Return to Play Following Open Treatment of Femoroacetabular Impingement in Adolescent Athletes

Nonsurgical Versus Surgical Management of Femoroacetabular Impingement: What Does the Current Best Evidence Tell Us

Controversy exists as to the management of femoroacetabular impingement (FAI). When nonsurgical management of symptomatic FAI fails, surgical management is generally indicated. However, many groups with a stake in patient care (particularly payors) have insisted on higher levels of evidence. Recently, there have been several Level I studies published, comparing physical therapy (PT) with hip arthroscopy in the management of symptomatic FAI. All of these studies have used outcomes tools developed and validated for patients with nonarthritic hip pain (the International Hip Outcome Tool). Most highest level evidence confirms that although patients with FAI do benefit from PT, patients who undergo surgical management for FAI with hip arthroscopy benefit more than those who undergo PT (mean difference in the International Hip Outcome Tool 6.8 [minimal clinically important difference 6.1], P = 0.0093). Future large prospective studies are needed to evaluate the effect on the outcomes when there is a delay in surgical management in symptomatic individuals, assess whether FAI surgery prevents or delays osteoarthritis, and determine the role of other advanced surgical techniques.

Can We Identify Why Athletes Fail to Return to Sport After Hip Arthroscopy for Femoroacetabular Impingement Syndrome? A Systematic Review and Meta-analysis

BACKGROUND

No previous systematic review has focused on the athletes who fail to return to sport after hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

PURPOSE

To review the literature on the athletes who fail to return to sport after hip arthroscopy for FAIS to determine the rate of nonreturning athletes and explore the reasons for their inability to return to sport after arthroscopic FAI surgery.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Three electronic databases were searched for eligible articles. Two reviewers independently screened the titles, abstracts, and full-text articles using prespecified criteria. Eligible articles were those that clearly stated the rate of athletes who did not return to sport after hip arthroscopy for FAIS. Data collected were the rate of patients who did not return to sport, the level of competition (high level, recreational, or mixed), the type of sport, comments on patients who did not return to sport, the rate of subsequent hip surgeries (total hip replacement or revision hip arthroscopy) in nonreturning athletes, and the reported reason for not returning to sport. A random-effects model was used for meta-analysis.

RESULTS

Twenty studies were eligible for inclusion, and 1093 athletes were analyzed. The weighted rate of athletes who did not return to sport after hip arthroscopy for FAIS was 12.1% (95% CI, 7.7-17.4). Only 2 studies (2/20;10%) reported the age of the athletes who did not return, while sex was reported in 3 studies (3/20;15%). The estimated proportion of athletes who did not return to sport because of hip-related issues was significantly greater than the percentage of athletes who did not return for reasons unrelated to their hip (74.3% vs 22.3%; P < .0001). Persistent hip pain was the most commonly reported factor (52/110 patients; 47.2%) associated with failure to return to sport. Whether the nonreturning athletes underwent any subsequent hip procedure after hip arthroscopy for FAIS was reported in only 4 out of 20 studies (20%). There was evidence of publication bias and study heterogeneity.

CONCLUSION

The estimated rate of athletes who did not return to sport after hip arthroscopy for FAIS was 12%, with the majority of athletes being unable to return because of persistent hip pain. There is a severe lack of evidence on the athlete characteristics and clinical course of the nonreturning athletes, and the rate of subsequent hip procedures is unknown. The outcomes and reasons for athletes not returning to sport should be reported in detail to improve patient care.

The Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS): Normative Data

BACKGROUND

Recent data have shown an increase in youth sports participation at younger ages, which may be linked to greater musculoskeletal injury risk. The Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) is a validated 8-item instrument designed to quantify the activity of children between 10 and 18 years old. Normative data on pediatric and adolescent activity level are unknown.

PURPOSE

To establish normative activity-level data for American youth and to determine if there is a natural decrease in activity level during adolescence.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A cross-sectional investigation was performed among 2002 US children and adolescents equally split by sex and age and representing census-weighted distributions of state of residency, race/ethnicity, and health insurance status. Respondents completed the HSS Pedi-FABS, as well as survey questions on demographics and sports participation. Normative data were reported with descriptive statistics. Linear regression analysis was performed to determine if there was an effect of age on activity level during adolescence.

RESULTS

A total of 2002 respondents completed the survey; the mean age of the respondents at the time of survey completion was 14.0 ± 2.6 years. Mean weekly amount of reported physical activity was 9.3 ± 8.4 hours. HSS Pedi-FABS scores were normally distributed with a mean of 15.4 ± 8.5 points (out of 30 possible points). There was a modest but statistically significant decrease in HSS Pedi-FABS activity scores with increasing age ( r = -0.175, P < .001), corresponding to a linear decrease in activity scores by 27% on average from age 10 to 18 years.

CONCLUSION

The current study provides baseline normative data for activity level in a census-weighted representative population sample of 2002 American youth through the use of a validated activity score (HSS Pedi-FABS). There was a modest but statistically significant decrease in activity scores with increasing age. These results will aid future research by providing normative, representative population-level activity data and will help to quantify the natural rate of decreased activity during adolescence.

Prevalence and Consistency in Surgical Outcome Reporting for Femoroacetabular Impingement Syndrome: A Scoping Review

PURPOSE

The purposes of this review were (1) to collate and synthesize research studies reporting any outcome measure on both open and arthroscopic surgical treatment of femoroacetabular impingement (FAI) syndrome and (2) to report the prevalence and consistency of outcomes across the included studies.

METHODS

A computer-assisted literature search of the MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Embase databases was conducted using keywords related to FAI syndrome and both open and arthroscopic surgical outcomes, resulting in 2,614 studies, with 163 studies involving 14,824 subjects meeting the inclusion criteria. Two authors independently reviewed study inclusion and data extraction with independent verification. The prevalence of reported outcomes was calculated and verified by separate authors.

RESULTS

Between 2004 and 2016, there has been a 2,600% increase in the publication of surgical outcome studies. Patients had a mean duration of symptoms of 27.7 ± 21.5 months before surgery. Arthroscopy was the surgical treatment used in 71% of studies. The mean final follow-up period after surgery was 32.2 ± 17.3 months. Follow-up time frames were reported in 78% of studies. Ten different patient-reported outcome measures were reported. The alpha angle was reported to be measured 42% less frequently as a surgical outcome than as a surgical indication. Surgical complications were addressed in only 53% of studies and failures in 69%. Labral pathology (91% of studies reporting) and chondral pathology (61%) were the primary coexisting pathologies reported. Clinical signs, as defined by the Warwick Agreement on FAI syndrome, were reported in fewer than 25% of studies.

CONCLUSIONS

Most FAI syndrome patients have longstanding pain and potential coexisting pathology. Patient-reported outcome measures and diagnostic imaging are the most frequently reported outcomes. Measures of hip strength and range of motion are under-reported. It is unclear whether the inconsistency in reporting is because of lack of measurement or lack of reporting of specific outcomes in these studies. Current surgical outcomes are limited to mid-term surgical follow-up time frames and inconsistent outcome reporting.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through IV studies.

Femoroacetabular impingement surgery allows 74% of athletes to return to the same competitive level of sports participation but their level of performance remains unreported: a systematic review with meta-analysis

BACKGROUND

Femoroacetabular impingement (FAI) syndrome is one source of hip pain that can limit sport participation among athletes.

OBJECTIVE

To summarise the return to sport (RTS) rate for athletes after surgery for FAI syndrome.

METHODS

A computer-assisted search of MEDLINE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and EMBASE databases was performed using keywords related to RTS and RTS at preinjury level (RTS_PRE) of competition for FAI syndrome. The risk of bias in the included studies was assessed using the Methodological Index for Non-Randomized Studies scale.

RESULTS

35 studies (1634 athletes/1828 hips) qualified for analysis. Based on evidence of limited to moderate strength (level 3b to 4 studies), athletes return to sport at preinjury level post surgery for FAI syndrome at a rate of only 74% (67%-81%). Only 37% of studies reported RTS_PRE. The mean time from surgery to RTS was 7.0±2.6 months. The mean follow-up postsurgery was 28.1±15.5 months. Professional athletes returned to sport (p=0.0002) (although not the preinjury sport level; p=0.63) at a higher rate than collegiate athletes. Only 14% of studies reported on athletic presurgery and postsurgery athletic performance, which means it is impossible to comment on whether athletes return to their previous level of performance or not. No studies reported on the specific criteria used to permit players to return to sport. 20% of studies reported on career longevity, 51% reported surgical complications and 77% reported on surgical failures.

CONCLUSION

There was limited to moderate evidence that one in four athletes did not return to their previous level of sport participation after surgery for FAI syndrome. Only 37% of the included studies clearly distinguished RTS from RTS_PRE. Poor outcome reporting on athletic performance postsurgery makes it difficult to determine to what level of performance these athletes actually perform. Thus, if a player asks a surgeon 'Will I get back to my previous level of performance?' there are presently little to no published data from which to base an answer.

PROSPERO REGISTRATION NUMBER

CRD42017072762.