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Criteria for return to play after hip arthroscopy in the treatment of femoroacetabular impingement: a systematic review

Review written by Dr Michael Reiman info

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Key Points

  1. The mean time to return to play (RTP) was 6.6 months.
  2. Time was by far the primary RTP criterion but was only reported in 80% of studies, and the time frame was variable.
  3. Only 25% of studies utilized strength as a criterion for RTP.

BACKGROUND & OBJECTIVE

The authors reported that hip arthroscopy is a minimally invasive, yet highly effective treatment for femoroacetabular impingement (FAI). In addition, they reported a previous systematic review on return to sport post hip arthroscopy for FAI (1), still, there needs to be more reporting on the criteria used, and several studies have been published since this review.

Therefore, the primary objectives of this systematic review were to systematically review the rates and level of return to play (RTP) and the criteria for RTP after hip arthroscopy for femoroacetabular impingement (FAI) in athletes.

Hip arthroscopy is a minimally invasive, yet highly effective treatment for femoroacetabular impingement.
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A notable number of athletes do not return to play after hip arthroscopy, especially at their pre-injury level.

METHODS

  • The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized.

  • PubMed, Embase, and Scopus databases were searched independently by two authors from their inception to May 2020 using the search terms: (hip arthroscopy) AND (femoroacetabular impingement OR FAI).

  • Title, abstracts, and full text were screened for inclusion and exclusion criteria.

  • Exclusion criteria were 1) concomitant injuries or procedures alongside FAI, 2) review articles, 3) case reports, 4) biomechanical studies, and 5) surgical technique reports.

  • Data extracted (independently by two authors) included study characteristics, patient characteristics, RTP rate, rate of RTP at the preinjury level, and criteria explicitly used for RTP.

  • Descriptive statistics were performed using SPSS software.

RESULTS

  • 824 full-text articles were screened for eligibility.

  • 130 studies qualified for quantitative synthesis; 694 studies were excluded with reasons.

  • 14,069 patients (54% female), with the mean age of 30.4 years, were included.

  • The overall RTP was 85.4% over a mean of 6.6 months.

  • RTP in professional sports was 92% in 23 studies.

  • The mean follow-up was 29.1 months (96 studies, 74% of included studies).

  • The mean time to RTP was 6.6 months, as reported in 34 studies (26% of included studies).

  • 97 of the 130 included studies (75%) reported RTP criteria:

    • Time was the primary criterion (reported in 62% of studies), and the time frame was variable.
    • The most common criterion was strength, reported in 22% of included studies.

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LIMITATIONS

  • Author reported: (stated all directly related to the limitations of included studies)

    • A significant number of studies failed to categorize RTP by the level of sport
    • Low number of included studies on return to duty in military studies
    • Variation of surgeon technique in hip arthroscopy
    • Most studies had a low level of evidence, particularly uncontrolled level 4 studies.

  • Additional things to keep in mind from my perspective:

    • The review of previous work in this area appears negligent. There are several systematic reviews and meta-analyses including our work in 2018 that only included 35 studies. A discussion on the significantly higher number of different studies in this review is warranted.
    • Why was a meta-analysis not performed with 130 studies? One of the many values of meta-analysis is the calculation of heterogeneity and variance amongst studies. This is a common problem in RTP studies (2-5). There is likely significant heterogeneity between studies, and the variance of the RTP rates is notable.
    • The review was not registered on Prospero, and the authors do not provide their completed PRISMA guidelines which doesn’t allow for transparency for the reader to determine how well the review was done.
    • The authors do not include their reasons for the exclusion of studies.

CLINICAL IMPLICATIONS

The lack of comparison to previous studies leaves me needing clarification on how to process these findings such as the following:

  • Is there a significant increase in the number of surgical studies examining RTP?

  • Are the rates of RTP increasing as a result?

  • In our review, we had 35 studies with a RTP rate of 74% and insufficient data to determine RTP at the pre-injury level accurately. This review reports much higher numbers especially in professional athletes for RTP and RTP at the previous level. Did the additionally included studies improve these values?

  • Our review was did not include level V studies without subjects. This review had five such studies, despite their exclusion criteria not including such articles.

The limitations of this study are significant. They are substantial enough that I need clarification about my clinical take-home. The authors conclude that the “overall rate of RTP was high after hip arthroscopy for FAI. However, more than one-fourth of athletes who return to sports fail to do so at their preinjury level.” I suspect these numbers could be inflated due to some of the issues stated previously.

Regardless, a take-home is similar to other review findings: a notable number of athletes do not RTP after hip arthroscopy, especially at their pre-injury level, which is likely their reason for undergoing hip arthroscopy.

The authors provide some suggestions that others have advocated in this area, namely the development of validated rehabilitation criteria for a safe return to sports after hip arthroscopy. However, another big concern: properly defining return to sport vs. RTP, as advocated by Ardern et al. (6).

+STUDY REFERENCE

Davey M, Hurley E, Davey M, Fried J, Hughes A, Youm T, McCarthy T (2022) Criteria for Return to Play After Hip Arthroscopy in treating Femoroacetabular Impingement: A Systematic Review. Am J Sports Med, 50(12), 3417-24.

SUPPORTING REFERENCE

  1. O'Connor M, Minkara AA, Westermann RW, et al. Return to Play After Hip Arthroscopy: A Systematic Review and Meta-analysis. Am J Sports Med 2018;46(11):2780-88.
  2. Reiman MP, Peters S, Sylvain J, et al. 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. Br J Sports Med 2018;52(15):972-81.
  3. Reiman MP, Peters S, Rhon DI. Most Military Service Members Return to Activity Duty With Limitations After Surgery for Femoroacetabular Impingement Syndrome: A Systematic Review. Arthroscopy 2018;34(9):2713-25.
  4. Peters SD, Bullock GS, Goode AP, et al. The success of return to sport after ulnar collateral ligament injury in baseball: a systematic review and meta-analysis. J Shoulder Elbow Surg 2018;27(3):561-71 [published Online First: 2018/02/13]
  5. Reiman MP, Sylvain J, Loudon JK, et al. Return to sport after open and microdiscectomy surgery versus conservative treatment for lumbar disc herniation: a systematic review with meta-analysis. Br J Sports Med 2016;50(4):221-30. [published Online First: 2015/10/23]
  6. Ardern CL, Glasgow P, Schneiders A, et al. 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. Br J Sports Med 2016;50(14):853-64 [published Online First: 2016/05/27]
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