April 2018. Inclusion criteria were preoperative and minimum 2-year follow-up PROs for the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score–Sports Specific Subscale (HOS-SSS), and visual analog scale for pain. Exclusion criteria were Tönnis grade >1, hip dysplasia, and previous ipsilateral hip surgery or conditions. Rates of achieving the minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), and maximum outcome improvement satisfaction threshold were recorded in addition to RTS. Athletes with retroversion were propensity matched in a 1:2 ratio to elite athletes with normal femoral version (5°-20°) for comparison.

Results:

A total of 33 elite athletes (33 hips) with femoral retroversion who underwent hip arthroscopy met the inclusion criteria, and follow-up was available for 30 hips in 30 athletes (90.9%) at an average of 36.1 ± 25.6 months. Elite athletes with femoral retroversion demonstrated significant improvements in all recorded PROs, achieved the MCID and PASS for the HOS-SSS at high rates (86.7%), and returned to sports at a rate of 83.3%. PROs, rates of achieving MCID and PASS for the HOS-SSS, and RTS rates were similar between the study and propensity-matched control group.

Conclusion:

Elite athletes with femoral retroversion undergoing primary hip arthroscopy demonstrated favorable PROs and high RTS rates at a minimum 2-year follow-up. These results were comparable with those of a propensity-matched control group of elite athletes with normal femoral version.

Sex-Based Differences in Athletes Undergoing Primary Hip Arthroscopy With Labral Reconstruction: A Propensity-Matched Analysis With Minimum 2-Year Follow-up

Background:

There is a paucity of literature comparing sex-based outcome differences in athletes after primary hip arthroscopy with labral reconstruction for femoroacetabular impingement syndrome (FAIS) and irreparable labral tears.

Purpose:

To report sex-based differences in clinical characteristics, patient-reported outcome (PRO) scores, and return-to-sports (RTS) rates in athlete who underwent primary hip arthroscopy with labral reconstruction.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Data were reviewed for recreational, organized amateur, high school, collegiate, and professional athletes who underwent primary hip arthroscopy with labral reconstruction for FAIS and irreparable labral tears between July 2014 and May 2019. Inclusion criteria included preoperative and minimum 2-year postoperative PRO scores (modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score–Sports Specific Subscale, International Hip Outcome Tool [iHOT-12], and visual analog scale [VAS] for pain). Exclusion criteria were Tönnis grade >1, hip dysplasia (lateral center-edge angle, <18°), or prior ipsilateral hip surgery/conditions. Patients were divided into groups by sex and were propensity-matched in a 1:1 ratio by age, body mass index, graft type, labral tear size, and sports level.

Results:

A total of 101 hips were eligible, and 94 hips (93.1%) had a minimum 2-year follow-up. Twenty-nine female athlete hips were propensity-matched to 29 male athlete hips. Female athletes underwent higher rates of capsular repair (79.3% vs 24.1% for men; P < .001) and lower rates of acetabular microfracture (0.0% vs 20.7% for men; P = .024). Both female and male athletes experienced significant improvement on all PRO scores (P < .001 for all), high RTS rates (women, 84% vs men, 80.8%), and high rates of achieving the minimal clinically important difference for the iHOT-12 and VAS pain (women, 88.5% vs men, 71.4% for both) and achieving the patient acceptable symptom state for the iHOT-12 (women, 88.5% vs men, 71.4%), with no significant difference between the sexes.

Conclusion:

Despite different clinical characteristics and surgical procedures, both female and male athletes undergoing primary hip arthroscopy with labral reconstruction had significant improvements in all PROs at the minimum 2-year follow-up, high RTS rates, and similar rates of achieving the minimal clinically important difference and patient acceptable symptom state.

Basketball Players Undergoing Primary Hip Arthroscopy Exhibit Higher Grades of Acetabular Cartilage Damage but Achieve Favorable Midterm Outcomes and Return to Sports Rates Comparable With a Propensity-Matched Group of Other Cutting Sports Athletes

BACKGROUND

Favorable short-term outcomes in competitive basketball players have been reported. Midterm outcomes in these athletes and how they compare with athletes in sports with similar demands have not been well established.

PURPOSE

(1) To report minimum 5-year patient-reported outcomes (PROs) and return to sports data in competitive basketball players undergoing primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and (2) to compare outcomes with a propensity-matched control group of other cutting sports athletes.

STUDY DESIGN

Cohort study, Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed for basketball players who competed at the professional, collegiate, high school, or competitive amateur levels and underwent primary hip arthroscopy for FAIS between May 2009 and March 2016. Patients with preoperative and minimum 5-year postoperative outcomes for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain were included. Patients were propensity matched to athletes in other cutting sports (soccer, lacrosse, field hockey, and tennis) according to age, sex, body mass index (BMI), and preoperative competition level for comparison.

RESULTS

A total of 28 competitive basketball players were included, with a mean follow-up time of 67.1 ± 5.1 months and a mean BMI of 23.7 ± 4; there were 12 (42.9%) female athletes. The cohort was composed of 1 professional, 10 collegiate, 13 high school, and 4 organized amateur athletes. They demonstrated significant improvements in all recorded PROs from baseline to the minimum 5-year follow-up (P < .001) and had high rates of achieving the minimal clinically important difference (MCID) for the mHHS (75%), NAHS (75%), HOS-SSS (67.9%), and VAS for pain (71.4%). Furthermore, 76.5% of basketball players who returned to sports were still competing at a minimum of 5 years postoperatively. When compared with a propensity-matched cohort of other cutting athletes, basketball athletes demonstrated a significantly higher acetabular labrum articular disruption (ALAD) grade (P < .001) and trended toward a higher Outerbridge grade of the acetabular cartilage (P = .067). Despite this, basketball players demonstrated similar preoperative, postoperative, and improvement scores in all recorded PROs. Moreover, both groups exhibited similar rates of achieving psychometric thresholds and rates of continued sports participation at minimum 5-year follow-up.

CONCLUSION

Competitive basketball players undergoing primary hip arthroscopy for FAIS demonstrated significant improvements in all recorded PROs and high rates of continued play at a minimum 5-year follow-up. When compared with a control group of other cutting sports athletes, basketball players exhibited more severe ALAD grades intraoperatively but similar midterm outcomes.

Automated Text-Messaging After Hip Arthroscopy: A Randomized-Controlled Trial of "Post-Op Buddy"

PURPOSE

To assess an automated text-messaging system for patients after hip arthroscopy and its impact at 90 days on the Hip Disability Osteoarthritis Outcome Score Physical Function Short form (HOOS-PS, HOOS-Pain), compliance with rehabilitation guidelines, and patient satisfaction.

METHODS

One hundred twenty-one participants (average age 29 ± 8.7 years, 52% female) undergoing hip arthroscopy at 2 academic institutions were prospectively enrolled and randomized to receive (1) standard perioperative communication or (2) additional automated mobile phone text messages. Inclusion criteria included ability to communicate in written English and access to a mobile phone with text-messaging capability. Patients undergoing revision surgery or simultaneous femoral or acetabular osteotomy were excluded. HOOS-PS and HOOS-Pain were collected preoperatively, and after surgery an automated mobile phone robot sent participants in the therapeutic arm intermittent text messages for 90 days. At 90 days all participants again completed HOOS-PS, HOOS-Pain, and additional survey questions on satisfaction with their experience (10-point scale), communication from the surgical team (10-point scale) and adherence to physical therapy exercises, weight-bearing guidelines, and brace use, The primary outcome assessed was a statistically significant change in HOOS-PS and HOOS-Pain; secondary outcomes included change in satisfaction, communication, and adherence to physical therapy exercises, weightbearing guidelines, or brace use. Wilcoxon rank sum was used to compare HOOS-PS and HOOS-Pain scores at 0 and 90 days. Demographic characteristics and survey variables were compared using Students t test for continuous variables and χ² or Fisher exact test for categorical variables as appropriate.

RESULTS

There were statistically significant and clinically relevant improvements in HOOS-PS and HOOS-Pain in both groups (P < .05). Subjective feedback was strongly positive, with 96% of text message participants reporting they would choose automated messages if it was offered to them again in the future.

CONCLUSIONS

Ninety days of automated text messaging after hip arthroscopy failed to show a significant difference in HOOS-PS (P = .09), HOOS-Pain (P = .13), patient-reported compliance with postoperative guidelines, or satisfaction with support and communication from the surgical team.

LEVEL OF EVIDENCE

I, randomized control trial (RCT).

Return to Sport in Athletes With Borderline Hip Dysplasia After Hip Arthroscopy for Femoroacetabular Impingement Syndrome

BACKGROUND

Data on outcomes in patients with borderline hip dysplasia (BHD) who undergo hip arthroscopy remain limited, particularly in regard to return to sport (RTS).

PURPOSE

To evaluate outcomes in patients with BHD and their ability to RTS after hip arthroscopy for treatment of femoroacetabular impingement syndrome (FAIS).

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Consecutive patients with self-reported athletic activity and radiographic evidence of BHD, characterized by a lateral femoral center-edge angle (LCEA) between 18° and 25° and a Tönnis angle >10°, who underwent hip arthroscopy for FAIS between November 2014 and March 2017 were identified. Patient characteristics and clinical outcomes including the Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), international Hip Outcome Tool (iHOT-12), and visual analog scale (VAS) for pain and satisfaction were analyzed at minimum 2-year follow-up. In addition, all patients completed an RTS survey.

RESULTS

A total of 41 patients with a mean age and body mass index (BMI) of 29.6 ± 13.4 years and 25.3 ± 5.6, respectively, were included. Mean LCEA and Tönnis angle for the study population were 22.7°± 1.8° and 13.3°± 2.9°, respectively. A total of 31 (75.6%) patients were able to RTS after hip arthroscopy at a mean of 8.3 ± 3.2 months. A total of 14 patients (45.2%) were able to RTS at the same level of activity, 16 patients (51.6%) returned to a lower level of activity, and only 1 (3.2%) patient returned to a higher level of activity. Of the 11 high school and collegiate athletes, 10 (90.9%) were able to RTS. All patients demonstrated significant improvements in all patient-reported outcome measures (PROMs) as well as in pain scores at a mean of 26.1 ± 5.4 months after surgery. Patients who were able to RTS had a lower preoperative BMI than patients who did not RTS. Analysis of minimum 2-year PROMs demonstrated better HOS-ADL, HOS-SS, mHHS, iHOT-12, and VAS outcomes for pain in patients able to RTS versus those who did not RTS (P < .05).

CONCLUSION

Of the patients with BHD studied here, 75.6% of patients successfully returned to sport at a mean of 8.3 ± 3.2 months after hip arthroscopy for FAIS. Of the patients who successfully returned to sport, 45.2% returned at the same level, and 3.2% returned at a higher activity level.

Return to Sports and Minimum 2-Year Outcomes of Primary Arthroscopic Hip Labral Reconstruction for Irreparable Tears in High-Level Athletes With a Propensity-Matched Benchmarking Against a Labral Repair Control Group

BACKGROUND

Labral reconstruction has shown promise for the treatment of irreparable labral tears in high-level athletes. The literature is scarce regarding outcomes and timing of return to sports (RTS) in these patients.

PURPOSE

(1) To report minimum 2-year patient-reported outcome (PRO) scores and RTS characteristics for high-level athletes undergoing primary labral reconstruction for irreparable labral tears and (2) to compare clinical results with a matched control group of athletes undergoing labral repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed for high school, college, and professional athletes who underwent a primary arthroscopic labral reconstruction between January 2010 and June 2018. Minimum 2-year PROs were compared for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and Hip Outcome Score-Sport Specific Subscale (HOS-SSS), as well as the visual analog scale (VAS) pain score, patient satisfaction, and RTS. The percentages of patients achieving the Patient Acceptable Symptom State (PASS) and minimal clinically important difference (MCID) for the mHHS (PASS, >74 points; MCID, >8 points) and HOS-SSS (PASS, >75 points; MCID, >6 points) were also recorded. These patients were propensity score matched in a 1:3 ratio to other high-level athletes undergoing labral repair.

RESULTS

A total of 17 high-level athletes with primary arthroscopic labral reconstruction were included with a median follow-up time of 37.1 months (95% CI, 37.2-60.3 months). They demonstrated significant improvement from preoperatively to the latest follow-up for mHHS, NAHS, HOS-SSS, and VAS for pain (P < .05). Further, patients achieved PASS/MCID for mHHS at high rates (PASS, 84.2%; MCID, 68.4%). Athletes were able to return to sport-specific training at a median of 3.33 months (95% CI, 3.07-4.71 months) and RTS at a median of 6.2 months (95% CI, 5.08-11.98 months). Fourteen (82.4%) of reconstructions and 29 (82.8%) of repairs either returned to sport or decided not to do so for reasons unrelated to the hip. PROs, RTS rate, and PASS/MCID rates were similar between the labral reconstruction group and a control labral repair group (P > .05).

CONCLUSION

Primary arthroscopic labral reconstruction for irreparable labral tears was associated with significant improvement in PROs and high rates of RTS in high-level athletes. These results were comparable with those of a control group of athletes undergoing labral repair.

Achieving Successful Outcomes in High-Level Athletes With Borderline Hip Dysplasia Undergoing Hip Arthroscopy With Capsular Plication and Labral Preservation: A Propensity-Matched Controlled Study

BACKGROUND

Return to sports (RTS) rates and patient-reported outcomes (PROs) after hip arthroscopy in athletes with borderline dysplasia (BD) have not been established.

PURPOSE

(1) To report minimum 2-year PROs and RTS rates in high-level athletes with BD who underwent hip arthroscopy for labral pathology in the setting of microinstability and (2) to compare clinical results with those of a matched control group of athletes with normal acetabular coverage.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were reviewed for surgery performed between January 2012 and July 2018. Patients were considered eligible if they received a primary hip arthroscopy in the setting of BD (lateral center-edge angle, 18°-25°) and competed in professional, collegiate, or high school sports. Inclusion criteria included preoperative and minimum 2-year follow-up scores for the modified Harris Hip Score, Non-arthritic Hip Score, Hip Outcome Score-Sport Specific Subscale, and visual analog scale for pain. Athletes with BD were matched to a control group of athletes with normal acetabular coverage (lateral center-edge angle, 25°-40°).

RESULTS

A total of 65 patients with BD were included in the study with a mean ± standard deviation follow-up of 47.5 ± 20.4 months. Athletes with BD showed significant improvement in all outcome measures recorded, demonstrated high RTS rates (80.7%), and achieved the minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) for the Hip Outcome Score-Sport Specific Subscale at high rates (MCID, 90.8%; PASS, 75.4%). When compared with a propensity-matched control group with normal acetabular coverage, capsular plication was performed more commonly in the BD group (93.8% vs 82.7%; P = .037). PROs and RTS, PASS, and MCID rates were similar between the BD and control groups (P > .05).

CONCLUSION

High-level athletes with BD who undergo primary hip arthroscopy for labral pathology in the setting of microinstability may expect favorable PROs and RTS rates at minimum 2-year follow-up. These results were comparable with those of a control group of athletes with normal coverage.

High rate of return to tennis after hip arthroscopy for patients with femoroacetabular impingement syndrome

OBJECTIVE

The purpose of this study was to evaluate return to sport (RTS) outcomes in tennis athletes following hip arthroscopy for femoroacetabular impingement syndrome (FAIS). It was hypothesized that there would be a high rate of return to tennis after hip arthroscopy.

STUDY DESIGN

Level IV, Retrospective Analysis.

SETTING

Outpatient sports medicine clinic at a single institution.

PARTICIPANTS

A total of 28 patients (60.8% female; mean age, 36.2 ± 9.2 years; mean BMI, 22.8 ± 2.1 kg/m²) with self reported tennis activity prior to hip arthroscopy.

MAIN OUTCOME MEASURES

A postoperative return to sport and minimum two-year patient reported outcomes.

RESULTS

There was a high rate of return to tennis, with 78% of patients eventually returning to tennis. An additional 9% of patients had the necessary hip function to return, but did not return due to lack of interest or resources. The patients returned to tennis at an average of 8.0 ± 3.3 months after surgery. The majority of athletes (66.7%) were able to continue competing at the same or higher levels following surgery.

CONCLUSIONS

Patients return to tennis 78% of the time at a mean of 8.0 ± 3.3 months following hip arthroscopy for FAIS.

Complete Capsular Closure Provides Higher Rates of Clinically Significant Outcome Improvement and Higher Survivorship Versus Partial Closure After Hip Arthroscopy at Minimum 5-Year Follow-Up

PURPOSE

To (1) compare the rates of reaching threshold hip-specific outcome scores for achieving the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) in patients who underwent partial versus complete T-capsulotomy repair and (2) identify the failure rates in each group 5 years after undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

METHODS

Data from consecutive patients who underwent hip arthroscopy for FAIS performed by a single fellowship-trained surgeon from January 2011 to March 2013 were collected and analyzed. Baseline data, hip-specific outcomes, and clinical failure rates were recorded at a minimum of 5 years postoperatively. Patients with partial T-capsulotomy repair were matched 1:3 by age, body mass index, and sex to patients with complete T-capsulotomy repair. Threshold scores for achieving the MCID and PASS were calculated and compared between the 2 groups. Additionally, rates of revision and conversion to total hip arthroplasty (THA) were compared between the groups.

RESULTS

A total of 379 patients were available for analysis (39 partial and 340 complete repairs), with 100 patients included in the matching process (25 in the partial-repair group and 75 in the complete-repair group). Comparison of radiographic parameters, including the Tönnis grade, alpha angle, and lateral center-edge angle, between the 2 groups showed no statistically significant difference (P > .05 for all). Comparison of postoperative score averages between the partial- and complete-closure groups showed a significant difference in the Hip Outcome Score-Activities of Daily Living Subscale (85.4 ± 17.7 vs 94.6 ± 7.8, P < .001), Hip Outcome Score-Sports Subscale (76.6 ± 26.2 vs 89.3 ± 16.8, P = .034), modified Harris Hip Score (83.2 ± 19.7 vs 90.5 ± 11.2, P = .035), and visual analog scale pain score (24.5 ± 30.8 vs 13.4 ± 15.8, P = .035). A total of 65 complete-repair patients (95.6%) achieved the MCID for at least 1 outcome measure versus 18 patients with partial repair (78.3%) (P = .04). A total of 69 complete-repair patients (92%) achieved the PASS for at least 1 outcome measure versus 18 partial-repair patients (72%) (P = .017). Of the 39 partial-repair patients, 35.9% (n = 14) underwent revision or conversion to THA, as compared with 2.9% (n = 10) in the overall cohort.

CONCLUSIONS

At a minimum 5-year follow-up, patients with complete capsular closure after hip arthroscopy for FAIS show superior long-term outcomes and achieve higher rates of meaningful clinical success when compared with patients with partial capsular closure. Furthermore, patients with partial capsular repair undergo revision or conversion to THA at high rates.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Hip Arthroscopy for Femoroacetabular Impingement Syndrome in Adolescents Provides Clinically Significant Outcome Benefit at Minimum 5-Year Follow-Up

PURPOSE

To report the rates of achieving clinically significant outcomes as defined by the minimal clinically important difference (MCID), patient acceptable symptomatic state (PASS), or substantial clinical benefit (SCB) in adolescent patients and the rates of clinical failure 5 years after undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

METHODS

Data from consecutive adolescent patients (defined by the American Academy of Pediatrics as age 11 to 21 years) who underwent primary hip arthroscopy with routine capsular closure for the treatment of FAIS between January 2012 and January 2015 by a single, fellowship-trained surgeon was collected. Baseline data, clinical outcomes including Hip Outcome Score (HOS)-Activities of Daily Living, HOS-Sports Subscale, modified Harris hip score, international Hip Outcome Tool, and clinical failure rates were recorded at 5 years after operative. Clinical failure was defined by revision hip arthroscopy or conversion to total hip arthroplasty. Clinically significant outcomes was defined as achieving MCID, PASS, or SCB on at least 1 hip-specific outcome measure.

RESULTS

Of the 139 eligible patients, a total of 85 (60.4%) patients (85 hips) were included in the final analysis, with an age and body mass index average of 17.6 ± 2.5 years (range 13-21) and 22.3 ± 3.1 kg/m², respectively. The majority of the patients were female (80.6%) and participated in sports (76.2%). There was statistically significant difference between preoperative and postoperative score averages across every reported outcome (P < .001). At 5 years, 88.4%, 67.6%, and 64.9% reached at least 1 threshold for achieving MCID, PASS, and SCB, respectively, whereas 89.2% achieved at least one of the meaningful outcome thresholds. Last, 2 patients (2.4%) failed clinically, with both undergoing revision (2.4%) because of continued pain. There were no conversions to total hip arthroplasty.

CONCLUSION

This study demonstrated that a large majority (89.2%) of adolescent patients undergoing primary arthroscopic treatment for symptomatic FAIS achieved meaningful clinically significant outcomes. Furthermore, only 2.4% of patients failed clinically, requiring revision hip arthroscopy because of continued pain.

LEVEL OF EVIDENCE

IV, Retrospective Case Series.

Surgical Treatment of Labral Tears: Debridement, Repair, and Reconstruction

Advances in hip preservation surgery have to lead to increased utilization of hip arthroscopy. With this, there has also been a growth in the understanding of various hip conditions, therefore, leading to an increase in hip conditions amenable to arthroscopic intervention. The acetabular hip labrum has been at the forefront of arthroscopic advances in the hip. The labrum is important for hip stability, provision of the suction seal, and joint proprioception. Given the labrum's central role in hip biomechanics, there is increasing emphasis on labral preservation in the form of debridement and repair. In revision settings, advanced techniques such as labral augmentation and reconstruction may play a role in the management of labral pathology. Appropriate management of the hip labrum at the time of surgery can be an important mediator of the outcome. As such, an understanding of the evolving evidence base and surgical indications and techniques are integral to the treatment and management of labral pathology.

Cutting, Impingement, Contact, Endurance, Flexibility, and Asymmetric/Overhead Sports: Is There a Difference in Return-to-Sport Rate After Arthroscopic Femoroacetabular Impingement Surgery? A Systematic Review and Meta-analysis

BACKGROUND

Previous studies have established a classification of sports based on hip mechanics: cutting, impingement, contact, endurance, flexibility, and asymmetric/overhead. No previous review has compared the outcomes of hip arthroscopy for femoroacetabular impingement syndrome (FAIS) using this classification.

PURPOSE

To determine whether the rate of return to sport differs among cutting, impingement, contact, endurance, flexibility, and asymmetric/overhead athletes who undergo hip arthroscopy for FAIS. We also aimed to identify differences in patient characteristics, intraoperative procedures performed, and time to return to play among the 6 sport categories.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Three electronic databases were searched for eligible articles. Two reviewers independently screened the titles, abstract, and full-text articles using prespecified criteria. Eligible articles were those that reported the rate of return to sport (defined by the number of hips) after hip arthroscopy for FAIS in athletes of all levels. Data collected were patient age, sex, body mass index, type of sport, rate and time to return to sport, and intraoperative procedures performed. A mixed effects model was used for meta-analysis.

RESULTS

A total of 29 articles and 1426 hip arthroscopy cases were analyzed with 185 cutting, 258 impingement, 304 contact, 207 endurance, 116 flexibility, and 356 asymmetric/overhead athletes. The mean age was similar among the 6 subgroups (P = .532), but the proportion of female athletes was significantly higher in flexibility, endurance, and asymmetric/overhead sports as compared with impingement and contact athletes. Flexibility athletes had the highest rate of return to sport after hip arthroscopy for FAIS (94.8%), whereas contact athletes had the lowest rate (88%). The longest mean ± SD time (8.5 ± 1.9 months) to return to sport was reported in cutting sports, while endurance athletes returned faster than the rest (5.4 ± 2.6 months). The difference in rate and time to return to sport, as well as the intraoperative procedure performed, did not reach statistical significance among the 6 subgroups. There was evidence of publication bias and study heterogeneity, and the mean Methodological Index for Non-randomized Studies score was 13 ± 2.6.

CONCLUSION

Flexibility athletes had the highest rate of return to sport after hip arthroscopy for FAIS, while endurance athletes returned the fastest. The difference in rate and time to return to sport and intraoperative procedures performed did not reach statistical significance among the 6 subgroups. These results are limited by the evidence of publication bias and should be interpreted with caution. Laboratory-based studies are necessary to validate the classification of sports based on hip mechanics.

Return to Sports After Joint Preservation Hip Surgery

Femoroacetabular impingement results from a mismatch of congruency between the femoral head and the acetabulum. This condition is most common among young, active patients and may lead to pain, decreased quality of life, and inability to participate in athletics. Hip preservation surgery is widely performed is used as a definitive treatment option in athletes at all levels of competition. Athletes have reported high rates of return to play and satisfaction and expect rehabilitation to require approximately 4 to 6 months. This article provides an overview of femoroacetabular impingement, including diagnosis and treatment, with focus on athletes and return to play.

The Hip Suction Seal, Part II: The Effect of Rim Trimming, Chondrolabral Junction Separation, and Labral Repair/Refixation on Hip Distractive Stability

BACKGROUND

The acetabular labrum contains free nerve endings, and an unstable labrum can result in increased femoral head movement during hip motion. This can be caused by chondrolabral junction (CLJ) separation, especially in association with pincer-type femoroacetabular impingement, and may contribute to hip pain.

HYPOTHESIS

Rim resection alone has no effect on suction seal biomechanics. Further, separation of the CLJ changes hip suction seal biomechanics when compared with those of the native state, whereas repair and refixation with suture anchors restore these biomechanical parameters.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 12 fresh-frozen human cadaveric hips were used in this study. Hips were mounted in a saline bath on a dynamic tensile testing machine and were distracted at a rate of 0.5 mm/s from neutral position. A total of 3 parameters (force, displacement, and intra-articular pressure) were measured throughout testing. Before testing, hips were randomly allocated to 1 of 2 groups: 1 that included the CLJ separation (CLJ Cut group) and 1 that did not (CLJ Intact group). Hips were tested in the following states: (1) native, (2) rim trimming, (3) separated CLJ (CLJ Cut group only), and (4) labral repair/refixation. For each group a linear mixed-effects model was used to compare biomechanical parameters between states.

RESULTS

Rim trimming did not affect any suction seal parameters relative to those of the native state. In the CLJ Cut group, no significant difference in distance to break the suction seal was observed for any states compared with that of the native state. In the CLJ Intact group, the distance to break the suction seal was significantly shorter in the labral refixation state (1.8 mm) than the native state (5.6 mm; P = .002). The maximum distraction force (62.1 ± 54.1 N) and the peak negative pressure (-36.6 ± 24.2 kPa) of the labral repair/refixation state were significantly lower than those of the native state in both groups (93.4 ± 41.7 N, P = .01; -60.7 ± 20.4 kPa, P = .02).

CONCLUSION

Rim trimming did not change the biomechanical properties of the labral suction seal. Labral refixation resulted in a shorter distance to break the labral suction seal. This indicates that labral mobility is reduced by the labral refixation procedure, which could be beneficial in postoperative pain relief and labral healing.

CLINICAL RELEVANCE

The labral refixation reduced labral mobility, which could be beneficial for both pain relief and labral healing to the acetabulum after pincer-type femoroacetabular impingement resection.

Recreational Sports and Intra-articular Hip Injuries in Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement

Purpose

We aimed to determine the relationship between recreational sports and intra-articular hip injuries in an active population that had undergone hip arthroscopy for femoroacetabular impingement syndrome.

Methods

A retrospective review was performed of prospectively collected data from patients undergoing hip arthroscopy between January 2015 and December 2016. Inclusion criteria included patients between 18 and 50 years of age who had participated in recreational sports prior to surgery and had a minimum of a 2-year follow-up. Labral injury was evaluated using the Multicenter Arthroscopic Hip Outcome Research Network classification, and rim chondral injuries were evaluated using the Acetabular Labral Articular Disruptions system. Ligamentum teres tear and psoas impingement were also recorded. Sports were classified as rotational running (soccer, basketball, handball), flexibility (martial arts, dance), asymmetric-overhead (racquet), or endurance (running, swimming, cycling). Primary univariate analysis of sports’ independent associations, demographic characteristics, intra-articular hip injuries, and outcomes was performed.

Results

Patients included 185 people with a mean age of 36.7 years. Patients participating in rotational running sports and flexibility sports had a significantly greater proportion of rim chondral injuries than those participating in endurance sports or asymmetric overhead sports (P = 0.02). Ligamentum teres tears were significantly associated with flexibility sports (P < 0.001). A total of 84.7%, 67.7%, 67.2%, and 71.2% of patients met minimal clinically important difference levels for the modified Harris Hip Score (mHHS), the Hip Outcome Score (HOS)¹⁰ questionnaire with activities of daily living (HOS-ADL), the sports subscale (HOS-SSS), and the International Hip Outcome Tool (iHOT-12), respectively; 94.9%, 66.2% and 62.7% met the patient acceptable symptom state for mHHS, HOS-ADL, and HOS-SSS, respectively; 86.7%, 48.5%, 47.8%, and 32.4% found substantial clinical benefit for mHHS, HOS-ADL, HOS-SSS, and iHOT-12, respectively.

Conclusions

Rotational running sports were significantly associated with rim chondral injuries. Flexibility sports were significantly associated with rim chondral injuries and ligamentum teres tears. Athletes participating in these sports are more likely to have intra-articular hip injuries than those in the other sports categories.

Level of Evidence

Level IV, prognostic case series.

Return to play after hip arthroscopy among tennis players: outcomes with minimum five-year follow-up

BACKGROUND

Playing tennis is associated with various movements that can lead to labral injuries and may require arthroscopic surgery. While hip arthroscopies have demonstrated good outcomes in athletes, there is limited literature reporting patient reported outcomes (PROs) and return to sport (RTS) in competitive or recreational tennis players after arthroscopic hip surgery. Therefore, the purpose of the present study was to (1) report minimum five-year PROs and RTS in tennis players who underwent arthroscopic hip surgery and (2) compare outcomes between recreational and competitive tennis players.

METHODS

Data for patients who underwent hip arthroscopy surgery in the setting of femoroacetabular impingement and labral tears between March 2009 and January 2014 and who played tennis within one-year of surgery were retrospectively reviewed. Patients with preoperative and minimum five-year postoperative scores for the following PROs were included: modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sport Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain. Patient Acceptable Symptomatic State (PASS) and Minimal Clinically Important Difference (MCID) for mHHS and HOS-SSS were calculated.

RESULTS

Of 28 patients, 31 hips met all inclusion and exclusion criteria of which 28 (90.3%) had minimum 5-year follow-up (mean: 72.8 ± 13.9 months). There were 3 professional, 3 collegiate, 2 high school, 2 organized amateur, and 18 recreational level tennis players. All PROs significantly improved at latest follow-up: mHHS from 67.0 to 86.7 (P <  0.001), NAHS from 65.9 to 87.2 (P <  0.001), HOS-SSS from 50.0 to 77.9 (P = 0.009), and VAS from 5.4 to 1.8 (P <  0.001). There was a 75.0% RTS rate. Additionally, 66.7% of patients achieved MCID and 83.3% achieved PASS for mHHS, and 63.6% achieved MCID and 58.3% achieved PASS for HOS-SSS.

CONCLUSION

Regardless of the level of participation, tennis players who underwent arthroscopic hip surgery reported statistically significant PRO improvements. A favorable rate of RTS was also achieved by players with a continued interest in playing. The data here may be useful in counseling tennis players of various levels who are considering arthroscopic treatment of a hip injury.

LEVEL OF EVIDENCE

IV.

Patients With Borderline Hip Dysplasia Achieve Clinically Significant Improvement After Arthroscopic Femoroacetabular Impingement Surgery: A Case-Control Study With a Minimum 5-Year Follow-up

BACKGROUND

Hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS) in patients with borderline hip dysplasia (BHD) is becoming a more common practice. However, the literature on achieving meaningful outcomes at midterm follow-up, as well as predictors of these outcomes, is limited.

PURPOSE

To (1) compare the rates of achieving meaningful clinical outcomes between patients with and without BHD and (2) identify the predictors for achieving clinical success among patients with BHD 5 years after undergoing hip arthroscopic surgery for FAIS.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data from consecutive patients who underwent primary hip arthroscopic surgery with routine capsular closure for the treatment of FAIS between January 2012 and August 2014 were collected and retrospectively analyzed. Patients with BHD (lateral center-edge angle [LCEA] 20°-25°) were matched 1:2 by age (±1 year) and body mass index (BMI; ±5 kg/m²) to control patients with normal acetabular coverage (LCEA 25°-40°). Data collected included baseline and 5-year postoperative patient-reported outcomes. The minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) were calculated for each patient-reported outcome measure and compared between the 2 groups. A binary logistic regression analysis was used to identify significant predictors of achieving the MCID and PASS in the BHD group.

RESULTS

The MCID in the BHD group was defined as 9.6, 14.1, and 9.5 for the Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports Subscale, and modified Harris Hip Score, respectively. Threshold scores for achieving the PASS in both groups were 90.9, 76.6, and 81.9, respectively. A total of 88 patients were identified with having BHD and were matched to 176 controls. No statistical differences were identified for age, BMI, or sex. Both the BHD and the non-BHD groups had statistically significant increases in patient-reported outcome scores over the 5-year period, but the difference in both groups was not statistically significant (P > .05 for all). There was no statistical difference in the frequency of patients in the BHD and non-BHD groups achieving the MCID (86.6% vs 85.2%, respectively; P = .804) or PASS (76.0% vs 73.7%, respectively; P = .675) on at least 1 outcome measure. The logistic regression model demonstrated that being physically active (odds ratio [OR], 27.59; P = .005) and being female (OR, 14.64; P = .025) were independent predictors of achieving the MCID, while running (OR, 11.1; P = .002), being female (OR, 7.6; P = .011), and a larger preoperative LCEA (OR, 2.3; P = .001) were independent preoperative predictors of achieving the PASS.

CONCLUSION

The rates of achieving clinical success 5 years after undergoing arthroscopic treatment with capsular closure for FAIS were not significantly different between patients with BHD and those with normal acetabular coverage. Being physically active, running for exercise, female sex, and a larger LCEA were preoperative predictors of achieving clinical success at 5 years in patients with BHD.

Return to Sport After Femoroacetabular Impingement Surgery and Sport-Specific Considerations: a Comprehensive Review

PURPOSE OF REVIEW

Recent advancements in surgical technology and techniques have improved functional results for operative treatment of femoroacetabular impingement syndrome (FAIS). Few studies have comprehensively evaluated the literature regarding return to sport criteria, timing, level, and rates. The purpose of this study was to review recent studies regarding return to play after surgical correction of FAIS. We will specifically evaluate the level of return to play and look to compare pre- and postoperative competition levels when available. We will also analyze timing of return to play from injury to surgery. Additionally, we will elucidate any sport-specific criteria that may determine readiness for return.

RECENT FINDINGS

Athletes with FAIS treated non-operatively have a low rate of return to sport and are often functionally limited in their level of performance. Surgical management of FAIS includes hip arthroscopy as well as open techniques. Current literature suggests a high rate of return to sport after contemporary surgery for FAIS at 87-93% overall. Rate of return to the same level of competition following surgery for FAIS is 55-83% in pooled studies. Limited evidence is available comparing postoperative rehabilitation protocols and timing of return among different sports. Operative treatment of FAIS results in high rates of return to sport and functional performance. The results of this study may help educate patients preoperatively in regard to the likelihood of functional return to sport and sport-specific considerations. Further research evaluating rehabilitation protocols and return criteria may better elucidate timing intervals for patients to maximize function while limiting complications.

Return to Sport After Hip Arthroscopy for Femoroacetabular Impingement Syndrome in NCAA Division I Athletes: Experience at a Single Institution

Background:

The rate of return to sport after surgical treatment of femoroacetabular impingement (FAI) syndrome (FAIS) has been studied in high-level athletes. However, few studies examining this rate have focused exclusively on National Collegiate Athletic Association (NCAA) Division I athletes.

Purpose:

To evaluate the return-to-sport rate after hip arthroscopy for FAIS and to examine the influence of sport type on the clinical presentation of FAIS in collegiate athletes.

Study Design:

Case series; Level of evidence, 4.

Methods:

Included in this study were NCAA Division I student-athletes who underwent hip arthroscopy for FAIS at our institution between 2010 and 2017. Exclusion criteria were history of previous hip pathology, pediatric hip disease, radiographic evidence of osteoarthritis (Tönnis grade >0), prior lower extremity procedure, history of chronic pain, osteoporosis, or history of systemic inflammatory disease. Athletes were categorized into 6 subgroups based on the type of sport (cutting, contact, endurance, impingement, asymmetric/overhead, and flexibility) by using a previously reported classification system. Patient characteristics and preoperative, intraoperative, and return-to-sport variables were compared among sport types.

Results:

A total of 49 hip arthroscopies for FAIS were performed in 39 collegiate athletes (10 females, 29 males; mean age, 19.5 ± 1.3 years). A total of 1 (2.6%) cutting athlete, 15 (38.5%) contact athletes, 8 (20.5%) impingement athletes, 6 (15.4%) asymmetric/overhead athletes, and 9 (23.1%) endurance athletes were included in the study. There were no differences among sports groups with respect to the FAI type. Endurance athletes had lower rates of femoral osteochondroplasty (45.5%) and labral debridement (0.0%) (P < .0001). Contact sport athletes had higher rates of labral debridement (50.0%; P < .0001). Patients were evaluated for return to sport at an average of 1.96 ± 0.94 years. Overall, the return-to-sport rate was 89.7%. There were no differences in return-to-sport rates based on the sport type except for endurance athletes, who returned at a lower rate (66.6%; P < .001). No differences in return-to-sport rate (P = .411), duration after return (P = .265), or highest attempted level of sport resumed (P = .625) were found between patients who underwent labral repair versus debridement.

Conclusion:

Collegiate-level athletes who underwent hip arthroscopy for FAIS returned to sport at high and predictable rates, with endurance athletes possibly returning to sport at lower rates than all other sport types. Surgical procedures may be influenced by sport type, but the rate of return to sport between athletes who underwent labral debridement versus labral repair was similar.

Outcomes of Hip Arthroscopic Surgery in Adolescents With a Subanalysis on Return to Sport: A Systematic Review

BACKGROUND

There is a plethora of literature on outcomes after hip arthroscopic surgery in the adult population; however, outcomes in the adolescent population have not been as widely reported. Additionally, as adolescents represent a very active population, it is imperative to understand their athletic activity and return to sport after hip arthroscopic surgery.

PURPOSE

To analyze patient-reported outcomes (PROs) after hip arthroscopic surgery in adolescents (aged 10-19 years) and present a return-to-sport analysis in the athletic adolescent subgroup.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The PubMed, Embase, and Cochrane databases were searched according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify articles that reported PROs after hip arthroscopic surgery in adolescents. The standardized mean difference was calculated to compare the effect size of hip arthroscopic surgery on various PROs. For the athletic subgroup, a return-to-sport summary was also provided.

RESULTS

Ten studies, with 618 adolescent hips and a collective study period of December 2004 to February 2015, were included in this systematic review. Across all studies, the mean age was 15.8 years (range, 11.0-19.9 years), and female patients composed approximately 56.7% of the entire cohort. The mean follow-up was 34.5 months (range, 12-120 months). The modified Harris Hip Score (mHHS) was reported in 9 studies, and at latest follow-up, scores were excellent in 4 studies (range, 90-95) and good in the remaining 5 studies (range, 82.1-89.6). All adolescents also showed significant improvement on the Non-Arthritic Hip Score (NAHS), the Hip Outcome Score-Activities of Daily Living (HOS-ADL), the HOS-Sport-Specific Subscale (HOS-SSS), the physical component of the 12-Item Short Form Health Survey (SF-12P), a visual analog scale for pain (VAS), and both versions of the International Hip Outcome Tool (iHOT-12 and iHOT-33) at latest follow-up (P < .05). Further, mean improvements reported in all studies surpassed reported values of the minimal clinically important difference and patient acceptable symptomatic state for the mHHS, HOS-ADL, HOS-SSS, and iHOT-33. Finally, the collective return-to-sport rate among athletic adolescents was 84.9%.

CONCLUSION

In the setting of labral tears and femoroacetabular impingement, hip arthroscopic surgery can safely be performed in adolescents and leads to significant functional improvement. Furthermore, athletic adolescents return to sport at high levels after hip arthroscopic surgery.

Defining Meaningful Functional Improvement on the Visual Analog Scale for Satisfaction at 2 Years After Hip Arthroscopy for Femoroacetabular Impingement Syndrome

PURPOSE

To (1) define Substantial Clinical Benefit (SCB), Patient Acceptable Symptomatic State (PASS), and Minimal Clinically Important Difference (MCID) for the visual analog scale (VAS) Satisfaction in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS), and (2) identify preoperative predictors of achieving each outcome end-point.

METHODS

Data from consecutive patients who underwent primary hip arthroscopy between November 2014 and January 2017 were prospectively collected and retrospectively analyzed. Inclusion criteria consisted of patients with clinical and radiographic diagnosis of FAIS, who failed nonoperative treatment, underwent primary hip arthroscopy to address the FAIS, and had at minimum 2-year follow-up. Baseline data and postoperative patient-reported outcome scores were recorded at 2 years postoperatively. To quantify clinical significance of outcome achievement on the VAS)Satisfaction, we calculated MCID, PASS, and SCB for this outcome measure. A multivariate logistic regression analysis was used to identify preoperative predictors of achieving SCB, PASS, and MCID satisfaction.

RESULTS

A total of 335 patients were included in the final analysis, with an average age and body mass index (BMI) of 32.8 (standard deviation ± 12.4) years and 25.2 (standard deviation ± 5.3), respectively, and the majority being female (69.3%). The values on the VAS satisfaction were identified to represent MCID, PASS, and SCB, respectively: 52.8, 80.9, and 89.7. The rates of achieving clinically significant improvement on the VAS Satisfaction was 85.6%, 68.1%, and 56.9% for MCID, PASS, and SCB, respectively. A larger preoperative alpha angle was predictive for achieving SCB (odds ratio [OR], 1.076; P = .046), whereas lower BMI (OR, 0.955; P = .047) and larger preoperative alpha angle (OR, 1.12; P = .025) were predictors for achieving PASS.

CONCLUSIONS

This study identified threshold VAS satisfaction scores of 52.8, 80.9, and 89.7 for achieving MCID, SCB, and PASS, respectively, at 2-year follow-up following hip arthroscopy for FAIS. Furthermore, preoperative variables including larger preoperative alpha angles and lower BMI are predictors of achieving superior clinical satisfaction.

LEVEL OF EVIDENCE

Level IV, Case Series.

Squat and gait biomechanics 6 months following hip arthroscopy for femoroacetabular impingement syndrome

The purpose of this study was to (i) assess whether squat and gait biomechanical measures improve in patients with femoroacetabular impingement syndrome (FAIS) 6 months after surgery compared to pre-operative measures and (ii) compare biomechanical properties to controls without FAIS. In this prospective study, biomechanical data during a double leg squat task and gait for 15 FAIS patients and 9 controls were collected using three-dimensional motion analysis. Data were collected in the FAIS group at two-time points, pre-operatively and 6-month post-operatively following arthroscopic hip surgery, and at a single time point for the healthy controls. Independent sample's t-test were used to compare the FAIS group to the controls, and paired samples t-test were used to determine within-group differences before and after hip arthroscopy in the FAIS group. The results indicated that there were significant within-group increases for sagittal plane moment rate during the double leg squat task (P = 0.009) between the pre-operative and post-operative time points for the FAIS group. Between-group differences showed that FAIS patients pre-operatively exhibit slower squat velocities during the descent (P = 0.005) and ascent phase (P = 0.012) of a double leg squat when compared healthy controls. Reduced hip external rotation moments during gait (P = 0.02) were also found between FAIS patients pre-operatively and controls. In conclusion, alterations in hip biomechanics are present before surgery for FAIS when compared to healthy controls, and joint mechanics change 6 months after surgery. However, the biomechanical differences during a double leg squat and gait were minimal.

Return to Sport and Athletic Function in an Active Population After Primary Arthroscopic Labral Reconstruction of the Hip

Background:

Labral reconstruction has been advocated as an alternative to debridement for the treatment of irreparable labral tears, showing favorable short-term results. However, literature is scarce regarding outcomes and return to sport in the nonelite athletic population.

Purpose:

To report minimum 1-year clinical outcomes and the rate of return to sport in athletic patients who underwent primary hip arthroscopy with labral reconstruction in the setting of femoroacetabular impingement syndrome and irreparable labral tears.

Study Design:

Case series; Level of evidence, 4.

Methods:

Data were prospectively collected and retrospectively analyzed for patients who underwent an arthroscopic labral reconstruction between August 2012 and December 2017. Patients were included if they identified as an athlete (high school, college, recreational, or amateur); had follow-up on the following patient-reported outcomes (PROs): modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score–Sport Specific Subscale (HOS-SSS), and visual analog scale (VAS); and completed a return-to-sport survey at 1 year postoperatively. Patients were excluded if they underwent any previous ipsilateral hip surgery, had dysplasia, or had prior hip conditions. The proportions of patients who achieved the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) for mHHS and HOS-SSS were calculated. Statistical significance was set at P = .05.

Results:

There were 32 (14 females) athletes who underwent primary arthroscopic labral reconstruction during the study period. The mean age and body mass index of the group were 40.3 years (range, 15.5-58.7 years) and 27.9 kg/m² (range, 19.6-40.1 kg/m²), respectively. The mean follow-up was 26.4 months (range, 12-64.2 months). All patients demonstrated significant improvement in mHHS, NAHS, HOS-SSS, and VAS (P < .001) at latest follow-up. Additionally, 84.4% achieved MCID and 81.3% achieved PASS for mHHS, and 87.5% achieved MCID and 75% achieved PASS for HOS-SSS. VAS pain scores decreased from 4.4 to 1.8, and the satisfaction with surgery was 7.9 out of 10. The rate of return to sport was 78%.

Conclusion:

At minimum 1-year follow-up, primary arthroscopic labral reconstruction, in the setting of femoroacetabular impingement syndrome and irreparable labral tears, was associated with significant improvement in PROs in athletic populations. Return to sport within 1 year of surgery was 78%.

The Influence of Lumbosacral Spine Pathology on Minimum 2-Year Outcome After Hip Arthroscopy: A Nested Case-Control Analysis

BACKGROUND

Previous literature has examined the association between lumbosacral pathology and hip pathomechanics. However, the effect of lumbosacral pathologies and previous lumbosacral surgery on achieving meaningful outcomes after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) has yet to be studied conclusively.

PURPOSE

To determine whether a history of lumbosacral spine pathology has an influence on achieving minimal clinically important differences (MCIDs) after hip arthroscopy for FAIS.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients undergoing hip arthroscopy for FAIS by a single, fellowship-trained orthopaedic surgeon between January 2012 and April 2017 with minimum 2-year follow-up were retrospectively reviewed. Patients with a history of lumbosacral spine pathology (eg, lumbosacral fusion, disc or vertebral pathology, or history of lumbosacral fractures) were matched 1:2 by age, body mass index, and sex to patients without spine pathology. Clinical outcomes including the Hip Outcome Score-activities of daily living subscale (HOS-ADL), HOS-sports subscale (HOS-SS), modified Harris Hip Score (mHHS), international Hip Outcome Tool-12 (iHOT-12), visual analog scale (VAS) pain, and VAS satisfaction were compared between the groups using an independent t test. The threshold of every outcome score for achieving MCID was calculated separately for each group and frequencies were compared.

RESULTS

A total of 83 of 108 eligible patients with lumbosacral pathology were identified and matched to 166 patients without any spine pathology. When compared with the non-spine pathology group, the lumbosacral pathology group had significantly lower 2-year postoperative outcome score averages across all reported outcome tools (all P < .001). There were significant differences in the proportion achieving the threshold for HOS-ADL (60.6% vs 80.0%; P = .004), HOS-SS (57.6% vs 82.1%; P < .001), mHHS (66.7% vs 81.7%; P = .025), and iHOT-12 (54.8% vs 87.6%; P < .001) scores for MCID when comparing the lumbosacral and nonlumbosacral pathology groups.

CONCLUSION

Patients with a history of lumbosacral pathology achieved significantly lower short-term meaningful clinical outcomes after undergoing hip arthroscopy for FAIS when compared with patients without spine pathology. The present study findings have implications for preoperative patient screening, shared decision-making processes/expectation management, and rehabilitation strategies.

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

What is the Role of Kinesiophobia and Pain Catastrophizing in Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome?

Purpose

To (1) investigate trends in kinesiophobia and pain catastrophizing after hip arthroscopy for femoroacetabular impingement syndrome (FAIS), and (2) determine whether kinesiophobia and pain catastrophizing scores are associated with achieving minimal clinically important difference (MCID) for any of the hip-specific patient-reported outcome questionnaires.

Methods

Patients undergoing primary hip arthroscopy for treatment of FAIS between December 2016 and March 2017 were prospectively enrolled. Patients received the Tampa Scale of Kinesiophoibia-11 (TSK-11) and Pain Catastrophizing Scale (PCS) questionnaires preoperatively, 6 months, and 1 year postoperatively. They also received the hip-specific patient-reported outcome questionnaires (Hip Outcome Score Activities of Daily Living and Sport-Specific subscales, modified Harris Hip Score, and International Hip Outcome Tool-12), as well as visual analog scale for satisfaction and pain preoperatively and 1-year postoperatively. The threshold for achieving MCID was determined for each hip outcome tool, and patients achieving MCID were compared with those who did not.

Results

A total of 85 (80.2%) patients (mean age: 33.7 ± 12.4 years; female: 75.3%) were included in the final analysis. At 1-year follow-up, there was a significant reduction in TSK-11 scores (26.22 ± 5.99 to 18.70 ± 6.49; P < .001) and PCS scores (17.81 ± 10.13 to 4.77 ± 7.57; P < .001) when compared with preoperative scores. 1-year PCS scores were significantly lower in patients achieving MCID compared with patients failing to achieve MCID (3.2 ± 4.4 vs 10.8 ± 15.2; P = .006). There were no significant differences in TSK-11 scores between those achieving and not achieving MCID.

Conclusions

Patient kinesiophobia and pain catastrophizing both show significant improvements 1 year after undergoing hip arthroscopy for FAIS. However, pain catastrophizing scores at 1 year are significantly greater in patients not achieving MCID, whereas no association was identified between kinesiophobia and likelihood for MCID achievement. This suggests PCS may be a more useful tool than TSK-11 during postoperative rehabilitation for identifying patients at risk for not achieving MCID.

Level of Evidence

Level II, prospective case series.

Defining the Minimal Clinically Important Difference in Athletes Undergoing Arthroscopic Correction of Sports-Related Femoroacetabular Impingement: The Percentage of Possible Improvement

BACKGROUND

Measures of clinically meaningful improvement in patient-reported outcomes within orthopaedics are becoming a minimum requirement to establish the success of an intervention.

PURPOSE

To (1) define the minimal clinically important difference (MCID) at 2 years postoperatively in competitive athletes undergoing hip arthroscopic surgery for symptomatic, sports-related femoroacetabular impingement utilizing existing anchor- and distribution-based methods and (2) derive a measure of the MCID using the percentage of possible improvement (POPI) method and compare against existing techniques.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

There were 2 objective outcome measures-the modified Harris Hip Score (mHHS) and 36-Item Short Form Health Survey (SF-36)-administered at baseline and 2 years postoperatively. External anchor questions were used to determine the MCID through mean change, mean difference, and receiver operating characteristic (ROC) techniques. Distribution-based calculations consisted of 0.5 SD, effect size, and standard error of measurement techniques. The POPI was calculated alongside each technique as an achieved percentage change of maximum available improvement for each athlete relative to the individual baseline score. The impact of the preoperative baseline score on the MCID was assessed by assigning athletes to groups determined by baseline percentiles. Statistical analysis was performed, with P < .05 considered significant.

RESULTS

There were 576 athletes (96% male; mean age, 25.9 ± 5.7 years). The MCID score change (and POPI) for the mHHS and SF-36 ranged from 2.4 to 16.7 (21.6%-63.6%) and from 3.3 to 24.9 (22.1%-57.4%), respectively. The preoperative threshold value for achieving the ROC-determined MCID was 80.5 and 86.5 for the mHHS and 70.1 and 72.4 for the SF-36 for the patient-reported outcome measure (PROM) score- and POPI-calculated MCID, respectively. Through the commonly used mean change method, 40.0% (mHHS) and 42.4% (SF-36) of athletes were unable to achieve the MCID because of high baseline scores and PROM ceiling effects compared with 0% when the POPI technique was used. A highly significant difference for the overall MCID was observed between preoperative baseline percentile groups for the mHHS (P = .014) and SF-36 (P = .004) (improvement in points), while there was no significant difference between groups for either the mHHS (P = .487) or SF-36 (P = .417) using the POPI technique.

CONCLUSION

The MCID defined by an absolute value of improvement was unable to account for postoperative progress in a large proportion of higher functioning athletes. The POPI technique negated associated ceiling effects, was unrestricted by the baseline score, and may be more appropriate in quantifying clinically important improvement.

Preoperative Predictors of Achieving Clinically Significant Athletic Functional Status After Hip Arthroscopy for Femoroacetabular Impingement at Minimum 2-Year Follow-Up

PURPOSE

To identify predictors of achieving clinically significant sport function in athletic patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

METHODS

Data were analyzed for all patients who treated for FAIS between 2012 to 2016 and reported being athletes, including recreational and competitive athletes. All patients had a minimum of 2-year follow-up with patient-reported athletic function in the form of the Hip Outcome Score-Sport Specific (HOS-SS), visual analog score-pain, and patient satisfaction. Achieving clinically significant sports function was defined as either reaching the minimally clinical important difference (MCID) or the patient acceptable symptomatic state (PASS) for HOS-SS at 2-year follow-up. An exploratory factor analysis was used to determine specific domains for the predictor variables and to reduce the redundancy in these variables. A logistic regression analysis was used to identify significant predictors of achieving clinically significant sports function [corrected].

RESULTS

Of 780 qualifying patients, 626 completed the 2-year minimum follow-up (80%), with a mean age and body mass index of 31.6 ± 11.9 years and 24.6 ± 8.6, respectively. A total of 500 patients (86.5%) achieved high functional status, with 77.9% achieving MCID HOS-SS and 68.7% achieving PASS HOS-SS. Logistic regression analysis identified increased the α angle (odds ratio [OR] 0.976; P = .027), preoperative pain duration (OR 0.729; P = .011), and body mass index (BMI) (OR 0.919; P = .018), as well as the presence of femoral chondral defects (OR 0.769; P = .013), as negative predictors for achieving MCID. Negative predictors for achieving PASS HOS-SS included the presence of a preoperative limp (OR 0.384; P = .013), anxiety or depression (OR 0.561; P = .041), and increased BMI (OR 0.945; P = .018) and preoperative pain duration (OR 0.987; P < .001).

CONCLUSIONS

Several predictors of achieving clinically significant sport function performance exist, including a history of anxiety or depression, BMI, preoperative α angle, limp, femoral chondral damage, *and preoperative symptom duration. Our results suggest there are both modifiable and nonmodifiable preoperative factors that have the potential to predict achieving high athletic function after hip arthroscopy for FAIS.

LEVEL OF EVIDENCE

IV, Case Series.

How Can We Define Clinically Important Improvement in Pain Scores After Hip Arthroscopy for Femoroacetabular Impingement Syndrome? Minimum 2-Year Follow-up Study

BACKGROUND

Patient postoperative pain is being increasingly reported in the field of hip preservation surgery. The visual analog scale (VAS) for pain is one of the most commonly utilized measures for perioperative pain assessment. Currently, there is limited understanding of clinically significant improvement in VAS pain.

PURPOSE

(1) To define the substantial clinical benefit (SCB), patient acceptable symptomatic state (PASS), and minimal clinically important difference (MCID) for the VAS pain score in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome after 2 years from surgery and (2) to identify preoperative predictors of achieving each outcome endpoint.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Data from consecutive patients who underwent primary hip arthroscopy between November 2014 and March 2017 were collected and analyzed. Baseline data and postoperative patient-reported outcome scores were recorded at 2 years postoperatively. To quantify clinical significance of outcome achievement for the VAS pain score, the MCID, PASS, and SCB were calculated.

RESULTS

A total of 976 patients were included in the final analysis. The VAS pain score threshold for achieving the MCID was defined as a decrease of 14.8; the PASS was defined as achieving a 2-year postoperative score of 21.6 points; and the SCB was defined as a decrease of 25.5 or a score of 15.4 points at 2 years. The rates of achieving the MCID, PASS, and SCB were 97.6%, 66.4%, and 71.2%, respectively. Regression analysis demonstrated that sports involvement, low body mass index, smaller preoperative alpha angle, and absence of articular damage and chondromalacia were predictive of achieving the PASS (all P < .05). Preoperative predictors for achieving the SCB included being male, no smoking history, smaller alpha angle, higher modified Harris Hip Score, and lower VAS pain score (all P < .05).

CONCLUSION

This study identified scores for VAS pain that can be used to define clinically significant outcome after arthroscopic treatment of femoroacetabular impingement syndrome. Specifically, a decrease in pain score of 14.8 was a clinically important improvement in VAS pain, while an absolute score <15.4 or a change of 25.5 represented the upper threshold of VAS pain improvement. Additionally, there were both modifiable and nonmodifiable factors that predicted achieving clinically significant levels of postoperative pain improvement.

Athletes experience a high rate of return to sport following hip arthroscopy

PURPOSE

The purpose of this systematic review was to evaluate the rate at which patients return to sport following arthroscopic hip surgery.

METHODS

The databases MEDLINE, EMBASE, and PubMed were searched by two reviewers, and titles, abstracts, and full-text articles screened in duplicate. English language studies investigating hip arthroscopy with reported return to sport outcomes were included. A meta-analysis of proportions was used to combine the rate of return to sports using a random effects model.

RESULTS

Overall, 38 studies with 1773 patients (72% male), with a mean age of 27.6 years (range 11-65) and mean follow-up of 28.1 months (range 3-144) were included in this review. The pooled rate of return to sport was: 93% [95% confidence interval (CI) = 87-97%] at any level of participation; 82% (95% CI = 74-88%) at preoperative level of sporting activity; 89% (95% CI = 84-93%) for competitive athletes; 95% (95% CI = 89-98%) in pediatric patients; and 94% (95% CI 89.2-98.0%) in professional athletes. There was significant correlation between a shorter duration of preoperative symptoms and a higher rate of return to sports (Pearson correlation coefficient = - 0.711, p = 0.021).

CONCLUSION

Hip arthroscopy yields a high rate of return to sport, in addition to marked improvement in pain and function in the majority of patients. The highest rates of return to sport were noted in pediatric patients, professional athletes, and those with a shorter duration of preoperative symptoms. This study provides clinicians with evidence-based data on athletes' abilities to return to sport after arthroscopic hip surgery and identifies sub-populations with the highest rates of return to sport.

LEVEL OF EVIDENCE

IV, systematic review of Level II-IV studies.

Return to Basketball After Hip Arthroscopy: Minimum 2-Year Follow-up

PURPOSE

To present minimum 2-year patient-reported outcomes (PROs) and return to sport (RTS) data for a population of basketball players after hip arthroscopy.

METHODS

Data were prospectively collected and retrospectively reviewed for all patients who underwent hip arthroscopy between February 2009 and May 2014. Patients with preoperative and minimum 2-year postoperative PROs, visual analog scale score for pain, and satisfaction, who regularly played basketball within 1 year before surgery, and who attempted to RTS met the inclusion criteria. Exclusion criteria were previous ipsilateral hip surgery or conditions such as fracture, dysplasia, or femoral avascular necrosis. Patients were matched 1:1 to a control group composed of those who did not play any sports before surgery, based on the following matching criteria: age ±5 years, sex, and body mass index ±5. Statistical analysis was performed to determine significant differences in PROs. Conversion to total hip arthroplasty (THA) was considered an endpoint.

RESULTS

Thirty-one patients (81.6%) met inclusion criteria with follow-up of 46.8 ± 20.6 months. The mean age was 30.0 ± 12.3, and the mean body mass index was 26.3 ± 6.5. Male patients (64.5%) outnumbered female patients (35.5%). A majority of the players (54.8%) identified themselves as recreational athletes; the remainder competed at the high school, collegiate, amateur, or professional level. There was significant (P < .001) improvement in all PRO measures and visual-analog scale scores from baseline to a minimum 2-year follow-up. At the most recent follow-up, mean patient satisfaction was 8.1 ± 2.1. Twenty-two (78.6%), and 23 patients (82.1%) achieved the patient acceptable symptom state on the modified Harris Hip Score and the Hip Outcomes Score-Sports Specific Subscale. Twenty-one (75.0%) and 17 (60.7%) patients had a minimal clinically important difference on the modified Harris Hip Score and the Hip Outcomes Score-Sports Specific Subscale, respectively. Three patients (9.7%) with an average age of 47.5 (P = .023) converted to THA at a mean of 35.9 ± 7.2 (range 29.66-43.75) months after arthroscopy. At the most recent follow-up, the RTS rate was 83.9%. Subjective ability level was the same or higher in 23 patients (74.2%).

CONCLUSION

Hip arthroscopy in basketball athletes demonstrates a significant increase in PROs, a high RTS rate, and a low risk of complications. Hip arthroscopy may be considered in basketball players <40 years old for whom nonoperative treatment fails and who have a significantly limited level of play. Careful patient selection and counseling should be used when considering hip arthroscopy in basketball players >40 years old because there may be a high rate of conversion to THA.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Editorial Commentary: How Do We Measure Return-to-Sport "Success" After Hip Arthroscopy for Femoroacetabular Impingement?

Hip arthroscopy for femoroacetabular impingement has generally been considered to enjoy a high rate of success. These patients tend to be young and active. One measure of "success" has been return to sport. However, much of the literature has used subjective return criteria and reported on diverse groups in terms of skill levels, sports, and sexes, as well as small numbers, thus limiting specific recommendations.

Surgical Treatment of Labral Tears: Debridement, Repair, Reconstruction

PURPOSE OF REVIEW

With the rapid growth of hip arthroscopy over the past decade, new treatment paradigms as well as recognition of new disease states have sprung forth. The ability to perform complex arthroscopic procedures of the hip such as labral augmentation and reconstruction is essential for hip arthroscopists in the revision setting, with patient selection and indications for various labral treatments the key driver for improved short- and mid-term clinical outcomes.

RECENT FINDINGS

Current techniques have been developed to address disease states where the labrum is either unstable, torn, deficient, or otherwise incompetent. Many early reports focused on the description of these techniques with new literature reporting short- and mid-term outcomes. A few of these have demonstrated improved outcomes with a contemporary arthroscopy with emphasis on capsule preservation and repair. Studies have demonstrated that labral repair has improved outcomes over labral debridement, with results of labral reconstruction in a revision approaching those of labral repair. In addition, newer reports have shown significantly improved outcomes and survivorship with capsule repair and therefore should be included in every hip arthroscopy.

Patients With Borderline Hip Dysplasia Achieve Clinically Significant Outcome After Arthroscopic Femoroacetabular Impingement Surgery: A Case-Control Study With Minimum 2-Year Follow-up

BACKGROUND

There is a growing trend for hip arthroscopists to treat patients with borderline hip dysplasia (BHD) for femoroacetabular impingement syndrome (FAIS) without addressing the acetabular coverage. However, the literature of outcomes and failure rates for these patients is conflicting.

PURPOSE

(1) To identify whether patients with BHD achieved 2-year similar patient-reported outcome, minimal clinically important difference (MCID), and patient acceptable symptomatic state (PASS) when compared with patients without BHD and (2) to identify predictors for achieving the MCID and PASS among patients with BHD who are undergoing hip arthroscopy for FAIS.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data from consecutive patients who underwent primary hip arthroscopy with routine capsular closure for the treatment of FAIS between January 2012 and January 2017 were collected and retrospectively analyzed. Patients with BHD (lateral center-edge angle [LCEA], 20°-25°) were matched 2:1 by age, sex, and body mass index (BMI) to control patients with normal acetabular coverage (LCEA, >25°-40°). Patient-reported outcome, MCID, and PASS were compared between the groups. Multivariate logistic regression analysis identified significant predictors of achieving the MCID and PASS in the BHD group.

RESULTS

The MCID in the BHD group was defined as 9.2, 13.7, 8.5, and 15.2 for the Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sport Specific, modified Harris Hip Score, and iHOT-12, respectively. Threshold scores for achieving the PASS in both groups were 87.9, 76.4, 78.1, and 60.0. A total of 112 patients were identified as having BHD (LCEA, 20°-25°) and were matched to 224 controls. Both groups saw statistically significant increases in score averages over the 2-year period; however, the differences between them were not statistically significant (P > .05 for all). There was no statistical difference in the frequency of the BHD and non-BHD cohorts achieving the MCID on at least 1 threshold score (86.6% vs 85.6%, P = .837) and the PASS (78.6% vs 79.8%, P = .79). There was, however, a statistically significant difference between the rates of patients with and without BHD achieving the PASS on the modified Harris Hip Score threshold (62.5% vs 74.5%, P = .028). The final logistic models demonstrated that lower BMI (odds ratio [OR], 0.872; P = .029), lower preoperative alpha angle (OR, 0.965; P = .014), and female sex (OR, 3.647; P = .03) are independent preoperative predictors of achieving the MCID, while lower preoperative alpha angle (OR, 0.943; P = .018) and self-reported limp (OR, 18.53; P = .007) are independent preoperative predictors of achieving the PASS.

CONCLUSION

Outcome improvements in patients with BHD who are undergoing arthroscopic treatment with capsular closure for FAIS are not significantly different from patients with normal acetabular coverage. Lower BMI, lower alpha angle, absence of limp, and female sex are preoperative predictors of achieving meaningful clinically significant outcome improvements in patients with BHD.

Outcomes for Surgical Treatment of Femoroacetabular Impingement in Adults

PURPOSE OF REVIEW

To assess the outcomes of modern techniques for arthroscopic surgery in the treatment of femoroacetabular impingement.

RECENT FINDINGS

While initially approached by means of open surgical hip dislocation, recent literature has shown generally good outcomes of arthroscopic treatment for femoroacetabular impingement. Modern advances in hip arthroscopy technique and implants now allow for labral repair or reconstruction when indicated. Arthroscopic treatment of femoroacetabular impingement results in significant improvements in patient pain and function, with low complication rates and high patient satisfaction. A majority of improvements in these patients occur within 1 to 2 years post-operatively. Hip arthroscopy for femoroacetabular impingement yields the best results in patients without significant arthritis or hip dysplasia.

Predictors of Outcomes After Hip Arthroscopic Surgery for Femoroacetabular Impingement: A Systematic Review

Background

The benefits of hip arthroscopic surgery in the setting of femoroacetabular impingement (FAI) have been well established; however, some patients may experience a greater degree of improvement than others. Identifying positive and negative predictors of outcomes would assist the orthopaedic surgeon's management algorithm for patients with FAI.

Purpose/Hypothesis

The objective of this systematic review was to identify demographic, radiographic, and other operative predictors of positive and negative outcomes after hip arthroscopic surgery for patients with FAI. It was hypothesized that factors including FAI morphology, age, body mass index (BMI), sex, dysplasia, articular cartilage damage, radiographic joint space, and labral treatment would predict outcomes after hip arthroscopic surgery.

Study Design

Systematic review; Level of evidence, 4.

Methods

This systematic review was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Three databases (Embase, PubMed, and Ovid [MEDLINE]) were searched on May 19, 2018, using terms including "hip," "arthroscopy," and "FAI." Studies were screened and data extracted in duplicate.

Results

A total of 39 studies were included in this systematic review, comprising 9272 hips with a mean age of 36.5 years (47.2% female). Younger age, male sex, lower BMI (<24.5 kg/m²), Tönnis grade 0, and preoperative pain relief from diagnostic intra-articular hip injections predicted positive outcomes. Female sex, older age (>45 years), longer duration of preoperative symptoms (>8 months), elevated BMI, increased Tönnis grade (≥1), chondral defects, decreased joint space (≤2 mm), increased Kellgren-Lawrence grade (>3), increased lateral center-edge angle (LCEA), and undergoing labral debridement alone were predictors of negative outcomes.

Conclusion

In patients with FAI, younger age, male sex, lower BMI (<24.5 kg/m²), Tönnis grade 0, and pain relief from preoperative intra-articular hip injections are significantly more likely to achieve positive outcomes after hip arthroscopic surgery. On the other hand, older age (>45 years), female sex, elevated BMI, osteoarthritic changes, decreased joint space (≤2 mm), chondral defects, increased LCEA, and undergoing labral debridement compared with labral repair are associated with negative outcomes.

The association between specific sports activities and sport performance following hip arthroscopy for femoroacetabular impingement syndrome: A secondary analysis of a cross-sectional cohort study including 184 athletes

The main purpose of this secondary analysis was to compare the proportion of athletes with moderate-to-extreme difficulties in eight specific sport activities in athletes with optimal versus impaired sport performance after a hip arthroscopy for femoroacetabular impingement syndrome. Subjects were identified in a nationwide registry and invited to answer a return to sport and performance questionnaire, and the Copenhagen Hip and Groin Outcome Score Sport subscale investigating difficulties in eight specific sports activities (HAGOS sport items) as; none, mild, moderate, severe or extreme. Subjects were divided into two groups based on sport performance (optimal or impaired). The proportion of athletes with none-to-mild versus moderate-to-extreme difficulties in the eight specific sport activities was compared between groups. The association between difficulties in sport activities and sport performance were investigated using logistic regression analysis. One hundred and eighty-four athletes (31 athletes with optimal and 153 athletes with impaired sport performance) were included at a mean follow-up of 33.1 ± 16.3 months. Up to six athletes (<20%) with optimal sport performance had moderate-to-extreme difficulties in sport activities. Contrary, 43–108 athletes (28.1–70.6%) with impaired performance had moderate-to-extreme difficulties in sport activities. Furthermore, moderate-to-extreme difficulties in HAGOS sport items: ‘running as fast as you can’ and ‘kicking, skating etc.’ increased the odds (14.7 and 6.1 times, respectively) of having impaired sport performance. Many athletes with impaired sport performance reported moderate-to-extreme difficulties in sport activities, specifically moderate-to-extreme difficulties in ‘running as fast as you can’ and ‘kicking, skating etc.’ were associated with patients having impaired sport performance.

Performance and Return to Sport After Hip Arthroscopy for Femoroacetabular Impingement in Professional Athletes Differs Between Sports

PURPOSE

To determine (1) return-to-sport rates for National Football League, Major League Baseball, National Basketball Association, and National Hockey League (NHL) athletes after hip arthroscopy for femoroacetabular impingement syndrome, (2) postoperative return-to-sport rate differences between sports, (3) differences in postoperative career length and games per season, (4) differences in preoperative and postoperative performance, and (5) postoperative performance compared with that of matched control players.

METHODS

Professional athletes who underwent hip arthroscopy for femoroacetabular impingement syndrome were identified. Matched control players were identified by position, age, experience, and performance. Return to sport was defined as playing in at least 1 game after surgery. Continuous variables for each group were compared by using a 2-tailed paired-samples Student t test or χ² test. A Bonferroni correction was used to control for multiple comparisons with statistical significance defined by a P value < .002.

RESULTS

One hundred seventy-two players (86.4%) (mean age, 28.8 ± 5.2 years) were able to return to sport at an average of 7.1 ± 4.1 months. Athletes played 3.5 ± 2.4 years after surgery without significant differences between sports (P > .002). NHL players who underwent surgery played significantly fewer years (4.4 vs 3.3 years) (P < .001) and fewer games per season (4 fewer games) (P <.001) after surgery compared with control players. NHL players also had a significant decrease in performance after surgery compared with their performance before surgery (P < .001). In National Football League, Major League Baseball, and National Basketball Association athletes, no significant differences were found in games per season, career length, or preoperative performance compared with postoperative performance and performance of matched control players (P > .002).

CONCLUSION

The RTS rate for professional athletes after surgery for femoroacetabular impingement syndrome is high. Only NHL athletes had significantly shorter careers and played significantly fewer games per season compared with matched control players, with no difference between sports. NHL athletes had significantly worse postoperative performance compared with preoperative performance, with all other sports demonstrating a career-related decline similar to that of matched control players.