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

Return-to-sports criteria used by professional team physicians in elite athletes after hip arthroscopy - a qualitative study

OBJECTIVES

The purpose of this study was to explore currently utilized readiness to Return to Sport (RTS) criteria after Hip Arthroscopy (HA) used in elite athletes to gain novel insights into the RTS decision-making process of professional team physicians. The authors hypothesized that even among this group of highly specialized physicians, there exists variability of measures and criteria used to determine RTS after HA.

METHODS

A total of 15 qualitative semi-structured interviews with professional team physicians were conducted by a single trained interviewer. The interviews were used to identify team physician concepts and themes regarding the criteria used to determine RTS after HA. Themes and sub-themes were identified using a general inductive analysis and a coding process. A hierarchical approach in coding helped to link themes.

RESULTS

Four key themes and several subordinate themes were identified from the interviews that seem to influence the return to sports decision. The most important RTS criteria were muscle strength (especially symmetric hip strength and muscle bulk with low side-to-side variance compared to the contralateral side) followed by pain-free sport-specific activity (pain-free drill skills and play at a lower level), physical examination (with major emphasis on the absence of hip pain with a painless hip range of motion compared to the contralateral side), and functional testing (including full squats, Ober test, FABER test, and pain-free FADIR position).

CONCLUSION

Besides objective findings, including muscle strength, we identified time after surgery as well as subjective findings, including absence of pain and feedback of clinical team members that influence RTS decision after HA. We showed that even among specialized professional team physicians, the main criteria to RTS in these categories were not consistent necessitating the further development of specific RTS guidelines.

Current understanding of articular cartilage lesions in femoroacetabular impingement syndrome

The concept of femoroacetabular impingement syndrome (FAIS) has received much attention over the past 20 years. Currently, it is believed that FAIS can lead to intra-articular pathologies such as labral tears and articular cartilage lesions, resulting in clinical symptoms and subsequent poor clinical outcomes. FAIS-related articular cartilage lesions are common but unique, and their natural course always leads to early osteoarthritis of the hip. However, despite these cartilage lesions having gradually gained considerable attention, limited consensus has been reached on key aspects, such as diagnosis, mechanisms, classification, and management strategies, which limits clinical and research advances. Hence, an intensive comprehensive overview based on the existing evidence is necessary. The purpose of this review was to introduce the general consensus, controversial issues, and recent advances in FAIS-related articular cartilage lesions.

Females Have Higher Return-to-Sport Rate Than Males Among Collegiate Athletes After Hip Arthroscopy for Femoroacetabular Impingement Due to the Difference in the Type of Sports, Type of Impingement, and Prevalence of Severe Cartilage Damage

PURPOSE

To investigate the return to sport (RTS) rate and the sex-based difference of collegiate athletes after arthroscopic treatment for femoroacetabular impingement (FAI).

METHODS

Patients who were collegiate athletes at the time of surgery and underwent hip arthroscopy for treatment of FAI between January 2009 and June 2020 were included. Patients were excluded if they were in their final year of eligibility, graduated, retired, or had plans to retire from collegiate play before surgery. Publicly available data were collected regarding each patient's collegiate team and division and RTS status after surgery. Comparisons were made based on the RTS status and gender.

RESULTS

Of the 181 hips (144 athletes) who met the inclusion criteria, 114 were male (63%) and 67 were female (37%), with a median age of 20.4 (range: 18.0-24.5). Eighty-six percent (155 hips) returned to sport at the collegiate level after hip arthroscopy. Males were significantly less likely to return to sport compared with females (82% vs 93%, odds ratio = 2.8, 95% confidence interval: 1.003-7.819, P = .042). Males participated in more contact sports (26% vs 1.5%, P < .001) and had more mixed-type FAI (95.6% vs 80.6%, P = .003) compared with females. In addition, males had more grade 3/4 chondral defects (28% vs 13%, P = .023) and underwent microfracture more frequently (11% vs 3%, P = .047). Further, males had significantly larger postoperative alpha angles (46.2 vs 43.6, P < .001).

CONCLUSIONS

Collegiate athletes were found to have a high RTS rate of 86% after arthroscopy for the treatment of FAI; however, males were less likely to RTS compared with females. Sex-based differences were identified in the type of sports, type of FAI, prevalence of severe cartilage damage, and postoperative alpha angle.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Team Approach: Hip Preservation Surgery

The evaluation and treatment of adolescents and young adults with hip pain has seen tremendous growth over the past 20 years. Labral tears are well established as a common cause of hip pain but often occur because of underlying bony abnormalities. Femoroacetabular impingement (FAI) and acetabular dysplasia are now well-established causes of hip osteoarthritis and are increasingly treated in the prearthritic stage in hopes of improving symptoms and prolonging the longevity of the native hip. Beyond FAI and acetabular dysplasia, this patient population can present with a complex and variable group of underlying conditions that need to be taken into account. Expertise in the conservative management of this population, including physical therapy, is valuable to maximize the success. Preoperative, surgical, and postoperative decision-making and care in this population is complex and evolving. A comprehensive, multidisciplinary approach to the care of this patient population has been used for over 20 years by our institution with great success. The purpose of this article is to review the "team-based approach" necessary for successful management of the spectrum of adolescent and young adult hip disorders.

Clinical Commentary: A Criteria-Based Testing Protocol for Return to Sport Post Hip Arthroscopy for Impingement

Overall, 84%-87% of athletes will return to sport following hip arthroscopy; however, some literature suggests that only 57% of athletes return to their preinjury level, and only 16.9% report optimal performance. This discrepancy may be due to a lack of consistency within the definition of return to sport as well as a lack of consistency within rehabilitation programs when determining return to sport readiness. Athletes who are returning to sport must demonstrate adequate range of motion, strength, and the ability to perform multi-directional movements without the risk of reinjury. There has yet to be a comprehensive, criteria-based, return to sport testing protocol that utilizes objective measures to ensure athletes are ready for return to sport. The goal of the authors was to create a criteria-based testing protocol for return to sport following hip arthroscopy utilizing components best supported in the literature. The following parameters were identified as key areas to assess for within a return to sport testing protocol: range of motion, strength, functional testing, self-reported outcomes including psychological readiness and time. The purpose of this clinical commentary is to propose a criteria-based testing protocol to be used following hip arthroscopy for impingement from early rehabilitation through return to previous level of sport. Criteria are presented clearly to promote objective progression through rehabilitation while still being mindful of the biological healing time required for safe and efficient progression. It is the authors' hope that in identifying and establishing a criteria-based testing protocol a higher percentage of athletes will be able to return to sport.

Level of Evidence

5.

Majority of competitive soccer players return to soccer following hip arthroscopy for femoroacetabular impingement: female and older aged players are less likely to return to soccer

PURPOSE

To determine return to soccer rates and soccer performance in a large cohort of competitive soccer players after hip arthroscopic surgery for the treatment of femoroacetabular impingement (FAI) and to identify possible risk factors associated with not returning to soccer.

METHODS

An institutional hip preservation registry was retrospectively reviewed for patients identified as competitive soccer players who underwent primary hip arthroscopy for FAI performed between 2010 and 2017. Patient demographics and injury characteristics as well as clinical and radiographic findings were recorded. All patients were contacted for return to soccer information using a soccer-specific return to play questionnaire. Multivariable logistic regression analysis was used to identify potential risk factors for not returning to soccer.

RESULTS

Eighty-seven competitive soccer players (119 hips) were included. 32 players (37%) underwent simultaneous or staged bilateral hip arthroscopy. The mean age at surgery was 21.6 ± 7.0 years. Overall, 65 players (74.7%) returned to soccer, of which 43 players (49% of all included players) returned to pre-injury level of play or better. Most common reasons for not returning to soccer were pain or discomfort (50%) followed by fear of re-injury (31.8%). The mean time to return to soccer was 33.1 ± 26.3 weeks. Among 22 players who did not return to soccer, 14 (63.6%) reported satisfaction from surgery. Multivariable logistic regression analysis revealed female players (odds ratio [OR] = 0.27; confidence interval [CI] = 0.083 to 0.872; p = 0.029) and older aged players (OR = 0.895; 95% CI = 0.832 to 0.963; p = 0.003) were less likely to return to soccer. Bilateral surgery was not found to be a risk factor.

CONCLUSION

Hip arthroscopic treatment for FAI in symptomatic competitive soccer players allowed three-quarters of them to return to soccer. Despite not returning to soccer, two-thirds of players who did not return to soccer were satisfied with their outcome. Female and older aged players were less likely to return to soccer. These data can better guide clinicians and soccer players with realistic expectations related to the arthroscopic management of symptomatic FAI.

LEVEL OF EVIDENCE

III.

High-level soccer players have a low rate of return to performance after hip arthroscopy for femoroacetabular impingement syndrome

PURPOSE

Femoroacetabular impingement syndrome (FAIS) is a known cause of impaired sports performance in athletes and the relationship between FAIS and soccer players has previously been described. Hip arthroscopy is a viable treatment option that can facilitate athletes' return to sport (RTS). The aim of this study was to evaluate the RTS and return to performance (RTP) with objective measurements in high-level soccer players after hip arthroscopy for FAIS.

METHOD

Soccer players, with a hip sports activity scale (HSAS) level of 7 or 8 before symptom onset and undergoing hip arthroscopy for FAIS between 2011 and 2019 were identified in the Gothenburg hip arthroscopic registry. A total of 83 high-level soccer players, with a mean age of 23.9 (SD 4.4) years at surgery, were included. To verify the activity level and further stratify players as elite or sub-elite, player statistics were collected from soccer-specific scout webpages and the Swedish national soccer association. The return to sport was defined as return to one game of soccer. Return to performance was defined as playing at the same level, or higher, and participating in at least 80% of the number of games played the season before symptom onset or the season before surgery either the first or second season after hip arthroscopy.

RESULTS

In total, 71 (85.5%, 95% confidence interval (CI) 76.1-92.3%) of the players returned to sport the first or second season after surgery. Compared to the season before symptom onset, 31 (37.3%, 95% CI 27.0-48.7%) players returned to performance the first or second season after surgery, and 32 (38.6%, 95% CI 28.1-49.9%) players returned to performance the first or second season after surgery compared to the season before surgery.

CONCLUSION

A high rate of elite and sub-elite soccer players return to soccer after hip arthroscopy for FAIS. However, less than half of the players RTP when evaluating performance through level of play and number of games played.

LEVEL OF EVIDENCE

Level IV.

Why Is There a Range in Time Returning to Preoperative Activity Habits After Femoroacetabular Impingement Treatment in Recreational Athletes?

CONTEXT

Professional athletes showed excellent results after hip preserving procedures. However, there is still a lack of knowledge regarding the rate of return to activity and the rehabilitation time of recreational athletes. Thus, the aim of this study was to investigate factors that were associated with an extended return-to-activity time in nonprofessional athletes.

DESIGN

Retrospective, quantitative case-control study.

METHODS

This study included 47 cases (45 nonprofessional athletes), which were divided according to return-to-activity time (short term: 0.0-7.0 mo vs long term: >7.0 mo). The clinical outcome were evaluated with the modified Harris hip score, the nonarthritic hip score, the Western Ontario and McMaster Universities Osteoarthritis Index, and the University of California, Los Angeles activity score. For statistical analysis between both groups, an unpaired student t test and a paired Wilcoxon test were used. In addition, the sports behavior, intraoperative findings, and surgical procedures were also assessed.

RESULTS

After a mean follow-up of 4.3 years (±0.6; 3.4-5.6), the overall postoperative modified Harris hip score was 81.8 points, the nonarthritic hip score was 75.8 points, the Western Ontario and McMaster Universities Osteoarthritis Index was 36.7 points, and the University of California, Los Angeles activity score was 7.9. Compared with the preoperative results, all scores improved significantly (P < .001). Patients of the short-term return-to-activity group showed a higher preoperative activity diversity and, postoperatively, a higher rate in high-impact sports (P = .024).

CONCLUSIONS

After mini-open arthrotomy for femoroacetabular impingement syndrome treatment, 92.5% of the recreational athletes returned to sports activity. The findings did not detect factors influencing the return-to-activity time. However, a higher preoperative diversity of activities and a shift to high-level impact sport activities might support a shorter rehabilitation.

Pain Is the Most Frequently Cited Reason Athletes Fail to Return to Sport After Ulnar Collateral Ligament Surgery: A Systematic Review and Meta-analysis

Background

No previous systematic review to our knowledge has examined the reasons that athletes fail to return to sport (RTS) after ulnar collateral ligament (UCL) surgery.

Purpose

To report the rate of failure to RTS after UCL surgery and identify reasons that preclude an athlete's ability to successfully RTS.

Study Design

Systematic review; Level of evidence, 4.

Methods

This study was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We searched the PubMed, Scopus, and SPORTDiscus databases for studies on athletes who underwent either UCL reconstruction or repair that reported RTS rates and identified reasons for failure to RTS. Data were collected on the number of athletes included, average age, sport played, operative technique, average follow-up, rate of failure to RTS, and reasons for failure to return. A random-effects model was used to conduct the meta-analysis.

Results

Included were 26 studies reporting on 1019 athletes. Primary or revision UCL reconstruction was performed in 913 patients (89.6%), while the remaining 106 patients (10.4%) underwent UCL repair. The pooled rate of failure to RTS after UCL reconstruction or repair was calculated to be 11.4% (95% CI, 8.4-14.7). A significantly higher estimated proportion of athletes failed to return because of elbow-related reasons compared with non-elbow-related reasons (55.3% vs 40.6%; P = .0352). Persistent pain (29/103; 28.2%) was the most common reason for failure to return, followed by elbow limitations and other unspecified elbow problems (19/103; 18.4%). There was moderate evidence for publication bias and study heterogeneity across the included studies.

Conclusion

This meta-analysis estimated the rate of failure to RTS after UCL surgery as 11.4%, with the majority of athletes unable to return because of elbow pain. Future studies reporting outcomes and providing details as to why athletes are unable to RTS can better inform sport surgeons on factors precluding RTS and can guide clinical practice to better help athletes achieve their postoperative goals.

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

PURPOSE

1) To report minimum 2- and 5-year outcomes of high-level athletes who did not return to sport (RTS) after hip arthroscopy for reasons unrelated to their hip (T athletes) and 2) to benchmark these findings against a propensity-matched control group of high-level athletes who returned to sport (RTS athletes).

METHODS

Data were prospectively collected and retrospectively reviewed for professional, collegiate, and high school athletes between April 2008 and October 2015, who underwent primary hip arthroscopy. Athletes were considered eligible if they did not return to sport for reasons unrelated to their hip such as loss of interest, graduation, or a lifestyle transition (T athletes). Inclusion criteria were preoperative and minimum 5-year postoperative patient-reported outcomes (PROs) for the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and the visual analog scale (VAS) for pain. Clinical outcomes were assessed using the minimal clinically important difference (MCID) and maximum outcome improvement satisfaction threshold (MOIST). T athletes were then propensity-matched to a control group of high-level athletes who returned to sport after hip arthroscopy (RTS athletes) for comparison.

RESULTS

Twenty-seven T hips (25 patients) were included in the analysis with a mean follow-up time of 38.9 ± 16.8 and 72.1 ± 16.8 months for minimum 2- and 5-year outcomes, respectively. They demonstrated significant improvement in all measured PROs. When compared to a propensity-matched control group of RTS athletes, T athletes demonstrated similar improvement in PROs (mHHS, NAHS, and HOS-SSS) and achieved MCID at similar rates for NAHS (T: 77.8% vs RTS: 68.8%; P = .570) and HOS-SSS (T: 70.3% vs RTS: 76.6%, P = .824) compared to RTS athletes; however T athletes demonstrated higher rates of achieving MCID for mHHS (T: 88.9% vs RTS: 72.9% P = .033).

CONCLUSION

Athletes who did not return to sport for reasons unrelated to their hip demonstrated favorable outcomes at minimum 2- and 5-year follow-up. They had similar PROs and rates of achieving MCID for HOS-SSS compared to a propensity-matched control group of high-level athletes who returned to sport. Return to sport status may not necessarily be correlated to the patient's perception of their own outcome.

LEVEL OF EVIDENCE

III, retrospective cohort study.

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.

Return to Sport for Professional and Subelite Ice Hockey Players After Arthroscopic Surgery for Femoroacetabular Impingement Syndrome

Background:

Femoroacetabular impingement syndrome (FAIS) is a common cause of hip pain, which can prevent ice hockey players from sports participation. Hip arthroscopy is often performed to relieve pain and enable the player to return to sport (RTS) and return to performance (RTP).

Purpose:

To determine the RTS and RTP rates for ice hockey players at the professional and subelite levels after hip arthroscopy for FAIS.

Study Design:

Case series; Level of evidence, 4.

Methods:

High-level ice hockey players who underwent hip arthroscopy for FAIS between 2011 and 2019 were identified using a local hip arthroscopy registry. The player’s level was confirmed with ice hockey–specific web pages and was stratified as subelite or professional. Data on the players’ careers were extracted from these web pages. Player position was divided into goalkeepers, defensemen, and forwards. Data on participation in games included the season before onset of symptoms, the season before surgery, and the first and second seasons after surgery. RTS was defined as returning to ice hockey after surgery, and RTP was considered as returning to the same league at a comparable level to before symptoms.

Results:

A total of 80 ice hockey players were included. Comparing presymptom performance with the first season after surgery, the RTS rate was 72%, of which 94% of the players returned to the same or higher level of play. Comparing the presurgery season with the first season after surgery, the RTS rate was 78%. At the second season after surgery, 64% of players still played ice hockey, with a significantly higher return rate among professional players compared with subelite players (96% vs 69%; P = .014). Overall, 85% goalkeepers, 74% forwards, and 60% defensemen returned to sport. Only 28% played at least the same number of games during the first season after surgery as they did during the presymptom season.

Conclusion:

High-level ice hockey players who underwent hip arthroscopy for FAIS had a high RTS rate, in which the majority returned to the same league. However, only 28% played the same number of games the first season after surgery as they did at the presymptom level. Professional ice hockey players returned more frequently than players on the subelite level.

Editorial Commentary: Postoperative Alpha Angle and Return to Sport: One Piece of the Puzzle

Return-to-sport rates following arthroscopic treatment of femoroacetabular impingement are high; however, the predictors of failure to return to sport must be elucidated. Recent data suggest that the postoperative alpha angle may be a significant predictor of return to sport in athletes, despite the fact that the role of radiographic measurements on postoperative outcomes is debated in the literature. Nonetheless, it is incumbent on surgeons to fully understand the unique biomechanics of the hip in each sport and consider each patient's unique anatomy when undertaking cam resection. Recreation of the motion at-risk during a careful intraoperative dynamic examination is imperative to ensure that all areas of impingement have been eradicated while attentively avoiding over-resection. While the postoperative alpha angle is an important metric for surgeons to keep in mind, it may only represent one piece of the puzzle.

Postoperative Alpha Angle Is Predictive of Return to Sport in Athletes Undergoing Hip Arthroscopy for Femoroacetabular Impingement

PURPOSE

To identify clinical and radiographic factors that predict return to sport in athletes undergoing hip arthroscopy and to determine thresholds for significant predictors.

METHODS

Data were reviewed on all patients who underwent primary hip arthroscopy between November 2008 and August 2018. Patients were included if they played professional, college, or high school sports within 1 year before surgery and had preoperative, 3-month, 1-year, and 2-year postoperative patient-reported outcome scores for modified Harris Hip Score, Hip Outcome Score-Sport Specific-Subscale, and Nonarthritic Hip Score. Rates of achieving the minimal clinically important difference also were evaluated. Patients were divided into groups based on whether they returned to sport at the same or greater level. Multivariate logistic regression and receiver operator characteristic analysis were used to evaluate the correlation between significant variables and return to sport.

RESULTS

A total of 136 patients with a mean age of 20.8 ± 7.07 years were included. Among athletes who attempted to return, professional and collegiate athletes returned to sport at any level at a rate of 85.0% (51/60), and high-school athletes returned at a rate of 88.1% (52/59). Competition level, postoperative alpha angle, change in alpha angle, and postoperative patient-reported outcomes were significantly different between groups. Athletes who returned to sport achieved the minimal clinically important difference for Hip Outcome Score-Sport Specific-Subscale at significantly higher rates than athletes who did not return to sport (91.6% vs 71.7%, P = .002, S = 8.97). The multivariate logistic regression model identified postoperative alpha angle as a statistically significant predictor of return to sport (P < .001, S > 9.97 [odds ratio 0.85, 95% confidence interval 0.79-0.91]). The receiver operator characteristic curve for postoperative alpha angle demonstrated acceptable discrimination between patients returning to sport and patients not returning to sport with an area under the curve of 0.71 and a threshold value of 46°. Athletes with a postoperative alpha angle ≤46° returned to sport at significantly higher rates than those with a postoperative alpha angle >46° [(P < .001, S > 9.97 [odds ratio 6.3, 95% confidence interval 2.6-15.2]).

CONCLUSIONS

Postoperative alpha angle was identified as a predictor of return to sport in athletes. The odds of returning to sport were 6.3 times greater in athletes with postoperative alpha angles ≤46° compared with athletes with angles >46°.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Revision Hip Arthroscopy in High-Level Athletes: Minimum 2-Year Outcomes Comparison to a Propensity-Matched Primary Hip Arthroscopy Control Group

BACKGROUND

Outcomes of revision hip arthroscopy in the athletic population have not been well established.

PURPOSE

(1) To report clinical outcomes for high-level athletes undergoing revision hip arthroscopy in the setting of femoroacetabular impingement syndrome (FAIS) or labral tears and (2) to compare these outcomes against a propensity-matched group of high-level athletes undergoing primary hip arthroscopy.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data for professional, college, and high school athletes were prospectively collected and retrospectively reviewed between January 2012 and October 2018. Patients were included if they underwent revision or primary hip arthroscopy and had preoperative and minimum 2-year patient-reported outcome (PRO) scores for modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score Sports-Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain. The findings and outcomes of revision athletes were compared with a propensity-matched control group of high-level athletes undergoing primary hip arthroscopy.

RESULTS

A total of 32 hips (29 patients) undergoing revision hip arthroscopy and 92 hips (88 patients) undergoing primary hip arthroscopy were included in our final analysis with a median follow-up time of 29.5 months (95% CI, 27.2-32.1 months) and 36.5 months (95% CI, 33.5-37.7 months), respectively. Athletes undergoing revision surgery showed significant improvement in all recorded PRO measurements and achieved patient acceptable symptomatic state (PASS) and minimal clinically important difference (MCID) for mHHS at high rates (80.6% and 83.9%, respectively). When compared with a propensity-matched primary control group, patients undergoing revision surgery demonstrated lower preoperative and postoperative scores for mHHS, NAHS, and HOS-SSS, but the magnitude of improvement in functional scores was similar between groups. Athletes undergoing revision surgery achieved PASS for HOS-SSS at lower rates than the control group (P = .005), and they were less likely to attempt to return to sport compared with the control group (62.5% vs 87.0%; P < .01).

CONCLUSION

Revision hip arthroscopy is a viable treatment option to improve PROs in high-level athletes at minimum 2-year follow-up. The study group showed significant improvement in functional scores and a high rate of successful outcomes. They experienced similar magnitude of improvement as that of a propensity-matched control group; however, they achieved lower postoperative PRO scores and attempted to return to sport at lower rates.

The Natural Course of Recovery After Hip Arthroscopy for Femoroacetabular Impingement According to the International Hip Outcome Tool-12 and Hip Outcome Score Sports Subscale

BACKGROUND

A paucity of literature exists regarding trajectories of functional and sports-specific recovery after hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

PURPOSE

To determine if subgroups of patients exist based on the recovery trajectory of patient-reported outcomes (PROs) after hip arthroscopy for FAIS in the short-term period and to determine clinical predictors for these subgroups of patients.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A prospectively maintained repository was queried for patients who had undergone primary hip arthroscopy for the treatment of FAIS between January 2012 and May 2018. Patients who completed the preoperative, 1-year, and 2-year International Hip Outcome Tool-12 (iHOT-12) or the Hip Outcome Score Sports Subscale (HOS-SS) were included. The latent class growth analysis (LCGA) and growth mixture models (GMMs) were used to identify subgroups of patients based on trajectories of recovery for the iHOT-12 and the HOS-SS utilizing preoperative, 1-year, and 2-year follow-ups. LCGA and GMM models using 1 to 6 classes for each PRO were performed, and the best-fit model for each PRO was selected. After final model selection, a multivariable multinomial logistic regression was performed, with the largest class being the reference group to determine clinical predictors of subgroup membership.

RESULTS

A total of 443 and 556 patients were included in the iHOT-12 and HOS-SS analyses, respectively. For the iHOT-12, we identified the following 3 subgroups: early progressors (70%), late regressors (22.3%), and late progressors (7.7%). Predictors of late regression were workers' compensation status, psychiatric history, preoperative chronic pain, and lower preoperative iHOT-12 scores; and late progressors were less likely to participate in sports. For the HOS-SS, we identified the following 4 subgroups: early progressors (47.7%), late regressors (17.4%), late progressors (6.8%), and steady progressors (28.1%). Predictors of less favorable recovery trajectories (late regressors and late progessors) were older age, male sex, back pain, psychiatric history, preoperative chronic pain, greater alpha angle, and lower preoperative HOS-SS scores.

CONCLUSION

Using the growth mixture modeling, 3 natural courses of health-related quality of life (early progression, late regression, and late progression) and 4 natural courses of recovery of athletic function (steady progression, late regression, late progression, and early progression) were identified. Preoperative psychiatric conditions, chronic pain, workers' compensation status, and lower iHOT-12 scores were predictive of less than favorable trajectories of recovery according to the iHOT-12, and male sex, older age, back pain, preoperative narcotic use, and lower preoperative HOS-SS were predictors of less favorable recovery trajectories according to the HOS-SS.