Orthopedics

Feature Article 

Performance and Return to Sport After Femoroacetabular Impingement Surgery in National Football League Players

Kyle R. Sochacki, MD; Robert A. Jack II, MD; Takashi Hirase, MD; Justin Vickery, BS; Patrick C. McCulloch, MD; David M. Lintner, MD; Anthony Echo, MD; Joshua D. Harris, MD

Abstract

The purpose of this study was to determine the (1) return-to-sport rate for National Football League (NFL) players following femoroacetabular impingement surgery, (2) postoperative career length and games per season, (3) pre- and postoperative performance, and (4) postoperative performance compared with control players matched by position, age, years of experience, and performance. National Football League athletes who underwent hip arthroscopy for femoroacetabular impingement and matched controls were identified. A Bonferroni correction was used to control for multiple comparisons, with statistical significance set at P≤.007. Fifty-five players (63 surgeries) were analyzed (mean age, 27.5±3.4 years; mean years in NFL at time of surgery, 4.7±2.9). Forty-seven (53 surgeries, 84.1%) NFL players returned to sport at a mean of 6.7±3.8 months following surgery. There was no difference (P>.007) in the mean career length of players in the control group (3.7±2.2 years) vs players who underwent hip arthroscopy (3.5±2.1 years). There was no difference (P>.007) in mean games played per season of players in the control group (12.5±3.1) vs those who underwent hip arthroscopy (12.1±4.0). Quarterbacks had significantly better postoperative performance scores when compared with post-index matched controls (P=.007). The return-to-sport rate is high for NFL athletes after hip arthroscopy for femoroacetabular impingement. There were similar games per season and career lengths postoperatively compared with preoperatively and matched controls. Quarterbacks had significantly better postoperative performance when compared with matched controls. All other positions had similar postoperative performance compared with preoperatively and matched controls. [Orthopedics. 2019; 42(5):e423–e429.]

Abstract

The purpose of this study was to determine the (1) return-to-sport rate for National Football League (NFL) players following femoroacetabular impingement surgery, (2) postoperative career length and games per season, (3) pre- and postoperative performance, and (4) postoperative performance compared with control players matched by position, age, years of experience, and performance. National Football League athletes who underwent hip arthroscopy for femoroacetabular impingement and matched controls were identified. A Bonferroni correction was used to control for multiple comparisons, with statistical significance set at P≤.007. Fifty-five players (63 surgeries) were analyzed (mean age, 27.5±3.4 years; mean years in NFL at time of surgery, 4.7±2.9). Forty-seven (53 surgeries, 84.1%) NFL players returned to sport at a mean of 6.7±3.8 months following surgery. There was no difference (P>.007) in the mean career length of players in the control group (3.7±2.2 years) vs players who underwent hip arthroscopy (3.5±2.1 years). There was no difference (P>.007) in mean games played per season of players in the control group (12.5±3.1) vs those who underwent hip arthroscopy (12.1±4.0). Quarterbacks had significantly better postoperative performance scores when compared with post-index matched controls (P=.007). The return-to-sport rate is high for NFL athletes after hip arthroscopy for femoroacetabular impingement. There were similar games per season and career lengths postoperatively compared with preoperatively and matched controls. Quarterbacks had significantly better postoperative performance when compared with matched controls. All other positions had similar postoperative performance compared with preoperatively and matched controls. [Orthopedics. 2019; 42(5):e423–e429.]

Femoroacetabular impingement (FAI) syndrome is an increasingly recognized cause of hip pain in athletes. Up to 95% of elite athletes may exhibit at least 1 radiographic finding of cam or pincer morphology.1–3 Symptoms are due to abnormal joint morphology leading to aberrant contact between the proximal femur (cam) and acetabular rim (pincer).4–7 For symptomatic athletes, this can lead to decreased function and performance.7,8 For patients dissatisfied with their hip condition despite nonsurgical treatments, hip arthroscopy with correction of cam and/or pincer morphology and labral preservation is successful in reducing pain and permitting return to sport.9

Previous studies have examined the epidemiology and outcomes of corrective surgery for FAI syndrome in professional athletes, with only 1 study investigating postoperative performance in National Football League (NFL) players.10–13 However, this study was limited to a subset of patients from a single institution. Given this limited evidence and the increasing popularity of professional football, it is important to understand surgical outcomes in these patients.

The purpose of this study was to determine the (1) return-to-sport (RTS) rate of NFL players following FAI surgery, (2) postoperative career length and games per season, (3) pre- and postoperative performance, and (4) postoperative performance compared with control players matched by position, age, years of experience, and performance. The authors hypothesized that NFL players who underwent hip arthroscopy would have (1) an 85% RTS rate, (2) no significant differences in postoperative career length and games per season compared with preoperatively, (3) no significant differences in postoperative performance compared with preoperative, and (4) no significant differences in postoperative performance compared with matched controls.

Materials and Methods

National Football League players who underwent hip arthroscopy for FAI syndrome between 2000 and 2017 were identified through team websites, publicly available internet-based injury reports, player profiles and biographies, and press releases. The search was manually conducted by 2 orthopedic surgery residents (K.R.S., R.A.J.) in December 2017. Searches were performed for all professional teams. This method of data collection has been used successfully in multiple studies of professional athletes, including the NFL.14–20

All players identified were included in this study as it related to RTS rate. A player was deemed to have RTS if he played in any regular season game after surgery. A player did not RTS if he did not play in any game after surgery. Inclusion criteria were any player on an active roster prior to hip arthroscopy for FAI. Players were included if they were found to have undergone hip arthroscopy for FAI as reported by at least 2 separate sources. Data from these databases were verified against each other and through independent web-based searches of team press releases that confirmed the date of surgery for each player.14,15 If this information was unclear, unverified, or unobtainable, then the athlete was excluded. Athletes who were injured and underwent procedures before completing their first regular season were excluded because no preoperative data would be available for comparison. Players who underwent hip arthroscopy for FAI in the 2017 season were excluded from analysis because they had less than a 1-year opportunity to RTS and to have postoperative statistics.

Demographic variables, including a player's age, position, previous professional experience, and date of surgery, were recorded. Players were categorized by their positions, including quarterback, running back, tight end, wide receiver, offensive lineman, defensive lineman, line-backer, defensive back, kicker, or punter. Performance statistics before and after hip arthroscopy for FAI were collected from profootballreference.com for each player identified. Statistics were collected for regular season NFL games only, with preseason and playoff games excluded. There were no players for whom performance data could not be identified. Each performance data category was divided by the games played to account for discrepancies in the number of games played per season. A player's performance score was then calculated by using a previously published and standardized scoring system based on metrics important to the player's specific position.21

Because of the possible benefits or detriments of aging and/or experience in relation to player performance and number of games played, matched control players were selected to use for comparison with post-surgery performance in the surgically treated players. This control group of players was selected by matching the exact position, age (±1 year), years of experience (±1 year), body mass index (±2 kg/m2), and performance data prior to the case's surgery date. To compare postoperative or post-index performance, each control was given an index date that matched the case player's surgery date. For example, if a player had surgery 3 years into his career, the control's index date was 3 years into his career.

A Kaplan–Meier survivorship curve with “retirement” as the endpoint was constructed. The continuous variables of each cohort were compared using a 2-tailed paired samples Student's t test for normally distributed data. The chi-square test was used to analyze categorical data. A Bonferroni correction was used to control for multiple comparisons, with statistical significance set at P≤.007.

Results

Eighty-nine NFL players who underwent hip arthroscopy from 2000 to 2017 were identified. Eighteen players were excluded because they did not undergo FAI surgery. Seven players were excluded because they had either no or less than 1 year of professional experience, and 9 players were excluded because they had less than 1-year follow-up. Fifty-five players (63 surgeries) were analyzed (Figure 1). The mean age was 27.5±3.4 years, and the mean professional experience was 4.7±2.9 years in the NFL at the time of surgery. Four players had staged bilateral procedures, 2 players had revisions, and 1 player had 3 surgeries (staged bilateral procedures followed by a unilateral revision). The largest proportion of players to undergo FAI surgery was offensive line-man at 22%. Fifty-six (88.9%) surgeries occurred outside of the regular season. There were no significant (P>.007) differences in demographic, performance, and games per season data between cases and matched controls pre-surgery and pre-index.

Flowchart illustrating application of exclusion criteria. Abbreviation: NFL, National Football League.

Figure 1:

Flowchart illustrating application of exclusion criteria. Abbreviation: NFL, National Football League.

Return to Sport and Career Length

Forty-seven NFL players (53 surgeries, 84.1%) were able to RTS at a mean of 6.7±3.8 months following surgery (Table 1). The overall 1-year survival rate of continued play in the NFL of players undergoing hip arthroscopy for FAI was 79.4% (Figure 2). The mean career length of players in the control group (3.7±2.2 years) was similar (P>.007) to that of players who underwent hip arthroscopy for FAI (3.5±2.1 years) (Table 2).

Return to Sport Rate and Time by Player Position

Table 1:

Return to Sport Rate and Time by Player Position

Kaplan–Meier survival analysis for cases and controls. Zero (0) signifies year of surgery for cases and index year for controls.

Figure 2:

Kaplan–Meier survival analysis for cases and controls. Zero (0) signifies year of surgery for cases and index year for controls.

Games Per Season and Career Lengths for Cases and Controls by Player Position

Table 2:

Games Per Season and Career Lengths for Cases and Controls by Player Position

Games and Performance Outcomes After Surgery

There was no significant difference in games per season postoperatively compared with preoperatively (P>.007). Players in the control group played in a similar number of games per season post-index compared with players who underwent hip arthroscopy for FAI after surgery (12.5±3.1 vs 12.1±4.0 games per season) (P>.007) (Table 2). Postoperative performance scores were similar for all positions (P>.007) compared with preoperative scores (Table 3, Figure 3). Quarterbacks had significantly better postoperative performance scores when compared with post-index matched controls (P=.007) (Figure 3). There were no other significant differences in postoperative performance compared with post-index matched controls for all other position groups (P>.007).

Performance Scores for Cases Pre- and Postoperatively by Player Position

Table 3:

Performance Scores for Cases Pre- and Postoperatively by Player Position

Performance scores by position before and after surgery compared with controls pre-and post-index. The ■ symbol signifies significant difference between post-surgery and post-index performance scores. Abbreviations: DB, defensive back; DL, defensive lineman; LB, linebacker; QB, quarterback; RB, running back; TE, tight end; WR, wide receiver.

Figure 3:

Performance scores by position before and after surgery compared with controls pre-and post-index. The ■ symbol signifies significant difference between post-surgery and post-index performance scores. Abbreviations: DB, defensive back; DL, defensive lineman; LB, linebacker; QB, quarterback; RB, running back; TE, tight end; WR, wide receiver.

Discussion

The study hypotheses were partially confirmed. The authors' first hypothesis was not confirmed because of an 84.1% RTS rate vs the authors' hypothesis of 85%. The authors' second and third hypotheses were confirmed, as NFL athletes played in a similar number of games per season and had similar career lengths postoperatively as preoperatively and matched controls. The authors' fourth hypothesis was confirmed among all positions excluding quarterbacks, who had significantly better postoperative performance scores when compared with post-index matched controls.

Previous studies of professional football players have shown RTS rates ranging from 80% to 96% at an average of 6.0 months postoperatively.12,13 This is similar to the mean RTS rate in the current study of 84.1% at 6.8 months. The large variation in RTS rates is likely due to previous studies being limited to the outcomes of a single institution, while the current study investigated all NFL players undergoing hip arthroscopy for FAI. Additionally, RTS time is likely affected by surgeon preference and guidelines for RTS. According to a recent study by Domb et al,22 football was classified as a high-risk sport for hip injury and re-injury following hip arthroscopy, with 70% of surgeons recommending RTS at 3 to 5 months postoperatively. As such, returning too early or too late may have an effect on postoperative performance and/or career longevity in the NFL.

The multifactorial nature of hip arthroscopy for FAI also likely contributed to the varied RTS rates and times in previous studies. Surgeon experience, skill, and/or technique likely play a role in RTS rates, with higher-volume, more experienced surgeons having fewer complications and improved outcomes.23 Additionally, cam or pincer morphology may increase the incidence of soft tissue (labrum, capsule, musculotendinous) injuries around the hip as stress is transferred from the impingement to the surrounding area.24 A previous study examining RTS rates following sports hernia repair showed a significant decline in career length and games per season.25 This increased incidence of sports hernia among players with FAI also may have potentially confounded the RTS rates, times, and performance in this and previous studies.

National Football League athletes played in a similar number of games per season and had similar career lengths following surgery as preoperatively and matched controls. This same trend was seen in the study by Nwachukwu et al,12 with NFL athletes playing 9.5 games per season and having an average career length of 3.5 years following hip surgery. However, this differs from a previous study of NFL players undergoing anterior cruciate ligament reconstruction. These players had significantly shorter career lengths and played in significantly fewer games per season after surgery.21 This was believed to be due to the effect of high body mass index in those NFL athletes, which has been shown to place more stress on the reconstructed ligament and lead to associated intra-articular injuries at the time of anterior cruciate ligament injury.21,26 This same detrimental effect of body mass index on patient outcomes has not been found in patients following hip arthroscopy.27–29 Furthermore, reconstruction of an injured ligament typically requires a longer recovery period prior to RTS compared with hip arthroscopy for FAI. This was also seen in the previous study, with a mean RTS of 12.1 months following anterior cruciate ligament reconstruction among NFL athletes.21

Although not statistically significant, performance scores among linebackers and defensive linemen decreased postoperatively, which aligns with the previous study.12 However, declines in performance scores were also seen among the matched controls for linebackers and defensive linemen and thus are most likely attributable to natural career-based declines rather than a direct result of surgery. Quarterback performance improved postoperatively compared with preoperatively while the performance of the matched controls decreased, leading to a significant difference between cases and controls following arthroscopic FAI surgery. Although not statistically significant, this same trend was seen for running backs, wide receivers, and defensive backs. Interestingly, this is in contrast to the previous study that found both offensive and defensive performance to decrease in postoperative cases and post-index controls using data from 2014.12 The current study used data that are more recent with longer follow-up, providing NFL athletes a longer time to recover and improve their performance following surgery. This indicates that, particularly for these positions, hip arthroscopy for FAI may mitigate the career-based postoperative decline in performance that is typically seen in professional athletes. Studies using comparative trials with large samples are necessary to further investigate and confirm the mechanisms of this finding.

There are limitations to this study and other studies of similar methodology. The use of publicly available data to identify players who underwent hip arthroscopy for FAI may be prone to selection, reporting, and observer bias. However, this method of data acquisition has been used in multiple previous studies.14,15,25,30–37 By only including the highest level of professional players, these data may only apply to elite-level athletes. Professional players have a higher rate of return to play than non-professional players.38 This is believed to be because of the inherently high talent and determination present at this level with higher income potential.11 Additionally, players may retire for reasons not related to performance that cannot be accounted for in this type of study. The authors may not have been able to identify all previous hip surgeries for the included players, which has been shown to have an effect on the outcomes of hip arthroscopy for FAI.39,40 Also, career length and performance were not adjusted for “time missed” for players who underwent hip arthroscopy for FAI. Multiple unknown confounding variables, such as no direct physical contact, patient-reported outcomes, or medical records access to corroborate diagnosis and treatment, are inherent to this type of study. The use of public data limits the ability to determine the chronicity and severity of the injury. In addition, the surgeon who performed the operation or the exact operative procedure used in each hip arthroscopy (labral debridement vs repair vs reconstruction, degree of cam/pincer correction/under-correction/overcorrection, chondral treatments for variable degrees of articular cartilage pathology/arthritis, or capsular closure/repair/plication/shift; periarticular extra-articular peritrochanteric, deep gluteal space, or athletic pubalgia/core muscle injury) could not be reliably determined. Heterogeneity of surgeons or surgeons' experience was also a limitation. Other limitations included the absence of patient-reported outcomes and incomplete follow-up and career length for players still in their respective leagues.

Conclusion

The RTS rate for NFL athletes after hip arthroscopy for FAI is high. The NFL athletes had similar games per season and career lengths postoperatively as preoperatively and matched controls. Quarterbacks had significantly better postoperative performance scores when compared with post-index matched controls, with all other position groups having similar postoperative performance as preoperatively and matched controls.

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Return to Sport Rate and Time by Player Position

PositionNo. of SurgeriesNo. (%) to Return to SportMean±SD Time to Return to Sport, mo
Quarterback33 (100.0)2.6±2.9
Running back43 (75.0)6.0±3.1
Tight end66 (100.0)10.1±7.1
Wide receiver98 (88.9)5.1±1.6
Defensive back86 (75.0)5.9±1.2
Linebacker98 (88.9)6.7±3.5
Defensive line66 (100.0)8.2±3.0
Offensive line1410 (71.4)7.7±3.9
Kicker43 (75.0)4.7±2.7
Total6353 (84.1)6.7±3.8

Games Per Season and Career Lengths for Cases and Controls by Player Position

PositionNo. of SurgeriesMean±SD Games per Season, No.Mean±SD Career Length, y


CasesControlsPCasesControlsP
Quarterback311.3±3.46.9±2.0.2433.7±2.52.0±1.0.464
Running back312.4±3.611.3±2.3.7752.7±1.22.3±1.5.423
Tight end614.5±1.614.5±2.3.9782.3±1.54.3±1.4.096
Wide receiver812.5±3.614.0±1.5.3534.4±2.44.3±2.1.783
Defensive back612.4±1.512.3±2.3.9414.4±1.74.0±1.7.374
Linebacker812.4±3.612.0±2.6.8122.8±1.33.1±2.0.476
Defensive line69.5±7.414.7±1.1.2232.1±1.13.0±0.8.141
Offensive line1010.5±5.412.0±4.0.4812.8±1.93.4±1.9.111
Kicker314.4±0.511.5±3.9.3068.0±0.06.7±5.1.697
Overall5312.1±4.012.5±3.1.5953.5±2.13.7±2.2.437

Performance Scores for Cases Pre- and Postoperatively by Player Position

PositionMean±SD Performance Score, pointsP

Before SurgeryAfter Surgery
Quarterback10.7±7.214.3±2.4.401
Running back8.9±5.48.9±9.5.995
Tight end4.5±1.25.3±1.9.211
Wide receiver8.3±1.38.9±3.3.549
Defensive back4.5±2.15.4±0.3.296
Linebacker5.5±2.74.8±1.2.497
Defensive line3.4±1.91.7±1.5.046
Authors

The authors are from Houston Methodist Orthopedic and Sports Medicine (KRS, RAJ, TH, JV, PCM, DML, JDH) and Houston Methodist Plastic & Reconstructive Surgery (AE), Houston, Texas.

Dr Sochacki, Dr Jack, Dr Hirase, Mr Vickery, Dr Lintner, and Dr Echo have no relevant financial relationships to disclose. Dr McCulloch has received research support from Arthrex and DePuy and is on the speaker's bureau of Vericel. Dr Harris is a paid consultant for NIA Magellan, Ossur, and Smith & Nephew; has received research support from DePuy and Smith & Nephew; and is on the speaker's bureau of Ossur and Smith & Nephew.

Correspondence should be addressed to: Joshua D. Harris, MD, Houston Methodist Orthopedic and Sports Medicine, 6445 Main St, Ste 2500, Houston, TX 77030 ( joshuaharrismd@gmail.com).

Received: May 30, 2018
Accepted: October 10, 2018
Posted Online: April 09, 2019

10.3928/01477447-20190403-01

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