Stratified care in hip arthroscopy: can we predict successful and unsuccessful outcomes? Development and external temporal validation of multivariable prediction models.

OBJECTIVE: Although hip arthroscopy is a widely adopted treatment option for hip-related pain, it is unknown whether preoperative clinical information can be used to assist surgical decision-making to avoid offering surgery to patients with limited potential for a successful outcome. We aimed to develop and validate clinical prediction models to identify patients more likely to have an unsuccessful or successful outcome 1 year post hip arthroscopy based on the patient acceptable symptom state. METHODS: Patient records were extracted from the Danish Hip Arthroscopy Registry (DHAR). A priori, 26 common clinical variables from DHAR were selected as prognostic factors, including demographics, radiographic parameters of hip morphology and self-reported measures. We used 1082 hip arthroscopy patients (surgery performed 25 April 2012 to 4 October 2017) to develop the clinical prediction models based on logistic regression analyses. The development models were internally validated using bootstrapping and shrinkage before temporal external validation was performed using 464 hip arthroscopy patients (surgery performed 5 October 2017 to 13 May 2019). RESULTS: The prediction model for unsuccessful outcomes showed best and acceptable predictive performance on the external validation dataset for all multiple imputations (Nagelkerke R2 range: 0.25-0.26) and calibration (intercept range: -0.10 to -0.11; slope range: 1.06-1.09), and acceptable discrimination (area under the curve range: 0.76-0.77). The prediction model for successful outcomes did not calibrate well, while also showing poor discrimination. CONCLUSION: Common clinical variables including demographics, radiographic parameters of hip morphology and self-reported measures were able to predict the probability of having an unsuccessful outcome 1 year after hip arthroscopy, while the model for successful outcome showed unacceptable accuracy. The externally validated prediction model can be used to support clinical evaluation and shared decision making by informing the orthopaedic surgeon and patient about the risk of an unsuccessful outcome, and thus when surgery may not be appropriate.

Maximal hip muscle strength and rate of torque development 6-30 months after hip arthroscopy for femoroacetabular impingement syndrome: A cross-sectional study.

OBJECTIVES: Reduced sports function is often observed after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Impaired muscle strength could be reasons for this. We aimed to investigate hip muscle strength after hip arthroscopy for FAIS and its association with sports function and participation. DESIGN: Cross-sectional study. METHODS: We included 45 patients (34 males; mean age: 30.6 ±â€¯5.9 years) after unilateral hip arthroscopy for FAIS (mean follow-up [range]: 19.3 [9.8-28.4] months). Maximal isometric hip muscle strength (Nm/kg) including early- (0-100 ms) and late-phase (0-200 ms) rate of torque development (Nm∗kg-1∗s-1) for adduction, abduction, flexion, and extension was measured with an externally fixated handheld dynamometer and compared between operated and non-operated hip. Associations between muscle strength and self-reported sports function and return to sport were investigated. RESULTS: For maximal hip muscle strength, no between-hip differences were observed for adduction, abduction, flexion, and extension (p ≥ 0.102). For rate of torque development, significantly lower values were observed for the operated hip in flexion at both 0-100 ms (mean difference: 1.58 Nm∗kg-1∗s-1, 95% CI [0.39; 2.77], p = 0.01) and 0-200 ms (mean difference: 0.72 Nm∗kg-1∗s-1, 95% CI [0.09; 1.35], p = 0.027). Higher maximal hip extension strength was significantly associated with greater ability to participate fully in preinjury sport at preinjury level (odds ratio: 17.71 95% CI [1.77; 177.60]). CONCLUSIONS: After hip arthroscopy for FAIS subjects show limited impairments in maximal and explosive hip muscle strength between operated and non-operated hip. Higher muscle strength was positively associated with higher sports function and ability to participate in sport.

How Many Patients Achieve an Acceptable Symptom State After Hip Arthroscopy for Femoroacetabular Impingement Syndrome? A Cross-sectional Study Including PASS Cutoff Values for the HAGOS and iHOT-33.

BACKGROUND: Hip arthroscopy is a viable treatment for femoroacetabular impingement syndrome (FAIS). Clinically relevant improvements in hip function and pain after surgery are often reported, but it is less clear how many patients achieve an acceptable symptom state (Patient Acceptable Symptom State [PASS]). PURPOSE: To investigate the proportion of patients who achieved a PASS 12 to 24 months after hip arthroscopy and to determine the cutoff scores of the 2 recommended and valid patient-reported outcome measures (the subscales of the Copenhagen Hip and Groin Outcome Score [HAGOS] and the International Hip Outcome Tool-33 [iHOT-33]) for which patients are most likely to achieve PASS. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Eligible study patients were identified in the Danish Hip Arthroscopy Registry. An electronic questionnaire was used to collect data on PASS, HAGOS, and iHOT-33 12 to 24 months after surgery. PASS was measured using an anchor question. Receiver operating characteristic curve analyses were applied to identify the PASS cutoff values of HAGOS and iHOT-33 scores. RESULTS: A total of 137 individuals (mean age at surgery, 35.4 ± 9.4 years) were included in the study at a mean follow-up of 18.5 ± 3.2 months after surgery. At follow-up, 64 individuals (46.7%; 95% CI, 38.6-55.1) reported PASS. Higher HAGOS and iHOT-33 values were observed for participants who reported PASS compared with those who did not report PASS (Cohen d ≥ 1.06; P < .001). Cutoff scores for HAGOS subscales (42.5-82.5) and iHOT-33 (67.00) showed excellent to outstanding discriminative ability in predicting PASS (area under the curve, 0.82-0.92). CONCLUSION: In total, 46% of individuals having hip arthroscopy for FAIS achieved PASS at 12 to 24 months of follow-up. Patients who achieved PASS had statistically significant and substantially better self-reported hip function compared with those who did not achieve PASS. Cutoff values at HAGOS subscales and iHOT-33 showed excellent to outstanding discriminative ability in predicting patients with PASS.

THE SUCCESS OF RETURN TO SPORT AFTER SUPERIOR LABRUM ANTERIOR TO POSTERIOR (SLAP) TEARS: A SYSTEMATIC REVIEW AND META-ANALYSIS.

BACKGROUND: Reviews on superior labral anterior to posterior (SLAP) injuries have been reported in the literature. However, current reviews have not focused on the success of athletes return to their previous level of sport or athletic performance. HYPOTHESIS/PURPOSE: Systematically review return to sport (RTS) and return to sport at previous level (RTSP) proportions after SLAP injury while reporting any additional performance metrics and outcome measures. STUDY DESIGN: Systematic Review & Meta-Analysis. METHODS: A computer assisted literature search of MEDLINE, CINAHL, Embase and SportDiscus databases utilizing keywords related to RTS post-surgery for SLAP tear was implemented. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were utilized for study methodology. Quality assessment utilized the MINORS scale. RESULTS: Twenty-two studies (617 athletes) qualified for analysis. Based on limited evidence from level 3b to 4 studies, athletes RTS post intervention for SLAP injury occurred at a rate of 93% (95% CI:87 to 98%) and overall RTSP rate was 72% (95% CI:60 to 83%). The mean time to RTS post intervention was reported in 59% of studies at 6.9 ± 2.9 months. Patient reported outcome measures (PROM's) were reported in 86% of studies. There was limited reporting of performance statistics, rehabilitation guidelines, return to sport criteria, and information regarding SLAP diagnosis in the available studies. None of the included studies reported post-surgical athletic performance or career longevity. CONCLUSIONS: Limited evidence suggests that less than three in four athletes return to their previous level of sport participation after SLAP injury intervention. Treatment success for an athlete with SLAP injury remains relatively unknown as only 59% of included studies clearly delineate RTS from RTSP and neither athletic performance nor career longevity were reported in any included studies. Future studies of higher quality are required for this determination. LEVEL OF EVIDENCE: Level 1a.

Classifying Cam Morphology by the Alpha Angle: A Systematic Review on Threshold Values.

BACKGROUND: The alpha angle is the most often used measure to classify cam morphology. There is currently no agreement on which alpha angle threshold value to use. PURPOSE: To systematically investigate the different alpha angle threshold values used for defining cam morphology in studies aiming to identify this threshold and to determine whether data are consistent enough to suggest an alpha angle threshold to classify cam morphology. STUDY DESIGN: Systematic review; Level of evidence, 3. METHODS: The Embase, Medline (Ovid), Web of Science, Cochrane Central, and Google Scholar databases were searched from database inception to February 28, 2019. Studies aiming at identifying an alpha angle threshold to classify cam morphology were eligible for inclusion. RESULTS: We included 4 case-control studies, 10 cohort studies, and 1 finite-element study from 2437 identified publications. Studies (n = 3) using receiver operating characteristic (ROC) curve analysis to distinguish asymptomatic people from patients with femoroacetabular impingement syndrome consistently observed alpha angle thresholds between 57° and 60°. A 60° threshold was also found to best discriminate between hips with and without cam morphology in a large cohort study based on a bimodal distribution of the alpha angle. Studies (n = 8) using the upper limit of the 95% reference interval as threshold proposed a wide overall threshold range between 58° and 93°. When stratified by sex, thresholds between 63° and 93° in male patients and between 58° and 94° in female patients were reported. CONCLUSION: Based on the available evidence, mostly based on studies using ROC curve analysis, an alpha angle threshold of ≥60° is currently the most appropriate to classify cam morphology. Further research is required to fully validate this threshold.

There Is Limited and Inconsistent Reporting of Postoperative Rehabilitation for Femoroacetabular Impingement Syndrome: A Scoping Review of 169 Studies.

OBJECTIVE: To evaluate the reporting of rehabilitation guidelines in studies of postoperative outcomes of patients with femoroacetabular impingement (FAI) syndrome and/or labral tear. DESIGN: Scoping review. LITERATURE SEARCH: A computer-assisted literature search was conducted of the MEDLINE, CINAHL, and Embase databases on June 17, 2018. Using key words related to FAI syndrome/labral tear and both open and arthroscopic surgical outcomes, we identified 169 studies that included 16 675 patients. Separate authors calculated and verified the prevalence of reported outcomes. STUDY SELECTION CRITERIA: We included intervention and observational studies that were prospective or retrospective in design. Studies must have included patients with a primary diagnosis of FAI syndrome and/or labral tear. DATA SYNTHESIS: We calculated the mean ± SD prevalence for continuous variables, where possible. RESULTS: Hip arthroscopy was the primary surgical procedure (76% of studies). The mean ± SD age of participants was 34.8 ± 9.2 years and the mean ± SD follow-up time was 27 ± 15.3 months. Of the 169 included studies, 74 (44%) discussed phases of rehabilitation, 49 (29%) reported details on goals between phases, 1 in 3 described details on rehabilitation progression, and fewer than 1 in 10 reported sufficient detail to replicate the rehabilitation protocol. Weight-bearing and range-of-motion restrictions were poorly reported and variable in duration. CONCLUSION: Surgical outcome studies do not provide sufficient detail or consistency for practicing clinicians to replicate a postoperative rehabilitation protocol for patients with FAI syndrome/labral tear. J Orthop Sports Phys Ther 2020;50(5):252-258. doi:10.2519/jospt.2020.9189.

Patient-reported outcome measures for hip-related pain: a review of the available evidence and a consensus statement from the International Hip-related Pain Research Network, Zurich 2018.

Hip-related pain is a well-recognised complaint among active young and middle-aged active adults. People experiencing hip-related disorders commonly report pain and reduced functional capacity, including difficulties in executing activities of daily living. Patient-reported outcome measures (PROMs) are essential to accurately examine and compare the effects of different treatments on disability in those with hip pain. In November 2018, 38 researchers and clinicians working in the field of hip-related pain met in Zurich, Switzerland for the first International Hip-related Pain Research Network meeting. Prior to the meeting, evidence summaries were developed relating to four prioritised themes. This paper discusses the available evidence and consensus process from which recommendations were made regarding the appropriate use of PROMs to assess disability in young and middle-aged active adults with hip-related pain. Our process to gain consensus had five steps: (1) systematic review of systematic reviews; (2) preliminary discussion within the working group; (3) update of the more recent high-quality systematic review and examination of the psychometric properties of PROMs according to established guidelines; (4) formulation of the recommendations considering the limitations of the PROMs derived from the examination of their quality; and (5) voting and consensus. Out of 102 articles retrieved, 6 systematic reviews were selected and assessed for quality according to AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews). Two showed moderate quality. We then updated the most recent review. The updated literature search resulted in 10 additional studies that were included in the qualitative synthesis. The recommendations based on evidence summary and PROMs limitations were presented at the consensus meeting. The group makes the following recommendations: (1) the Hip and Groin Outcome Score (HAGOS) and the International Hip Outcome Tool (iHOT) instruments (long and reduced versions) are the most appropriate PROMs to use in young and middle-aged active adults with hip-related pain; (2) more research is needed into the utility of the HAGOS and the iHOT instruments in a non-surgical treatment context; and (3) generic quality of life measures such as the EuroQoL-5 Dimension Questionnaire and the Short Form Health Survey-36 may add value for researchers and clinicians in this field. We conclude that as none of the instruments shows acceptable quality across various psychometric properties, more methods studies are needed to further evaluate the validity of these PROMS-the HAGOS and iHOT-as well as the other (currently not recommended) PROMS.

Consensus recommendations on the classification, definition and diagnostic criteria of hip-related pain in young and middle-aged active adults from the International Hip-related Pain Research Network, Zurich 2018.

There is no agreement on how to classify, define or diagnose hip-related pain-a common cause of hip and groin pain in young and middle-aged active adults. This complicates the work of clinicians and researchers. The International Hip-related Pain Research Network consensus group met in November 2018 in Zurich aiming to make recommendations on how to classify, define and diagnose hip disease in young and middle-aged active adults with hip-related pain as the main symptom. Prior to the meeting we performed a scoping review of electronic databases in June 2018 to determine the definition, epidemiology and diagnosis of hip conditions in young and middle-aged active adults presenting with hip-related pain. We developed and presented evidence-based statements for these to a panel of 37 experts for discussion and consensus agreement. Both non-musculoskeletal and serious hip pathological conditions (eg, tumours, infections, stress fractures, slipped capital femoral epiphysis), as well as competing musculoskeletal conditions (eg, lumbar spine) should be excluded when diagnosing hip-related pain in young and middle-aged active adults. The most common hip conditions in young and middle-aged active adults presenting with hip-related pain are: (1) femoroacetabular impingement (FAI) syndrome, (2) acetabular dysplasia and/or hip instability and (3) other conditions without a distinct osseous morphology (labral, chondral and/or ligamentum teres conditions), and that these terms are used in research and clinical practice. Clinical examination and diagnostic imaging have limited diagnostic utility; a comprehensive approach is therefore essential. A negative flexion-adduction-internal rotation test helps rule out hip-related pain although its clinical utility is limited. Anteroposterior pelvis and lateral femoral head-neck radiographs are the initial diagnostic imaging of choice-advanced imaging should be performed only when requiring additional detail of bony or soft-tissue morphology (eg, for definitive diagnosis, research setting or when planning surgery). We recommend clear, detailed and consistent methodology of bony morphology outcome measures (definition, measurement and statistical reporting) in research. Future research on conditions with hip-related pain as the main symptom should include high-quality prospective studies on aetiology and prognosis. The most common hip conditions in active adults presenting with hip-related pain are: (1) FAI syndrome, (2) acetabular dysplasia and/or hip instability and (3) other conditions without distinct osseous morphology including labral, chondral and/or ligamentum teres conditions. The last category should not be confused with the incidental imaging findings of labral, chondral and/or ligamentum teres pathology in asymptomatic people. Future research should refine our current recommendations by determining the clinical utility of clinical examination and diagnostic imaging in prospective studies.

Standardised measurement of physical capacity in young and middle-aged active adults with hip-related pain: recommendations from the first International Hip-related Pain Research Network (IHiPRN) meeting, Zurich, 2018.

Hip-related pain can significantly impact quality of life, function, work capacity, physical activity and family life. Standardised measurement methods of physical capacity of relevance to young and middle-aged active adults with hip-related pain are currently not established. The aim of this consensus paper was to provide recommendations for clinical practice and research on standardised measurement methods of physical capacity in young and middle-aged active adults with hip-related pain. Four areas of importance were identified: (1) clinical measures (range of motion, muscle strength, functional impairments), (2) laboratory-based measures (biomechanics and muscle function (muscle activity, size and adiposity)), (3) physical activity, and (4) return to sport/performance. The literature was reviewed, and a summary circulated to the working group to inform discussion at the consensus meeting. The working group developed clinical and research recommendations from the literature review, which were further discussed and modified within the working group at the consensus meeting. These recommendations were then presented to all 38 International Hip-related Pain Research Network (IHiPRN) participants for further discussion, refinement and consensus voting. Therefore, the recommendations voted on were based on a combination of current evidence and expert opinion. The consensus meeting voted on 13 recommendations, six of which were clinically orientated, and seven more research specific. We recommended that clinicians working with young and middle-aged active adults with hip-related pain assess strength using objective methods of measurement, and clinically assess performance of functional tasks, including walking and running. Physical activity should be quantified using both self-reported and objective measures, and patient expectations of recovery should be quantified prior to treatment. It was recommended that return to physical activity (including sport and occupation) be quantified, and sport-specific activities should be assessed prior to return to sport. The IHiPRN participants were uncertain regarding recommendations for range of motion assessment. Research recommendations were that the measurement properties of range of motion, strength and functional performance tests be investigated, reported and improved in both clinical and research settings. Reporting of movement-related parameters (biomechanics and muscle function) should be standardised and the relationship among movement-related parameters, symptoms, function, quality of life, and intra-articular and imaging findings should be investigated. Quantification of return to physical activity (including sport and occupational demands) is required in future research, and the return to sport continuum should be used. Future research is required to determine the best criteria for rehabilitation progression and return to physical activity following hip-related pain management.

Systematic review of diagnostic accuracy of patient history, clinical findings, and physical tests in the diagnosis of lumbar spinal stenosis.

PURPOSE: To update evidence of diagnostic potential for identification of lumbar spinal stenosis (LSS) based on demographic and patient history, clinical findings, and physical tests, and report posttest probabilities associated with test findings. METHODS: An electronic search of PubMed, CINAHL and Embase was conducted combining terms related to low back pain, stenosis and diagnostic accuracy. Prospective or retrospective studies investigating diagnostic accuracy of LSS using patient history, clinical findings and/or physical tests were included. The risk of bias and applicability were assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS 2) tool. Diagnostic accuracy including sensitivities (SN), specificities (SP), likelihood ratios (+LR and -LR) and posttest probabilities (+PTP and -PTP) with 95% confidence intervals were summarized. RESULTS: Nine studies were included (pooled n = 36,228 participants) investigating 49 different index tests (30 demographic and patient history and 19 clinical findings/physical tests). Of the nine studies included, only two exhibited a low risk of bias and seven exhibited good applicability according to QUADAS 2. The demographic and patient history measures (self-reported history questionnaire, no pain when seated, numbness of perineal region) and the clinical findings/physical tests (two-stage treadmill test, symptoms after a March test and abnormal Romberg test) highly improved positive posttest probability by > 25% to diagnose LSS. CONCLUSION: Outside of one study that was able to completely rule out LSS with no functional neurological changes none of the stand-alone findings were strong enough to rule in or rule out LSS. These slides can be retrieved under Electronic Supplementary Material.

Physiotherapist-led treatment for young to middle-aged active adults with hip-related pain: consensus recommendations from the International Hip-related Pain Research Network, Zurich 2018.

The 1st International Hip-related Pain Research Network meeting discussed four prioritised themes concerning hip-related pain in young to middle-aged adults: (1) diagnosis and classification of hip-related pain; (2) patient-reported outcome measures for hip-related pain; (3) measurement of physical capacity for hip-related pain; (4) physiotherapist-led treatment for hip-related pain. Thirty-eight expert researchers and clinicians working in the field of hip-related pain attended the meeting. This manuscript relates to the theme of physiotherapist-led treatments for hip-related pain. A systematic review on the efficacy of physiotherapist-led interventions for hip-related pain (published separately) was conducted and found that strong evidence for physiotherapist-led treatments was lacking. Prior to the meeting, draft consensus recommendations for consideration in the meeting were also developed based on the systematic review. The draft consensus recommendations were presented to all of the meeting participants via email, at least 1 week prior to the meeting. At the meeting, these recommendations were discussed, revised and voted on. Six recommendations for clinical practice and five recommendations for research were included and all gained consensus. Recommendations for clinical practice were that (i) Exercise-based treatments are recommended for people with hip-related pain. (ii) Exercise-based treatment should be at least 3 months duration. (iii) Physiotherapist-led rehabilitation after hip surgery should be undertaken. (iv) Patient-reported outcome measures, measures of physical impairment and measures of psychosocial factors should be used to monitor response to treatment. (v) Physical activity (that may include sport) is recommended for people with hip-related pain. (vi) Clinicians should discuss patient expectations, use shared-decision making and provide education. Recommendations for research were (i) Reporting of exercise programmes: Exercise descriptors such as load magnitude, number of repetitions and sets, duration of whole programme, duration of contractile element of exercise, duration of one repetition, time under tension, rest between repetitions, range of motion through which the exercise is performed, and rest between exercise sessions should be reported. (ii) Research should investigate the optimal frequency, intensity, time, type, volume and progression of exercise therapy. (iii) Research should examine the effect of patient education in people with hip-related pain. (iv) Research should investigate the effect of other treatments used in people with hip-related pain (for example: manual therapy, medications, injections). (v) Research should examine the impact of comorbidities and social determinants on treatment effectiveness in people with hip-related pain. Clinicians and researchers working with young to middle-aged active adults with hip-related pain may use these consensus recommendations to guide, develop, test and implement individualised, evidence-based physiotherapist-led rehabilitation programmes.

The two-year incidence of hip osteoarthritis after arthroscopic hip surgery for femoroacetabular impingement syndrome.

BACKGROUND: One of the reported goals of hip preservation surgery is to prevent or delay the onset of osteoarthritis. This includes arthroscopic surgery to manage Femoroacetabular Impingement (FAI) Syndrome. The purpose of this study was to describe the prevalence of clinically-diagnosed hip OA within 2 years after hip arthroscopy for FAI syndrome, and 2) determine which variables predict a clinical diagnosis of OA after arthroscopy. METHODS: Observational analysis of patients undergoing hip arthroscopy between 2004 and 2013, utilizing the Military Health System Data Repository. Individuals with prior cases of osteoarthritis were excluded. Presence of osteoarthritis was based on diagnostic codes rendered by a medical provider in patient medical records. Adjusted odds ratios (95% CI) for an osteoarthritis diagnosis were reported for relevant clinical and demographic variables. RESULTS: Of 1870 participants in this young cohort (mean age 32.2 years), 21.9% (N = 409) had a postoperative clinical diagnosis of hip osteoarthritis within 2 years. The 3 significant predictors in the final model were older age (OR = 1.04; 95%CI = 1.02, 1.05), male sex (OR = 1.31; 95%CI = 1.04, 1.65), and having undergone an additional hip surgery (OR = 2.33; 95% CI = 1.72, 3.16). Military status and post-surgical complications were not risk factors. CONCLUSION: A clinical diagnosis of hip osteoarthritis was found in approximately 22% of young patients undergoing hip arthroscopy in as little as 2 years. These rates may differ when using alternate criteria to define OA, such as radiographs, and likely underestimate the prevalence. A more comprehensive approach, considering various criteria to detect OA will likely be necessary to accurately identify the true rates. Females were at lower risk, while increasing age and multiple surgeries increased the risk for an OA diagnosis. OA onset still occurs after "hip preservation" surgery in a substantial number of individuals within 2 years. This should be considered when estimating rates of disease prevention after surgery. Prospective trials with sound methodology are needed to determine accurate rates and robust predictors of osteoarthritis onset after hip preservation surgery.

Which criteria are used to clear patients to return to sport after primary ACL reconstruction? A scoping review.

OBJECTIVE: To describe the criteria used to clear athletes to return to sport (RTS) following primary ACL reconstruction. DESIGN: Scoping review. DATA SOURCES: MEDLINE, Embase, CINAHL and SPORTDiscus electronic databases were searched using keywords related to ACL and RTS. ELIGIBILITY CRITERIA: Prospective or retrospective studies reporting at least one RTS criterion for athletes who had primary ACL reconstruction with an autograft. RESULTS: In total, 209 studies fulfilled the inclusion criteria. RTS criteria were categorised into six domains: time, strength, hop testing, clinical examination, patient-report and performance-based criteria. From the 209 included studies, time was used in 178 studies (85%), and in 88 studies (42%) was the sole RTS criterion. Strength tests were reported in 86 studies (41%). Sixteen different hop tests were used in 31 studies (15%). Clinical examination was used in 54 studies (26%), patient report in 26 studies (12%) and performance-based criteria in 41 studies (20%). SUMMARY: Time and impairment-based measures dominated RTS criteria, despite sport being a complex physical and biopsychosocial activity with demands across all aspects of function. Time was included as a criterion in 85% of studies, and over 80% of studies allowed RTS before 9 months. Whether RTS tests are valid-do they predict successful RTS?-is largely unknown.

Accuracy of Clinical and Imaging Tests for the Diagnosis of Hip Dysplasia and Instability: A Systematic Review.

BACKGROUND: Evidence concerning the accurate clinical or imaging methods to diagnose hip instability or hip dysplasia is currently scarce. OBJECTIVE: To summarize the diagnostic accuracy of clinical and imaging tests for the diagnosis of hip dysplasia and instability. METHODS: A computer-assisted literature search of the MEDLINE, CINAHL, and Embase databases, using key words related to diagnostic accuracy of the hip joint, was conducted on March 6, 2018. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for the searching and reporting phases of the study. Quality assessment of bias and applicability was conducted using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Diagnostic accuracy, including sensitivity, specificity, likelihood ratio, and 95% confidence interval, was summarized. RESULTS: Out of 3109 citations, 7 articles were included. Two studies reported on 5 clinical tests for hip instability and 5 studies reported on 5 radiographic measures for hip dysplasia. Only 1 study was not of low methodological quality. The prone instability test moderately improved positive posttest probability by 38% to diagnose hip instability. The Shenton line moderately to highly improved posttest probability by 41% to 60% to diagnose hip dysplasia. CONCLUSION: This systematic review summarizes the diagnostic accuracy of various clinical tests and radiographic measures for hip instability and hip dysplasia. Further high-quality studies are necessary to examine the diagnostic accuracy of the clinical examination and radiography to assist in ruling in or ruling out the diagnoses of hip dysplasia and instability. Consensus is required to standardize the definitions of these diagnoses and their reference standards. The study was registered with the International Prospective Register of Systematic Reviews (CRD42018089019). LEVEL OF EVIDENCE: Diagnosis, level 3b. J Orthop Sports Phys Ther 2019;49(2):87-97. Epub 30 Nov 2018. doi:10.2519/jospt.2019.8476.

The Association Between Passing Return-to-Sport Criteria and Second Anterior Cruciate Ligament Injury Risk: A Systematic Review With Meta-analysis.

BACKGROUND: There is no consensus on the components of return-to-sport (RTS) testing following anterior cruciate ligament (ACL) reconstruction or whether passing RTS criteria can reduce a patient's risk of reinjury. OBJECTIVES: To determine whether impartial, criteria-based RTS decisions are associated with less risk of a second ACL injury (either graft failure or contralateral ACL injury). METHODS: In this systematic review with meta-analysis, the authors conducted an electronic literature search in PubMed/MEDLINE, Embase, CINAHL, SPORTDiscus, and ProQuest Dissertations and Theses Global using database-specific vocabulary related to ACL reconstruction and return to sport. Individual study quality was assessed using the modified Downs and Black checklist, and overall quality of evidence was determined with the Grading of Recommendations Assessment, Development and Evaluation scale. Pooled risk difference (passed versus failed RTS criteria), injury incidence proportion, and the diagnostic accuracy of each RTS criterion were calculated. RESULTS: Four studies met the selection criteria. Overall, 42.7% (95% confidence interval [CI]: 18%, 69%) of patients passed RTS criteria, and 14.4% (95% CI: 8%, 21%) of those who passed experienced a second ACL injury (graft rupture or contralateral ACL injury). There was a nonsignificant 3% reduced risk of a second ACL injury after passing RTS criteria (risk difference, -3%; 95% CI: -16%, 10%; I2 = 74%, P = .610). The evidence rating of the Grading of Recommendations Assessment, Development and Evaluation scale was "very low quality," due to imprecision and heterogeneity of the pooled risk difference estimate. CONCLUSION: Passing RTS criteria did not show a statistically significant association with risk of a second ACL injury. The quality-of-evidence rating prevents a definitive conclusion on this question and indicates an opportunity for future research. LEVEL OF EVIDENCE: Prognosis, Level 2a-. J Orthop Sports Phys Ther 2019;49(2):43-54. Epub 30 Nov 2018. doi:10.2519/jospt.2019.8190.

Risk factors for ulnar collateral ligament injury in professional and amateur baseball players: a systematic review with meta-analysis.

BACKGROUND: Risk factors for ulnar collateral ligament injury (UCLI) are unclear despite increasing injury rates. We sought to summarize UCLI risk factors in baseball players. METHODS: A computer-assisted search of 4 databases was performed using keywords related to UCLI risk factors. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for study methodology. Odds ratios and 95% confidence intervals were calculated for dichotomous outcomes, and mean differences and 95% confidence intervals were calculated for continuous outcomes using a random-effects model. RESULTS: Thirteen studies qualified for inclusion. A greater nondominant (ND) shoulder internal rotation (IR) range of motion (ROM) at 90° abduction arm demonstrated strong evidence as a significant risk factor for UCLI (P < .001) compared with a control group. Mean overall velocity (P < .001), fastball velocity (P < .001), changeup velocity (P = .03), and curveball velocity (P = .01), as well as fewer years of player experience (P < .001), less humeral retrotorsion in the ND arm (P < .001), and greater absolute side-to-side differences in retrotorsion (P = .006) were all moderate-evidence risk factors compared with control groups. Strong evidence suggests total ROM arc at 90° abduction in the dominant arm was not a risk factor for UCLI (P = .81). CONCLUSIONS: Greater ND shoulder IR ROM and less humeral retrotorsion (in professional and amateur players) as well as pitching velocity (in professional players) demonstrated strong to moderate evidence as risk factors for UCLI. Dominant arm total arc of motion, external, or IR ROM were not risk factors for UCLI. Standardized collection and reporting of risk factors is recommended to more clearly elucidate definitive risk factors for UCLI.

ACCURACY OF THE LEVER SIGN TO DIAGNOSE ANTERIOR CRUCIATE LIGAMENT TEAR: A SYSTEMATIC REVIEW WITH META-ANALYSIS.

BACKGROUND: The Lever sign has gained recent notoriety for its purported anterior cruciate ligament (ACL) diagnostics and simplicity of performance. PURPOSE: The purpose of this systematic review with meta-analysis is to summarize the diagnostic accuracy of the Lever sign for use during assessment of the knee for an ACL tear in subjects with suspected acute and chronic knee injury. STUDY DESIGN: Systematic review with meta-analysis. METHODS: A computer-assisted literature search of MEDLINE, CINAHL, and EMBASE databases using keywords related to diagnostic accuracy of the knee joint. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for the search and reporting phases of the study. Quality assessment of bias and applicability was conducted using the Quality of Diagnostic Accuracy Studies (QUADAS). Mixed effects models were used to summarize accuracy. RESULTS: Eight articles, with only two demonstrating high quality, were included. Six of the articles were included in a meta-analysis. Diagnostic values, utilizing arthroscopy as a gold standard, were: pooled SN 0.55 (95% CI 0.22 to 0.84), pooled SP 0.89 (95% CI 0.44 to 0.99), positive likelihood ratio (+LR) 9.2 (95% CI 0.70 to 46.1), negative likelihood ratio (-LR) 0.58 (95% CI 0.18 to 1.28). Post-test probability with a positive finding (57% sampling prevalence) reached 92% (95% CI 83 to 97%). Post-test probability with a negative finding (57% sampling prevalence) reached 43% (95% CI 39 to 47%). CONCLUSIONS: Based on limited evidence of heterogeneous methodological quality, the Lever sign can moderately change post-test probability to rule in an ACL tear. These results should be interpreted cautiously due to a limited number of studies, with small sample sizes and study quality affecting test accuracy. Future investigation should be expanded to include additional high-quality studies examining diverse clinical contexts, as they become available, to enable a more comprehensive clinical examination of this test. LEVEL OF EVIDENCE: 3aPROSPERO Registration # CRD42018084954.

Most Military Service Members Return to Activity Duty With Limitations After Surgery for Femoroacetabular Impingement Syndrome: A Systematic Review.

PURPOSE: Determine which proportion of active-duty service members return to duty (RTD), RTD without limitations, which surgical intervention returns these personnel at a better proportion and with the ability to perform their military duties after surgery compared with the pre-injury state. METHODS: A computer-assisted search of MEDLINE, EMBASE and SCOPUS databases was performed with keywords related to RTD for femoroacetabular impingement (FAI) syndrome. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for study methodology. Methodologic quality of individual studies was assessed with the Methodological Index for Non-Randomized Studies scale. RESULTS: A total of 5 studies (884 service members/886 hips) qualified for inclusion. Limited evidence from level III to IV studies indicates that service members RTD at a proportion ranging from 57% (95% confidence interval [CI]: 53% to 62%) to 84% (95% CI: 73% to 91%), but only 39% (95% CI: 35% to 44%) to 59% (95% CI: 49% to 69%) do so without limitations. Mean duration of follow-up was 33.2 ± 11.3 months. No studies reported on actual duty requirements before versus after surgery, RTD criteria, or career longevity. Only 1 of 5 studies reported the RTD time-frame (mean 5 months). Only 2 of 5 studies reported complications, with a rate of 9.4% ± 6.3%. Three of 5 studies reported failures at a rate of 7.2% ± 4.7%, respectively. Femoroplasty (mean 56% of procedures in 4 studies) and acetabuloplasty (mean 55% of procedures in 4 studies) were the most commonly used procedures in studies reporting. CONCLUSIONS: RTD is poorly defined in the included studies. Limited evidence substantiates that approximately 75% of service members remain on active duty for at least 1 to 2 years after surgery for FAI syndrome, whereas only approximately 47% do so without limitations at mid-term follow-up. Similarly, despite improvements in patient-reported outcome measures, service members still report continued pain and functional limitations after FAI syndrome surgery. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.