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Sports and Activity Levels After Open Surgical Treatment of Femoroacetabular Impingement Florian D. Naal, Michael Schär, Hermes H. Miozzari and Hubert P. Nötzli Am J Sports Med 2014 42: 1690 originally published online April 29, 2014 DOI: 10.1177/0363546514531552 The online version of this article can be found at: http://ajs.sagepub.com/content/42/7/1690
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Sports and Activity Levels After Open Surgical Treatment of Femoroacetabular Impingement Florian D. Naal,*yz MD, Michael Scha¨r,z§ MD, Hermes H. Miozzari,z|| MD, and Hubert P. No¨tzli,z§ MD Investigation performed at Spital Netz Bern–Ziegler, Bern, Switzerland Background: Several studies indicate that professional athletes can successfully return to competition after surgical treatment of femoroacetabular impingement (FAI). However, little is known about sports and activity levels after FAI surgery in the general patient population. Hypothesis/Purpose: The purpose was to determine the sports behavior, satisfaction with sports ability, and activity levels in a consecutive cohort of patients with FAI who were treated by surgical hip dislocation. The hypothesis was that the majority of patients (.75%) would be active in sports at follow-up. Study Design: Case series; Level of evidence, 4. Methods: This retrospective study included 153 patients (mean age, 30.0 years; 40.5% female) with 192 hips treated. Sports behavior and satisfaction were determined at a mean follow-up of 59.4 months with the use of a questionnaire. Activity levels at follow-up were assessed by the Hip Sports Activity Scale (HSAS) and the University of California, Los Angeles (UCLA) activity scale. Results: Of 126 patients who were regularly active in sports before surgery, 107 (85%) were so at follow-up. Nineteen patients (12.4%) stopped participating in regular sports, and 8 (5.2%) commenced with sports after the operation. The most popular activities before surgery were skiing (22%), cycling (22%), jogging (20%), and soccer (13%). At follow-up, most patients were engaged in cycling (23%), fitness/weight training (20%), skiing (18%), and jogging (11%). Of all patients, 75% were satisfied with their sports ability, and 25% were not. Moreover, 60.3% stated that their sports ability had improved after surgery, 20.5% declared no change, and 19.2% were subjectively deteriorated. The mean pain level during sports was rated to be 2.1 according to the visual analog scale. The mean HSAS score was 3.5 (range, 0-8), and the mean UCLA score was 7.7 (range, 3-10); male patients reported significantly higher scores than did female patients on the HSAS (4.1 vs 2.7, respectively) and UCLA scale (8.2 vs 7.0, respectively). Conclusion: The vast majority of patients with FAI who are treated by surgical hip dislocation return to sports activities, and most patients are satisfied with their sports ability at midterm follow-up. Activity levels are significantly higher in male patients, but this does not yield higher satisfaction rates. Keywords: femoroacetabular impingement; FAI; sport; activity; outcome; results; surgical hip dislocation
The concept of femoroacetabular impingement (FAI) described by Ganz and coworkers10,11 is widely accepted today. In this theory, deformities of the proximal femur and/or acetabulum can cause abnormal contact and cumulative damage to the acetabular labrum and adjacent articular surfaces. The severity of this damage and resulting disability are related to the intensity and frequency of abutment occurring during specific activities, usually those involving internal rotation and flexion of the hip joint.2,10-13 Most patients with symptomatic FAI are young, physically active people in their 20s or 30s. Sports activities requiring repetitive forceful flexion and internal rotation of the hip such as ice hockey or soccer are hence often associated with symptomatic FAI. Several studies of professional or semiprofessional athletes with FAI have been
*Address correspondence to Florian D. Naal, MD, Department of Orthopaedic Surgery, Schulthess Clinic, Lengghalde 2, 8008 Zurich, Switzerland (e-mail: [email protected]). y Department of Orthopaedic Surgery, Schulthess Clinic, Zurich, Switzerland. z Department of Orthopaedic Surgery, Spital Netz Bern–Ziegler, Bern, Switzerland. § Department of Orthopaedic Surgery, Sonnenhof Clinic, Bern, Switzerland. || Department of Orthopaedic Surgery, University Hospital of Geneva, Geneva, Switzerland. The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. The American Journal of Sports Medicine, Vol. 42, No. 7 DOI: 10.1177/0363546514531552 Ó 2014 The Author(s)
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published recently.3,6,7,19,21,25-27,29 These reports highlight that surgical treatment of FAI, either arthroscopically or open, is very successful at the level of the highest demand, that is, in professional sportsmen, but these reports represent the outcome in a highly selected group of patients in whom other factors such as the pressure to return to action may play an important role as well.19 Hence, such results cannot be generalized to the FAI population typically consisting of young and active but not professionally athletic patients. One recent study of sports and recreational activities in 53 patients at 2.4 years after arthroscopic surgery for FAI found that treatment did permit a return to sports in most of those who had participated in such activities before the onset of FAI symptoms.5 Byrd and Jones6 included 97 recreational athletes in a similar report. To our knowledge, no such study has been published for patients with FAI after open surgical treatment. The open approach via surgical hip dislocation still represents a commonly performed procedure, allowing excellent joint exposure and almost unlimited treatment options, which is indicated particularly in cases with posterior lesions, with gross pincer deformity, or requiring advanced cartilage repair techniques.23,24 The aim of the present study was therefore to investigate participation in sports and recreational activities and subjective outcomes related to sports in a large cohort of patients with FAI at a midterm follow-up after surgical hip dislocation.
MATERIALS AND METHODS Patient Cohort In a recently published retrospective study, patient-reported outcomes were determined in 185 patients (233 hips) who suffered from FAI and underwent surgical hip dislocation.18 Of these, 153 patients (192 hips) agreed to participate in the present survey and completed additional questionnaires (see Outcome Tools) inquiring about preoperative and postoperative sports, activity levels, and satisfaction with sports ability. There were 62 female (40.5%) and 91 male (59.5%) patients. The mean age at the time of surgery was 30.0 6 9.4 years (range, 14.0-55.0 years), and the mean body mass index (BMI) was 24.3 6 3.3 kg/m2 (range, 18.4-38.8 kg/m2). Twenty-six of the 192 hips (13.5%) had undergone 1 or more previous surgeries, mainly hip arthroscopic procedures (n = 14) and femoral correction osteotomies (n = 6). Questionnaires were completed at a mean of 59.4 6 10.9 months (range, 24.0-90.0 months) after surgery.
Diagnosis and Treatment Details on the diagnostic criteria, inclusion and exclusion criteria, and surgical approach have been published previously.18 Briefly, all patients of the present cohort had clinical (reduced flexion [usually \95°] and internal rotation [usually \10°], positive impingement test result) and radiographic (crossover sign or coxa profunda/protrusio, a angle .50°) signs of FAI and underwent obligatory
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magnetic resonance imaging of the involved hip using intra-articular gadolinium contrast.18,22 Most hips (77.1%) had mixed-type impingement, 12.5% had pure cam-type FAI, and 10.4% had pure pincer-type FAI. Surgical hip dislocation was performed under regional or general anesthesia using a Henry approach without splitting gluteus maximus fibers. Starting in 2006, Z-shaped stepped trochanteric osteotomy replaced the earlier flat osteotomy. Refixation of both osteotomy types was accomplished with two 3.5-mm cortical screws. Acetabular and labral lesions were addressed first, and the labrum was refixed with 2 to 5 bone anchors whenever possible. Formal labral takedown and refixation were performed in 103 hips (53.6%), pure debridement of loose fibers in 53 (27.6%), and partial labral resection in 14 (7.3%). Osteochondroplasty over the entire length of the femoral neck was performed in all hips. After relocation of the femoral head, repeated impingement testing was used to verify sufficient correction, that is, intraoperative impingement-free internal rotation of .30° and flexion of .110°.
Postoperative Care After stepped trochanteric osteotomy, weightbearing was restricted to one fourth of the body weight for 4 weeks, with a gradual increase thereafter and flexion limited to 90°. Low molecular weight heparin was given for 6 weeks. Continuous passive motion of the involved leg was started directly after surgery at 30° of flexion and rapidly increased to 90° during the hospital stay. Patients were encouraged to use an ergometer at home. After confirmation of trochanteric union at 6 weeks, patients began unlimited passive and active ranges of motion and hip abductor strengthening exercises. Sensorimotor exercises were emphasized to promote neuromuscular control of the pelvis and lower extremity. Sports-specific workouts were prescribed after 10 to 12 weeks, and at 12 weeks, depending on the muscular rehabilitation status, patients were allowed to restart their typical activities.
Outcome Tools The questionnaire set that was used in the main study18 consisted of the Western Ontario and McMaster Universities Arthritis Index (WOMAC; Likert scale transformed to 0 = best and 100 = worst), the Hip Outcome Score (HOS; range from 100 = best to 0 = worst), the Short Form–12 (SF-12) Physical and Mental Component Scales (PCS and MCS, respectively; range from 100 = best to 0 = worst, with 50 = normative mean), and the University of California, Los Angeles (UCLA) activity scale (10 = highest and 1 = lowest). The validated German versions of these questionnaires were used.9,15,16,30 Additionally, the patients of the present study completed the Hip Sports Activity Scale (HSAS; range from 0 = no recreational or competitive sports to 8 = competitive sports at elite level), which is a questionnaire inquiring about preoperative and postoperative regular engagement in different sports and
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TABLE 1 Outcome Scores at a Mean of 5 Years After Surgical FAI Treatmenta
Downhill skiing Cycling Jogging Soccer Fitness/Weight training Swimming Biking Hiking Tennis Ice hockey Field/Street hockey Volleyball Martial arts Aerobics/Gymnastics Inline skating Squash Horseback riding Mountaineering Dancing Climbing Handball Water gymnastics Snowboarding Cross-country skiing Nordic walking Motocross Indoor sports Track and field Table tennis Badminton Diving Endurance sports Baseball Surfing Golf
Outcome Score HOS ADL Sport WOMAC Pain Stiffness Function SF-12 PCS MCS UCLA activity scale HSAS
Mean 6 SD (Range)
89.0 6 13.1 (40.8-100.0) 75.4 6 23.1 (13.9-100.0) 10.3 6 15.7 (0.0-75.0) 15.9 6 17.3 (0.0-62.5) 9.6 6 13.0 (0.0-58.8) 47.5 52.3 7.7 3.5
6 6 6 6
6.3 7.4 1.9 2.2
(24.4-56.7) (19.9-65.6) (3.0-10.0) (0.0-8.0)
a ADL, activities of daily living; FAI, femoroacetabular impingement; HOS, Hip Outcome Score; HSAS, Hip Sports Activity Scale; MCS, Mental Component Scale; PCS, Physical Component Scale; SF-12, Short Form–12; UCLA, University of California, Los Angeles; WOMAC, Western Ontario and McMaster Universities Arthritis Index.
Preop Follow-up
0
5
10
15
20
25
Active Patients, %
Figure 1. Sports activities by patients before and 5 years after treatment for femoroacetabular impingement. activities,17 and questions related to satisfaction with their sports ability and the need for any pain medication.
Statistical Analysis Statistical analysis was performed using the software package SPSS (version 14, SPSS Inc, Chicago, Illinois, USA). Data were initially tested for normal distribution using the Shapiro-Wilk W test. For comparisons, unpaired t tests or Mann-Whitney U tests were used according to data distribution. Differences between proportions were examined using the x2 or Fisher exact test. Unless otherwise stated, descriptive results were demonstrated as the mean 6 standard deviation. The significance level was defined at P \ .05 for all tests.
RESULTS Return to Sports Of the 153 patients, 126 (82.4%) were regularly active in sports before surgery, and 115 (75.2%) were active at
follow-up (P = .125). One hundred seven (69.9%) were active before and after surgery, corresponding to a rate of return to sports of 84.9%. Nineteen patients (12.4%) stopped participating in regular sports, and 8 (5.2%) commenced with sports after the operation. Another 19 (12.4%) were never engaged in any regular sport.
Sports Activities The patients who were active in sports were engaged in a mean of 2.5 (range, 1.0-7.0) different athletic disciplines before surgery and in a mean of 2.2 (range, 1.0-4.0) at follow-up (P \ .001). Preoperatively, the most popular activities were downhill skiing, cycling, and jogging. At follow-up, the most common disciplines were cycling, fitness/weight training, and downhill skiing (Figure 1). Fewer patients were engaged in high-impact sports such as soccer, jogging, or indoor sports, and more patients participated in lower impact activities such as cycling, Nordic walking, or fitness/weight training (Figure 1).
Subjective Outcomes and Score Values Of all patients, 75% were satisfied with their sports ability, and 25% were not. Moreover, 60.3% stated that their sports ability had improved after surgery, 19.2% indicated deterioration, and 20.5% declared no change. The mean pain level during sports was rated to be 2.1 6 2.0 (range, 0.0-7.0) according to the visual analog scale (VAS). Painkillers during or after sports were occasionally taken by 17.4% of the patients, 2.6% required regular painkillers, and 80.0% never took any pain medication. Score values for the HOS Activities of Daily Living (ADL) and Sport subscales, the WOMAC subscales, the SF-12 PCS and MCS, the UCLA activity scale, and the HSAS are shown in Table 1.
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TABLE 2 Comparison Between Female and Male Patientsa Variable Sports activity, % Active preoperatively Active at follow-up Sports ability, % Ability improved Ability deteriorated Satisfied with ability Outcome score, mean 6 SD HOS ADL Sport WOMAC Pain Stiffness Function SF-12 PCS MCS UCLA activity scale HSAS
Female
Male
74.2 75.8
87.9 74.7
.029 .888
73.3 13.3 73.3
51.2 23.3 76.2
.007 .135 .699
85.7 6 15.5 72.3 6 26.2
91.3 6 10.7 77.6 6 20.6
.009 .172
12.8 6 18.7 15.3 6 16.6 12.1 6 15.1
8.5 6 13.1 16.4 6 17.9 7.8 6 11.0
.101 .702 .051
45.9 52.3 7.0 2.7
48.6 52.3 8.2 4.1
6 6 6 6
7.3 7.3 1.7 1.7
6 6 6 6
5.3 7.5 1.8 2.3
P Value
.009 .976 \.001 \.001
a
ADL, activities of daily living; HOS, Hip Outcome Score; HSAS, Hip Sports Activity Scale; MCS, Mental Component Scale; PCS, Physical Component Scale; SF-12, Short Form–12; UCLA, University of California, Los Angeles; WOMAC, Western Ontario and McMaster Universities Arthritis Index.
Group Differences No differences in sports participation, activity levels, satisfaction, or outcome scores were found between patients who had undergone previous surgery and those who had not and between patients who had unilateral or bilateral surgery. Also, we did not find any correlation between the return to sports and clinical, surgical, or radiographic findings. The mean age did not differ between patients who were satisfied with their sports ability (31.2 years) and those who were not (28.1 years) (P = .09). Significant differences were found between female and male patients, with a trend toward better postoperative subjective sports ratings but lower outcome scores in female patients (Table 2).
DISCUSSION The surgical treatment of FAI is performed more and more frequently, and the available literature indicates that good to excellent results can be achieved in 68% to 96% of the cases.8,18,20,23 Because symptomatic FAI is often encountered in young and athletically active patients, not only are improvements in pain and daily function important but also the ability to return to leisure-time activities and sports. Indeed, in a recent investigation, the improvement in sports ability has been indicated as the second most important expectation (besides pain relief) before FAI surgery.14 Numerous studies focusing on the return to play of professional or high-level athletes after FAI
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have been published in recent years.3,6,7,19,21,25-27,29 Philippon and coworkers27 reported on a series of 28 professional National Hockey League players treated arthroscopically for labral lesions with associated FAI. All patients returned to play and were subjectively satisfied after a mean follow-up of 24 months.27 In another study including a mixed group of 45 professional athletes who underwent hip arthroscopic surgery, 93% returned to professional competition, and 78% were still professionally active after a mean of 1.6 years.26 Recently, Naal and colleagues19 reported on 22 high-level athletes treated for FAI by surgical hip dislocation, and all except 1 (96%) were still competing at professional levels at a mean of 45 months postoperatively. While these studies suggest a very successful treatment outcome, irrespective of the surgical approach used, they represent results in a highly selected group of patients. Professional athletes may have the motivation to return to sports and competition (ie, financial aspects) that distinguishes them from the group of recreational or leisure-time sportsmen to which most of the patients with FAI belong. Accordingly, the top reasons for engaging in sports are reported to be ‘‘health promotion,’’ ‘‘having fun,’’ and ‘‘being fit’’ in the general Swiss population (http://www.baspo.admin.ch). The results of the present study show that about 85% of all patients will return to sports after open FAI treatment and that overall 75% will be active in sports. While some of the patients stopped sports activities after surgery, some others commenced. These figures are in line with the results reported by Brunner et al5 for 53 patients with FAI after hip arthroscopic surgery, despite the difference in follow-up times (2.4 years vs ~5.0 years in the present study). Most of their active patients participated in lower impact sports, with biking, hiking, swimming, and fitness being the most common activities.5 The most common athletic disciplines were more or less the same as in the present cohort except for downhill skiing, which remained the third most frequently performed activity. The proportion of athletically active patients that we found also corresponds to nationwide Swiss data published in 2008, with 73% of the entire population and about 80% of 25- to 34-year-old people being active in sports (http://www .baspo.admin.ch). The most common sports across the general population in Switzerland are cycling/biking, hiking, swimming, skiing, and jogging (http://www.baspo .admin.ch), which are also similar disciplines encountered in this present FAI cohort. Therefore, the tendency toward lower impact sports may be just a question of age. Yet, in cases of substantial joint damage, the patients may have changed their preferred sports based on our recommendation. In such cases, we usually recommend reducing participation in activities with intense stop-and-go or running and jumping sequences. We did not specifically inquire for the reasons for stopping sports or modifying activity behavior. Therefore, final conclusions are speculative. It can be assumed that a combination of age-related activity modifications, recommendations, environmental and social factors, and residual hip-related symptoms is responsible for the tendency toward lower impact activities or for stopping sports.
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More female patients indicated improvement in their sports ability, and more male patients indicated deterioration. This corresponds well to the fact that the proportion of female patients being engaged in sports remained stable, whereas that proportion diminished from 88% to 75% in male patients. However, overall satisfaction with sports ability at follow-up did not differ between male and female patients, and male patients had significantly higher activity levels according to the HSAS and UCLA scale. These findings could be explained, on one hand, by higher expectations that were not completely fulfilled in the male subgroup. Indeed, in a recent investigation, we found that expectations of patients with FAI were generally high and, in some domains, overly optimistic.14 On the other hand, past activity and sports levels could have been overestimated (recall bias), especially by the male patients. Most patients in the present series reported no or little pain during sports activities. The mean VAS score was 2.1, which is slightly higher than the value of 1.5 reported by Brunner and coworkers.5 The higher mean value can be explained by the fact that the patients in the present series were specifically asked to indicate pain levels experienced during or directly after sports activity and not including normal daily activities or resting periods. Score values for the WOMAC, SF-12, and UCLA scale compare very well with those found by Beaule´ et al1 in 2007, who investigated outcomes in 34 patients at a mean of 3.1 years after open FAI surgery, and with those calculated by Botser and colleagues4 based on systematic review data. Score values for the HOS ADL and Sport subscales are also in line with those reported by Botser et al4 and those indicated by Philippon et al28 for a subgroup of patients with FAI who rated their outcomes as excellent or good at 3 years after hip arthroscopic surgery. Expectedly, slightly higher values for the HOS ADL and Sport subscales and for the SF-12 PCS and MCS were reported for a cohort comprising only professional athletes after open FAI treatment.19 The present study has some limitations. First of all, this study is retrospective and includes the risk of recall bias, particularly related to the engagement in sports before surgery. Such a recall bias could be reflected by the differing results of female and male patients, with the male patients possibly tending to overestimate their activity levels some years before. Also, we have no information on when the patients exactly resumed their activities and if some of the patients were active at some point after surgery but stopped their activities before follow-up. Second, patient-oriented outcome measures have been only used at follow-up because preoperative scores were not routinely assessed at our institution, and some of the questionnaires used were not available in German at that time. Therefore, conclusions about former and actual intensity levels of sports participation are not possible. Finally, not all patients completed the additional sports questionnaire, which includes the risk of selection bias. However, demographics did not differ between this study cohort and the total cohort18 (female, 40.5% vs 40.0%, respectively
[P . .9]; BMI, 24.3 vs 24.2 kg/m2, respectively [P . .9]; age, 30.0 vs 30.0 years, respectively [P . .9]). In conclusion, the present data show that the vast majority of patients with FAI who are treated by surgical hip dislocation can return to sports activities and that most patients are subjectively satisfied with their sports ability at midterm follow-up. Activity levels as assessed by the HSAS and UCLA scale were significantly higher in male patients, but this did not yield higher satisfaction rates. Differing and overly optimistic expectations might explain this observation, indicating that sports expectations need to be comprehensively discussed and possibly adjusted downward before surgery.
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Sports and Activity Levels After Open Surgical Treatment of Femoroacetabular Impingement Florian D. Naal, Michael Schär, Hermes H. Miozzari and Hubert P. Nötzli Am J Sports Med 2014 42: 1690 originally published online April 29, 2014 DOI: 10.1177/0363546514531552 The online version of this article can be found at: http://ajs.sagepub.com/content/42/7/1690
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On behalf of: American Orthopaedic Society for Sports Medicine
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Sports and Activity Levels After Open Surgical Treatment of Femoroacetabular Impingement Florian D. Naal,*yz MD, Michael Scha¨r,z§ MD, Hermes H. Miozzari,z|| MD, and Hubert P. No¨tzli,z§ MD Investigation performed at Spital Netz Bern–Ziegler, Bern, Switzerland Background: Several studies indicate that professional athletes can successfully return to competition after surgical treatment of femoroacetabular impingement (FAI). However, little is known about sports and activity levels after FAI surgery in the general patient population. Hypothesis/Purpose: The purpose was to determine the sports behavior, satisfaction with sports ability, and activity levels in a consecutive cohort of patients with FAI who were treated by surgical hip dislocation. The hypothesis was that the majority of patients (.75%) would be active in sports at follow-up. Study Design: Case series; Level of evidence, 4. Methods: This retrospective study included 153 patients (mean age, 30.0 years; 40.5% female) with 192 hips treated. Sports behavior and satisfaction were determined at a mean follow-up of 59.4 months with the use of a questionnaire. Activity levels at follow-up were assessed by the Hip Sports Activity Scale (HSAS) and the University of California, Los Angeles (UCLA) activity scale. Results: Of 126 patients who were regularly active in sports before surgery, 107 (85%) were so at follow-up. Nineteen patients (12.4%) stopped participating in regular sports, and 8 (5.2%) commenced with sports after the operation. The most popular activities before surgery were skiing (22%), cycling (22%), jogging (20%), and soccer (13%). At follow-up, most patients were engaged in cycling (23%), fitness/weight training (20%), skiing (18%), and jogging (11%). Of all patients, 75% were satisfied with their sports ability, and 25% were not. Moreover, 60.3% stated that their sports ability had improved after surgery, 20.5% declared no change, and 19.2% were subjectively deteriorated. The mean pain level during sports was rated to be 2.1 according to the visual analog scale. The mean HSAS score was 3.5 (range, 0-8), and the mean UCLA score was 7.7 (range, 3-10); male patients reported significantly higher scores than did female patients on the HSAS (4.1 vs 2.7, respectively) and UCLA scale (8.2 vs 7.0, respectively). Conclusion: The vast majority of patients with FAI who are treated by surgical hip dislocation return to sports activities, and most patients are satisfied with their sports ability at midterm follow-up. Activity levels are significantly higher in male patients, but this does not yield higher satisfaction rates. Keywords: femoroacetabular impingement; FAI; sport; activity; outcome; results; surgical hip dislocation
The concept of femoroacetabular impingement (FAI) described by Ganz and coworkers10,11 is widely accepted today. In this theory, deformities of the proximal femur and/or acetabulum can cause abnormal contact and cumulative damage to the acetabular labrum and adjacent articular surfaces. The severity of this damage and resulting disability are related to the intensity and frequency of abutment occurring during specific activities, usually those involving internal rotation and flexion of the hip joint.2,10-13 Most patients with symptomatic FAI are young, physically active people in their 20s or 30s. Sports activities requiring repetitive forceful flexion and internal rotation of the hip such as ice hockey or soccer are hence often associated with symptomatic FAI. Several studies of professional or semiprofessional athletes with FAI have been
*Address correspondence to Florian D. Naal, MD, Department of Orthopaedic Surgery, Schulthess Clinic, Lengghalde 2, 8008 Zurich, Switzerland (e-mail: [email protected]). y Department of Orthopaedic Surgery, Schulthess Clinic, Zurich, Switzerland. z Department of Orthopaedic Surgery, Spital Netz Bern–Ziegler, Bern, Switzerland. § Department of Orthopaedic Surgery, Sonnenhof Clinic, Bern, Switzerland. || Department of Orthopaedic Surgery, University Hospital of Geneva, Geneva, Switzerland. The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. The American Journal of Sports Medicine, Vol. 42, No. 7 DOI: 10.1177/0363546514531552 Ó 2014 The Author(s)
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published recently.3,6,7,19,21,25-27,29 These reports highlight that surgical treatment of FAI, either arthroscopically or open, is very successful at the level of the highest demand, that is, in professional sportsmen, but these reports represent the outcome in a highly selected group of patients in whom other factors such as the pressure to return to action may play an important role as well.19 Hence, such results cannot be generalized to the FAI population typically consisting of young and active but not professionally athletic patients. One recent study of sports and recreational activities in 53 patients at 2.4 years after arthroscopic surgery for FAI found that treatment did permit a return to sports in most of those who had participated in such activities before the onset of FAI symptoms.5 Byrd and Jones6 included 97 recreational athletes in a similar report. To our knowledge, no such study has been published for patients with FAI after open surgical treatment. The open approach via surgical hip dislocation still represents a commonly performed procedure, allowing excellent joint exposure and almost unlimited treatment options, which is indicated particularly in cases with posterior lesions, with gross pincer deformity, or requiring advanced cartilage repair techniques.23,24 The aim of the present study was therefore to investigate participation in sports and recreational activities and subjective outcomes related to sports in a large cohort of patients with FAI at a midterm follow-up after surgical hip dislocation.
MATERIALS AND METHODS Patient Cohort In a recently published retrospective study, patient-reported outcomes were determined in 185 patients (233 hips) who suffered from FAI and underwent surgical hip dislocation.18 Of these, 153 patients (192 hips) agreed to participate in the present survey and completed additional questionnaires (see Outcome Tools) inquiring about preoperative and postoperative sports, activity levels, and satisfaction with sports ability. There were 62 female (40.5%) and 91 male (59.5%) patients. The mean age at the time of surgery was 30.0 6 9.4 years (range, 14.0-55.0 years), and the mean body mass index (BMI) was 24.3 6 3.3 kg/m2 (range, 18.4-38.8 kg/m2). Twenty-six of the 192 hips (13.5%) had undergone 1 or more previous surgeries, mainly hip arthroscopic procedures (n = 14) and femoral correction osteotomies (n = 6). Questionnaires were completed at a mean of 59.4 6 10.9 months (range, 24.0-90.0 months) after surgery.
Diagnosis and Treatment Details on the diagnostic criteria, inclusion and exclusion criteria, and surgical approach have been published previously.18 Briefly, all patients of the present cohort had clinical (reduced flexion [usually \95°] and internal rotation [usually \10°], positive impingement test result) and radiographic (crossover sign or coxa profunda/protrusio, a angle .50°) signs of FAI and underwent obligatory
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magnetic resonance imaging of the involved hip using intra-articular gadolinium contrast.18,22 Most hips (77.1%) had mixed-type impingement, 12.5% had pure cam-type FAI, and 10.4% had pure pincer-type FAI. Surgical hip dislocation was performed under regional or general anesthesia using a Henry approach without splitting gluteus maximus fibers. Starting in 2006, Z-shaped stepped trochanteric osteotomy replaced the earlier flat osteotomy. Refixation of both osteotomy types was accomplished with two 3.5-mm cortical screws. Acetabular and labral lesions were addressed first, and the labrum was refixed with 2 to 5 bone anchors whenever possible. Formal labral takedown and refixation were performed in 103 hips (53.6%), pure debridement of loose fibers in 53 (27.6%), and partial labral resection in 14 (7.3%). Osteochondroplasty over the entire length of the femoral neck was performed in all hips. After relocation of the femoral head, repeated impingement testing was used to verify sufficient correction, that is, intraoperative impingement-free internal rotation of .30° and flexion of .110°.
Postoperative Care After stepped trochanteric osteotomy, weightbearing was restricted to one fourth of the body weight for 4 weeks, with a gradual increase thereafter and flexion limited to 90°. Low molecular weight heparin was given for 6 weeks. Continuous passive motion of the involved leg was started directly after surgery at 30° of flexion and rapidly increased to 90° during the hospital stay. Patients were encouraged to use an ergometer at home. After confirmation of trochanteric union at 6 weeks, patients began unlimited passive and active ranges of motion and hip abductor strengthening exercises. Sensorimotor exercises were emphasized to promote neuromuscular control of the pelvis and lower extremity. Sports-specific workouts were prescribed after 10 to 12 weeks, and at 12 weeks, depending on the muscular rehabilitation status, patients were allowed to restart their typical activities.
Outcome Tools The questionnaire set that was used in the main study18 consisted of the Western Ontario and McMaster Universities Arthritis Index (WOMAC; Likert scale transformed to 0 = best and 100 = worst), the Hip Outcome Score (HOS; range from 100 = best to 0 = worst), the Short Form–12 (SF-12) Physical and Mental Component Scales (PCS and MCS, respectively; range from 100 = best to 0 = worst, with 50 = normative mean), and the University of California, Los Angeles (UCLA) activity scale (10 = highest and 1 = lowest). The validated German versions of these questionnaires were used.9,15,16,30 Additionally, the patients of the present study completed the Hip Sports Activity Scale (HSAS; range from 0 = no recreational or competitive sports to 8 = competitive sports at elite level), which is a questionnaire inquiring about preoperative and postoperative regular engagement in different sports and
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TABLE 1 Outcome Scores at a Mean of 5 Years After Surgical FAI Treatmenta
Downhill skiing Cycling Jogging Soccer Fitness/Weight training Swimming Biking Hiking Tennis Ice hockey Field/Street hockey Volleyball Martial arts Aerobics/Gymnastics Inline skating Squash Horseback riding Mountaineering Dancing Climbing Handball Water gymnastics Snowboarding Cross-country skiing Nordic walking Motocross Indoor sports Track and field Table tennis Badminton Diving Endurance sports Baseball Surfing Golf
Outcome Score HOS ADL Sport WOMAC Pain Stiffness Function SF-12 PCS MCS UCLA activity scale HSAS
Mean 6 SD (Range)
89.0 6 13.1 (40.8-100.0) 75.4 6 23.1 (13.9-100.0) 10.3 6 15.7 (0.0-75.0) 15.9 6 17.3 (0.0-62.5) 9.6 6 13.0 (0.0-58.8) 47.5 52.3 7.7 3.5
6 6 6 6
6.3 7.4 1.9 2.2
(24.4-56.7) (19.9-65.6) (3.0-10.0) (0.0-8.0)
a ADL, activities of daily living; FAI, femoroacetabular impingement; HOS, Hip Outcome Score; HSAS, Hip Sports Activity Scale; MCS, Mental Component Scale; PCS, Physical Component Scale; SF-12, Short Form–12; UCLA, University of California, Los Angeles; WOMAC, Western Ontario and McMaster Universities Arthritis Index.
Preop Follow-up
0
5
10
15
20
25
Active Patients, %
Figure 1. Sports activities by patients before and 5 years after treatment for femoroacetabular impingement. activities,17 and questions related to satisfaction with their sports ability and the need for any pain medication.
Statistical Analysis Statistical analysis was performed using the software package SPSS (version 14, SPSS Inc, Chicago, Illinois, USA). Data were initially tested for normal distribution using the Shapiro-Wilk W test. For comparisons, unpaired t tests or Mann-Whitney U tests were used according to data distribution. Differences between proportions were examined using the x2 or Fisher exact test. Unless otherwise stated, descriptive results were demonstrated as the mean 6 standard deviation. The significance level was defined at P \ .05 for all tests.
RESULTS Return to Sports Of the 153 patients, 126 (82.4%) were regularly active in sports before surgery, and 115 (75.2%) were active at
follow-up (P = .125). One hundred seven (69.9%) were active before and after surgery, corresponding to a rate of return to sports of 84.9%. Nineteen patients (12.4%) stopped participating in regular sports, and 8 (5.2%) commenced with sports after the operation. Another 19 (12.4%) were never engaged in any regular sport.
Sports Activities The patients who were active in sports were engaged in a mean of 2.5 (range, 1.0-7.0) different athletic disciplines before surgery and in a mean of 2.2 (range, 1.0-4.0) at follow-up (P \ .001). Preoperatively, the most popular activities were downhill skiing, cycling, and jogging. At follow-up, the most common disciplines were cycling, fitness/weight training, and downhill skiing (Figure 1). Fewer patients were engaged in high-impact sports such as soccer, jogging, or indoor sports, and more patients participated in lower impact activities such as cycling, Nordic walking, or fitness/weight training (Figure 1).
Subjective Outcomes and Score Values Of all patients, 75% were satisfied with their sports ability, and 25% were not. Moreover, 60.3% stated that their sports ability had improved after surgery, 19.2% indicated deterioration, and 20.5% declared no change. The mean pain level during sports was rated to be 2.1 6 2.0 (range, 0.0-7.0) according to the visual analog scale (VAS). Painkillers during or after sports were occasionally taken by 17.4% of the patients, 2.6% required regular painkillers, and 80.0% never took any pain medication. Score values for the HOS Activities of Daily Living (ADL) and Sport subscales, the WOMAC subscales, the SF-12 PCS and MCS, the UCLA activity scale, and the HSAS are shown in Table 1.
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TABLE 2 Comparison Between Female and Male Patientsa Variable Sports activity, % Active preoperatively Active at follow-up Sports ability, % Ability improved Ability deteriorated Satisfied with ability Outcome score, mean 6 SD HOS ADL Sport WOMAC Pain Stiffness Function SF-12 PCS MCS UCLA activity scale HSAS
Female
Male
74.2 75.8
87.9 74.7
.029 .888
73.3 13.3 73.3
51.2 23.3 76.2
.007 .135 .699
85.7 6 15.5 72.3 6 26.2
91.3 6 10.7 77.6 6 20.6
.009 .172
12.8 6 18.7 15.3 6 16.6 12.1 6 15.1
8.5 6 13.1 16.4 6 17.9 7.8 6 11.0
.101 .702 .051
45.9 52.3 7.0 2.7
48.6 52.3 8.2 4.1
6 6 6 6
7.3 7.3 1.7 1.7
6 6 6 6
5.3 7.5 1.8 2.3
P Value
.009 .976 \.001 \.001
a
ADL, activities of daily living; HOS, Hip Outcome Score; HSAS, Hip Sports Activity Scale; MCS, Mental Component Scale; PCS, Physical Component Scale; SF-12, Short Form–12; UCLA, University of California, Los Angeles; WOMAC, Western Ontario and McMaster Universities Arthritis Index.
Group Differences No differences in sports participation, activity levels, satisfaction, or outcome scores were found between patients who had undergone previous surgery and those who had not and between patients who had unilateral or bilateral surgery. Also, we did not find any correlation between the return to sports and clinical, surgical, or radiographic findings. The mean age did not differ between patients who were satisfied with their sports ability (31.2 years) and those who were not (28.1 years) (P = .09). Significant differences were found between female and male patients, with a trend toward better postoperative subjective sports ratings but lower outcome scores in female patients (Table 2).
DISCUSSION The surgical treatment of FAI is performed more and more frequently, and the available literature indicates that good to excellent results can be achieved in 68% to 96% of the cases.8,18,20,23 Because symptomatic FAI is often encountered in young and athletically active patients, not only are improvements in pain and daily function important but also the ability to return to leisure-time activities and sports. Indeed, in a recent investigation, the improvement in sports ability has been indicated as the second most important expectation (besides pain relief) before FAI surgery.14 Numerous studies focusing on the return to play of professional or high-level athletes after FAI
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have been published in recent years.3,6,7,19,21,25-27,29 Philippon and coworkers27 reported on a series of 28 professional National Hockey League players treated arthroscopically for labral lesions with associated FAI. All patients returned to play and were subjectively satisfied after a mean follow-up of 24 months.27 In another study including a mixed group of 45 professional athletes who underwent hip arthroscopic surgery, 93% returned to professional competition, and 78% were still professionally active after a mean of 1.6 years.26 Recently, Naal and colleagues19 reported on 22 high-level athletes treated for FAI by surgical hip dislocation, and all except 1 (96%) were still competing at professional levels at a mean of 45 months postoperatively. While these studies suggest a very successful treatment outcome, irrespective of the surgical approach used, they represent results in a highly selected group of patients. Professional athletes may have the motivation to return to sports and competition (ie, financial aspects) that distinguishes them from the group of recreational or leisure-time sportsmen to which most of the patients with FAI belong. Accordingly, the top reasons for engaging in sports are reported to be ‘‘health promotion,’’ ‘‘having fun,’’ and ‘‘being fit’’ in the general Swiss population (http://www.baspo.admin.ch). The results of the present study show that about 85% of all patients will return to sports after open FAI treatment and that overall 75% will be active in sports. While some of the patients stopped sports activities after surgery, some others commenced. These figures are in line with the results reported by Brunner et al5 for 53 patients with FAI after hip arthroscopic surgery, despite the difference in follow-up times (2.4 years vs ~5.0 years in the present study). Most of their active patients participated in lower impact sports, with biking, hiking, swimming, and fitness being the most common activities.5 The most common athletic disciplines were more or less the same as in the present cohort except for downhill skiing, which remained the third most frequently performed activity. The proportion of athletically active patients that we found also corresponds to nationwide Swiss data published in 2008, with 73% of the entire population and about 80% of 25- to 34-year-old people being active in sports (http://www .baspo.admin.ch). The most common sports across the general population in Switzerland are cycling/biking, hiking, swimming, skiing, and jogging (http://www.baspo .admin.ch), which are also similar disciplines encountered in this present FAI cohort. Therefore, the tendency toward lower impact sports may be just a question of age. Yet, in cases of substantial joint damage, the patients may have changed their preferred sports based on our recommendation. In such cases, we usually recommend reducing participation in activities with intense stop-and-go or running and jumping sequences. We did not specifically inquire for the reasons for stopping sports or modifying activity behavior. Therefore, final conclusions are speculative. It can be assumed that a combination of age-related activity modifications, recommendations, environmental and social factors, and residual hip-related symptoms is responsible for the tendency toward lower impact activities or for stopping sports.
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More female patients indicated improvement in their sports ability, and more male patients indicated deterioration. This corresponds well to the fact that the proportion of female patients being engaged in sports remained stable, whereas that proportion diminished from 88% to 75% in male patients. However, overall satisfaction with sports ability at follow-up did not differ between male and female patients, and male patients had significantly higher activity levels according to the HSAS and UCLA scale. These findings could be explained, on one hand, by higher expectations that were not completely fulfilled in the male subgroup. Indeed, in a recent investigation, we found that expectations of patients with FAI were generally high and, in some domains, overly optimistic.14 On the other hand, past activity and sports levels could have been overestimated (recall bias), especially by the male patients. Most patients in the present series reported no or little pain during sports activities. The mean VAS score was 2.1, which is slightly higher than the value of 1.5 reported by Brunner and coworkers.5 The higher mean value can be explained by the fact that the patients in the present series were specifically asked to indicate pain levels experienced during or directly after sports activity and not including normal daily activities or resting periods. Score values for the WOMAC, SF-12, and UCLA scale compare very well with those found by Beaule´ et al1 in 2007, who investigated outcomes in 34 patients at a mean of 3.1 years after open FAI surgery, and with those calculated by Botser and colleagues4 based on systematic review data. Score values for the HOS ADL and Sport subscales are also in line with those reported by Botser et al4 and those indicated by Philippon et al28 for a subgroup of patients with FAI who rated their outcomes as excellent or good at 3 years after hip arthroscopic surgery. Expectedly, slightly higher values for the HOS ADL and Sport subscales and for the SF-12 PCS and MCS were reported for a cohort comprising only professional athletes after open FAI treatment.19 The present study has some limitations. First of all, this study is retrospective and includes the risk of recall bias, particularly related to the engagement in sports before surgery. Such a recall bias could be reflected by the differing results of female and male patients, with the male patients possibly tending to overestimate their activity levels some years before. Also, we have no information on when the patients exactly resumed their activities and if some of the patients were active at some point after surgery but stopped their activities before follow-up. Second, patient-oriented outcome measures have been only used at follow-up because preoperative scores were not routinely assessed at our institution, and some of the questionnaires used were not available in German at that time. Therefore, conclusions about former and actual intensity levels of sports participation are not possible. Finally, not all patients completed the additional sports questionnaire, which includes the risk of selection bias. However, demographics did not differ between this study cohort and the total cohort18 (female, 40.5% vs 40.0%, respectively
[P . .9]; BMI, 24.3 vs 24.2 kg/m2, respectively [P . .9]; age, 30.0 vs 30.0 years, respectively [P . .9]). In conclusion, the present data show that the vast majority of patients with FAI who are treated by surgical hip dislocation can return to sports activities and that most patients are subjectively satisfied with their sports ability at midterm follow-up. Activity levels as assessed by the HSAS and UCLA scale were significantly higher in male patients, but this did not yield higher satisfaction rates. Differing and overly optimistic expectations might explain this observation, indicating that sports expectations need to be comprehensively discussed and possibly adjusted downward before surgery.
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