Systematic Review

Patient-Reported Outcomes in Athletes Following Hip

Arthroscopy for Femoroacetabular Impingement
With Subanalysis on Return to Sport and
Performance Level: A Systematic Review
Shawn Annin, M.D., Ajay C. Lall, M.D., M.S., Mitchell J. Yelton, B.S., Jacob Shapira, M.D.,
Philip J. Rosinsky, M.D., Mitchell B. Meghpara, M.D., David R. Maldonado, M.D.,
Hari Ankem, M.D., and Benjamin G. Domb, M.D.

Purpose: To identify present trends in demographics, surgical indications, preoperative findings, and surgical treatment
of athletes undergoing hip arthroscopy for femoroacetabular impingement and (2) to investigate the outcomes in this
patient population, including patient-reported outcome scores (PROS), return-to-sport, complications, and reoperation
data at minimum 2-year follow-up in the athletic population. Methods: Cochrane, Embase, and PubMed databases were
searched according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to distinguish
articles that reported PROS after hip arthroscopy in athletes. Athletes were defined as anyone who played a sport for
minimum 2 years at any level. The standardized mean difference was calculated to compare the effect size of hip
arthroscopy on various PROS. Results: Eighteen studies, with 904 athlete hips and a collective study period of January
1993 to April 2017, were included in this systematic review. Across all studies, the mean age and body mass index ranged
from 15.7-36.7 years and 20.3-26.3, respectively. The follow-up range was 24-240 months. Mean preoperative alpha
angle ranged from 57.7
to 80.0
. Athletes most commonly underwent femoroplasty and labral management. At latest
follow-up, the modified Harris Hip Score were excellent in 6 studies (range, 92.1-98), good in 10 studies (range, 84.2-
88.5), and fair in 1 study (77.1). Each studies’ individual athletic cohort showed significant improvement on the modified

From the American Hip Institute Research Foundation, Chicago (S.A.,
A.C.L., M.J.Y., J.S., P.J.R., M.B.M., D.R.M., H.A., B.G.D.); AMITA Health
St. Alexius Medical Center, Hoffman Estates (A.C.L., M.B.M., B.G.D.); and
American Hip Institute, Chicago (A.C.L., B.G.D.), Illinois, U.S.A.
The authors report the following potential conflicts of interest or sources of
funding: A.C.L. reports grants, personal fees, and nonfinancial support from
Arthrex; nonfinancial support from Iroko, Medwest, and Smith & Nephew;
grants and nonfinancial support from Stryker; nonfinancial support from
Vericel and Zimmer Biomet; and personal fees from Graymont Medical,
outside the submitted work. A.C.L. also is the Medical Director of Hip Pres-
ervation at St. Alexius Medical Center. J.S. reports nonfinancial support from
Arthrex, Smith & Nephew, Stryker, and Ossur, outside the submitted work.
P.J.R. reports nonfinancial support from Arthrex, Stryker, Smith & Nephew,
and Ossur, outside the submitted work. M.B.M. reports nonfinancial support
from Stryker, Smith & Nephew, and Arthrex, outside the submitted work.
D.R.M. reports nonfinancial support from Arthrex, Stryker, Smith & Nephew,
and Ossur, outside the submitted work. He is also an editorial board member
of Arthroscopy. B.G.D. reports grants and other from American Orthopedic
Foundation, during the conduct of the study; personal fees from Adventist
Hinsdale Hospital; personal fees and nonfinancial support from Amplitude;
grants, personal fees, and nonfinancial support from Arthrex; personal fees
and nonfinancial support from DJO Global; grants from Kaufman Founda-
tion; grants, personal fees, and nonfinancial support from Medacta; grants,
personal fees, nonfinancial support, and other from Pacira Pharmaceuticals;
grants, personal fees, nonfinancial support, and other from Stryker; grants
from Breg; personal fees from Orthomerica; grants, personal fees, nonfinancial
support, and other from Mako Surgical Corp; grants and nonfinancial support
from Medwest Associates; grants from ATI Physical Therapy; grants, personal
fees, and nonfinancial support from St. Alexius Medical Center; and grants
from Ossur, outside the submitted work. In addition, B.G.D. has a patent
8920497eMethod and instrumentation for acetabular labrum reconstruction
with royalties paid to Arthrex, a patent 8708941eAdjustable multi-
component hip orthosis with royalties paid to Orthomerica and DJO
Global, and a patent 9737292eKnotless suture anchors and methods of tissue
repair with royalties paid to Arthrex. B.G.D. also is the Medical Director of
Hip Preservation at St. Alexius Medical Center; a board member for the
American Hip Institute Research Foundation, AANA Learning Center Com-
mittee, the Journal of Hip Preservation Surgery, Arthroscopy; and has had
ownership interests in the American Hip Institute, Hinsdale Orthopedic As-
sociates, Hinsdale Orthopedic Imaging, SCD#3, North Shore Surgical Suites,
and Munster Specialty Surgery Center. Full ICMJE author disclosure forms
are available for this article online, as supplementary material.
This study was performed at the American Hip Institute Research Foun-
dation, Chicago, Illinois, U.S.A.
Received September 28, 2020; accepted March 29, 2021.
Address correspondence to Dr. Benjamin G. Domb, American Hip Institute,
999 E. Touhy Ave., Suite 450, Des Plaines, IL 60018. E-mail: DrDomb@
americanhipinstitute.org
Ó 2021 by the Arthroscopy Association of North America
0749-8063/201639/$36.00
https://doi.org/10.1016/j.arthro.2021.03.064

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 37, No 8 (August), 2021: pp 2657-2676 2657
2658 S. ANNIN ET AL.

Harris Hip Score, Nonarthritic Hip Score, the Hip Outcome ScoreeActivities of Daily Living, the Hip Outcome
ScoreeSport-Specific Subscale, visual analog scale for pain, and International Hip Outcome Tool at latest follow-up (P <
.05). The return-to-sport rate ranged from 72.7% to 100%, with 74.2-100% of these athletes returning to preinjury or
greater level. Conclusions: Athletes undergoing arthroscopic hip surgery in the setting of femoroacetabular impinge-
ment, not only exhibit significant functional improvement, but also have a high rate of return to sport at the same or
greater competition level compared with preinjury level. Level of Evidence: IV, systematic review of Level III and IV
studies.

F emoroacetabular impingement (FAI) has been

widely acknowledged as a common cause of hip
pain.1 The impingement between the femoral head and
the acetabulum is the result of abnormal bony archi-
tecture and may lead to damage of both the labrum and
the articular cartilage. One of the principal roles of the
labrum is to maintain the fluid suction seal of the hip
joint. Thus, labral tears secondary to FAI may lead to
further exacerbation by failure to maintain this func-
tion. These changes may ultimately result in arthritis of
the hip joint.1,2 The athletic population, however, is of
particular concern. Not only is the prevalence of FAI
greater in the athletic population as compared with
their nonathletic counterparts, they are more exposed
to continuous, repetitive forces on the hip joint, pre-
sumably making them more prone to rapid progression
of disease.3,4
With the advent of hip arthroscopy, efforts to pre-
serve this integral relationship between the native
labrum and femoral head have demonstrated promising
results with significant improvement observed in
patient-reported outcome scores (PROS) after sur-
gery.5,6 The ability to not only return to sport (RTS) but
to return at the same or greater level of competition or
performance are of paramount importance to this
cohort. More specifically, there is a need for examina-
tion of not only RTS but the level of RTS, patient
perception of athletic level, and desired level of sports.
These are elements that, at present, have been sparsely
reported in the literature. Nonetheless, there have been
a few systematic reviews solely focusing on return-to-
play with minimal follow-up.7,8 However, to have a
comprehensive analysis of RTS, a more in depth ex-
amination of the most commonly used validated PROS
in hip arthroscopy as well as performance level after
RTS must be performed.
Therefore, this systematic review aims to (1) identify
present trends in demographics, surgical indications,
preoperative findings, and surgical treatment of athletes
undergoing hip arthroscopy for FAI and (2) to investi-
gate the outcomes in this patient population, including
PROS, RTS, complications, and reoperation data at
minimum 2-year follow-up in the athletic population.
We hypothesized that athletes would demonstrate
favorable outcomes and high rates of return-to-play at
same or greater competition level.
Methods
This study was performed in accordance with the
ethical standards in the 1964 Declaration of Helsinki.
This study was carried out in accordance with relevant
regulations of the U.S. Health Insurance Portability and
Accountability Act (HIPAA). Details that might disclose
the identity of the subjects under study have been
omitted. This study was approved by the institutional
research board (ID: 5276)
Study Selection and Inclusion Eligibility
In January 2020, the PubMed, Embase, and Cochrane
databases were searched to identify articles that re-
ported outcomes after hip arthroscopic surgery in ath-
letes. The search was performed in accordance with the
PRISMA (Preferred Reporting Items for Systematic
Reviews and Meta-Analyses)9 guidelines and used the
following key words to ensure inclusion of relevant
articles: “hip arthroscopy,” “hip,” “arthroscopy,” “fem-
oroacetabular impingement,” “impingement,” “FAI,”
“athlete,” and “sport.” Two reviewers (S.A. and M.J.Y.)
examined the titles and abstracts before selecting arti-
cles for a full-text review. A third reviewer (A.C.L.)
settled any differences that arose between the first two.
The references of all reviewed articles also were
screened for additional studies.
Articles were included within this review if they
included minimum 2-year postoperative PROS in ath-
letes undergoing hip arthroscopy for FAI. Articles were
excluded if they did not meet the aforementioned in-
clusion criteria or contained overlapping patient pop-
ulations. In addition, abstracts, cadaveric studies, case
reports, review articles, and technical notes were
excluded. The selected studies were then comprehen-
sively reviewed for patient demographics, mean follow-
up, surgical indications, radiographic findings, surgical
treatment, PROS, RTS findings, subsequent surgical
procedures, and complications.
Quality Assessment
Two authors (S.A. and M.J.Y.) separately assessed
each article using the validated Methodological Index
for Non-Randomized Studies (MINORS) criteria. This
scoring system was used to create a numerical score for
each article based on the study’s purpose, data collec-
tion process, end points, follow-up rate, and statistical
 ATHLETE OUTCOMES FOLLOWING FAI
analysis. Any cases of disagreement between the 2
authors in MINORS scoring were resolved by the senior
author.
Data Extraction
Microsoft Excel (Microsoft Office 2018; Microsoft,
Redmond, WA) was used to organize the data from all
included studies. Reviewers extracted the title, author,
date of publication, number of hips, demographics,
follow-up time, duration of symptoms, competition
level, indications, radiographic readings, surgical treat-
ment/intraoperative findings, PROS, RTS data, compli-
cations, and reoperations from each study.
Statistical Analysis
Results of the PROS were categorized as excellent
(90 points), good (80-89), fair (70-79), or poor
(69).10,11 The standardized mean difference (SMD)
was calculated for studies that reported preoperative
PROS, postoperative PROS, and a measure of dispersion
of the data, such as standard deviation or range.
Calculated by the method described by Griffin et al.,5
the SMD estimates the effect size of arthroscopic hip
surgery on athletes in the select PROS. If the standard
difference of the respective preoperative PRO score was
not provided, it was approximated using the range or
the 95% confidence interval.12,13 The effect sizes were
analyzed using the established threshold values for
weak (SMD 0.20-0.49), moderate (SMD 0.50-0.79),
and large (SMD 0.80).14 The heterogeneity was
quantified using the I2 statistic.15 For studies including
both athletic and nonathletic patients, an analysis was
performed to break down PROs between cohorts.
Nonathletes were not otherwise used in the analyses of
this study. In addition, if available, RTS after hip
arthroscopy was summarized with the RTS rate, sport
type, and reasons for not returning to sport. The col-
lective RTS rate was calculated by weighting each
study’s RTS rate by the number of hips in each study.
Results
Study Selection
The literature search yielded a total of 746 studies
with 684 unique articles. Of the 684 unique articles,
626 were screened out based on review of the abstract/
title. After reviewing the full text of the remaining 58
studies, 40 studies were excluded due to the following:
28 studies had no PROs/ were nonoperative manage-
ment studies, 4 studies did not include an athlete pop-
ulation, 4 studies consisted of overlapping patient
populations, 2 were review articles, and 2 did not have
minimum 2-year follow-up. Eighteen studies, with
1123 hips (904 athletic hips, 219 nonathletic hips) and
a collective study period of January 1993 to April 2017
2659
were included in our systematic review.2,16-32 Our
search strategy is illustrated in Figure 1.
Patient Demographics
Across all studies, the age and body mass index
ranged from 15.7-36.7 years and 20.3-26.3, respec-
tively, with the majority of the cohort of each study
being female (Table 1). The collective mean follow-up
ranged from 24-240 months. Five studies reported
duration of symptoms, with athletes experiencing
symptomology ranging from 6 to 19 months before
undergoing hip arthroscopy.2,16,21,31,32 Seventeen of 18
studies reported the breakdown of their patient popu-
lation pertaining to sport played, with soccer and
running/cross-country cited most frequently (Fig 2A).
Eleven studies (489 hips) provided proportions of
athlete competition level.2,16,18-23,26,29,32 Athletes were
divided into specific categories based on level of per-
formance and demand (Fig 2B). Three studies reported
on athletes of recreational level (ranging from 22.2% to
77.0% of all athletes),19,21,23 4 studies reported on
athletes of amateur level (ranging from 15.8% to 100%
of all athletes),19,21,22,27 6 studies reported on athletes
of high school level (ranging from 16.1% to 61.7% of
all athletes),16,19,22,23,26,32 6 studies reported on athletes
of college level (ranging from 12.0% to 53.2% of all
athletes),16,19,22,23,26,32 and 7 studies reported on ath-
letes of professional level (ranging from 2.5% to 100%
of all athletes).2,18,19,23,26,29,32
Surgical Indications
All patients underwent hip arthroscopic surgery for
treatment of FAI. All studies cited failure of nonsurgical
treatment, including physical therapy, injections, and
activity modification ranging from six weeks to three
months duration, as the indication for operative
procedure.
Physical Examination Findings
Of the 3 studies (106 hips) which examined range of
motion pre- and postoperatively, 2 studies found signif-
icantly improvement in hip flexion (116.5
 10.4
to
120.0
 0.0
, P ¼ .02; 110.3
 11.4
to 117.1
 8.4
,
P ¼ .01), whereas the remaining study found no increase
in forward flexion (118.3
 24.3
to 118.1
 10.0
,
P ¼ .9). In addition, 1 study found significant improve-
ment in internal rotation (12.6
 9.9
to 21.0  9.6
,
P < .001), whereas the other 2 studies did not see sig-
nificant changes (16.0
 15.4
to 21.3
 5.0
, P ¼ .16;
21.7
 10.8
to 19.6
 10.4
, P ¼ .11).21,26,28
Radiographic Findings
Radiographic findings were reported in 10 of 18
studies.2,19,20-23,24,26,28,30 Mixed-type FAI was the most
common radiographic finding, followed by isolated cam
deformity and isolated overcoverage. Cam-type
2660 S. ANNIN ET AL.

Fig 1. Search strategy based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.
(PROs, patient-reported outcome scores.)

impingement was more prevalent in this cohort
compared with pincer-type impingement. The preop-
erative alpha angle and lateral center-edge angle ranges
were 57.7
-80.0
(Dunn-view) and 28.5
-36.5
,
respectively. However, mixed cam- and pincer-type
impingement was a common finding across all
studies. Of the studies reporting on Tönnis grade,
93.1% to 99.2% of the athletes had a Tönnis grade of
0.20,24,28 Only 4 of the 10 studies reported postoperative
radiographic findings.19,20,21,28 The postoperative alpha
angle and lateral center-edge angle ranges were 38.9

to 43.9
(Dunn-view) and 25.1
to 28.7
, respectively.
Tönnis grade remained unchanged.
Intraoperative Findings and Surgical Treatment
Fourteen studies reported on intraoperative
findings and surgical procedures
performed.2,16-19,21-23,25,26,28-30,32 In total, 618 labral
tears/lesions were observed, of which all underwent
some form of labral treatment. These included repair/
refixation (481/618 hips) which was the most common
labral management, followed by debridement/resection
(132/618 hips), and reconstruction (5/618 hips). Four
studies used the Outerbridge classification to define the
intraoperative state of the femoral and acetabular
cartilage.19,29,32,23 Of the 189 hips classified in these
studies, 159 hips were classified as grade 0, 7 hips were
Table 1. Characteristics of Included Studies

Duration of
Symptoms,
MINORS Age, y, Mean  SD BMI, Mean  SD Follow-up, mo, Mean  SD mo, Mean  SD
Study LoE Score No. of Hips (Sex) (Range) (Range) (Range/% Follow-up) (Range) Competition Level
Murata et al.,25 IV 19 Athletes: 47 (32 M, Athletes: 28.3  11.4 Athletes: Minimum: 24 (73%) NR School or in
2017 15 F) Nonathletes: 22.1  2.8 community
Nonathletes: 27 (11 39.7  6.6 Nonathletes:
M, 16 F) 22.3  2.7
Philippon et al.,2 IV 15 28 (28 M) 27 (18-36) NR 24 (12-42) 19 months (1.5- Professional
2010 99)
Barastegui IV 14 21 (21 M) 26.5  7.1 NR 45.4  15.6 NR Professional
et al.,29 2018
Przybyl et al.,27 IV 15 Athletes: Athletes: 36.7  13.3 NR Minimum: 24 (100%) NR >2 hours of activity 3
2018 95 (22 M, 37 F) (18-52) times per week
Nonathletes: 43 (33 Nonathletes: 38.5  required to be
M, 85 F) 14.4 (26-78) considered an athlete

ATHLETE OUTCOMES FOLLOWING FAI

Clapp et al.,20 III 20 Athletes: Athletes: Athletes: Minimum: 24 NR Professional
2020 59 (22 M, 37 F) 22  4.8 23.9  3.1 Semiprofessional
Nonathletes: 118 (33 Nonathletes: 23.2  Nonathletes: 23.8  Collegiate
M, 85 F) 5.4 3.2 Nonathlete (118)
Byrd et al.,17 IV 15 116 (47 M, 57 F) 16 (12-17) NR 38 (24-120) NR NR
2016
Nho et al.,26 IV 14 47 (34 M, 13 F) 22.8  6.2 (17-56) NR 27.0  5.5 (17-35) (72%) NR HS: 27.7%
2011 Collegiate: 53.2%
Professional: 19.1%
Frank et al.,30 IV 15 58 (22 M, 36 F) 30.0  7.1 23.2  2.7 31.14  0.71 (94%) NR Recreational or
2018 competitive
Levy et al.,22 IV 14 54 (22 M, 29 F) 26.3  7.8 23.7  3.3 Minimum: 24 (87%) NR Amateur: 74%
2017 HS runners: 14%
Intercollegiate: 12%
Frank et al.,21 IV 16 28 (10 M, 16 F) 31.3  7.2 (12-42) 24.2  2.7 31.2  4.95 (96%) 6.0  4.0 Amateur: 23%
2018 Recreational: 77%
Litrenta et al.,23 IV 14 81 (20 M, 61 F) 15.9  1.2 (13.1-18.0) 21.4  3.3 (15.7-34.7) 45.2  19.2 (24-84.5) (84%) NR HS: 61.7%
20202 Collegiate: 2.5%
Professional: 2.5%
Organized
competitive: 11.1%
Recreational: 22.2%
McConkey II 15 36 (5 M, 19 F) Bilateral group: 15.7  Bilateral group: 20.3  Minimum: 24 months* 6 (5-13) NR
et al.,31 2019 1.4 3.1
Unilateral group: Unilateral group:
16.5  1.9 21.5  2.9
(continued)

2661
Table 1. Continued

2662
Duration of
Symptoms,
MINORS Age, y, Mean  SD BMI, Mean  SD Follow-up, mo, Mean  SD mo, Mean  SD
Study LoE Score No. of Hips (Sex) (Range) (Range) (Range/% Follow-up) (Range) Competition Level
Chen et al.,19 III 19 Basketball group: 31 Basketball group: Basketball group: Basketball group: NR HS: 16.1%
2019 (20 M, 11 F) 30.0  12.2 (13.8- 26.3  6.5 (18-43.5) 45.9  21.6 (11.9-87.6) College: 19.4%
Control: 31 (20 M, 11 55.1) Control: Control: Professional: 3.2%
F) Control: 26.0  5.4 (18.7- 55.4  24 (3.5-96.3) Recreational: 54.8%
30.1  12.1 (14.1- 42.8) Amateur: 6.5% (not
55) paid)
Waterman IV 14 31 (23 M, 6 F) 36.0  11.9 (14-72) 25.2  2.4 Minimum: 24 NR NR
et al.,28 2018
Mohan et al.,24 IV 15 57 (17 M, 33 F) 17.8 (13-23) 23.1 (17-34) 34 (24-77) NR Competitive HS
2017 College
Recreational
Amenabar and IV 13 34 (26 M) 21.8 (16-30) 24.9 (20-31) 49.3  21.2 (24-97.6) NR Professional
O’Donnell,18
2013
Perets et al.,32 IV 14 66 (19 M, 47 F) 21.4  8.1 NR 67.8  6.4 18.6  21.5 HS: 56%
2018 Collegiate: 30%

S. ANNIN ET AL.
Professional: 14%
Byrd and IV 16 15 (11 M, 4 F) 31.7 (14-70) NR Minimum: 240 (100%) 14.2 HS: 27%
Jones,16 2009 Collegiate: 13%
Recreational: 60%
BMI, body mass index; F, female; HS, high school; LoE, level of evidence; M, male; MINORS, Methodological Index for Non-Randomized Studies; NR, not reported; PROS, patient-reported
outcome scores; SD, standard deviation.
*There were 2 patients in each group who did not have minimum 24-month follow-up; however, their scores were not included in the analysis of PROS.
 ATHLETE OUTCOMES FOLLOWING FAI
Fig 2. (A) Sport breakdown in the athletic population. (B) Level of competition.
classified as grade 1, 7 hips were classified as grade 2, 11
hips were classified as grade 3, and 5 hips (2.6%) were
classified as grade 4. Femoroplasty was the most com-
mon procedure performed (673/747 hips). Lastly, 56
hips underwent ligamentum teres debridement.
Further descriptive data are included in Tables 2 and 3.
Patient-Reported Outcome Scores
The selected studies used the following PROS within
their patient cohorts to assess for postoperative function
and success: modified Harris Hip Score (mHHS),33 Hip
Outcome Score- Activities of Daily Living (HOS-
ADL),34 HOS-Sport-Specific Subscale (HOS-SSS),34
Nonarthritic Hip Score (NAHS),35 International Hip
Outcome Tool (iHOT-12),36 visual analog scale for pain
(VAS pain),37 and patient satisfaction.38 All studies re-
ported at least 1 PROS with mHHS (17/18 studies,
94.4%) being the most frequently recorded and iHOT-
12 (4/18 studies, 22.2%) being the least reported. All
patient cohorts within their individual studies demon-
strated a significant improvement from pre- to post-
operative outcome scores at minimum 2-year follow-up
(P < .05).
Postoperative mHHS scores were excellent in 6
studies (range, 92.1-98),2,16,18,21,25,30 good in 10 studies
(range, 84.2-88.5),17,19,20,23,24,26-29,32 and fair in 1
study (competitive athlete group, 77.1).22 Although
Levy et al.22 was the only study to report a post-
operative mHHS score below 80 for their competitive
athlete group, the cohort’s effect size was still large, and
the standardized mean difference was similar to other
reported values in other studies (Fig 3). Moreover, their
recreational athlete cohort achieved a good mHHS score
(81.8).
2663
Of the studies that reported the remaining PROs, 12
studies determined the mean HOS-SSS (postoperative
range, 76.1-91.4),2,17,19-23,24,26,28-30 and 8 studies re-
ported the mean VAS2,19-21,28-30,32 (postoperative
scores 0.7-2.3). Moreover, 7 studies used the HOS-ADL
subscale (postoperative range, 82.5-96.7),20-22,24,28-30 6
studies reported the mean NAHS18,19,23,25,27,32 (post-
operative range, 75.8-97.1), 6 studies reported mean
patient satisfaction2,19,21,28,30,32 (8.2-10), and 4 studies
reported the mean iHOT-12 scores20,23,31,32 (post-
operative range, 72.9-88.1). Further data on PROs are
reported in Table 4.
Athlete Versus Nonathlete PROS
Five studies were caseecontrol studies and provided
nonathlete PROS as well.19,20,25,27,29 Murata et al.25
reported mHHS and NAHS scores at 6 months, 1-year,
and 2-year follow-up that were significantly greater for
the athlete cohort as opposed to the nonathletic.
Przybyl et al.27 drew similar conclusions, as they re-
ported athletes achieving significantly greater NAHS
scores at the 1-year and 2-year follow-up mark as well.
Comparing their matched cohorts, Clapp et al.20 found
a significant difference in postoperative HOS-ADL and
HOS-SS as athletes scored greater in both PROS than
nonathletes. In addition, Clapp et al.20 found a statis-
tically significant difference in the proportion of pa-
tients reaching minimal clinically important difference
(MCID) for HOS-SS between the athlete and nonath-
lete cohorts with a greater portion of athletes reaching
MCID. Chen et al.19 reported significant improvement
in postoperative PROS for both athletic and nonathletic
cohorts. However, a greater proportion of athletes
reached the patient acceptable symptomatic state
2664
Table 2. Indications, Radiographic Findings, and Surgical Treatment
Study Indications
Murata et al.,25 Symptomatic FAI on physical
2017 examination (<105
flexion,
<20
internal rotation) and
radiographs (alpha angle >55

or headeneck offset >8 mm)
for more than 3 months
Philippon et al.,2 Failure of nonoperative treatment 26 hips mixed FAI
2010 of FAI
Protocol, minimum of 6 weeks
Barastegui et al.,29 Clinical symptoms of cam-type
2018 FAI
Przybyl et al.,27 FAI diagnosis confirmed by NR
2018 clinical and X-ray diagnostics
Clapp et al.,20 2020 Diagnosis of symptomatic FAI and Athlete:
failure of nonoperative
management
Byrd et al.,17 2016 Persistent symptomatic FAI NR
unresponsive to nonoperative
treatment
Nho et al.,26 2011 Failed nonsurgical treatment of
FAI and inability to maintain
competition
Frank et al.,30 2018 Based on patient history, physical 58 hips (100%) cam deformity
examination findings, and
imaging findings consistent
with FAIS (alpha angle >50
,
LCEA >25
).
S. ANNIN ET AL.
Radiographic Findings
NR
1 hip isolated pincer lesion
1 hip isolated cam lesion mean
alpha angle 80
(69
-96
)
27% coxa profunda
37% retroversion
NR
Alpha angle, deg
Dunn:
Pre, 58.9  10.7
Post, 42.5  11.5 P ¼ .001
Lateral center-edge angle, deg:
Pre, 28.5 .5 6.1
Tönnis grade 0: 100%
Nonathlete:
Alpha angle, deg
Dunn:
Pre, 62.9  12.7
Post, 40.9  9.8 P ¼ .001
Tönnis grade 0: 98.6%
LCEA, deg:
Pre, 28.5 .5.3
Alpha angle, deg:
Preop, 76.4
Postop, 51.4 P ¼ .0003
Tönnis angle, deg:
Preop, 3.8
Postop, 3.1 P ¼ .98
Center-edge angle, deg:
Preop, 36.5
Postop, 35.9 P ¼ .07
Alpha angle, deg:
Preop, 61.7  10.3
Postop, 39.05  4.31 P < .0001
LCEA, deg:
Preop, 31.39  5.6
Postop, 26.89  4.32
Hip joint space width, mm:
Preop, 4.2  0.7
Postop, 4.1  0.7
Surgical Treatment
Labral repair
LT repair
Femoroplasty
Acetabular rim trimming
Labral repair: 100%
Rim trimming: 85%
Femoral osteoplasty: 100%
Microfracture: 33%
LT debridement: 93%
Loose body removal: 25%
Femoral osteoplasty: 100%
Partial labrectomy: 66%
Labral repair: 33%
Microfracture: 47.6%
100% femoral osteoplasty, 9% labral
debridement
Femoral osteoplasty
Acetabular rim trimming
Labral repair or debridement
Microfracture: 3%
Labral refixation: 71%
Labral debridement: 21%
LT debridement: 16%
Loose body removal: 7%
Femoral osteoplasty: 86%
Acetabular rim trimming: 76%
Chondral debridement: 100%
Labral debridement: 83%
Synovectomy: 95.7%
Partial psoas release: 48.9%
Acetabular rim trimming: 29.8%
Femoral osteoplasty: 12.8%
Both acetabular rim trimming and femoral
osteoplasty: 57.4%
Labral repair: 100%
Femoral osteochondroplasty: 100%
Acetabular rim trimming: 91%
Capsular plication: 100%
Synovectomy: 98%
Heterotopic ossification excision: 2%
Acetabular microfracture: 2%
(continued)
 ATHLETE OUTCOMES FOLLOWING FAI
Table 2. Continued
Study Indications
Levy et al.,22 2017 Diagnosis of FAI and a positive
history of running documented
in the form
Frank et al.,21 2018 Based on clinical history, physical 26 hips cam deformity
examination findings, and
radiographic findings of FAIS
(alpha angle >50, LCEA >25)
Litrenta et al.,23 Failure of nonsurgical
2020 management and demonstrated
clinical findings consistent with
FAI and MRI consistent with
intra-articular pathology
McConkey et al.,31 Clinical indications for surgery
2019 included mixed-type FAI in 16
(66.7%) patients, isolated cam-
type FAI in 5 (20.8%) patients,
and isolated pincer-type FAI in
3 (12.5%) patients.
Chen et al.,19 2019 Assessed for signs of FAI using
patient history, physical
examination and radiographs.
Failure of 3 months of
conservative treatment
Radiographic Findings
Alpha angle, deg:
Preop, 61.0  8.8
Postop, 38.5  6.4
LCEA, deg:
Preop, 33.9  4.0
Postop, 33.7  5.3
Hip joint space, width, mm:
Preop, 4.0  0.72
Postop, 4.3  0.6
23 hips pincer lesion
Alpha angle (AP, Dunn), deg:
Preop, 59.91  11.08
Postop, 38.91  4.37 P < .0001
LCEA, deg:
Preop, 29.91  4.81
Postop, 25.10  4.63 P ¼ .0002
Hip joint space width, mm:
Preop, 4.30  1.54
Postop, 4.49  0.94, P ¼ .3
Alpha angle, deg:
57.7  11.6 (range, 37-99)
LCEA
Dysplasia (<18
): 0
Borderline dysplasia (18-25
): 23
No dysplasia/overcoverage (>25
):
57
Anterior center-edge angle, deg:
Preop, 29.9  6.9
Crossover: 80 (70%)
Ischial spine sign: 78 (59%)
NR
Athlete:
Alpha angle, deg
Preop, 65.3  12.8
Postop, 44.5  6.1
LCEA, deg:
Preop, 30.3  6.2
Postop, 28.7  6.3
Hip joint space width, medial, mm:
Preop, 40.4  9.9
Postop, 40.9  11.5
Nonathlete:
Alpha angle, deg:
Preop, 63.2  12.6, P ¼ .541
Postop, 43.9  7.7, P ¼ .739
LCEA, deg:
Preop, 30.9  4.6, P ¼ .660
Postop, 28.8  5.5, P ¼ ..983
Hip joint space width, medial, mm:
Preop, 37.3  10.9, P ¼ .571
Postop, 37.4  10, P ¼ .216
2665
Surgical Treatment
Femoral osteoplasty: 100%
Acetabular rim trimming: 78%
Labral refixation: 100%
Labral repair: 100%
Acetabular rim trimming: 100%
Femoral osteoplasty: 100%
Capsular closure: 100%
Labral treatment: 97.5%
Debridement 14.8%
Repair 81.5%
Reconstruction 1.2%
Capsular treatment:
Release 13.6%
Repair/plication 86.4%
LT debridement 11.1%
Femoral osteoplasty 69.1%
Acetabuloplasty 66.7%
IPFL: 72.8%
TB: 16.0%
GM repair: 1.2%
Acetabular chondroplasty: 8.6%
Subspine decompression: 3.7%
Loose body removal: 3.7%
Synovectomy: 7.4%
Patients underwent at least one of the
following: labral repair, pincer resection, cam
resection, LT thermal debridement,
synovectomy (100%), capsule repair (100%)
Labral treatment:
Repair: 61.3%
Debridement: 35.5%
Reconstruction: 3.2%
Capsular treatment:
Release 71.0%
Repair/plication 29.0
Acetabuloplasty: 77.4%
Femoroplasty: 83.9%
Acetabular microfracture: 19.4%
Chondroplasty: 16.1%
Subspine decompression: 3.2%
Notchplasty: 3.2%
IPFL: 35.5%
Synovectomy: 9.7%
(continued)
2666 S. ANNIN ET AL.

Table 2. Continued

Study Indications Radiographic Findings Surgical Treatment

Waterman et al.,28 Patients were diagnosed with 25 hips (86%) cam deformity Labral repair: 100%
2018 FAIS based on positive 5 hips (16%) pincer lesion Acetabular rim trimming: 97%
radiographic (LCEA >30, alpha Alpha angle, deg: Femoral osteochondroplasty: 100%
angle >50) and positive Preop, 67.42  12.48 Capsule closure: 97%
physical examination (pain on Postop, 40.98  3.69 P < .0001 Femoral microfracture: 10%
flexion adduction and internal LCEA, deg:
rotation, positive flexion Preop, 34.07  7.09
abduction and external Postop, 27.65  4.89, P ¼ .0002
rotation) evidence of FAIS Joint width, average, mm:
Preop, 4.09  0.80
Postop, 4.09  0.80 P ¼ .6642
Tönnis 0: 27
Tönnis 1: 2
Mohan et al.,24 Clinically or radiographically Median alpha angle, deg: Labral repair: 98%
2017 supported diagnosis of FAI, Preop, 54.1 (IQR, 48.6-66.9) Labral takedown and reattachment: 35%
failed LCEA, deg: Capsular repair: 56%
prior conservative management Preop, 30.7 (IQR, 27.1-36.3) Chondrolabral delamination, debridement/
Tönnis grade: preservation:
Preop, 1.0 (IQR, 0.0-1.0) 35%,
Cam resection: 86%
Psoas lengthening: 35%
Amenabar and A history of hip pain, with or NR Labral debridement: 26%
O’Donnell,18 without mechanical symptoms, Labral repair: 3%
2013 that did not respond to Microfracture: 21%
conservative treatment for at LT debridement: 9%
least 3 months. Femoral ostectomy: 65%,
Acetabular ostectomy: 3%
Both femoral and acetabular ostectomy: 9%
Perets et al.,32 2018 Surgical intervention was NR Labral treatment:
indicated for those patients with Repair: 75.8%
hip pain or disability that Debridement: 21.2%
persisted for 3 months and was Reconstruction: 1.5%
unresponsive to nonoperative Acetabuloplasty: 75.8%
measures, such as rest, physical Femoroplasty: 42.4%
therapy, intra-articular Capsular treatment:
injection, and nonsteroidal anti- Repair/plication 68.2%
inflammatory drugs Release 31.8%
Acetabular microfracture: 3.0%
IPFL: 60.6%
Synovectomy: 18.2%
Notchplasty: 1.5%
TB: 7.6%
GM repair: 1.5%
Byrd and Jones,16 Recalcitrant hip pain that was NR NR
2009 unresponsive to nonoperative
treatment of FAI, or imaging
evidence of joint lesions
amendable to arthroscopic
intervention
AP, anteroposterior; FAI, femoroacetabular impingement; FAIS, femoroacetabular impingement syndrome; GM, gluteus medius; IPFL, iliopsoas
fractional lengthening; IQR, interquartile range; LCEA, lateral center-edge angle; LT, ligamentum teres; MRI, magnetic resonance imaging; NR,
not reported; TB, trochanteric bursectomy.

(PASS) (mHHS 74 and HOS-SSS 75) and MCID
(mHHS 6 and HOS-SSS 8) for mHHS (78.6% and
75.0%, respectively) and HOS-SSS (82.1% and 60.7%,
respectively) than nonathletes (mHHS PASS of 63.0%,
HOS-SSS PASS of 48.1%, MCID mHHS and HOS-SSS
of 70.4% each). Lastly, Barastegui et al.29 reported
the HOS-SSS and mHHS test showed significant dif-
ferences during follow-up at 12 months, 24 months,
and at the final evaluation, with active professional
football players scoring greater than their nonactive
counterparts.
Return to Sport
Sixteen studies (830 hips) reported the RTS rate for
their patient populations (Fig 4).2,17-19,21-32 The RTS
rate ranged from 72.7 to 100 among studies. Of these
 ATHLETE OUTCOMES FOLLOWING FAI
16 studies, 5 studies provided proportions of RTS based
on competition level.2,18,19,22,32 A trend toward greater
RTS rates was observed for greater-level athletes.
Of the 10 studies (376 athletes) who reported both
RTS and level of return, 74.2% to 100% of athletes
(282 athletes) returned to sport at the same or greater
level compared with preinjury level, whereas 0% to
25.8% (94 athletes) returned to a lower level (Table 5).
The most commonly cited reasons for failure to RTS
was postoperative pain and apprehension of worsening
symptoms.
SMD and Heterogeneity
A summary of the SMD values for all studies report-
ing PROs can be found in Figure 3. Fifteen of the 18
articles provided sufficient information for effect sizes to
be estimated based on at least one PROS.2,17-30,32 All of
the studies reported a large effect size of 0.8. When
only assessing the studies, which provided sufficient
information for SMD calculation, the I2 was 37.9%.
Based on visual review, it is apparent that the studies
Frank et al.21,30 and Philippon et al.2 are primarily
responsible for the heterogeneity among these studies.
There was minimal heterogeneity (I2 ¼ 5.04) seen
among studies that provided sufficient information for
RTS rate (Fig 4).2,17-30,32
Reoperations and Complications
Fifty of 904 athletes underwent a secondary revision.
Eight athletes converted to total hip arthroplasty at a
range of 4-119 months. Eleven patients had post-
operative complications. There were 5 cases of transient
lateral femoral cutaneous nerve palsy (one case
resolved after 1 year),31,32 4 cases of general leg
numbness,23 2 cases of transient pudendal nerve neu-
rapraxias,17 2 cases of minor infections,23 and 1 case of
pulmonary embolism.32 The number of revision surgi-
cal procedures as well as complication rates are shown
in Table 6.
Discussion
The present systematic review demonstrates that
favorable clinical outcomes of hip arthroscopy in the
treatment of FAI were obtained in all athlete cohorts
within their respective studies. Postoperatively, each
athletic cohort demonstrated statistically (P < .05) sig-
nificant improvement in all 6 PROS reported by the
reviewed studies at minimum 2-year follow-up: mHHS,
NAHS, HOS-ADL, HOS-SSS, iHOT-12, and VAS. The
RTS rate ranged from 72.7 to 100 (747/816 patients) at
minimum 2-year follow-up, with 74.2-100% of ath-
letes (282 athletes) returning to sport at the same or
greater level compared with preinjury level. Fifty of 904
patients had a secondary revision and eight athletes
converted to total hip arthroplasty. Eleven patients had
postoperative complications.
2667
Traditionally, if an athlete experienced any hip pain,
they were resigned to live within the constraints of their
symptoms, often having to limit game time and reduce
career length. With the advent of hip arthroscopy
provided an opportunity to treat hip pathology while
extending a career which would otherwise be prema-
turely terminated. Byrd et al.39 initially described the
indications for hip arthroscopy in athletes falling within
2 categories, either as an alternative to open techniques
for hip pathology which caused mechanical distur-
bances in range of motion, such as impinging osteo-
phytes, or a method of treatment for previously
unrecognized pathology like labral tears. Over time, it
became clear that success of hip arthroscopy was
dependent on patient selection, and more stringent
exclusion criteria were needed for optimal results. Our
literature search revealed a plethora of indications for
hip arthroscopy in athletes; however, consensus was
found on a few selection criteria. Similar to the general,
nonathletic population, signs of FAI on physical ex-
amination (decreased flexion/internal rotation) and/or
on patient history (pain with torsional and twisting
maneuvers) were consistently reported. Moreover, all
studies required radiographic and magnetic resonance
imaging to show signs of FAI signified by a large alpha
angle (>55
), limited advanced arthritis as indicated by
a Tönnis grade 1, or signs of labral pathology.
Recent studies have reported high prevalence of
symptomatic cam deformity in athletes participating in
high-impact activities.3,39 Agricola et al.40 conducted a
prospective study on the development of cam defor-
mity. The authors showed that a cam deformity is
gradually acquired throughout skeletal maturation
when the growth plate is open. This study supported
past studies such as Nicholls et al.,41 who showed that
adults greater than 45 years of age did not show an
increase in prevalence of cam deformities, favoring the
notion that this is a growth-related phenomenon.41,42
The increased prevalence of FAI in athletic cohorts
compared with their nonathletic controls in both adults
and adolescents would suggest that cam deformity
formation may be a consequence of increased stress
along the growth plate of the hip leading to increased
stress reaction bone formation, resulting in subsequent
impingement as a structural adaptation to greater
loads.43,44 This becomes important, as the athletic
cohort has a predisposition to injuries commonly seen
in relation to FAI, such as labral tears and cartilage
defects.
Indeed, it has been shown in the literature that the
most common hip pathologies in relation to FAI are
labral lesions and cartilage defects, present in as high as
61% and 40% of athletes undergoing hip arthroscopy,
respectively.45 The present study found 82.7% of the
cohort underwent labral management for labral pa-
thology, as well as a slightly greater proportion of
2668 S. ANNIN ET AL.

Table 3. Intraoperative Findings

Study Labral Tear Acetabulum Cartilage Femoral Head Cartilage Ligamentum Teres
Murata et al.,25 Athlete: Athlete: Nonathlete: Athlete
2017 Complete: 9 (19.1) MAHORN: ICRS: Complete: 2 (4.3)
Partial: 36 (76.6) 0: 10 (21.3%) Grade 0: 3 (6.4%) Partial: 2 (4.3)
Degenerative: 2 (4.3%) 1: 17 (36.2) I: 40 (85.1) Hypertrophic: 1 (2.1)
Nonathlete: 2: 9 (19.1) II: 3 (6.4) Synovitis: 6 (12.8)
Complete: 6 (22.2) 3: 8 (17.0) III: 0 Intact: 36 (76.6)
Partial: 21 (77.8) 4: 1 (2.1) IV: 1 (2.1) Nonathlete:
Degenerative: 0 5: 2 (4.2) Nonathlete: Complete: 4 (14.8)
Nonathlete: ICRS: Partial: 4 (14.8)
MAHORN: Grade 0: 2 (7.4) Hypertrophic: 2 (7.4)
0: 4 (14.8) I: 24 (88.9) Synovitis: 6 (22.2)
1: 9 (33.3) II: 0 (0) Intact: 11 (40.7)
2: 7 (25.9) III: 0
3I: 4 (14.8) IV: 1 (3.7)
4: 2 (7.4)
5: 1 (3.7)
Philippon et al.,2 All athletes had labral Grade IV defect: 4 (14.3) Grade IV defect: 1 (3.5) Lesions present: 26 (93)
2010 lesions
Mean size: 7 mm (4-10
mm)
Barastegui NR Athlete: NR
et al.,29 2018 Acetabular/femoral Outerbridge:
0: 5
1: 2
2: 0
3: 0
4: 4
Nonathlete:
Acetabular/femoral Outerbridge
0: 6
1: 0
2: 0
3: 2
4: 2
Przybyl et al.,27 NR NR NR NR
2018
Clapp et al.,20 NR NR NR NR
2020
Byrd et al.,17 Labral tear: 106 Chondral lesion grade: Chondral lesion grade: Lesion present: 19
2016 1: 42 2: 1
2: 18 3: 2
3: 34
4: 4
Nho et al.,26 Labral tear: 46 (97.9) Abnormal chondrolabral junction: 47 (100) NR NR
2011
Frank et al.,30 Labral tear: 60 (100) Intra-articular cartilage delamination: 26 (43) NR
2018
Levy et al.,22 Labral tear: 51 (100) Cartilage delamination: 25 (49) NR
2017
Frank et al.,21 Labral tear: 26 (100) Cartilage delamination: 9 (35) NR
2018
Litrenta et al.,23 Labral tear: 79 (97.5) ALAD: Outerbridge: Complete: 1
2020 Seldes I: 32 (39.5) 0: 19 (23.5) 0: 76 (93.8) Partial: 19 (23.5)
Seldes II: 34 (66.7) 1: 42 (51.9) 1: 1 (1.2)
Seldes I&II: 13 (16.0) 2: 17 (21.0) 2: 2 (2.5)
3: 3 (3.7) 3: 2 (2.5)
4: 0 4: 0
Outerbridge:
0: 19 (23.5)
1: 43 (53.1)
2: 16 (19.8)
3: 3 (3.7)
4: 0
(continued)
 ATHLETE OUTCOMES FOLLOWING FAI 2669

Table 3. Continued

Study Labral Tear Acetabulum Cartilage Femoral Head Cartilage Ligamentum Teres
McConkey NR NR NR NR
et al.,31 2019
Chen et al.,19 Athlete: Athlete: Athlete Athlete:
2019 Labral tear: 31 Outerbridge: Outerbridge: Complete: 1 (3.2)
Seldes I: 11 (35.5) 0: 4 (12.9) 0: 25 (80.6) Partial: 12 (38.7)
Seldes II: 8 (25.8) 1: 8 (25.8) 1: 0 Nonathlete:
Seldes I&II: 12 (38.7) 2: 6 (19.4) 2: 1 (3.2) Complete: 1 (3.2)
Nonathlete: 3: 5 (16.1) 3: 4 (12.9) Partial: 16 (51.6)
Labral tear: 31 4: 8 (25.8) 4: 1 (3.2)
Seldes I: 19 (61.3) Nonathlete: Nonathlete:
Seldes II: 5 (16.1) Outerbridge: Outerbridge:
Seldes I and II: 7 (22.6) 0: 2 (6.4) 0: 30 (96.7)
1: 8 (25.8) 1: 1 (3.2)
2: 10 (32.3) 2: 0
3: 8 (25.8) 3: 0
4: 3 (9.7) 4: 0
Waterman Labral lesion: 29 (100) NR NR NR
et al.,28 2018
Mohan et al.,24 NR NR NR NR
2017
Amenabar and Labral tear: 10 Rim lesions: NR Complete: 0
O’Donnell,18 Full-thickness cartilage loss <30%: Partial: 3
2013 16
Labral separation:
8
Full-thickness cartilage loss >30%:
5
Edge softening: 4
Perets et al.,32 Labral lesion: 64 ALAD: Outerbridge: Percentile class:
2018 Seldes I: 2 (3.0) 0: 8 (12.1) 0: 53 (80.3) 0: 44 (66.7)
Seldes II: 23 (34.8) 1: 25 (37.9) 1: 4 (6.1) 1: 12 (18.2)
Seldes I and II: 16 (24.2) 2: 23 (34.8) 2: 4 (6.1) 2: 9 (13.6)
3: 9 (13.6) 3: 5 (7.6) 3: 1 (1.5)
4: 1 (1.5) 4: 0 Villar class:
Outerbridge: 0: 44 (66.7)
0: 7 (10.6) 1: 21 (31.8)
1: 29 (43.9) 2: 5 (12.5)
2: 22 (33.3) 3: 2 (3.0)
3: 5 (7.6)
4: 0
Byrd and Labral tear: 7 Chondral damage: 8
Jones,16 2009
ALAD, acetabular labrum articular disruption; ICRS, International Cartilage Repair Society grading system; MAHORN, Multicenter Arthroscopy
of the Hip Outcomes Research Network grading system; NR, not reported.

athletes with acetabular cartilage damage when
compared with their nonathlete counterparts. Due to
the high offset of the femoral head, increased stress is
placed on the labrum, and as athletes undergo repeti-
tive microtrauma due to being predisposed to unnatu-
ral, continuous movements, insidious onset of
acetabular cartilage damage and labral tears may result.
More specifically, sports with continuously and repeti-
tive pivoting motions on a loaded femur, like soccer,
football, and hockey, which frequently require external
rotation at the hip, are susceptible to this injury.6,40,46,47
In addition, during range of motion extremes such as
hyperabduction, hyperextension, and hyperflexion, the
labrum functions as a weight-bearing construct and has
been proposed to contribute to a greater incidence of
labral tears in runners.22 The literature reflects this
study, which found a greater prevalence of hip
arthroscopy being performed in soccer (13%), running/
cross-country (13%), and football (12%) athletes.
Nonetheless, those athletes who met the indications
for hip arthroscopy generally have successful outcomes.
This study reported statistically (P < .05) significant
improvement in all 6 PROS reviewed at minimum 2-
year follow-up. These findings were indifferent of
whether a cohort was of amateur, recreational, high
school, collegiate, or professional status. However, dif-
ferences appeared when examining studies within this
systematic review, specifically comparing athletic and
2670 S. ANNIN ET AL.

Fig 3. Forest plot displaying the standardized mean difference with 95% CI. I2 ¼ 37.90. (CI, confidence interval; HOS-ADL, Hip
Outcome Score Activities of Daily Living; HOS-SSS, Hip Outcome Score-Sport Specific Subscale; iHOT-12, International Hip
Outcome Tool-12; mHHS, modified Harris Hip Scope; NAHS, Nonarthritic Hip Score.)

nonathletic populations. Murata et al.25 showed that that although hip arthroscopy is beneficial to all groups,
the mean mHHS and NAHS at 24 months and 6, 12, it appears to provide better clinical outcome in athletes.
and 24 months, respectively, was significantly greater These results were mirrored by Przybyl et al.,27 who
in the athletic than nonathletic group. They concluded showed that athletes performed better in NAHS at 12
Table 4. Patient-Reported Outcome Scores
mHHS HOS NAHS iHOT-12 VAS Patient
Study Preop Postop P Value Preop Postop P Value Preop Postop P Value Preop Postop P Value Preop Postop P Value Satisfaction
Murata et al.,25 A: 70.2  A: 95.4  <.001 ADL A: 50.8  A: 75.8  <.001
2017 13.1 7.7 <.001 SSS 14.1 6.4 <.001
NA: 65.2 NA: 88.2 NA: 43.9 NA: 64.6
 14.7  12.3  11.3  14.2
Philippon et al.,2 70 (57- 95 (74- <.001 6.07 2.16 <.001 10 (5-10)
2010 100) 100)
Barastegui et 72.5 88.8 <.001 ADL 67.7 96.7 <.001 7.4 2.3 <.001
al.,29 2018 SSS 37.6 86.7 <.001
Przybyl et al.,27 A: 68.10 A: 84.90  <.001 A: 72.50  A: 87.39  <.001
2018  15.88 20.61 <.001 19.45 17.82 <.001
NA: NA: NA: NA:
56.98  79.99  56.45  76.05 
19.25 20.12 18.57 17.90
Clapp et al.,20 A: 61.4  A: 85.6  <.001 ADL A: 71.4  A: 92.4  <.001 A: 42.6  A: 72.9  <.001 A: 61.3  A: 16.3 <.001
2020 11.8 10.9 <.001 SSS 15.2 8.8 <.001 18.2 23.8 <.001 19.8  <.001
<.001

ATHLETE OUTCOMES FOLLOWING FAI

NA: 56.9 NA: 81.7 NA: 61.9 NA: 86.1 NA: 32.5 NA: 68.5 NA: 60.6 18.0
 12.2  16.1   14.4 <.001  15.0   NA: 21.7
14.5 A: 84.5 26.2 21.9 
A: 45.7  19.0 23.2
 18.2 NA: 76.1
NA: 41.3 
 23.8
20.7
Byrd et al.,17 69  12.8 88.5  .002 SSS 78.8  91.4 <.001
2016 17.7 11.3 
14.0
Nho et al.,26 68.6  88.5 .002 SSS 78.8  91.4 <.001
2011 12.8  11.3 
17.7 14.0
Frank et al.,30 61.7  92.1 <.0001 ADL 70.3  92.9  9.0 <.0001 71.9  8.5 <.0001 90.7  12
2018 11.2  SSS 16.3 85.2  <.0001 17.3 
9.9 41.5  16.0 12.7
23.2
Levy et al.,22 CA: 64.0 CA: 77.7 .001 ADL CA: 73.8 CA: 92.4 .001
2017   .001 SSS   .001
9.7 10.7 14.7 13.2 .001
RA: 60.1 RA: 81.8 RA: 67.3 RA: 93.0 .001
   
13.2 10.1 18.4 6.9
P¼.26 P¼.001 P¼.18 P¼.83
A: 50.9 A: 84.6
 21.4 
NA: 44.9 19.8
 NA: 82.8
19.9 
P ¼ .31 16.9
P¼.74

(continued)

2671
Table 4. Continued

2672
mHHS HOS NAHS iHOT-12 VAS Patient
Study Preop Postop P Value Preop Postop P Value Preop Postop P Value Preop Postop P Value Preop Postop P Value Satisfaction
Frank et al.,21 59.5  94.1  8.6 .0001 ADL 68.5  93.9  <.0001 7.7  0.7  <.0001 90.7  12
2018 12.1 SSS 19.9 5.7 <.0001 1.1 1.2
44  21 85.3 
16
Litrenta et al.,23 64.6  88.1  <.001 SSS 45.1  82.5  <.001 66.8  89.8  <.001 - 80.7 -
2020 15.9 12.3 23.4 19.2 17.9 11.4 
20.6
McConkey et 38.7 88.1 <.001
al.,31 2019
Chen et al.,19 A: 61.9  A: 81.8  <.001 SSS A: 38.9  A: 76.1  <.001 A: 60.1  A: 83.5  <.001 A: 5.9  A: <.001 A: 8.2
2019 13.4 20.02 <.001 20.3 25.8 <.001 16.9 19.5 <.001 2.5 2.5  <.001  2.0 NA:
C: 61.5 C: NA: NA: NA: NA: NA: 2.6 7.5 
 18.6 78.9  40.3  64.4  58.9  76.1  5.7  NA: 2.5
16.9 25.9 27.5 18.7 25.8 2.4 3.2 
2.2
Waterman et 54.8  84.2  .0002 ADL 65.9  91.5  .0001 7.3  1.7  .0001 85.1  22.3
al.,28 2018 15.6 15.8 SSS 19.9 12.8 .0002 1.6 2.3
38.2  79.7 
23.5 28.8
Mohan et al.,24 63.9  84.8  <.01 ADL 78.1  91.3  <.01

S. ANNIN ET AL.
2017 16.2 15.2 SSS 11.5 10.8 <.01
43.7  80.1 
19.2 22.9
Amenabar and 83.6  98  <.05 85.3  97.1  <.05
O’Donnell,18 14.1 5.1 10.6 6.4
2013 (77.1- (95.6- (80.3- (94.1-
90.1) 100) 90.2) 100)
Perets et al.,32 66.8  87.0  <.001 SSS 47.0  79.1  <.001 66.2  87.2  <.001 e 78.8  e 5.4  2.5 1.8  2.1 <.001 8.2  1.9
2018 16.3 14.8 22.4 23.0 19.9 15.2 22.7
Byrd and 51 96 .004
Jones,16 2009
A, athlete; C, control; CA, competitive athlete; HOS-ADL, Hip Outcome ScoreeActivities of Daily Living; HOS-SSS, Hip Outcome ScoreeSport-Specific Subscale; iHOT-12, International Hip
Outcome Tool-12; mHHS, modified Harris Hip Score; N, nonathlete; NA, not available; NAHS, Nonarthritic Hip Score; RA, recreational athlete; VAS, visual analog scale for pain.
 ATHLETE OUTCOMES FOLLOWING FAI
Fig 4. Forest plot describing the return to sport rate with 95% CI. I2 ¼ 5.04. (CI, confidence interval; RTS, return to sport.)
and 24 months postoperatively. Although treatment of
FAI in athletes and nonathletes was beneficial, there
was quicker recovery in the athletic population, with
NAHS being the better measurement tool than mHHS
to elucidate these differences. Moreover, Clapp et al.20
showed that although competitive athletes and non-
athletes produced clinically meaningful outcomes,
competitive athletes achieved the MCID on the HOS-SS
at greater rates than nonathletes and had significantly
greater scores at 2 years’ postoperatively on the HOS-
SS. Clearly, whether it be due to stricter RTS pro-
tocols or different motivations during rehabilitations,
athletes undergoing hip arthroscopy for FAI generally
resulted with greater PROS in this analysis when
compared with their nonathletic counterparts.
When assessing postoperative success in the athletic
cohort, the literature relies on RTS rate as the end point
for athletes after hip arthroscopy. The present study re-
ports a range of RTS rate of 74.2% to 100%, much
greater than previously recognized literature values.7 In
their systematic review of 22 articles and 1296 patients,
O’Connor et al.7 reported a RTS rate of 84.6%. However,
this was for at mean 2-year follow-up whereas the
2673
current study describes the RTS rate at minimum 2-year
follow-up. We show a greater RTS rate, at a greater
follow-up. Moreover, Nho et al.26 reported the lowest
RTS (72.7%) and found that high schoolers had the
lowest RTS rate in their cohort (59%), whereas pro-
fessionals had the highest RTS rate (100%). This was
similar in other studies that provided proportions of RTS
based on competition level,2,18,19,22,26,32 with greater
RTS rates correlating with greater competition level. It is
conceivable that whereas high school level athletes may
change career paths after hip arthroscopy, professional
athletes are more inclined to RTS to generate income and
greater access to support during rehabilitation.
Nevertheless, in addition to favorable hip function,
athlete passion for sport and social benefits to returning
quicker motivate the athlete to RTS.48 However, the
literature does not elucidate the function at which ath-
letes return. Approximately 74.2% to 100% of athletes
who returned did so the same or greater level compared
with preinjury level, whereas 0% to 25.8% returned to a
lower level. Athletes returning to lower level have been
shown to either have worse outcomes than those that
returned to the same or greater level.25 When counseling
2674 S. ANNIN ET AL.

Table 5. Return to Sport

Study
Murata et al.,25 2017
Philippon et al.,2 2010
Barastegui et al.,29 2018
Przybyl et al.,27 2018
Byrd et al.,17 2016
Nho et al.,26 2011
Frank et al.,30 2018
Levy et al.,22 2017
Frank et al.,21 2018
Litrenta et al.,23 2020
McConkey et al.,31 2019
Chen et al.,19 2019
Waterman et al.,28 2018
Mohan et al.,24 2017
Amenabar and O’Donnell,18 2013
Perets et al.,32 2018
CI, confidence interval; RTS, return to sport; VAS, visual analog scale.
RTS, n (Rate, %) (95% CI)
45/47 (95.74) (67.77-100.00)
28/28 (100) (62.96-100.00) 28 (100) returned to skating/
21/21 (100) (57.23-100.00)
129/129 (100) (79.22-100.00)
100/116 (86) (77.31-100.00)
24/33 (72.7) (34.06-76.58)
56/58 (96.55) (71.26-100.00)
48/51 (94%) 84.21 (60.39-100.00)
26/26 (100) (61.56-100.00)
68/81 (84%) (75.13-100.00)
24/24 (100) (59.99-100.00)
26/31 (83.87) (51.63-100.00)
28/29 (96.55) (60.79-100.00)
46/50 (92) (65.41-100.00)
25/26 (96.15) (58.46-100.00)
53/66 (80.3) 75.76 (54.76-96.76) 38 (71.2) returned to same or
Level of Return (Rate, %) Reason for Failure to RTS
e Postoperative pain
e
hockey drills
11 (54.2) maintained preinjury e
level
e e
e Persistent postoperative hip pain
24 (100) returned to same level Persistent postoperative hip pain
54 (96.4) returned to same level Persistent postoperative hip pain;
2 (3.6) returned to lower level loss of interest
e e
14 (54) returned to greater level e
10 (38) returned to same level
2 (7) returned to lower level
52 (76.5) returned to same or e
greater level
e e
23 (74.2) returned to same or Increased postoperative VAS
greater level
16 (55) returned to greater level Fear of reinjury
12 (41) returned to same level
1 (3) returned to lower level
46 (92) returned with median Lower postoperative scores
Tegner activity level 1 point
below preinjury level
e Persistent postoperative hip pain
Prevent worsening symptoms;
greater level lifestyle transition

Table 6. Secondary Procedures and Complications

Study Revisions/Conversions to THA Complications

Murata et al.,25 2017
Philippon et al.,2 2010
Nho et al.,26 2011
Mohan et al.,24 2017
Byrd et al.,17 2016
Litrenta et al.,23 2020
McConkey et al.,31 2019
Chen et al.,19 2019
Amenabar and O’Donnell,18 2013 5 (19.2%) revision cases at mean 28.9 (8.1-83.8) months after index
Perets et al.,32 2018
Byrd and Jones,16 2009
THA, total hip arthroplasty.
3 (6.4%) of athletes required a secondary arthroscopy whereas 4 (14.8%) None
of nonathletes required a revision
2 (7.14%) of athletes required secondary arthroscopy for labral tears None
1 (3.03%) revision case None
3 secondary arthroscopies (however were excluded from study) None
4 (3.4%) secondary arthroscopies for recurrent/residual symptoms: 3 cases 2 (1.7%) transient pudendal
of capsular adhesions, 1 femoroplasty and acetabular rim trimming with nerve neurapraxias
labral refixation)
6 (7.4%) secondary arthroscopies at mean 37.3 months due to: reinjury (3) 4 (4.9%) numbness, 2 (2.5%)
and insidious recurrence of symptoms (3) minor infections treated
with antibiotics
None 1 (2.8%) transient lateral
femoral cutaneous nerve
palsy in both unilateral and
bilateral groups
4 (12.9%) secondary arthroscopies in basketball group at mean 13.9 1 (3.2%) numbness in leg
months due to: painful internal snapping (2), heterotopic ossification (1), proximal to knee that
labral repair (1) vs, 5 (16.1%) in control group after mean 13.1 months, 3 resolved after 1 year
(9.7%) conversion to THA at mean 35.9 months
None
procedure
10 (15.2%) revision cases after 5 years 3 (4.5%) cases of numbness
(lateral femoral cutaneous
nerve), 1 (1.5%) case of
pulmonary embolism
1 (6.7%) patient underwent revision twice for labral debridement None
5 (33.3%) conversions to THA after 73 (4-119) months
 ATHLETE OUTCOMES FOLLOWING FAI
athletes, it is important to communicate expected out-
comes after hip arthroscopy, as although the RTS rate is
high, there is a 1 in 4 chance an athlete may not return to
expected level of play. Common reasons for not
returning to preinjury level include worsening post-
operative pain and apprehension due to fear of reinjury
and reoperation. However, with low cited complications,
revisions, and conversions to total hip arthroplasty, rest
can be assured on the safety of hip arthroscopy and its
postoperative success in this cohort.
The strength of this systematic review includes its
comprehensive review of quantitative functional out-
comes on athletes undergoing hip arthroscopy in
comparison with nonathletes as well as the analysis on
level of performance upon RTS, unlike previous sys-
tematic reviews which solely focused on RTS. More-
over, this study provides a synopsis on the types of
athletes (i.e., sport, level of performance) undergoing
hip arthroscopy for FAI.
Limitations
There are some limitations that must be addressed.
We acknowledge the heterogeneity of the analyzed
studies regarding the age of the cohorts, the underlying
pathology leading to the index procedure, as well as in
the way at which the PROS were reported. However, to
reduce heterogeneity, this article solely focused on
athletes who were indicated for hip arthroscopy due to
symptomatic FAI. Moreover, we decided to not limit
the study by age to increase the findings generaliz-
ability. We also acknowledge the included studies have
a wide range of study dates (1993-2017) and that
during this time, hip arthroscopy, the treatment of FAI,
and the recovery process following surgery have
continued to evolve. Therefore, patients in earlier
studies may have had different experiences than those
in more recent literature. In addition, there were a
limited number of studies reporting athletes’ rate of
achieving MCID, PASS, or substantial clinical benefit.
Analyzing MCID, PASS, and substantial clinical benefit
in future studies could strengthen the present findings
and provide further comparison of athlete outcomes in
relation to nonathletes.
Conclusions
Athletes undergoing arthroscopic hip surgery in the
setting of FAI, not only exhibit significant functional
improvement but also have a high rate of RTS at the
same or greater competition level compared with pre-
injury level.
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