Athletic Training and Sports Health Care

Systematic Review Supplemental Data

Return to Sport Following Arthroscopic Treatment of Acetabular Labral Tears in Competitive Athletes: A Systematic Review

Kate Jochimsen, MS, ATC; Chaitu S. Malempati, DO; Cale A. Jacobs, PhD, ATC; Stephen T. Duncan, MD

Abstract

Purpose:

To determine the return to sport rate after arthroscopic treatment of labral tears in a subset of competitive athletes. The authors hypothesized that arthroscopically treated labral tears would be highly effective in allowing competitive athletes to successfully return to competition.

Methods:

A comprehensive search was performed according to the PRISMA guidelines of the MEDLINE, CINAHL, and SPORTDiscus electronic databases to identify articles that analyzed return to sport in competitive athletes following arthroscopic treatment of labral tears. The primary outcome, return to sport, was defined as the self-reported ability to postoperatively participate at the patient's preoperative level of competition.

Results:

A total of 10 articles, with an overall mean follow-up of 26.4 months, were identified. There were a total of 301 athletes (210 male [69.8%]; 91 female [30.2%]; mean age = 24.5 years [range: 11 to 56 years]), with most athletes participating in hockey (n = 65), running/cross-country (n = 55), baseball (n = 40), American football (n = 36), or lacrosse (n = 20). Chondral procedures were performed in 87 athletes (28.9%) (39 microfracture, 48 chondroplasty). Of the 301 athletes, 263 (87.4%) were able to successfully return to their pre-injury level of competition at a mean of 7.7 months after surgery.

Conclusions:

Arthroscopic treatment of labral tears is a viable treatment option for athletes who desire to successfully return to sport because 87.4% of patients returned to high-level sport despite a high incidence of concomitant chondral injuries. However, these results were found in a predominantly male patient population, and future studies are necessary to determine whether females demonstrate a similar ability to return to sport after arthroscopic treatment of labral injuries.

[Athletic Training & Sports Health Care. 201X;XX(X):XX–XX.]

Abstract

Purpose:

To determine the return to sport rate after arthroscopic treatment of labral tears in a subset of competitive athletes. The authors hypothesized that arthroscopically treated labral tears would be highly effective in allowing competitive athletes to successfully return to competition.

Methods:

A comprehensive search was performed according to the PRISMA guidelines of the MEDLINE, CINAHL, and SPORTDiscus electronic databases to identify articles that analyzed return to sport in competitive athletes following arthroscopic treatment of labral tears. The primary outcome, return to sport, was defined as the self-reported ability to postoperatively participate at the patient's preoperative level of competition.

Results:

A total of 10 articles, with an overall mean follow-up of 26.4 months, were identified. There were a total of 301 athletes (210 male [69.8%]; 91 female [30.2%]; mean age = 24.5 years [range: 11 to 56 years]), with most athletes participating in hockey (n = 65), running/cross-country (n = 55), baseball (n = 40), American football (n = 36), or lacrosse (n = 20). Chondral procedures were performed in 87 athletes (28.9%) (39 microfracture, 48 chondroplasty). Of the 301 athletes, 263 (87.4%) were able to successfully return to their pre-injury level of competition at a mean of 7.7 months after surgery.

Conclusions:

Arthroscopic treatment of labral tears is a viable treatment option for athletes who desire to successfully return to sport because 87.4% of patients returned to high-level sport despite a high incidence of concomitant chondral injuries. However, these results were found in a predominantly male patient population, and future studies are necessary to determine whether females demonstrate a similar ability to return to sport after arthroscopic treatment of labral injuries.

[Athletic Training & Sports Health Care. 201X;XX(X):XX–XX.]

Intra-articular pathology in the hip such as labral tears can cause pain and limit the ability to play competitive sports at a high level. Acetabular labral tears are often a result of bony impingement; however, they can also result from an acute trauma.1 Athletes involved in highly dynamic activities, such as cutting, running, and squatting, have a high prevalence of femoral acetabular impingement (FAI). This has been described in the military,2 professional football,3 and elite soccer players.4 FAI combined with dynamic activity accelerates joint breakdown, often leading to labral damage.1,5

Treatments for symptomatic labral tears that have failed conservative treatment include surgical debridement, repair, or reconstruction of the labrum. The evidence for successful conservative treatment of symptomatic labral tears in an athletic population is limited,6–8 whereas the evidence for labral repair in this population is promising.9–24 In 2015, a review examining return to sport after surgery for FAI found positive outcomes.25 The authors acknowledged that the labrum was surgically addressed in 79% of the athletes25; however, they did not complete a subgroup analysis. Their review included open procedures (21%), which can be more traumatizing to the surrounding musculature, are often done for more severe anatomical anomalies, and are invasive and can feasibly affect an athlete's ability to return to a high level of competition. As such, the previous review may be underestimating the ability of patients with arthroscopically treated FAI with labral pathology to return to sport. On the contrary, the labrum is the main pain generator of the hip,26 which may affect return to play rates. Because it is unclear whether previous results are clouded by the inclusion of patients undergoing open procedures or whether labral pathology is the primary driver of a failure to return to sport, a targeted analysis of arthroscopically treated athletes is warranted.

Due to the anatomic function of the labrum, repair is the preferred treatment; however, it is not always feasible because of tissue integrity or healing potential. In these cases, labral debridement or reconstruction can be considered. The goal of arthroscopic treatment of labral injuries is to improve the pain and function of the patient while attempting to normalize hip joint structures with the hopes of preventing further damage. Highly competitive patients will seek treatment options that will allow them to return to a similar high activity level. Successful outcomes following arthroscopic treatment of labral tears have been shown in an athletic population; however, a systematic evaluation of return to play in a highly competitive population has not been conducted. Therefore, the purpose of this systematic review was to determine the return to sport rate after arthroscopic treatment of labral tears in competitive athletes. Building on the promising results of the 2015 review, we hypothesized that arthroscopic treatment of acetabular labral tears would be highly effective in allowing approximately 75% of competitive athletes to successfully return to competition.

Methods

Inclusion and Exclusion Criteria

To be included in this review, studies must have been written in the English language, limited to humans, and included return to play as the self-reported ability to postoperatively participate at the patient's preoperative level of competition, athletes actively competing in sport above a recreational level (ie, high school, collegiate, or professional athletes), and primary arthroscopic labral treatment including debridement, repair, or reconstruction.

Studies were excluded from this review if participants were only engaged in recreational activity or the mean age was older than 40 years. These groups were excluded with the hopes of identifying a homogenous, athletic population. We included studies with mixed surgical interventions to ensure all athletes with arthroscopically treated labral injuries were represented. Concomitant and parallel cohort procedures included femoral osteochondroplasty, acetabuloplasty, iliopsoas release, chondroplasty, and/or microfracture. All patients received treatment for a torn labrum, including labral debridement, repair, or reconstruction.

Search Strategy and Study Selection

A comprehensive electronic literature search was completed for articles published between January 1, 2000, and December 1, 2016. MEDLINE, SPORTDiscus, and CINAHL databases were used to identify studies meeting the PICO criteria described in Table 1. In addition, a hand search of the American Journal of Sports Medicine and the Journal of Orthopaedic and Sports Physical Therapy was performed for the past 6 months of publication. Search results were entered into EndNote (Clarivate Analytics, Philadelphia, PA) to remove duplicate studies.

Database PICO Search Termsa

Table 1:

Database PICO Search Terms

Data Extraction

Our primary outcome was return to sport, yes or no. In addition, we recorded patient demographic information and examined the number of concomitant cartilage injuries treated with microfracture or chondroplasty, preoperative duration of symptoms, and time to return to sport as secondary outcomes. Grand means and ranges are reported for all outcomes of interest. Standard deviations were not reported in all studies, so grand standard deviations (SDs) and confidence intervals (CIs) were not able to be calculated.

Quality Assessment/Appraisal

Study methodologies were appraised using the National Institutes of Health (NIH) Quality Assessment Tool (Table A, available in the online version of this article) by two independent reviewers.27 Consensus was reached between reviewers and results are described in Table 2.

Quality Assessment Tool for Case Series Studies

Table A:

Quality Assessment Tool for Case Series Studies

Article Quality Assessed via the National Institutes of Health's Quality Assessment Tool for Case Series Studies

Table 2:

Article Quality Assessed via the National Institutes of Health's Quality Assessment Tool for Case Series Studies

Results

Of the 11,977 hits identified in the initial search (Table 3), a total of 26 articles were identified and, following removal of duplicates, 19 were read for possible inclusion. Of the original 19 studies, 4 were excluded because not all athletes received surgical treatment for a labral tear,9,21,23,28 4 more were excluded because they contained duplicate athletes,11,12,16,17 and 1 was excluded because most athletes had previous ipsilateral primary hip arthroscopy.29 After exclusion, 10 articles were included for analysis in this review. A flow chart of this search strategy and study selection process can be found in Figure 1. All articles scored a 7 of 9 or higher on the NIH Quality Assessment tool, which is a quality rating of “good” (Table 2).

Search Terms and Results for Each Database

Table 3:

Search Terms and Results for Each Database

Flow chart of search strategy and study selection.

Figure 1.

Flow chart of search strategy and study selection.

In total, there were 301 athletes (210 male, 91 female; mean age = 24.5 years; [range: 11 to 56 years]), with the majority of athletes participating in hockey (n = 65), running/cross-country (n = 55), baseball (n = 40), American football (n = 36), or lacrosse (n = 20). Of the 301 athletes, 263 (87.4%) were able to successfully return to their pre-injury level of competition at a mean of 7.7 months after surgery (range: 4 to 9.4 months). The overall mean duration of symptoms prior to undergoing surgical treatment was 9 months. In total, 22 sports were represented (Table 4).

Sport Representations

Table 4:

Sport Representations

The mean follow-up across studies was 26.4 months (range: 4 to 77 months), providing sufficient time for athletes to complete rehabilitation and return to a high level of competition. Chondral procedures were performed in 87 athletes (39 microfracture, 48 chondroplasty); however, not all studies reported on concomitant procedures, nor did most report a level of granularity that allowed us to determine whether the ability to return to sport differed for those who had undergone chondral procedures. Further article details can be seen in Table 5.

Demographics and Return to Sport Details for Included Articles

Table 5:

Demographics and Return to Sport Details for Included Articles

Discussion

The purpose of this systematic review was to determine the return to sport rate after arthroscopic treatment of labral injuries in competitive athletes. We hypothesized that arthroscopic treatment for acetabular labral tears would be highly effective in allowing approximately 75% of competitive athletes to successfully return to competition, which was supported by the current results. Current evidence supports arthroscopic treatment for acetabular labral tears as a viable treatment option for athletes with a desire to successfully return to sport because 87.4% of patients returned to a high level of competition. This is similar to the prevalence of military “warrior athletes” who are able to return to active duty following arthroscopic hip procedures. In 2016, Byrd et al.2 reported an 80% return to active duty following hip arthroscopy in active military service members at an average of 5 months.

The 87.4% return to play rate is noteworthy given the high incidence of concomitant chondral injuries (39 of 301, 12.9% microfracture; 48 of 301, 15.9% chondroplasty). Although we were unable to evaluate whether return to play differed due to concomitant procedure based on the articles included in this review, the fact that most patients were able to return to competitive sports may suggest that concomitant chondral procedures do not negatively affect functional ability. Further studies are necessary to examine return to play following arthroscopic treatment of labral tears in athletes with and without chondral injuries.

In the native hip, the labrum reduces femoral head translation and also increases the surface area of the acetabulum.30 These functions reduce both contact pressures and shear forces acting on the articular cartilage.30 Labral tears may destabilize the joint, leading to increased forces borne by the articular cartilage, which may initiate the onset of osteoarthritic changes.31 Labral repair and reconstruction has been demonstrated to restore the function of the native labrum,3 and the current results suggest that, even for those with concomitant chondral injury, restoration of labral function often allows a successful return to competitive sports. Although labral debridement does not completely restore native hip function, debridement of small tears only affecting the periphery may successfully eliminate the pain generator without grossly affecting the biomechanics of the joint.32,33

This systematic review is limited by several factors. Unfortunately, the available literature addressing return to sport after arthroscopic treatment of labral tears includes a predominantly male patient population (69.8%, 210 male/91 female). Attempts were made to distinguish return rates between males and females; however, this analysis was not possible with the available information. Bony deformity magnitude differs between sexes because males often have a more substantial cam deformity and females often have a more prominent pincer deformity.34–36 Although a combined cam and pincer deformity is common, this review does not address differences in bony anatomy and labral tear patterns between sexes. Future studies are necessary to determine whether females demonstrate a similar ability to return to sport after acetabular labral repair.

Another limitation of this study is the lack of studies that had a long-term follow-up of up to 5 years. Most articles included in this review had shorter follow-up periods, with a mean follow-up of just over 2 years. It has been suggested that acetabular labral tears are the first step in the osteoarthritis process, and longer follow-up is required to determine whether high levels of activity following labral repair are beneficial or potentially harmful for overall joint health.

This review is also limited by the eagerness and willingness of athletes to return to play. Although we limited our search to only competitive athletes, the results still describe a range of talent, motivation, and skill. The athletes included in this study ranged from young high school athletes to seasoned professionals. Differences in return to play between sports were also not identified by this review; however, further research should be done to identify the most appropriate athletes for this treatment. Return to play likely depends on a variety of other variables, such as age and duration of symptoms. The mean duration of symptoms for the subset of articles that included this information was 11 months, which is significantly less than the 28 months previously reported.2 This discrepancy may be explained by an increase in hip arthroscopies performed and advances in this surgical technique. Finally, the articles in this review included a variety of labral procedures. The majority of athletes were treated with a labral repair; however, some athletes were treated with labral debridement. With the available articles, it was not possible to isolate individual athletes who received a labral repair within each cohort so the entire cohort was included in this analysis. We could not directly compare labral repair and labral debridement because our search did not yield any articles that allowed us to independently assess labral debridement and return to play. We also did not directly compare labral repair and labral reconstruction because these procedures often have different indications, making a direct comparison difficult.

Conclusion

Arthroscopic labral repair is a viable treatment option for high-level athletes seeking to return to play. This review concluded that 87.4% of competitive athletes returned to play in an average of 7.7 months. This return is multifactorial and additional research is necessary to determine whether return to play rates differ among variables such as sex, sports, and management of the labral pathology.

References

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Database PICO Search Termsa

PICO CategorySearch Term
PopulationCompetitive athlete
High level athlete
InterventionLabral repair
Acetabular labral repair
Hip
ComparisonNot applicable
OutcomeReturn to play
Return to sport
Return to activity

Article Quality Assessed via the National Institutes of Health's Quality Assessment Tool for Case Series Studies

StudyWas the study question or objective clearly stated?Was the study population clearly and fully described, including a case definition?Were the cases consecutive?Were the subjects comparable?Was the intervention clearly described?Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all study participants?Was the length of follow-up adequate?Were the statistical methods well described?Were the results well described?Quality rating
Boykin (2013)NANANA7/9
Cheatham (2012)NANANA8/9
Klingenstein (2012)9/9
Lee (2012)NANANA7/9
Levy (2017)9/9
Mohan (2017)8/9
McDonald (2013)8/9
Nho (2011)9/9
Philippon (2009)NANANA8/9
Philippon (2008)9/9

Search Terms and Results for Each Database

Search TermsMEDLINECINHALSPORTDiscusTotal
Labral Repair AND Hip89945143
Acetabular Labral Repair AND Hip1811231
Labral Repair AND Return to Play OR Return to Sport OR Return to Activity AND Hip2,2359082,2125,355
Acetabular Labral Repair AND Return to Play OR Return to Sport OR Return to Activity AND Hip2,2349082,2125,354
Labral Repair AND Competitive Athlete OR High Level Athlete AND Hip2589433547
Acetabular Labral Repair AND Competitive Athlete OR High Level Athlete AND Hip2589433547
Total4,6262,0045,34711,977

Sport Representations

SportNumber of Athletes
Hockey65
Running/cross-country55
Baseball40
American football36
Lacrosse20
Soccer17
Golf13
Recreational12
Volleyball8
Dance7
Tennis5
Track and field5
Basketball3
Field hockey3
Equestrian2
Figure skating2
Skiing2
Swimming2
Crew1
Fencing1
Gymnastics1
Softball1
Total301

Demographics and Return to Sport Details for Included Articles

Lead AuthorNYearSport# M/FRTP %Mean Time to RTP (mo)Arthroscopic Labral Treatment
Boykin12013Soccer (1)1M100% (1/1)Not reportedLabral repair
Cheatham12012Football (1)1M100% (1/1)4Labral repair
Klingenstein342012Lacrosse (18); Baseball (16)29M/5F97% (33/34)Not reported13 labral repairs, 21 labral debridement
Lee12012Soccer (1)1M100% (1/1)5Labral repair
Levy512017Runners (51)22M/29F95% (48/51)8.548 labral repairs, 3 labral debridement
McDonald1202013Football (25); Hockey (53); Soccer (6); Golf (13); Baseball (19); Tennis (4)120M82% (98/120)Season of/season following surgery113 labral repair, 20 labral debridement
Mohan502017Recreational (12); Volleyball (5); Soccer (5); Football (5); Cross-country (4); Hockey (4); Track and Field (3); Basketball (3); Baseball (2); Dance (2); Lacrosse (2); Fencing (1); Gymnastics (1); Softball (1)17M/33F92% (46/50)Not reported56 labral repair, 1 labral debridement (7 patients had bilateral procedures)
Nho262011Hockey (7); Soccer (4); Football (4); Field Hockey (3); Swimming (2); Track (2); Crew (2);Tennis (1); Equestrian (1)16M/10F69.2% (18/26)9.4Labral repair, labral debridement (exact ratio unknown)
Philippon12009Football (1)1M100% (1/1)4Labral repair
Philippon162008Dance (5); Volleyball (3); Skating (2); Baseball (2); Skiing (2); Hockey (1); Horseback Riding (1)2M/14F100% (16/16)47 labral repair, 9 labral debridement
Total301210M/91F87.4% (263/301)7.7 months

Quality Assessment Tool for Case Series Studies

CriteriaYesNoOther (CD, NR, NA)*
1. Was the study question or objective clearly stated?
2. Was the study population clearly and fully described, including a case definition?
3. Were the cases consecutive?
4. Were the subjects comparable?
5. Was the intervention clearly described?
6. Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all study participants?
7. Was the length of follow-up adequate?
8. Were the statistical methods well-described?
9. Were the results well-described?
Quality Rating (Good, Fair, or Poor)
Rater #1 initials:
Rater #2 initials:
Additional Comments (If POOR, please state why):
Authors

From the Departments of Rehabilitation Science (KJ) and Orthopaedic Surgery and Sports Medicine (CSM, CAJ, STD), University of Kentucky, Lexington, Kentucky; and Western Kentucky University, Bowling Green, Kentucky (CSM).

The authors have no financial or proprietary interest in the materials presented herein.

Correspondence: Kate Jochimsen, MS, ATC, University of Kentucky, Department of Rehabilitation Science, 900 South Limestone Street, CTW 214A, Lexington, KY 40536. E-mail: kate.jochimsen@uky.edu

Received: September 12, 2017
Accepted: February 02, 2018
Posted Online: June 25, 2018

10.3928/19425864-20180510-01

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