Restricted accessResearch articleFirst published online 2021-11
Return to Sports and Minimum 2-Year Outcomes of Bilateral Hip Arthroscopy in High-Level Athletes With a Propensity-Matched Benchmarking Against a Unilateral Control Group
Return to sports (RTS) and patient-reported outcomes (PROs) for high-level athletes after bilateral hip arthroscopy have not been well established.
Purpose:
(1) To report minimum 2-year PROs and RTS rates in high-level athletes who underwent staged bilateral primary hip arthroscopies and (2) to compare clinical results against a propensity-matched control group of high-level athletes who underwent unilateral primary hip arthroscopy.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
Data were prospectively collected and retrospectively reviewed for high-level athletes (professional, college, or high school) who underwent staged bilateral hip arthroscopy for femoroacetabular impingement syndrome between September 2009 and October 2018. Inclusion criteria were preoperative and minimum 2-year follow-up for modified Harris Hip Score, Non-arthritic Hip Score, Hip Outcome Score–Sports Specific Subscale (HOS-SSS), and visual analog scale for pain. Exclusion criteria were Tönnis grade >1, hip dysplasia (lateral center-edge angle <18°), and previous ipsilateral hip surgery/conditions. Rates of achieving the minimal clinically important difference (MCID), patient acceptable symptomatic state (PASS), and maximum outcome improvement satisfaction threshold were recorded in addition to RTS. These athletes were then propensity matched in a 1:3 ratio to high-level athletes who underwent unilateral arthroscopy for comparison. Outcomes were compared among the first hip of the study group, the second hip of the study group, and the control group.
Results:
A total of 74 high-level athletes who underwent bilateral hip arthroscopy met the inclusion criteria, and follow-up was available for 68 (91.9%) at 58.9 ± 24.5 months (mean ± SD). Athletes undergoing bilateral hip arthroscopy returned to sports at a high rate (81.7%), demonstrated significant improvements in all recorded PROs, and achieved the MCID and PASS for the HOS-SSS at rates of 80.9% and 64.7%, respectively. PROs, RTS rate, and rates of achieving the MCID and PASS for the HOS-SSS were similar when the bilateral study group was compared with the unilateral control group (P > .05).
Conclusion:
High-level athletes who undergo staged bilateral primary hip arthroscopy for femoroacetabular impingement syndrome may expect favorable PROs and RTS rates at minimum 2-year follow-up. These results were comparable with those of a propensity-matched control group of high-level athletes who underwent unilateral primary hip arthroscopy.
AgarwallaAPuzzitielloRNLiuJN, et al. Timeline for maximal subjective outcome improvement after anterior cruciate ligament reconstruction. Am J Sports Med. 2019;47(10):2501-2509. doi:10.1177/0363546518803365
2.
AgricolaRBessemsJHJMGinaiAZ, et al. The development of cam-type deformity in adolescent and young male soccer players. Am J Sports Med. 2012;40(5):1099-1106. doi:10.1177/0363546512438381
3.
AliMSPrieto-AlhambraDLopesLC, et al. Propensity score methods in health technology assessment: principles, extended applications, and recent advances. Front Pharmacol. 2019;10:973. doi:10.3389/fphar.2019.00973
4.
AlradwanHPhilipponMJFarrokhyarF, et al. Return to preinjury activity levels after surgical management of femoroacetabular impingement in athletes. Arthroscopy. 2012;28(10):1567-1576. doi:10.1016/j.arthro.2012.03.016
5.
AmenabarTO’DonnellJ. Return to sport in Australian Football League footballers after hip arthroscopy and midterm outcome. Arthroscopy. 2013;29(7):1188-1194. doi:10.1016/j.arthro.2013.05.001
6.
AndersonSAKeeneJS. Results of arthroscopic iliopsoas tendon release in competitive and recreational athletes. Am J Sports Med. 2008;36(12):2363-2371. doi:10.1177/0363546508322130
7.
ApratoAJayasekeraNVillarRN. Does the modified Harris Hip Score reflect patient satisfaction after hip arthroscopy?Am J Sports Med. 2012;40(11):2557-2560. doi:10.1177/0363546512460650
8.
AustinPC. Optimal caliper widths for propensity-score matching when estimating differences in means and differences in proportions in observational studies. Pharm Stat. 2011;10(2):150-161. doi:10.1002/pst.433
9.
AustinPC. Some methods of propensity-score matching had superior performance to others: results of an empirical investigation and Monte Carlo simulations. Biometrical J. 2009;51(1):171-184. doi:10.1002/bimj.200810488
10.
BartonCSalinerosMJRakhraKSBeauléPE. Validity of the alpha angle measurement on plain radiographs in the evaluation of cam-type femoroacetabular impingement. Clin Orthop Relat Res. 2011;469(2):464-469. doi:10.1007/s11999-010-1624-x
11.
BeckECGowdAKLiuJN, et al. How is maximum outcome improvement defined in patients undergoing shoulder arthroscopy for rotator cuff repair? A 1-year follow-up study. Arthroscopy. Published online March20, 2020. doi:10.1016/j.arthro.2020.02.047
12.
BerglundDDDamodarDVakhariaRM, et al. Predicting outstanding results after anatomic total shoulder arthroplasty using percentage of maximal outcome improvement. J Shoulder Elbow Surg. 2019;28(2):349-356. doi:10.1016/j.jse.2018.08.016
13.
CasartelliNCLeunigMMaffiulettiNABizziniM. Return to sport after hip surgery for femoroacetabular impingement: a systematic review. Br J Sports Med. 2015;49(12):819. doi:10.1136/bjsports-2014-094414
14.
ChahalJThielGSVMatherRCLeeSSalataMJNhoSJ. The minimal clinical important difference (MCID) and patient acceptable symptomatic state (PASS) for the modified Harris Hip Score and Hip Outcome Score among patients undergoing surgical treatment for femoroacetabular impingement. Orthop J Sports Med. 2014;2(7)(suppl 2):2325967114S00105. doi:10.1177/2325967114S00105
15.
ChahalJVan ThielGSMatherRC, et al. The patient acceptable symptomatic state for the modified Harris Hip Score and Hip Outcome Score among patients undergoing surgical treatment for femoroacetabular impingement. Am J Sports Med. 2015;43(8):1844-1849. doi:10.1177/0363546515587739
16.
ChandrasekaranSDarwishNMuBH, et al. Arthroscopic reconstruction of the irreparable acetabular labrum: a match-controlled study. Arthroscopy. 2019;35(2):480-488. doi:10.1016/j.arthro.2018.09.024
17.
ChandrasekaranSGuiCWalshJPLodhiaPSuarez-AhedoCDombBG. Correlation between changes in visual analog scale and patient-reported outcome scores and patient satisfaction after hip arthroscopic surgery. Orthop J Sports Med. 2017;5(9):2325967 117724772. doi:10.1177/2325967117724772
18.
ChristensenCPAlthausenPLMittlemanMALeeJMcCarthyJC. The nonarthritic hip score: reliable and validated. Clin Orthop Relat Res. 2003;406:75-83. doi:10.1097/01.blo.0000043047.84315.4b
19.
ClappIMNwachukwuBUBeckECJanKGowdAKNhoSJ. Comparing outcomes of competitive athletes versus nonathletes undergoing hip arthroscopy for treatment of femoroacetabular impingement syndrome. Am J Sports Med. 2020;48(1):159-166. doi:10.1177/0363546519885359
20.
ClohisyJCCarlisleJCBeauléPE, et al. A systematic approach to the plain radiographic evaluation of the young adult hip. J Bone Joint Surg Am. 2008;90(suppl 4):47-66. doi:10.2106/JBJS.H.00756
21.
DegenRMFieldsKGWentzelCS, et al. Return-to-play rates following arthroscopic treatment of femoroacetabular impingement in competitive baseball players. Phys Sportsmed. 2016;44(4):385-390. doi:10.1080/00913847.2016.1226123
22.
DombBGAnninSChenJW, et al. Optimal treatment of cam morphology may change the natural history of femoroacetabular impingement. Am J Sports Med. 2020;48(12):2887-2896. doi:10.1177/0363546520949541
23.
DombBGChaharbakhshiEORybalkoDCloseMRLitrentaJPeretsI. Outcomes of hip arthroscopic surgery in patients with Tonnis grade 1 osteoarthritis at a minimum 5-year follow-up: a matched-pair comparison with a Tonnis grade 0 control group. Am J Sports Med. 2017;45(10):2294-2302. doi:10.1177/0363546517706957
24.
DombBGChenSLGoCC, et al. Predictors of clinical outcomes after hip arthroscopy: 5-year follow-up analysis of 1038 patients. Am J Sports Med. 2021;49(1):112-120. doi:10.1177/036354 6520968896
25.
DombBGHartiganDEPeretsI. Decision making for labral treatment in the hip: repair versus débridement versus reconstruction. J Am Acad Orthop Surg. 2017;25(3):e53-e62. doi:10.5435/JAAOS-D-16-00144
26.
EkhtiariSde SaDHaldaneCE, et al. Hip arthroscopic capsulotomy techniques and capsular management strategies: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2017;25(1):9-23. doi:10.1007/s00167-016-4411-8
27.
EssilfieAABloomDAZusmanovichMKesterBWolfsonTYoumT. Staged bilateral hip arthroscopy compared with a matched unilateral hip arthroscopy group: minimum 2-year follow-up. Arthroscopy. 2020;36(7):1856-1861. doi:10.1016/j.arthro.2020.02.025
28.
GerhardtMBRomeroAASilversHJHarrisDJWatanabeDMandelbaumBR. The prevalence of radiographic hip abnormalities in elite soccer players. Am J Sports Med. 2012;40(3):584-588. doi:10.1177/0363546511432711
29.
HarrisJDBrandJCCoteMPFaucettSCDhawanA. Research pearls: the significance of statistics and perils of pooling, part 1: clinical versus statistical significance. Arthroscopy. 2017;33(6):1102-1112. doi:10.1016/j.arthro.2017.01.053
30.
HarrisMDKapronALPetersCLAndersonAE. Correlations between the alpha angle and femoral head asphericity: implications and recommendations for the diagnosis of cam femoroacetabular impingement. Eur J Radiol. 2014;83(5):788-796. doi:10.1016/j.ejrad.2014.02.005
31.
HassebrockJDChhabraAMakovickaJLEconomopoulosKJ. Bilateral hip arthroscopy in high-level athletes: results of a shorter interval between staged bilateral hip arthroscopies. Am J Sports Med. 2020;48(3):654-660. doi:10.1177/0363546519895259
32.
HassebrockJDMakovickaJLChhabraA, et al. Hip arthroscopy in the high-level athlete: does capsular closure make a difference?Am J Sports Med. 2020;48(10):2465-2470. doi:10.1177/0363546520 936255
33.
HawellekTHubertJHischkeS, et al. Calcification of the acetabular labrum of the hip: prevalence in the general population and relation to hip articular cartilage and fibrocartilage degeneration. Arthritis Res Ther. 2018;20(1):104. doi:10.1186/s13075-018-1595-y
34.
JesselRHZurakowskiDZilkensCBursteinDGrayMLKimY-J. Radiographic and patient factors associated with pre-radiographic osteoarthritis in hip dysplasia. J Bone Joint Surg Am. 2009;91(5): 1120-1129. doi:10.2106/JBJS.G.00144
35.
KapronALPetersCLAokiSK, et al. The prevalence of radiographic findings of structural hip deformities in female collegiate athletes. Am J Sports Med. 2015;43(6):1324-1330. doi:10.1177/0363546515576908
36.
KlingensteinGGZbedaRMBediAMagennisEKellyBT. Prevalence and preoperative demographic and radiographic predictors of bilateral femoroacetabular impingement. Am J Sports Med. 2013;41(4):762-768. doi:10.1177/0363546513476854
37.
KuhnsBDHannonCPMakhniEC, et al. A comparison of clinical outcomes after unilateral or bilateral hip arthroscopic surgery: age- and sex-matched cohort study. Am J Sports Med. 2017;45(13): 3044-3051. doi:10.1177/0363546517719020
38.
KvienTKHeibergTHagenKB. Minimal clinically important improvement/difference (MCII/MCID) and patient acceptable symptom state (PASS): what do these concepts mean?Ann Rheum Dis. 2007;66(suppl 3):iii40-iii41. doi:10.1136/ard.2007.079798
39.
KwonJYSawatzkyR. Examining gender-related differential item functioning of the Veterans RAND 12-Item Health Survey. Qual Life Res. 2017;26(10):2877-2883. doi:10.1007/s11136-017-1638-x
40.
LallACAnninSChenJW, et al. Achieving a perfectly spherical femoroplasty: pearls, pitfalls, and optimal surgical technique. Arthrosc Tech. 2020;9(3):e303-e313. doi:10.1016/j.eats.2019.10.011
41.
LallACSaadatAABattagliaMRMaldonadoDRPeretsIDombBG. Perineal pressure during hip arthroscopy is reduced by use of Trendelenburg: a prospective study with randomized order of positioning. Clin Orthop Relat Res. 2019;477(8):1851-1857. doi:10.1097/CORR.0000000000000804
42.
LarsonCMSikkaRSSardelliMC, et al. Increasing alpha angle is predictive of athletic-related “hip” and “groin” pain in collegiate National Football League prospects. Arthroscopy. 2013;29(3):405-410. doi:10.1016/j.arthro.2012.10.024
43.
LeeSKuhnADraovitchPBediA. Return to play following hip arthroscopy. Clin Sports Med. 2016;35(4):637-654. doi:10.1016/j.csm.2016.05.008
44.
LequesneMde Seze. False profile of the pelvis: a new radiographic incidence for the study of the hip. Its use in dysplasias and different coxopathies. Article in French. Rev Rhum Mal Osteoartic. 1961;28:643-652.
45.
LevyDMKuhnsBDFrankRM, et al. High rate of return to running for athletes after hip arthroscopy for the treatment of femoroacetabular impingement and capsular plication. Am J Sports Med. 2017;45(1):127-134. doi:10.1177/0363546516664883
46.
LindmanIÖhlinADesaiN, et al. Five-year outcomes after arthroscopic surgery for femoroacetabular impingement syndrome in elite athletes. Am J Sports Med. Published online March20, 2020. doi:10.1177/0363546520908840
47.
LouerCRPashosGClohisyJCNeppleJJ. A prospective analysis of the contralateral hip among patients with femoroacetabular impingement: what are the risk factors for disease progression?Am J Sports Med. 2018;46(10):2486-2491. doi:10.1177/0363546518786246
48.
MaldonadoDRChenJWWalker-SantiagoR, et al. Radiographic and demographic factors can predict the need for primary labral reconstruction in hip arthroscopic surgery: a predictive model using 1398 hips. Am J Sports Med. 2020;48(1):173-180. doi:10.1177/0363546519887749
49.
MaldonadoDRChenSLWalker-SantiagoR, et al. An intact ligamentum teres predicts a superior prognosis in patients with borderline dysplasia: a matched-pair controlled study with minimum 5-year outcomes after hip arthroscopic surgery. Am J Sports Med. 2020;48(3):673-681. doi:10.1177/0363546519898716
50.
MaldonadoDRKyinCShapiraJ, et al. Defining the maximum outcome improvement of the modified Harris Hip Score, the Nonarthritic Hip Score, the visual analogue scale for pain, and the International Hip Outcome Tool–12 in the arthroscopic management for femoroacetabular impingement syndrome and labral tear. Arthroscopy. Published online January12, 2021. doi:10.1016/j.arthro.2021.01.002
51.
MaldonadoDRLallACWalker-SantiagoR, et al. Hip labral reconstruction: consensus study on indications, graft type and technique among high-volume surgeons. J Hip Preserv Surg. 2019;6(1):41-49. doi:10.1093/jhps/hnz008
52.
MaldonadoDRLaReauJMPeretsI, et al. Outcomes of hip arthroscopy with concomitant periacetabular osteotomy: minimum 5-year follow-up. Arthroscopy. 2019;35(3):826-834.
53.
MaldonadoDRRosinskyPJShapiraJDombBG. Stepwise safe access in hip arthroscopy in the supine position: tips and pearls from A to Z. J Am Acad Orthop Surg. Published online May22, 2020. doi:10.5435/JAAOS-D-19-00856
54.
MansorYPeretsICloseMRMuBHDombBG. In search of the spherical femoroplasty: cam overresection leads to inferior functional scores before and after revision hip arthroscopic surgery. Am J Sports Med. 2018;46(9):2061-2071. doi:10.1177/036354651 8779064
55.
MartinRLKivlanBRChristoforettiJJ, et al. Defining variations in outcomes of hip arthroscopy for femoroacetabular impingement using the 12-Item International Hip Outcome Tool (iHOT-12). Am J Sports Med. 2020;48(5):1175-1180. doi:10.1177/0363546520906408
56.
MartinRLPhilipponMJ. Evidence of validity for the Hip Outcome Score in hip arthroscopy. Arthroscopy. 2007;23(8):822-826. doi:10.1016/j.arthro.2007.02.004
57.
NawabiDHBediATiborLMMagennisEKellyBT. The demographic characteristics of high-level and recreational athletes undergoing hip arthroscopy for femoroacetabular impingement: a sports-specific analysis. Arthroscopy. 2014;30(3):398-405. doi:10.1016/j.arthro.2013.12.010
58.
OgataSMoriyaHTsuchiyaKAkitaTKamegayaMSomeyaM. Acetabular cover in congenital dislocation of the hip. J Bone Joint Surg Br. 1990;72(2):190-196. doi:10.1302/0301-620X.72B2.23 12554
59.
RiffAJKunzeKNMovassaghiK, et al. Systematic review of hip arthroscopy for femoroacetabular impingement: the importance of labral repair and capsular closure. Arthroscopy. 2019;35(2):646-656.e3. doi:10.1016/j.arthro.2018.09.005
60.
RosinskyPJKyinCLallACShapiraJMaldonadoDRDombBG. Rate of return to sport and functional outcomes after bilateral hip arthroscopy in high-level athletes. Am J Sports Med. 2019;47(14): 3444-3454. doi:10.1177/0363546519885354
61.
SansoneMAhldénMJonassonP, et al. Good results after hip arthroscopy for femoroacetabular impingement in top-level athletes. Orthop J Sports Med. 2015;3(2):2325967115569691. doi:10.1177/2325967115569691
62.
SeldesRMTanVHuntJKatzMWiniarskyRFitzgeraldRH. Anatomy, histologic features, and vascularity of the adult acetabular labrum. Clin Orthop Relat Res. 2001;382:232-240.
63.
VigdorchikJMNeppleJJEftekharyNLeunigMClohisyJC. What is the association of elite sporting activities with the development of hip osteoarthritis?Am J Sports Med. 2017;45(4):961-964. doi:10.1177/0363546516656359
64.
WareJKosinskiMKellerSD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34(3):220-233.
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