Return to Sport in Australian Football League Footballers After Hip Arthroscopy and Midterm Outcome

doi:10.1016/j.arthro.2013.05.001

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 29, Issue 7, July 2013, Pages 1188-1194

https://doi.org/10.1016/j.arthro.2013.05.001 Get rights and content

Purpose

To study the return to sport in a series of professional athletes in a single sport (Australian Rules Football), operated on arthroscopically for hip joint pathology.

Methods

We performed a retrospective review of the senior author's surgical database starting in 2003. All of the patients who were Australian Football League (AFL) professional players with a minimum of 2 years' follow-up were included. Intra-articular pathologies were identified and treated. All patients were prospectively assessed with the modified Harris Hip Score (MHHS) and the Non-Arthritic Hip Score (NAHS). In addition, information about the active participation of the patients in their teams and return to professional sport was obtained from AFL registers and team physicians.

Results

Since 2003, the senior author has operated on 36 male professional AFL players; 26 of 27 with at least 2 years' follow-up were available for review. The mean age at the time of surgery was 22.1 years (range, 16 to 30 years), and 8 patients had bilateral pathology; therefore 34 hips were operated on. This report refers to those 26 players and 34 hips. All but 1 of the patients returned to play professionally. By the last survey (October 2011), 16 patients (62%) were still playing professional AFL football, and they have been playing for a mean of 52.5 months after surgery. Ten patients had retired from professional football, but they had all returned to play professionally after surgery. Only one of them retired for causes related to hip disability. There was a significant improvement in preoperative outcome scores. The MHHS and NAHS improved from 83.6 to 98 and from 85.3 to 97.1, respectively, in the players who were still playing (P < .05). Rim lesions were present in 33 hips (97%). Femoral osteochondroplasty was performed in 26 hips (76%).

Conclusions

Arthroscopic treatment of intra-articular pathologies in professional athletes resulted in a 96% rate of return to elite-level sport and a durable increase in the MHHS and NAHS.

Level of Evidence

Level IV, therapeutic case series.

Section snippets

Patient Inclusion and Data Collection

A retrospective review of the surgical database of the senior surgeon was performed. All of the patients who were professional AFL players at the time of their hip arthroscopy were reviewed. The indication for hip arthroscopy was a history of hip pain, with or without mechanical symptoms, that did not respond to conservative treatment for at least 3 months. Each of the players was previously evaluated by his team physician, a sports physician, before being referred to us. The referral was

Return to Sports

Of the 27 players, 26 were available for review (one declined to participate). The mean follow-up period was 49.3 months (SD, 21.2 months; range, 24 to 97.6 months).

The mean age at the time of surgery was 21.8 years (range, 16 to 30 years), and 8 patients had bilateral pathology; therefore 34 hips were operated on. The mean height and weight at the time of surgery was 187.4 cm (range, 176 to 201 cm) and 87.7 kg (range, 70 to 103 kg), respectively. The mean body mass index was 24.9 (range, 20 to

Discussion

This study showed that AFL players can return to play at the same professional level after arthroscopic surgery for intra-articular hip pathology. Moreover, all but one of the patients operated on were able to return to play, and more than half are still playing at a mean of 52.5 months (and up to 97.6 months) after surgery. It is of interest that the average playing career of an AFL footballer is approximately 48 months (4 seasons). Most then retire either because of chronic injuries or

Conclusions

Arthroscopic treatment of intra-articular pathologies in professional athletes resulted in a 96% rate of return to elite-level sport and a substantial improvement in outcome scores (modified Harris Hip Score and Non-Arthritic Hip Score). Moreover, this return has been durable because, at a mean follow-up of 52.5 months, more than half of them are still playing. We believe that hip arthroscopy is an effective method for the treatment of intra-articular hip pathology in these athletes.

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Cited by (50)

Return to sport after arthroscopic surgery for femoroacetabular impingement
2023, Surgeon
Femoroacetabular impingement (FAI) is common among the active and young population. The present study analysed the rate of return to sport, related influencing factors, and the sport activity level according to the Hip Outcome Score - Sport-Specific Subscale (HOS-SSS).
The literature search was performed in December 2020. All clinical trials investigating HOS-SSS and/or return to sport after arthroscopic treatment for FAI were considered for inclusion. The outcomes of interest were to analyse the rate of return to sport and the sport activity level according to the HOS-SSS in patients who underwent arthroscopic osteoplasty for FAI.
Data from 41 studies (4063 procedures) were retrieved. A total of 88.75% (581 of 655) of patients returned to sports within a mean of 37.4 ± 16.5 months. The HOS-SSS score improved from 45.0 ± 10.6 to 73.1 ± 9.5 (P < 0.0001) at last follow-up. The following baseline characteristics evidenced positive association with post-operative activity level: lighter weight (P = 0.01), younger age (P = 0.001), Tönnis angle grade I (P = 0.009), greater HHS (P = 0.01), NAHS (P < 0.0001) and HOS-ADL (P = 0.01).
Arthroscopic treatment for FAI resulted in excellent results in terms of return to sport. Moreover, lighter weight and younger age, greater HHS, NAHS, HOS-ADL at baseline were positively associated with post-operative sport activity level.
IV, systematic review.
Postoperative Alpha Angle Is Predictive of Return to Sport in Athletes Undergoing Hip Arthroscopy for Femoroacetabular Impingement
2022, Arthroscopy - Journal of Arthroscopic and Related Surgery
To identify clinical and radiographic factors that predict return to sport in athletes undergoing hip arthroscopy and to determine thresholds for significant predictors.
Data were reviewed on all patients who underwent primary hip arthroscopy between November 2008 and August 2018. Patients were included if they played professional, college, or high school sports within 1 year before surgery and had preoperative, 3-month, 1-year, and 2-year postoperative patient-reported outcome scores for modified Harris Hip Score, Hip Outcome Score-Sport Specific-Subscale, and Nonarthritic Hip Score. Rates of achieving the minimal clinically important difference also were evaluated. Patients were divided into groups based on whether they returned to sport at the same or greater level. Multivariate logistic regression and receiver operator characteristic analysis were used to evaluate the correlation between significant variables and return to sport.
A total of 136 patients with a mean age of 20.8 ± 7.07 years were included. Among athletes who attempted to return, professional and collegiate athletes returned to sport at any level at a rate of 85.0% (51/60), and high-school athletes returned at a rate of 88.1% (52/59). Competition level, postoperative alpha angle, change in alpha angle, and postoperative patient-reported outcomes were significantly different between groups. Athletes who returned to sport achieved the minimal clinically important difference for Hip Outcome Score–Sport Specific-Subscale at significantly higher rates than athletes who did not return to sport (91.6% vs 71.7%, P = .002, S = 8.97). The multivariate logistic regression model identified postoperative alpha angle as a statistically significant predictor of return to sport (P < .001, S > 9.97 [odds ratio 0.85, 95% confidence interval 0.79-0.91]). The receiver operator characteristic curve for postoperative alpha angle demonstrated acceptable discrimination between patients returning to sport and patients not returning to sport with an area under the curve of 0.71 and a threshold value of 46°. Athletes with a postoperative alpha angle ≤46° returned to sport at significantly higher rates than those with a postoperative alpha angle >46° [(P < .001, S > 9.97 [odds ratio 6.3, 95% confidence interval 2.6-15.2]).
Postoperative alpha angle was identified as a predictor of return to sport in athletes. The odds of returning to sport were 6.3 times greater in athletes with postoperative alpha angles ≤46° compared with athletes with angles >46°.
III, retrospective cohort study.
Pain Catastrophizing and Kinesiophobia Affect Return to Sport in Patients Undergoing Hip Arthroscopy for the Treatment of Femoroacetabular Impingement
2021, Arthroscopy, Sports Medicine, and Rehabilitation
Citation Excerpt :
Furthermore, pain catastrophizing and kinesiophobia were negatively correlated with achieving a CSO with regards to sporting function. Hip arthroscopy for the treatment of FAI has yielded improved patient outcomes for the vast majority of patients with a high rate of RTS.1-3,10,13 Despite this, there continues to be a subset of patients who are unable to RTS at a preinjury level.
To assess whether pain catastrophizing and kinesiophobia affect return to sport (RTS) or clinically significant outcome (CSO) achievement in patients undergoing hip arthroscopy for the treatment of femoroacetabular impingement (FAI).
Patients undergoing primary hip arthroscopy at a single institution between January 2017 and March 2017 were prospectively enrolled. Patients received the Tampa Scale of Kinesiophobia-11 (TSK-11) and Pain Catastrophizing Scale (PCS) questionnaires preoperatively, 3 weeks, 6 weeks, 3 months, 6 months, and 1 year postoperatively. Patients also received the Hip Outcome Score Sport-Specific (HOS-SS) questionnaire preoperatively and 1 year and 2 years’ postoperatively. An RTS questionnaire was completed at final follow-up. Bivariate correlations were conducted between PCS and TSK-11 scores and RTS status and achievement of CSOs of HOS-SS, based on patient acceptable symptom state (PASS) and substantial clinical benefit (SCB).
Fifty-eight patients with an average age of 31.9 ± 12.2 and body mass index of 24.0 ± 3.8 participated in sport prior to surgery and were included in the study. Forty-two (72.4%) patients returned to sport at 10.5 ± 7.1 months following surgery. There was a significant reduction in TSK-11 and PCS scores at 1-year follow-up (TSK-11, 26.1 ± 6.0 vs 18.6 ± 6.1, P < .001; PCS, 17.7 ± 10.5 vs 4.3 ± 6.8, P < .001) as well as a significant improvement in HOS-SS (P < .001). At 1 year, fair correlations were demonstrated between PCS (r = –0.446, P = .010) and TSK (r = –0.330, P = .029) scores and RTS. Patient who returned to sport had lower PCS (8.5 ± 11.7 vs 3.0 ± 3.7, P = .010) and TSK-11 (21.8 ± 8.5 vs 17.6 ± 4.8, P = .029) scores at 1 year. At 1-year follow-up, PCS (r = –0.572, P = .001) and TSK-11 (r = –0.441, P = .012) scores demonstrated fair correlations with achieving PASS for HOS-SS at 2-year follow-up.
Patient kinesiophobia and pain catastrophizing at 1-year follow-up were negatively correlated with RTS and achievement of a CSO in sport-related activities at 2-year follow-up.
III, prospective cohort study.
Patient-Reported Outcomes in Athletes Following Hip Arthroscopy for Femoroacetabular Impingement With Subanalysis on Return to Sport and Performance Level: A Systematic Review
2021, Arthroscopy - Journal of Arthroscopic and Related Surgery
Citation Excerpt :
The RTS rate ranged from 72.7 to 100 among studies. Of these 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.
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.
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.
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 Harris Hip Score, Nonarthritic Hip Score, the Hip Outcome Score–Activities of Daily Living, the Hip Outcome Score–Sport-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.
Athletes undergoing arthroscopic hip surgery in the setting of femoroacetabular impingement, 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.
IV, systematic review of Level III and IV studies.
Return to Basketball After Hip Arthroscopy: Minimum 2-Year Follow-up
2019, Arthroscopy - Journal of Arthroscopic and Related Surgery
To present minimum 2-year patient-reported outcomes (PROs) and return to sport (RTS) data for a population of basketball players after hip arthroscopy.
Data were prospectively collected and retrospectively reviewed for all patients who underwent hip arthroscopy between February 2009 and May 2014. Patients with preoperative and minimum 2-year postoperative PROs, visual analog scale score for pain, and satisfaction, who regularly played basketball within 1 year before surgery, and who attempted to RTS met the inclusion criteria. Exclusion criteria were previous ipsilateral hip surgery or conditions such as fracture, dysplasia, or femoral avascular necrosis. Patients were matched 1:1 to a control group composed of those who did not play any sports before surgery, based on the following matching criteria: age ±5 years, sex, and body mass index ±5. Statistical analysis was performed to determine significant differences in PROs. Conversion to total hip arthroplasty (THA) was considered an endpoint.
Thirty-one patients (81.6%) met inclusion criteria with follow-up of 46.8 ± 20.6 months. The mean age was 30.0 ± 12.3, and the mean body mass index was 26.3 ± 6.5. Male patients (64.5%) outnumbered female patients (35.5%). A majority of the players (54.8%) identified themselves as recreational athletes; the remainder competed at the high school, collegiate, amateur, or professional level. There was significant (P < .001) improvement in all PRO measures and visual-analog scale scores from baseline to a minimum 2-year follow-up. At the most recent follow-up, mean patient satisfaction was 8.1 ± 2.1. Twenty-two (78.6%), and 23 patients (82.1%) achieved the patient acceptable symptom state on the modified Harris Hip Score and the Hip Outcomes Score–Sports Specific Subscale. Twenty-one (75.0%) and 17 (60.7%) patients had a minimal clinically important difference on the modified Harris Hip Score and the Hip Outcomes Score–Sports Specific Subscale, respectively. Three patients (9.7%) with an average age of 47.5 (P = .023) converted to THA at a mean of 35.9 ± 7.2 (range 29.66-43.75) months after arthroscopy. At the most recent follow-up, the RTS rate was 83.9%. Subjective ability level was the same or higher in 23 patients (74.2%).
Hip arthroscopy in basketball athletes demonstrates a significant increase in PROs, a high RTS rate, and a low risk of complications. Hip arthroscopy may be considered in basketball players <40 years old for whom nonoperative treatment fails and who have a significantly limited level of play. Careful patient selection and counseling should be used when considering hip arthroscopy in basketball players >40 years old because there may be a high rate of conversion to THA.
Level III, retrospective comparative study.
Prevalence and Consistency in Surgical Outcome Reporting for Femoroacetabular Impingement Syndrome: A Scoping Review
2018, Arthroscopy - Journal of Arthroscopic and Related Surgery
The purposes of this review were (1) to collate and synthesize research studies reporting any outcome measure on both open and arthroscopic surgical treatment of femoroacetabular impingement (FAI) syndrome and (2) to report the prevalence and consistency of outcomes across the included studies.
A computer-assisted literature search of the MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Embase databases was conducted using keywords related to FAI syndrome and both open and arthroscopic surgical outcomes, resulting in 2,614 studies, with 163 studies involving 14,824 subjects meeting the inclusion criteria. Two authors independently reviewed study inclusion and data extraction with independent verification. The prevalence of reported outcomes was calculated and verified by separate authors.
Between 2004 and 2016, there has been a 2,600% increase in the publication of surgical outcome studies. Patients had a mean duration of symptoms of 27.7 ± 21.5 months before surgery. Arthroscopy was the surgical treatment used in 71% of studies. The mean final follow-up period after surgery was 32.2 ± 17.3 months. Follow-up time frames were reported in 78% of studies. Ten different patient-reported outcome measures were reported. The alpha angle was reported to be measured 42% less frequently as a surgical outcome than as a surgical indication. Surgical complications were addressed in only 53% of studies and failures in 69%. Labral pathology (91% of studies reporting) and chondral pathology (61%) were the primary coexisting pathologies reported. Clinical signs, as defined by the Warwick Agreement on FAI syndrome, were reported in fewer than 25% of studies.
Most FAI syndrome patients have longstanding pain and potential coexisting pathology. Patient-reported outcome measures and diagnostic imaging are the most frequently reported outcomes. Measures of hip strength and range of motion are under-reported. It is unclear whether the inconsistency in reporting is because of lack of measurement or lack of reporting of specific outcomes in these studies. Current surgical outcomes are limited to mid-term surgical follow-up time frames and inconsistent outcome reporting.
Level IV, systematic review of Level I through IV studies.

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: The authors report that they have no conflicts of interest in the authorship and publication of this article.

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Original ArticleReturn to Sport in Australian Football League Footballers After Hip Arthroscopy and Midterm Outcome

Purpose

Methods

Results

Conclusions

Level of Evidence

Section snippets

Patient Inclusion and Data Collection

Return to Sports

Discussion

Conclusions

Arthroscopy

Arthroscopy

J Sci Med Sport

Arthroscopy

Clin Sports Med

Arthroscopic labral repair and treatment of femoroacetabular impingement in professional hockey players

Am J Sports Med

Arthroscopic management of femoroacetabular impingement in athletes

Am J Sports Med

UEFA Champions League study: A prospective study of injuries in professional football during the 2001-2002 season

Br J Sports Med

Femoroacetabular impingement: A cause for osteoarthritis of the hip

Clin Orthop Relat Res

Current concept in the management of femoroacetabular impingement

J Bone Joint Surg Br

Clinical presentation of patients with tears of the acetabular labrum

J Bone Joint Surg Am

Prevalence of radiological signs of femoroacetabular impingement in patients presenting with long-standing adductor-related groin pain

Br J Sports Med

Original Article
Return to Sport in Australian Football League Footballers After Hip Arthroscopy and Midterm Outcome