High-Level Athletes Who Did Not Return to Sport for Reasons Unrelated to Their Hip Achieve Successful Midterm Outcomes With a Benchmarking Against High-Level Athletes Who Returned to Sport

High-Level Competitive Athletes Who Undergo Hip Arthroscopy Demonstrate Durable 5-Year Outcomes and Lower Subjective Pain: A Propensity-Matched Analysis

BACKGROUND

Hip arthroscopy (HA) has been proven to be an effective treatment for femoroacetabular impingement syndrome (FAIS) in both competitive athletes (CA) and non-CA at short-term follow-up. However, there is a paucity of literature investigating midterm outcomes comparing athletes with Controls.

HYPOTHESIS

Athletes would have significant improvements at 5 years, with favorable outcomes compared with their control counterparts, and high return-to-sport (RTS) rate.

STUDY DESIGN

Propensity-matched retrospective comparative cohort study.

LEVEL OF EVIDENCE

Level 3.

METHODS

CAs who underwent primary HA for FAIS from January 1, 2012 to April 30, 2017 were identified and propensity matched on a 1:4 basis to Controls by age, sex, and body mass index (BMI). Patient-reported outcomes (PROs) were collected preoperatively and at 5 years. Minimal clinically important differences (MCID) and patient acceptable symptom states (PASS) rates were calculated using previously published thresholds. Rate and duration of RTS were collected retrospectively.

RESULTS

A total of 57 high-level CA (33 female, 24 male; age, 21.7 ± 4.2 years; BMI, 23.1 ± 2.8 kg/m2) were propensity matched to 228 Controls (132 female, 96 male; P > 0.99; age, 23.3 ± 5.8 years; P = 0.02; BMI, 23.8 ± 4.3 kg/m2, P = 0.24). Significant differences were observed in preoperative Hip Outcome Score Sports Specific and Activities of Daily Living (HOS-ADL) subscales (CA, 74.9 ± 13.7 vs Controls, 66.4 ± 18.4; P = 0.01) and modified Harris Hip Score (mHHS) (CA, 64.7 ± 12.9 vs Controls, 59.7 ± 14.3; P = 0.04). Both groups demonstrated significant postoperative improvements in all outcome scores measured (P ≤ 0.01). At 5 years postoperatively, there were significant differences between groups in Visual Analog Scale (VAS) Pain (CA, 17.3 ± 17.6 vs Controls, 24.7 ± 25.9; P = 0.02). There were no significant differences in achieving MCID or PASS. Athletes RTS at a median of 25.2 weeks (Q1 22.4-Q3 30.7) with an overall RTS rate of 90%. Similar rates of revision were seen between CA patients (n = 3; 5.3%) and Control patients (n = 9; 3.9%) (P = 0.66).

CONCLUSION

CAs demonstrated significant and durable improvements in PROs as well as high MCID and PASS achievement rates after primary HA, which were comparable with those of Controls. Clinicians should be aware that CA patients demonstrate higher preoperative mHHS and HOS-ADL scores than Controls and achieve lower average self-reported pain at 5 years postoperatively. In addition, CA patients demonstrate high rates of RTS at a median of 25 weeks postoperatively.

CLINICAL RELEVANCE

This study provides insight into CA versus Control PROs and rates of achieving MCID and PASS at a midterm follow-up of 5 years. Furthermore, this study offers perception into RTS rate, both in general as well as specified to individualized sports.

Dancers Show Significant Improvement in Outcomes and Favorable Return-to-Dance Rates After Primary Hip Arthroscopy With Femoral Head Cartilage Status Being a Predictor of Secondary Surgical Procedures at Mid-Term Follow-Up

PURPOSE

To report minimum 5-year follow-up patient-reported outcome measurement (PROM) scores and return-to-dance rates in dancers who underwent primary hip arthroscopy and to identify predictors of secondary surgical procedures.

METHODS

Prospectively collected data from patients who underwent hip arthroscopy between May 2010 and June 2016 were retrospectively reviewed. Patients were included if they participated in dance at any level 1 year prior to surgery and had preoperative and minimum 5-year follow-up scores consisting of the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, and visual analog scale pain score. The exclusion criteria were previous hip conditions, previous ipsilateral hip surgery, Tönnis grade greater than 1, or lateral center-edge angle less than 18°. The minimal clinically important difference (MCID) was reported. Dancers who discontinued dance for reasons other than pain in the operative hip were excluded from the return-to-dance analysis. A logistic regression model was used to identify predictors of secondary surgical procedures.

RESULTS

Fifty-one hips (48 female dancers) were included. The average age and average follow-up period were 29.8 ± 17.2 years and 79.1 ± 23.2 months, respectively. Improvement in all PROM scores (P < .001) was reported. Achievement rates of the MCID for the modified Harris Hip Score, Nonarthritic Hip Score, and visual analog scale pain score were 83.3%, 85.7%, and 85.7%, respectively. Revision hip arthroscopy was performed in 5 dancers (9.8%). Conversion to total hip arthroplasty was performed in 4 dancers (7.8%). The return-to-dance rate was 78.6%, with 57.6% returning to the preinjury performance level or a higher level. Higher femoral head Outerbridge grade was identified as a predictor of secondary surgical procedures (P = .045; odds ratio, 6.752 [95% confidence interval, 1.043-43.688]).

CONCLUSIONS

After primary hip arthroscopy, dancers experienced significant improvement in all PROM scores collected and achieved the MCID at a high rate at minimum 5-year follow-up. The return-to-dance rate in dancers who did not discontinue dance because of lifestyle transitions was 78.6%, with 57.6% returning to the preinjury performance level or a higher level. Higher femoral head Outerbridge grade was found to be a predictor of secondary surgical procedures.

LEVEL OF EVIDENCE

Level IV, case series.

Athletes Report Favorable Outcomes at 5-Year Minimum Follow-Up After Primary Hip Arthroscopy: A Systematic Review

PURPOSE

To evaluate minimum 5-year outcomes and survivorship after primary hip arthroscopy in athletes.

METHODS

A systematic review of current literature was performed with the following key words: "hip arthroscopy," "long-term," "outcomes," "ten-year," "survivorship," "10-year," "5-year," "five-year," "midterm," "athlete," "sport," and "femoroacetabular impingement" in PubMed, Cochrane Trials, and Scopus in April 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Study and demographic variables such as title, author, publication date, study design, demographic, number of hips, follow-up time, study period, indications for hip arthroscopy, patient-reported outcome scores, and rates of secondary surgeries and conversion to total hip arthroplasty. Radiographic, intraoperative surgical treatment, and clinical benefit was documented as well.

RESULTS

Ten studies that captured data on 691 hips were included in this study. Eight studies reported mean and standard deviation for the modified Harris Hip Score. Significant improvements were reported in all studies with postoperative scores ranging from 83.3 to 94.4 (standardized mean difference [SMD] 1.65; 95% confidence interval [CI] 1.39-1.91, P < .00001). Eight studies reported significant improvement in Hip Outcome Score - Sports Specific Scale with postoperative scores ranging from 59.2 to 94.6 (SMD 1.66; 95% CI 1.33-1.98, P < .00001). Seven studies reported significant improvement in Nonarthritic Hip Score with postoperative scores ranging from 79.6 to 95.3 (SMD 1.41; 95% CI 1.16-1.65, P < .00001). Seven studies also reported significant improvement in VAS with postoperative scores ranging from 0.7 to 3.1 (SMD -1.57; 95% CI -1.88, -1.26, P < .00001). Nine of 10 studies reported achieving at least 1 psychometric threshold at a rate of least 75%. Rates of secondary arthroscopy and conversion to total hip arthroplasty varied from 0% to 15.2% and 0% to 33.3%.

CONCLUSIONS

Athletes who underwent primary hip arthroscopy demonstrated favorable outcomes and high rates of clinical benefit at 5-year follow-up. In addition, they demonstrated high rates of survivorship and achieving psychometric thresholds.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Short Symptom Duration Is Associated With Superior Outcomes in Patients Undergoing Primary Hip Arthroscopy: A Systematic Review

PURPOSE

To evaluate the effect of duration of preoperative hip pain symptoms on outcomes in patients undergoing primary hip arthroscopy for the treatment of femoroacetabular impingement syndrome.

METHODS

A systematic review of the literature was conducted with the following key words: "hip arthroscopy," "outcomes," "femoroacetabular impingement," "duration," "symptoms," "time," "delay," "earlier," and "timing" was performed in PubMed and Cochrane in May 2022. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used for this review. When available, article information including the author, study type, study period, and follow-up, demographics, preoperative duration of symptoms, surgical outcome tools, and secondary surgeries were recorded.

RESULTS

Six studies including 3,298 hips were included in this systematic review. Five studies had a minimum of 2 years' follow-up, and 1 study had a minimum of 5 years' follow-up. Femoroacetabular impingement (including subtypes cam and pincer impingement) was a surgical indication in all 6 studies and the most common indication for surgery. All 6 studies reported patient-reported outcome scores. All studies conducted statistical analyses comparing the duration of symptoms' effect on outcomes and found superior outcomes in patients with shorter duration of symptoms before hip arthroscopy. In 3 studies, modified Harris Hip Score, Hip Outcome Score - Activities of Daily Living, Hip Outcome Score - Sports-Specific Subscale, and visual analog scale for satisfaction ranged from 79.1-82.6, 86.3-88.4, 75-75.5. and 75.3-82.5, respectively, in cohorts with <2-year duration of symptoms, compared with 72-77.7, 79.6-84, 65.0-66.7, and 69.7-75.3 in >2-year cohort. Similarly, in one study, the <2-year duration group was reported to have a conversion to total hip arthroplasty rate of 0.6% and an overall secondary surgery rate of 0.9%, whereas the >2-year duration group had a conversion to total hip arthroplasty rate of 6.4% and an overall secondary surgery rate of 10.1%.

CONCLUSIONS

Patients with hip pain symptoms of less than 2 years before arthroscopic treatment of femoroacetabular impingement syndrome have better outcomes than those patients who had a longer duration of symptoms. However, significant improvements can still be expected regardless of time between onset of symptoms and surgery.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and Level IV studies.

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.

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.

Editorial Commentary: Failure to Return to Sport, or Rather a Failure to Attempt a Return After Hip Arthroscopy Is Not Correlated With Poor Clinical Outcome: The Devil Is in the Details

While hip arthroscopy has been shown to be highly effective at improving pain and restoring function, postoperative outcome reporting remains heterogeneous, particularly as it relates to return to sport (RTS). Previous studies have identified significant variability in RTS rates, and often studies fail to accurately report on the population of patients who do not attempt RTS for reasons other than their hip. Despite failing to attempt an RTS, patients can still experience statistically significant, and clinically meaningful improvements in patient-reported outcome measures. Clinical results of those who do not RTS may be otherwise similar to results experienced by a group of high-level athletes who have successful RTS. Failure to attempt to RTS does not equate to a poor clinical outcome. To improve the clinical utility of future published RTS rates, better consensus on the means of evaluating and reporting on a patients' readiness for RTS are required. Additionally, comprehensive reporting should include identifying patients who do not RTS for reasons other than their hip.