Pathologic Findings on Hip Arthroscopy in High-Level Athletes Competing in Flexibility Sports

Hip arthroscopy is an effective treatment for high-level female athletes

OBJECTIVES

This study aimed to assess the outcomes of hip arthroscopic surgery in high-level female athletes diagnosed with femoroacetabular impingement (FAI) compared to those with lower levels of sports activity. Additionally, we investigated the effectiveness of patient-reported outcomes (PROs) and the potential ceiling effect as a lack of sensitivity in detecting clinically statistically significant changes in high-level female athletes due to high baseline scores.

METHODS

We conducted a retrospective analysis of prospectively collected data from female patients who underwent hip arthroscopy for FAI between January 2016 and August 2022 with a minimum 1-year follow-up. Patients were categorised into two groups: high-level athletes (group A) and low sports activity level (group B). Various PROs, visual analogue scales for pain, and patient satisfaction were assessed preoperatively and postoperatively. Return to sports (RTS) rates were determined based on the patient's reported ability to return to their previous level of sports activity. The minimally clinically important differences (MCIDs) and the Patient-Acceptable Symptomatic State (PASS) analyses were used to evaluate the clinical impact of the Hip Outcome Score-Sport Subscale (HOS-SSS).

RESULTS

A total of 11 high-level female athletes were included in group A, and 22 were included in the low sports activity level group B. Both groups showed significant improvements in PROs, with no significant differences between them. RTS rates were lower in high-level athletes (63.6%) than in low sports activity patients (85.7%). Visual analogue scales for pain improved significantly in both groups. Patient satisfaction was high in both groups, with a median score of 9. The HOS-SSS showed no ceiling effect, and the MCID and PASS analyses indicated that a high proportion of patients in both groups achieved clinically relevant improvement in HOS-SSS.

CONCLUSION

Hip arthroscopic surgery is effective for FAI treatment in high-level female athletes, with outcomes similar to those in patients with lower sports activity levels. The absence of a ceiling effect in sports-related outcomes suggests that PROs can detect clinically significant changes in high-level female athletes. Although RTS rates were lower in high-level athletes, this difference was not significant. These findings underscore the value of using PROs to evaluate outcomes in female athletes with different sports-activity levels.

LEVEL OF EVIDENCE

IV.

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.

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.

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.

Excellent Clinical Outcomes and Return to Dance of 6 Active, Professional Ballet Dancers Aged Younger Than 40 Years at Total Hip Arthroplasty Through Direct Anterior Approach With a Custom Stem: A Case Report

OBJECTIVE

To report clinical outcomes and return to dance after total hip arthroplasty (THA) by direct anterior approach (DAA) using custom stems in young, active, professional ballet dancers.

DESIGN

Case report.

SETTING

Tertiary.

PATIENTS

Six active, professional ballet dancers younger than 40 years who intended to resume ballet after THA.

INTERVENTIONS

Primary THA by muscle-sparing DAA using custom stems.

MAIN OUTCOME MEASURES

Return to dance, Oxford hip score (OHS), forgotten joint score (FJS), and satisfaction with surgery and pain using numeric rating scale (NRS). CTs were acquired 2 days after surgery to assess implant position. Descriptive statistics were used.

RESULTS

The cohort comprised 4 women and 2 men aged 15 to 39 years. At 2.5 to 5.1 years of follow-up, all patients returned to professional ballet dance. Time to return to dance was 3 to 4 months for 3 patients and 12 to 14 months for 3 patients. Clinical scores were excellent, except for FJS in 1 patient who had considerable pain at her spine and ipsilateral foot. All patients were satisfied with surgery (NRS = 10). There were no complications, reoperations, or revisions. CTs confirmed that stems and cups were correctly positioned.

CONCLUSIONS

All 6 young, active, professional ballet dancers who underwent THA by muscle-sparing DAA using custom stems returned to professional ballet dance and were completely satisfied with surgery. At >2 years of follow-up, 5 patients had excellent clinical outcomes and reported their dancing level to be as expected or better, whereas 1 patient had a lower FJS and was unable to return to her expected dance level.

High Rates of Satisfaction and Return to Dance in Current or Former Professional Ballet Dancers After Total Hip Arthroplasty With a Muscle-Sparing Direct Anterior Approach Using Custom Femoral Stems

Background

Professional ballet dancers have high expectations after total hip arthroplasty (THA), particularly if they intend to resume dancing as performers or teachers.

Purpose

To report clinical outcomes and return to dance after THA with a muscle-sparing direct anterior approach using a custom femoral stem in a cohort of current or former professional ballet dancers.

Study Design

Case series; Level of evidence, 4.

Methods

Twenty-three patients (26 hips) were included, that identified as current or former professional ballet dancers, from a consecutive series of 1699 hips that underwent primary THA by 1 of 2 surgeons. Both surgeons routinely implanted custom femoral stems using a muscle-sparing direct anterior approach in active and/or high-demand patients. All patients completed a questionnaire postoperatively that assessed dance capabilities, the visual analog scale (VAS) for hip pain (0-10), the VAS for satisfaction with surgery (0-10), the Oxford Hip Score (OHS), and the Forgotten Joint Score (FJS).

Results

The initial cohort comprised 19 women and 4 men, with a mean age of 50.5 ± 14.9 years and a mean 38.0 ± 14.4 years of dance experience. One patient underwent revision THA for a leg-length discrepancy, leaving 22 patients (25 hips) with a mean follow-up of 3.4 ± 1.4 years. The mean VAS satisfaction score was 9.8 ± 0.6, and the mean VAS pain score was 0.5 ± 1.0. The postoperative OHS and FJS were 46 ± 2 and 92 ± 15, respectively. Overall, 16 patients resumed ballet at 5.1 ± 3.9 months, 3 resumed other types of dance, and 3 did not resume any type of dance. None of the 6 patients who did not resume ballet indicated pain in the operated hip as the reason for stopping.

Conclusion

In current or former professional ballet dancers, THA by a muscle-sparing direct anterior approach using a custom femoral stem yielded excellent clinical outcomes at a minimum of 2 years, with the highest satisfaction score of 10 points reported for 88% of hips and 72% of hips being totally pain free. Furthermore, 73% of patients resumed ballet, and 86% resumed dance in general.

Hip Pain in Ballet Dancers: Evaluation and Management

Hip and groin injuries are common in ballet dancers, who often begin sport-specific training at a young age. The unique demands of ballet include extreme range of motion, with an emphasis on external rotation and abduction. This creates a distinctive constellation of hip symptoms and pathology in this cohort, which may differ from other flexibility sports. When managing hip symptoms in this cohort, orthopaedic surgeons should consider the unique factors associated with ballet, including ballet-specific movements, morphologic adaptations of the hip, and the culture of the sport. Three common etiologies of hip pain in ballet dancers include femoroacetabular impingement syndrome, hip instability, and extra-articular snapping hip syndrome. First-line treatment often consists of focused physical therapy to strengthen the core and periarticular hip musculature, with surgical management reserved for patients who fail to improve with conservative measures.