Patient Demographics
There were 28 patients (31 hips) that met the inclusion and exclusion criteria. Of these, 25 (89.3%) patients (28 hips) had minimum five-year follow-up (mean: 72.8 ± 13.9 months). There were 3 professional, 3 collegiate, 2 high school, 2 organized amateur, and 18 recreational level tennis players. This patient cohort consisted of 14 (50.0%) males and 14 (50.0%) females. Mean age at surgery was 41.4 ± 12.7 years and mean body mass index (BMI) was 25.1 ± 3.9 kg/m2. The demographics are summarized in Table 1.
Table 1. Demographics
|
Value
|
Patients and hips included in study
|
25 patients, 28 hips
|
Left
|
10 (35.7%)
|
Right
|
18 (64.3%)
|
Gender
|
|
Male
|
14 (50.0%)
|
Female
|
14 (50.0%)
|
Age at surgery (years, mean, SD, range)
|
41.4 ± 12.7 (14.5 - 70.0)
|
BMI (mean, SD, range)
|
25.1 ± 3.9 (18.3 - 34.2)
|
Follow-up time (months, mean, SD, range)
|
66.8 ± 20.2 (60.0 - 114.2)
|
Follow-up percentage
|
90.32%
|
Flexion° (mean, SD, range)
|
116.3 ± 14.8 (85 - 140)
|
Internal Rotation° (mean, SD, range)
|
20.0 ± 14.5 (5 - 55)
|
External Rotation° (mean, SD, range)
|
42.5 ± 13.6 (15 - 70)
|
Intraoperative Findings
Intraoperative findings from the diagnostic arthroscopy are summarized in Table 2. All patients had a labral tear. There were 12 (42.9%) Seldes Type 1, 4 (14.3%) Seldes type II, and 12 (42.9%) Seldes type I & II labral tears. Cartilage integrity was assessed using the ALAD and Outerbridge classification systems. Twenty-four (85.7%) hips were assigned an ALAD grade ≥ 2, 25 (89.3%) hips were assigned acetabular Outerbridge grade ≥ 2, and 12 (42.9%) hips were assigned a femoral head Outerbridge grade ≥ 2. Fourteen (50%) hips presented with LT tears.
Table 2. Intraoperative Findings
|
n (%)
|
Seldes Tear Type
|
|
0
|
0
|
1
|
12 (42.9%)
|
2
|
4 (14.3%)
|
1 & 2
|
12 (42.9%)
|
ALAD
|
|
0
|
1 (3.6%)
|
1
|
3 (10.7%)
|
2
|
10 (35.7%)
|
3
|
10 (35.7%)
|
4
|
4 (14.3%)
|
Outerbridge (Acetabular)
|
|
0
|
0 (0.0%)
|
1
|
3 (10.7%)
|
2
|
10 (35.7%)
|
3
|
5 (17.9%)
|
4
|
10 (35.7%)
|
Outerbridge (Femoral Head)
|
|
0
|
16 (57.1%)
|
1
|
0 (0.0%)
|
2
|
6 (21.4%)
|
3
|
3 (10.7%)
|
4
|
3 (10.7%)
|
LT Percentile Class (Domb)
|
|
0 - 0%
|
14 (50.0%)
|
1 - 0% < 50%
|
7 (25.0%)
|
2 - 50% < 100%
|
7 (25.0%)
|
3 - 100%
|
0 (0.0%)
|
LT Villar Class*
|
|
0 - No tear
|
14 (53.8%)
|
1 - Complete Rupture
|
0 (0%)
|
2 - Partial Tear
|
9 (34.6%)
|
3 - Degenerate Tear
|
3 (11.5%)
|
ALAD, acetabular labral articular disruption; LT, ligamentum teres; *only data on 26 of 28 patients
Arthroscopic Procedures
The intraoperative procedures are summarized in Table 3. The majority (64.3%) of labral tears were repaired. The capsule was repaired or plicated in 12 (42.9%) hips and released in 16 (57.1%) hips. Twenty-five (89.3%) hips underwent a femoroplasty and 21 (75.0%) hips underwent an acetabuloplasty. Of the 14 LT tears, 12 (85.7%) hips were treaded via debridement. Additionally, 10 (35.7%) hips underwent an iliopsoas fractional lengthening.
Table 3. Procedures
|
n (%)
|
Labral treatment
|
|
Repair
|
18 (64.3%)
|
Debridement
|
8 (28.6%)
|
Resection
|
1 (3.6%)
|
Reconstruction
|
1 (3.6%)
|
Capsular Treatment
|
|
Repair/Plication
|
12 (42.9%)
|
Release
|
16 (57.1%)
|
Femoroplasty
|
25 (89.3%)
|
Acetabuloplasty
|
21 (75.0%)
|
Iliopsoas fractional lengthening
|
10 (35.7%)
|
Ligamentum teres debridement
|
12 (42.9%)
|
Removal of loose body
|
7 (25.0%)
|
Synovectomy
|
8 (28.6%)
|
Trochanteric bursectomy
|
6 (21.4%)
|
Gluteus medius/minimus repair
|
5 (17.9%)
|
Acetabular microfracture
|
6 (21.4%)
|
Femoral head microfracture
|
2 (7.1%)
|
Acetabular chondroplasty
|
6 (21.4%)
|
Femoral head chondroplasty
|
4 (14.3%)
|
Outcomes at Latest Follow-Up
Preoperative and minimum five-year postoperative PROs, VAS, and patient satisfaction are detailed in Table 4. All mean scores improved significantly at latest follow-up: mHHS improved from 67.0 to 86.7 (P < 0.001), NAHS improved from 65.9 to 87.2 (P < 0.001), HOS-SSS improved from 50.0 to 77.9 (P = 0.009), and VAS improved from 5.4 to 1.8 (P < 0.001). Additionally, 66.7% of patients achieved MCID and 83.3% achieved PASS for mHHS, and 63.6% achieved MCID and 58.3% achieved PASS for HOS-SSS. Mean patient satisfaction with surgery was 8/10. There was a 75.0% return to sport rate in this tennis population, with 15 (71.4%) playing at the same or higher level postoperatively. Although not statistically significant, the patients who played tennis at a competitive level (professional, college, high school, or organized amateur) experienced greater improvements in outcome scores compared to patients who played tennis recreationally (Table 5). In fact, latest follow-up scores were significantly better for HOS-SSS and VAS in the competitive group compared to the recreational group (P = 0.027 and 0.041, respectively). Mean age was 34.9 years in the competitive group and 44.0 years in the recreational group (P = 0.099).
Table 4. PROs
|
Preoperative
|
Minimum Five-Year Follow-Up
|
P-Value
|
mHHS (mean, SD)
|
67.0 ± 17.2
|
86.7 ± 16.4
|
< 0.001
|
NAHS (mean, SD)
|
65.9 ± 17.3
|
87.2 ± 17.4
|
< 0.001
|
HOS-SSS (mean, SD)
|
50.0 ± 25.0
|
77.9 ± 25.2
|
0.009
|
IHOT (mean, SD)
|
|
80.7 ± 26.6
|
|
SF-12 Mental (mean, SD)
|
|
58.8 ± 3.0
|
|
SF-12 Physical (mean, SD)
|
|
51.9 ± 8.3
|
|
VR-12 Mental (mean, SD)
|
|
63.4 ± 3.5
|
|
VR-12 Physical (mean, SD)
|
|
52.9 ± 8.0
|
|
VAS (mean, SD)
|
5.4 ± 2.3
|
1.8 ± 2.5
|
< 0.001
|
Patient Satisfaction (mean, SD)
|
|
8.0 ± 3.2
|
|
PROs: patient reported outcomes, (mHHS): modified Harris Hip Score, (NAHS): Non-Arthritic Hip Score, (HOS-SSS): Hip Outcome Score-Sport Specific Subscale, VAS: visual analog scale, (iHOT-12): International Hip Outcome Tool (VR-12P and VR-12M): the physical and mental components of the Veterans RAND 12-Item Health Survey, respectively, (SF-12P and SF-12M, respectively): the physical and mental components of the Short Form 12, respectively, bold text: statistically significant
Table 5. Comparison of PROs between High Level and Recreational Tennis Players
|
Competitive (n = 12)
|
Recreational (n = 18)
|
P-value
|
mHHS (mean, SD)
|
|
|
|
Pre
|
69.7 ± 12.6
|
65.9 ± 18.9
|
0.607
|
Latest
|
95.6 ± 8.3
|
83.0 ± 17.7
|
0.075
|
Pre-Post P-Value
|
0.016
|
0.009
|
|
Δ
|
25.8 ± 16.4
|
17.5 ± 25.2
|
0.433
|
NAHS (mean, SD)
|
|
|
|
Pre
|
72.0 ± 16.2
|
63.5 ± 17.5
|
0.249
|
Latest
|
94.6 ± 10.4
|
84.2 ± 19.0
|
0.130
|
Pre-Post P-Value
|
0.047
|
0.002
|
|
Δ
|
20.4 ± 18.0
|
20.3 ± 24.2
|
0.991
|
HOS-SSS (mean, SD)
|
|
|
|
Pre
|
54.9 ± 25.0
|
48.0 ± 25.4
|
0.521
|
Latest
|
91.7 ± 22.0
|
71.9 ± 24.7
|
0.027
|
Pre-Post P-Value
|
0.063
|
0.058
|
|
Δ
|
34.9 ± 36.4
|
20.8 ± 33.7
|
0.381
|
VAS (mean, SD)
|
|
|
|
Pre
|
5.4 ± 1.8
|
5.4 ± 2.5
|
0.98
|
Latest
|
0.4 ± 0.8
|
2.4 ± 2.8
|
0.041
|
Pre-Post P-Value
|
0.016
|
< 0.001
|
|
Δ
|
-4.8 ± 2.0
|
-3.2 ± 2.5
|
0.146
|
IHOT (mean, SD)
|
91.4 ± 18.5
|
76.0 ± 28.6
|
0.062
|
SF-12 Mental (mean, SD)
|
59.0 ± 3.2
|
58.8 ± 3.0
|
0.535
|
SF-12 Physical (mean, SD)
|
55.5 ± 2.4
|
50.4 ± 9.5
|
0.058
|
VR-12 Mental (mean, SD)
|
64.4 ± 2.7
|
63.0 ± 3.8
|
0.535
|
VR-12 Physical (mean, SD)
|
56.3 ± 2.1
|
51.4 ± 9.1
|
0.058
|
Patient Satisfaction (mean, SD)
|
8.4 ± 2.9
|
7.8 ± 3.4
|
0.757
|
PROs: patient reported outcomes, Δ: delta, (mHHS): modified Harris Hip Score, (NAHS): Non-Arthritic Hip Score, (HOS-SSS): Hip Outcome Score-Sport Specific Subscale, VAS: visual analog scale, (iHOT-12): International Hip Outcome Tool, (VR-12P and VR-12M): the physical and mental components of the Veterans RAND 12-Item Health Survey, respectively, (SF-12P and SF-12M, respectively): the physical and mental components of the Short Form 12, respectively, bold text: statistically significant
Sub-Analysis on Return to Sport
Both competitive and recreational tennis players returned to play at similar rates (P = 0.233). There seemed to be a pattern in patients who returned to tennis having higher preoperative mHHS, NAHS, and HOS-SSS scores; however, there was no significant difference in preoperative scores (P > 0.05) between the return to sport and did not return to sport groups (Figure 1). Although only statistically significant for HOS-SSS (P = 0.018), there was a similar trend suggesting patients who were able to return to tennis at latest follow-up had superior PROs at latest follow up compared to patients who were not able to return to tennis (Figure 2). In addition, there was no significant difference (P > 0.05) in age or BMI between the return to sport and did not return to sport groups. With regard to physical examination findings, there was a negative correlation relationship between flexion, internal rotation, external rotation and return to sport ability, however none were statistically significant (P > 0.05).
Complications, Secondary Arthroscopies, and Conversions to Total Hip Arthroplasty
Of the entire cohort, one (3.6%) patient had follow-up complications. This patient reported piriformis syndrome and bursitis at six-year post-operatively. One (3.6%) hip required a secondary arthroscopy at 9.9 months and four (14.3%) hips converted to THA at mean of 31.3 months following the index surgery.
The intraoperative findings suggested sixteen patients had an acetabular Outerbridge or femoral head Outerbridge grade > 2 (10 acetabular Outerbridge > 2, 1 femoral head Outerbridge > 2, and 5 with both grades > 2). Of these 16 patients, 8 (50.0%) required follow-up treatment including 1 revision arthroscopy, 2 THA, and 4 platelet-rich plasma injections, and 1 lidocaine and depo-Medrol injection to the piriformis.