The effectiveness of hip arthroscopy for the treatment of femoroacetabular impingement syndrome: a meta‐analysis of randomized controlled trials

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.

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Physiotherapy as an Initial Treatment Option for Femoroacetabular Impingement: A Systematic Review of the Literature and Meta-analysis of 5 Randomized Controlled Trials

The American Journal of Sports Medicine ◽

10.1177/0363546519882668 ◽

2019 ◽

Vol 48 (8) ◽

pp. 2042-2050 ◽

Cited By ~ 1

Author(s):

Graeme Hoit ◽

Daniel B. Whelan ◽

Tim Dwyer ◽

Prabjit Ajrawat ◽

Jaskarndip Chahal

Keyword(s):

Systematic Review ◽

Randomized Controlled Trials ◽

Outcome Measures ◽

Femoroacetabular Impingement ◽

Meta Analysis ◽

Hip Pain ◽

Cochrane Library ◽

Controlled Trials ◽

Randomized Controlled

Background: Femoroacetabular impingement is a common and debilitating source of hip pain in young adults. Although physiotherapy is used as a mainstay of nonoperative care for femoroacetabular impingement, the evidence regarding different physiotherapy practices is poorly understood. Purpose: To collect and synthesize the best available evidence and arrive at a summary estimate of treatment effect for the utility of physiotherapy in the management of femoroacetabular impingement. Study Design: Meta-analysis. Methods: A systematic review was performed on February 2, 2019, of PubMed, EMBASE, and Cochrane Library databases using “femoroacetabular impingement OR hip pain” and “physiotherapy OR nonoperative management” and their synonyms as search terms. Central treatment themes were identified across protocols, and pooled analyses were conducted to assess for differences in patient-reported outcome measures across these themes. Results: A total of 5 randomized controlled trials met our inclusion criteria. The studies included 124 patients with a mean age of 35 years, of whom 24% were male. The average follow-up was 9.4 weeks (range, 6-12 weeks), and the follow-up rate across all participants was 86%. Among these 5 studies, 4 studies used a physiotherapy protocol that focused on core strengthening versus no core strengthening, 4 studies compared active strengthening versus passive modalities, and 3 studies compared supervised versus unsupervised physiotherapy. Pooled analysis across all studies demonstrated improved outcomes in the treatment groups compared with the controls (standardized mean difference [SMD], 0.76; 95% CI, 0.38-1.13; P < .0001). Core strengthening (SMD, 0.82; 95% CI, 0.39-1.26; P = .0002), active physiotherapy (SMD, 0.70; 95% CI, 0.29-1.10; P = .0008), and supervised physiotherapy (SMD, 0.58; 95% CI, 0.14-1.03; P = .01) were found to result in statistically significant improvements in functional outcomes compared with no core strengthening, passive modalities, and unsupervised care, respectively. Conclusion: Supervised physiotherapy programs focusing on active strengthening and core strengthening are more effective than unsupervised, passive, and non–core focused programs. Future studies with longer term follow-up and validated femoroacetabular impingement specific outcome measures are required to determine prognostic factors for success with nonoperative care as well as to determine the ideal patient profile and structured rehabilitation protocol.

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Effect of Capsular Closure After Hip Arthroscopy for Femoroacetabular Impingement Syndrome on Achieving Clinically Meaningful Outcomes: A Meta-analysis of Prospective and Comparative Studies

Orthopaedic Journal of Sports Medicine ◽

10.1177/23259671211017467 ◽

2021 ◽

Vol 9 (6) ◽

pp. 232596712110174

Author(s):

Kyle N. Kunze ◽

Amar Vadhera ◽

Annie Devinney ◽

Benedict U. Nwachukwu ◽

Bryan T. Kelly ◽

...

Keyword(s):

Femoroacetabular Impingement ◽

Comparative Studies ◽

Hip Arthroscopy ◽

Meta Analysis ◽

Impingement Syndrome ◽

Harris Hip Score ◽

Femoroacetabular Impingement Syndrome ◽

Outcome Improvement ◽

Clinically Significant

Background: Recent literature has demonstrated conflicting evidence as to whether capsular closure after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) results in superior outcomes compared with capsulotomy without repair. Additionally, these studies have not explored the effect of capsular management on clinically significant outcome improvement. Purpose: To perform a meta-analysis of prospective and comparative studies to determine whether capsular management influences the rate of clinically significant outcome improvement after hip arthroscopy for FAIS. Study Design: Systematic review; Level of evidence, 3. Methods: PubMed, OVID/Medline, EMBASE, and Cochrane databases were queried in September 2020 for studies with evidence levels 1 to 3 that directly compared capsular management cohorts and reported rates of achieving the minimal clinically important difference (MCID) at a minimum follow-up of 2 years. Studies of level 4 evidence, those not describing or directly comparing capsular management techniques as well as those not reporting the MCID were excluded. Methodological quality was assessed using the methodological index for nonrandomized studies tool. Mantel-Haenszel fixed-effects models were constructed to quantitatively evaluate the association between capsular management and achievement of the MCID by generating effect estimates in the form of relative risk (RR) with 95% CIs. Results: A total of 6 studies with 1611 patients were included. The overall pooled rate of MCID achievement for the modified Harris Hip Score (mHHS), Hip Outcome Score Activities of Daily Living (HOS-ADL), and HOS Sports Subscale (HOS-SS) were 84.4%, 80.3%, and 82.5%, respectively, at a mean follow-up of 40.8 months (range, 24-87.6 months). Capsular closure was associated with a significantly higher rate of MCID achievement for the mHHS (RR, 1.06; 95% CI, 1.01-1.10; P = .001) and trended toward statistical significance for the HOS-ADL (RR, 1.11; 95% CI, 1.0-1.24; P = .055) and the HOS-SS (RR, 1.09; 95% CI, 0.99-1.21; P = .094). Conclusion: Although capsular closure appeared to result in higher rates of clinically significant outcome improvement in hip function, there was no definitively increased likelihood of achieving clinically significant improvement in relevant hip outcome scores with capsular closure.

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HIP ARTHROSCOPY VS. PHYSICAL THERAPY IN PATIENTS WITH FEMOROACETABULAR IMPINGEMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120s00211 ◽

2020 ◽

Vol 8 (4_suppl3) ◽

pp. 2325967120S0021

Author(s):

Maria Schwabe ◽

Abby L Cheng ◽

Cecilia Pascual-Garrido ◽

Marcie Harris-Hayes ◽

Michael Harris ◽

...

Keyword(s):

Systematic Review ◽

Physical Therapy ◽

Randomized Controlled Trials ◽

Femoroacetabular Impingement ◽

Meta Analysis ◽

Patient Characteristics ◽

Mean Difference ◽

Controlled Trials ◽

Intention To Treat ◽

Randomized Controlled

Introduction: Both physical therapy (PT) and surgery appear to have some efficacy in treating femoroacetabular impingement (FAI). Only recently have high-level evidence studies compared these two options, though results of these randomized controlled trials (RCTs) are contradictory. The purpose of this study was to perform a systematic review and meta-analysis of RCTs comparing PT and surgery in patients with FAI. Methods: A systematic review was performed to identify randomized trials comparing FAI and PT. Data was extracted for demographics, study design, patient reported outcomes (PROs), and study quality/bias. In total, 819 abstracts were reviewed, with three RCTs identified (Griffin 2018, Mansell 2018, and Palmer 2019). All three RCTs reported iHOT-33, while two studies reported HOS ADL and Sport (Mansell 2019 and Palmer 2019). In a random effects meta-analysis, between-group differences in post-intervention scores were assessed using intention-to-treat analysis in each study. Results: All 3 RCTs reported PROs improvement from baseline to follow-up for both PT and surgery. The meta-analysis demonstrated greater improved iHOT-33 outcomes with surgery compared to PT with a mean relative difference of 11.3 (95% CI 1.86-20.73, p=0.014). The meta-analysis for HOS ADL and Sports (two RCTs) similarly demonstrated higher scores with surgery with a mean difference of 3.9 (95% CI -9.6-17.3, p=0.571) and 6.2 (95% CI -6.8-19.2, p=0.347), respectively, though without statistical significance. The quality of two RCTs was assessed as good with minimal bias (Griffin and Palmer). In the third RCT, an extremely high crossover rate may affect its validity (Mansell 2018, 70% crossover from PT to surgery). For instance, HOS ADL outcome based on treatment received, adjusting for Mansell’s crossover rate, favored surgery with a larger mean difference of 12.0 (95% CI 7.5-16.5, p<0.001) (compared to intention-to-treat difference of 3.9). Discussion: In patients with FAI, combined results of three RCTs demonstrate superior outcomes of surgery compared to PT. However, PT can result in improvements in some patients and does not appear to compromise surgical outcomes. Provided that the studies adjusted for certain patient characteristics, further research needs to identify patient characteristics that predict success of non-operative and operative treatment of FAI in specific patient subgroups. [Figure: see text]

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Short-term Clinical Outcomes of Hip Arthroscopy Versus Physical Therapy in Patients With Femoroacetabular Impingement: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120968490 ◽

2020 ◽

Vol 8 (11) ◽

pp. 232596712096849

Author(s):

Maria T. Schwabe ◽

John C. Clohisy ◽

Abby L. Cheng ◽

Cecilia Pascual-Garrido ◽

Marcie Harris-Hayes ◽

...

Keyword(s):

Systematic Review ◽

Physical Therapy ◽

Randomized Controlled Trials ◽

Hip Arthroscopy ◽

Meta Analysis ◽

Controlled Trials ◽

Short Term ◽

Intention To Treat ◽

Randomized Controlled

Background: Both physical therapy (PT) and surgery are effective in treating femoroacetabular impingement (FAI), but their relative efficacy has not been well established until recently. Several randomized controlled trials (RCTs) comparing the early clinical outcomes of these treatments have been published, with contradictory results. Purpose/Hypothesis: The purpose of this study was to perform a meta-analysis of RCTs that compared early patient-reported outcomes (PROs) of hip arthroscopy versus PT in patients with symptomatic FAI. The hypothesis was that surgical treatment of FAI leads to better short-term outcomes than PT. Study Design: Systematic review; Level of evidence, 1. Methods: In March 2019, a systematic review was performed to identify RCTs comparing hip arthroscopy and PT in patients with symptomatic FAI. A total of 819 studies were found among 6 databases; of these, 3 RCTs met eligibility (Griffin et al, 2018; Mansell et al, 2018; and Palmer et al, 2019). All 3 RCTs reported international Hip Outcome Tool--33 (iHOT-33) scores, and 2 reported Hip Outcome Score (HOS)–Activities of Daily Living (ADL) and HOS-Sport results. In a random-effects meta-analysis, between-group differences in postintervention scores were assessed according to intention-to-treat and as-treated approaches. Quality was assessed with CONSORT, CERT, TiDieR, and the Cochrane Collaboration tool. Results: The 3 RCTs included 650 patients with FAI; the mean follow-up ranged from 8 to 24 months. All studies reported PRO improvement from baseline to follow-up for both PT and surgery. The quality of the Griffin and Palmer studies was good, with minimal bias. In the Mansell study, a 70% crossover rate from PT to surgery increased the risk of bias. The meta-analysis demonstrated improved iHOT-33 outcomes with surgery compared with PT for intention-to-treat (mean difference [MD], 11.3; P = .046) and as-treated (MD, 12.6; P = .007) analyses. The as-treated meta-analysis of HOS-ADL scores favored surgery (MD, 12.0; P < .001), whereas the intention-to-treat analysis demonstrated no significant difference between groups for HOS-ADL (MD, 3.9; P = .571). Conclusion: In patients with FAI, the combined results of 3 RCTs demonstrated superior short-term outcomes for surgery versus PT. However, PT did result in improved outcomes and did not appear to compromise the surgical outcomes of patients for whom therapy failed and who progressed to surgery.

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