Return to Sport After Primary Hip Arthroscopic Surgery and Labral Repair in Female Athletes With Femoroacetabular Impingement: A Minimum 5-Year Follow-up

Abstract

Background:

Femoroacetabular impingement (FAI) is a common cause of hip pain in female athletes. There are limited data on midterm outcomes for female athletes undergoing hip arthroscopic surgery.

Purpose:

To evaluate return-to-sport rates and clinical outcomes in female athletes with FAI after primary hip arthroscopic surgery with labral repair and femoral osteochondroplasty.

Study Design:

Case series; Level of evidence, 4.

Methods:

A retrospective analysis of a single institution’s database was performed to identify female athletes who underwent primary hip arthroscopic surgery with labral repair and femoral osteochondroplasty from July 2011 to October 2019 with a minimum 5-year follow-up. Preoperative radiographs were evaluated for the lateral center-edge angle, Tonnis angle, Tonnis grade, and alpha angle. Patient-reported outcome measure (PROM) scores, including those for the modified Harris Hip Score, Hip Outcome Score, Tegner Activity Scale, and visual analog scale for pain, as well as patient satisfaction with surgery were analyzed postoperatively.

Results:

A total of 63 hips (27 left, 36 right) in 56 female patients (mean age, 21.6 ± 8.0 years; mean body mass index, 24.7 ± 4.8 kg/m²) were included and followed for a mean of 8.4 ± 2.1 years (range, 5.0-13.2 years). Preoperatively, patients participated in basketball (n = 18), dance (n = 21), hockey (n = 8), and soccer (n = 12). Of the 56 patients, 41 attempted to return to sport. There were 28 (68%) female athletes who successfully returned to their preoperative sport. Of the total cohort, 21 (38%) patients cited non–hip-related factors for discontinuing their sport. All postoperative PROM scores improved significantly compared with preoperatively (P ≤ .002) for patients with available preoperative data. Those who returned to sport had significantly improved Hip Outcome Score values compared with those who did not return to sport (P ≤ .010).

Conclusion:

Female athletes who underwent primary hip arthroscopic surgery for FAI had significant improvements in PROM scores and moderate return-to-sport rates at a minimum 5-year follow-up. Most athletes discontinued sports because of non–hip-related factors, although hip-related issues were also cited. Our analysis highlights the need for thorough perioperative counseling and establishing appropriate patient expectations for female athletes before hip arthroscopic surgery.

Keywords

RTS labral tear hip arthroscopic surgery FAI female athletes

Femoroacetabular impingement (FAI) consists of abnormal contact between the acetabulum and femur, causing damage to the hip labrum and acetabular cartilage and thus leading to hip pain in athletes.^4,17 Hip arthroscopic surgery is a recognized and proven treatment method for athletes with FAI and labral tears, and the literature suggests excellent clinical outcomes, return-to-sport (RTS) rates, and <2% complication rates.^3,14,32 Female patients comprise up to two-thirds of all people diagnosed with and treated for FAI.¹⁹

The literature is inconclusive regarding the influence of sex on clinical outcomes after primary hip arthroscopic surgery.²³ Female athletes may experience a higher rate of complications compared with male athletes after hip arthroscopic surgery, as evidenced by higher failure and reoperation rates in female athletes.^24,27,37 It is important to evaluate FAI in female patients separately from male patients because of differences in pelvic anatomy (wider and broader pelvises in female patients), femoral structure (generally smaller alpha angles in female patients), and femoral version (increased anteversion in female patients) as well as likely differential hormonal influences on hip morphology and abnormalities.^13,19 A previous study by Krych et al¹⁷ reported significant improvements in clinical outcomes at an average of 36 months’ follow-up in female patients with FAI after hip arthroscopic surgery; however, the authors did not report on athletes or RTS. There exists a paucity of literature documenting clinical outcomes and RTS rates in female athletes with FAI after primary hip arthroscopic surgery. Addressing sex-specific differences and needs will ultimately allow for a greater understanding of how we can best provide individualized patient care.

Therefore, the purpose of our study was to evaluate RTS rates, clinical outcomes, and sport continuation in female athletes with FAI after primary hip arthroscopic surgery. We hypothesized that hip arthroscopic surgery with labral repair and femoroplasty would produce satisfactory clinical outcomes as well as high RTS and sport continuation rates among female athletes.

Methods

Study Design

After institutional review board approval, all female patients who underwent primary hip arthroscopic surgery with labral repair for FAI with an associated labral tear from July 2011 to October 2019 at a single institution were retrospectively reviewed. Inclusion criteria consisted of female sex, participation in recreational or competitive (high school, collegiate, or professional) sports before surgery, radiographic and clinical diagnoses of FAI (radiographically defined as an alpha angle >55° and a lateral center-edge angle [LCEA] >35°), primary hip arthroscopic surgery, and minimum 5-year follow-up. Preoperative anteroposterior and lateral pelvic radiographs were evaluated for the LCEA, Tonnis angle, Tonnis grade, and alpha angle. For a subset of patients, preoperative patient-reported outcome measure (PROM) scores were available for the Tegner Activity Scale, modified Harris Hip Score (mHHS; Activities of Daily Living [ADL], Gait, Pain, and Total), Hip Outcome Score (HOS; ADL and Sports-Specific Subscale [SSS]), and visual analog scale (VAS) for pain with use. Patients were excluded if there was <5 years of clinical follow-up, there was a presence of hip dysplasia (defined as an LCEA <20°) on initial presentation, there was a history of hip arthroscopic surgery, labral reconstruction or augmentation was performed, or the surgical procedure did not include labral repair. Because of the timeline of enrollment, capsular repair after surgery was heterogeneous and therefore was not an exclusion criterion.

Data Collection

After the application of inclusion and exclusion criteria, eligible patients were contacted via telephone and/or email to complete validated PROMs and questions regarding RTS and sport continuation. Patient characteristics such as age, body mass index (at the time of surgery), laterality, and preoperative sports played were recorded. The patients’ medical records were accessed to obtain preoperative patient characteristics and radiographic measurements. Rates of return to preoperative sporting activity and discontinuation of sport participation, as well as postoperative PROM scores, were additionally evaluated. We defined RTS as returning to preoperative sports at any time postoperatively, whereas sport continuation was defined as continuing to play preoperative sports at final follow-up. Patients were classified as returning to sport if they returned to any level of their preoperative sport. For those with available preoperative data, their preoperative PROM scores were also collected. The PROMs included the mHHS, HOS-ADL, HOS-SSS, Tegner Activity Scale, VAS pain with rest (5-point scale), and VAS pain with use (5-point scale) as well as patient satisfaction with surgery (0-10 scale).

Surgical Technique

Surgical procedures were performed by 1 of the 4 senior authors (B.A.L., A.J.K., K.R.O., M.H.). Patients were positioned on a modified traction table with distraction of the operative hip. Standard anterolateral and midanterior portals were created in all cases. For some patients, additional distal anterolateral or posterolateral portals were created on a case-by-case basis. The characteristics of surgical procedures performed can be found in Table 1.

Table 1

Surgical Procedures Performed and Intraoperative Characteristics ^a

	Value (n = 56)
Labral repair	56 (100)
Cam resection	46 (82)
Pincer resection	22 (39)
Acetabular chondroplasty	6 (11)
Simultaneous periacetabular osteotomy	5 (9)
Iliopsoas release	8 (14)
Interportal capsulotomy	53 (95)
T-capsulotomy	3 (5)
Capsular repair	42 (75)
No. of anchors per labral repair, median (range)	3 (2-5)

Data are presented as n (%) unless otherwise specified.

All patients underwent a diagnostic arthroscopic examination with intraoperative grading of chondromalacia and chondrolabral delamination. Patients underwent T-capsulotomy or interportal capsulotomy per surgeon preference as well as femoroplasty and/or acetabuloplasty. Areas of cartilage damage were treated with chondroplasty only. Iliopsoas release was performed by identifying the psoas tendon at the level of the psoas notch and releasing it for fractional lengthening. Overall, 42 (75%) patients underwent capsular repair, and 14 (25%) patients did not undergo capsular repair at the time of surgery. Labral repair with arthroscopic suture anchor placement was performed in all included patients. There were 5 patients who underwent periacetabular osteotomy for borderline dysplasia. Intraoperative and postoperative radiographs were obtained to confirm correction.

Postoperative Rehabilitation

All patients completed the same standardized 5-phase rehabilitation program consisting of 4 weeks of partial weightbearing with a hip brace and crutches. At 2 weeks postoperatively, formal physical therapy commenced after a suture/wound check. Jogging was permitted at 3 months, and progression to sport-specific training and return to sporting activity were allowed at 6 months.

Statistical Analysis

Statistical analyses were performed using the Student t test or Wilcoxon rank-sum test (Mann-Whitney U test), after examining for normality, to compare preoperative and postoperative PROM scores as well as to evaluate patients who returned to sport participation. Multivariate analysis was conducted to assess predictors of RTS with a logistic regression model. Continuous variables were reported as mean ± standard deviation, and P values <.05 were considered significant. Statistical analyses were conducted in R (Version 4.4.1; RStudio).

Results

A total of 63 hips (27 left and 36 right) in 56 female patients (mean age, 21.6 ± 8.0 years; mean body mass index, 24.7 ± 4.8 kg/m²) were included (Figure 1). Patients were followed for a mean of 8.4 ± 2.1 years (range, 5.0-13.2 years) (Table 2). Preoperatively, 21 patients participated in dance (38%), 18 in basketball (32%), 12 in soccer (21%), and 8 in hockey (14%). Of note, 3 (5%) patients participated in 2 sports. The dancers participated in ballet (n = 10), jazz (n = 6), hip hop (n = 1), high kick (n = 1), and tap (n = 1), and 2 were unspecified. The level of competition included 23 (41%) recreational, 27 (48%) high school, 4 (7%) collegiate, and 2 (4%) professional. The mean preoperative LCEA was 30.9° ± 5.4°, the mean preoperative Tonnis angle was 4.8° ± 4.3°, and the mean preoperative alpha angle was 58.3° ± 9.3°. The Tonnis grade was 0 in 36 (64%) athletes, 1 in 18 (32%), and 2 in 2 (4%) (Table 2). The preoperative LCEA, Tonnis angle, alpha angle, and Tonnis grade by sport are reported in Table 2.

Figure 1.

CONSORT diagram detailing patient inclusion and exclusion.

Table 2

Patient Characteristics ^a

						Value (n = 56)
Age at surgery, y						21.6 ± 8.0
Body mass index, kg/m²						24.7 ± 4.8
Follow-up, mean (range), y						8.4 (5.0-13.2)
Sport ^b
Basketball						18 (32)
Dance						21 (38)
Hockey						8 (14)
Soccer						12 (21)
Preoperative level of sport
Recreational						23 (41)
High school						27 (48)
Collegiate						4 (7)
Professional						2 (4)
			Tonnis Grade, n
	LCEA, deg	Tonnis Angle, deg	0	1	2	Alpha Angle, deg
All sports	30.9 ± 5.4	4.8 ± 4.3	36	18	2	58.3 ± 9.3
Basketball	30.7 ± 4.1	3.9 ± 3.4	9	9	0	53.6 ± 9.0
Dance	30.9 ± 6.8	3.3 ± 4.0	16	3	2	59.7 ± 7.6
Hockey	30.0 ± 5.4	6.2 ± 5.7	4	4	0	56.7 ± 8.5
Soccer	30.6 ± 6.1	8.2 ± 4.1	9	3	0	68.8 ± 8.2

Data are presented as n (%) or mean ± SD unless otherwise specified. LCEA, lateral center-edge angle.

Some patients played up to 2 sports.

Overall, 41 female athletes attempted to return to sport, and 28 (68%) of them successfully returned to their preoperative sport (Table 3). Of the 28 athletes who returned to sport, 23 (82%) returned to the same or higher level of competition: 10 of 10 (100%) recreational, 9 of 14 (64%) high school, 2 of 2 (100%) collegiate, and 2 of 2 (100%) professional. Also, 13 (32%) female athletes who attempted to return to sport were unsuccessful in doing so (Table 3). There were 22 of 39 (56%) patients who underwent capsular repair and returned to sport, while 6 of 13 (46%) patients did not undergo capsular repair and returned to sport. The difference in RTS rates between those who underwent capsular repair and those who did not undergo capsular repair was not statistically significant (P = .541). Logistic regression analysis demonstrated that there were no preoperative predictors of RTS. This analysis yielded no significant difference in RTS rates based on the preoperative LCEA (P = .92), alpha angle (P = .88), Tonnis grade (P = .11), age (P = .63), or body mass index (P = .26).

Table 3

RTS and Current Sport Activity ^a

	RTS (n = 28)	No RTS (n = 13)
Returned to sport ^b,c
Basketball	6 (67)	3 (33)
Dance	15 (75)	5 (25)
Hockey	4 (57)	3 (43)
Soccer	5 (71)	2 (29)
Returned to preoperative sport level
Recreational	10 (71)	4 (29)
High school	14 (67)	7 (33)
Collegiate	2 (50)	2 (50)
Professional	2 (100)	0 (0)
	All (n = 56)
Currently active	13 (23)
Discontinued for hip-related reasons	20 (36)
Discontinued for non–hip-related reasons	21 (38)
Did not have time	8 (38)
Lost interest	4 (19)
Sustained additional non–hip-related injuries	3 (14)
Other	6 (29)

Data are presented as n (%). RTS, return to sport.

Some patients played up to 2 sports.

This excluded patients who did not return for non–hip-related reasons.

An additional analysis was performed to evaluate for continued sporting participation at final follow-up, which was, on average, 8.4 years (range, 5.0-13.2 years). At final follow-up, 41 (73%) patients had ceased preoperative sport participation, 13 (23%) were currently active, and 2 (4%) were unlisted. Of those who ultimately discontinued sports, 20 (36%) cited their hip as the primary reason for discontinuation. There were 21 (38%) patients who discontinued for non–hip-related reasons: 8 reported not having time, 4 lost interest, 3 sustained additional non–hip-related injuries, and 6 provided other reasons not related to their hip such as graduating from school, quitting the team, and focusing on a different sport. The 2 professional athletes discontinued sports for nonsurgical hip-related reasons: one sustained an additional unrelated injury, and the other lost interest. One (2%) patient underwent revision arthroscopic surgery for a labral retear, and 1 (2%) patient underwent subsequent total hip arthroplasty (THA) for osteoarthritic progression at 3 years after primary hip arthroscopic surgery at age 48 years. There were 6 (11%) patients who underwent contralateral hip arthroscopic surgery on a different surgical date. Of note, 13 (23%) patients remained active in their respective sport at a minimum 5-year follow-up. Of those 13 patients who are currently active, 1 (8%) has remained active in basketball, 6 (46%) have remained active in dance, 4 (31%) have remained active in hockey, and 2 (15%) have remained active in soccer.

Of the cohort of 56 patients, 20 had available preoperative data. At final follow-up, female athletes demonstrated significant improvements (P ≤ .002) in postoperative PROM scores for the Tegner Activity Scale, mHHS ADL, mHHS Gait, mHHS Pain, mHHS Total, HOS-ADL, and HOS-SSS compared with preoperatively (Table 4). The postoperative VAS pain with use score was significantly lower (2.0 ± 2.3) compared with the preoperative VAS pain with use score (5.3 ± 2.5) (P ≤ .001). The mean satisfaction with surgery was 7.4 ± 2.7 on a scale from 0 to 10. Female athletes who returned to sport had significantly higher (P ≤ .010) postoperative HOS-ADL, HOS-SSS, and HOS Total scores compared with those who did not return to sport (Table 5). There were no significant differences among athletes who returned to sport compared with those who did not return to sport for the mHHS Gait, mHHS Pain, mHHS ADL, mHHS Total, VAS pain with rest, VAS pain with use, and satisfaction with surgery postoperatively (P > .05 for all).

Table 4

Preoperative and Postoperative Patient-Reported Outcome Measure Scores ^a

	Preoperative	n	Postoperative	n	P
Tegner Activity Scale	4.7 ± 2.6	20	5.1 ± 2.1	52	.002
mHHS ADL	56.2 ± 12.7	22	44.4 ± 35.5	54	.002
mHHS Gait	25.0 ± 4.7	23	60.1 ± 32.9	54	<.001
mHHS Pain	15.7 ± 6.6	23	50.0 ± 26.3	54	<.001
mHHS Total	50.5 ± 11.6	23	81.9 ± 13.8	54	<.001
HOS-ADL	65.3 ± 16.1	29	86.4 ± 18.1	54	<.001
HOS-SSS	50.4 ± 19.0	28	73.7 ± 25.2	54	.001
VAS pain with use	5.3 ± 2.5	17	2.0 ± 2.3	52	<.001

Data are presented as mean ± SD. P values are bolded if significant. ADL, Activities of Daily Living; HOS, Hip Outcome Score; mHHS, modified Harris Hip Score; SSS, Sports-Specific Subscale; VAS, visual analog scale.

Table 5

Postoperative Patient-Reported Outcome Measure Scores by RTS Status ^a

	RTS	No RTS	P
Tegner Activity Scale	5.8 ± 2.0	4.3 ± 1.8	.006
mHHS ADL	34.9 ± 34.4	50.6 ± 34.5	.176
mHHS Gait	50.8 ± 30.9	66.2 ± 32.8	.259
mHHS Pain	47.5 ± 26.7	49.8 ± 26.7	.702
mHHS Total	84.7 ± 13.8	77.2 ± 13.4	.063
HOS-ADL	91.0 ± 13.6	83.9 ± 13.7	.010
HOS-SSS	81.2 ± 23.5	67.3 ± 21.8	.006
HOS Total	87.6 ± 16.5	78.3 ± 15.7	.008
Satisfaction with surgery (0-10)	7.9 ± 2.5	6.8 ± 2.9	.134
VAS pain with rest	2.9 ± 2.4	3.3 ± 2.1	.610
VAS pain with use	2.1 ± 2.5	2.0 ± 2.2	.976
VAS (5-point scale), n
Much better than before surgery	15	12
Slightly better than before surgery	8	7
No change	1	2
Slightly worse than before surgery	2	3
Much worse than before surgery	0	0

Data are presented as mean ± SD unless otherwise specified. P values are bolded if significant. ADL, Activities of Daily Living; HOS, Hip Outcome Score; mHHS, modified Harris Hip Score; RTS, return to sport; SSS, Sports-Specific Subscale; VAS, visual analog scale.

Discussion

The primary findings of this study are that RTS rates among female athletes undergoing hip arthroscopic surgery and labral repair in the setting of FAI were moderate, with 68% of athletes who attempted to return to sport achieving RTS postoperatively. Of these athletes who returned to sport, 82% did so at the same or higher level of competition. Furthermore, at a mean final follow-up of 8.4 years, 73% of all patients had discontinued their sport. When prompted, 36% of these patients who ceased sporting activity cited their hip as the primary reason for discontinuation. Female athletes demonstrated significant improvements on multiple PROMs, and those who returned to sport had significantly higher Tegner Activity Scale, HOS Total, HOS-ADL, and HOS-SSS scores compared with those who did not return to sport. Our findings differ from our hypothesis in that RTS rates were lower than expected and than those previously reported, although female athletes demonstrated improvements in several functional outcome scores.

Increasing attention in the literature is being given to clinical outcomes among female patients undergoing hip arthroscopic surgery. Historically, research has been focused on male-only or mixed cohorts, although relevant differences exist between male and female anatomic and pathophysiological developments.¹⁹ One such notable difference is that of generalized ligamentous laxity (GLL), measured with the Beighton score, which is an important consideration in hip arthroscopic surgery.^1,22,38 In their retrospective review of 1381 patients undergoing primary hip arthroscopic surgery, Saadat et al³³ found that 92.7% of patients with Beighton scores ≥4, indicating GLL, were female. In their cohort, those with higher Beighton scores were more likely to undergo labral repair, capsular repair, and iliopsoas fractional lengthening.³³ Similarly, Naal et al²⁸ found the prevalence of GLL in female patients diagnosed with FAI to be 50%. Importantly, it is theorized that GLL increases the risk of labral injuries by contributing to more stress across the hip capsule.³⁴ Overall, the literature suggests that in those with ligamentous laxity, special attention should be paid to capsular management in the setting of hip arthroscopic surgery.

The topic of capsular management has been evolving in the literature, with substantial recent support in favor of capsular repair across multiple clinical studies.^2,20,29,36 Our study spanned a time frame when attention to capsular closure was increasing from 2011 to 2019. Among our included patients, 42 (75%) female athletes underwent capsular repair at the time of hip arthroscopic surgery. Boos et al² evaluated long-term outcomes after primary hip arthroscopic surgery and found a failure rate (defined as conversion to THA) of 3% in those who underwent capsular repair versus 31% in those who did not (P = .006). Similarly, in a systematic review and meta-analysis, Dasari et al⁸ demonstrated superior outcomes in terms of mHHS and HOS-ADL scores and hip survivorship among patients who underwent capsular repair versus those without capsular repair. In our cohort, we did not find a significant difference in our primary outcome, RTS, between the capsular repair and non–capsular repair groups (P = .541). However, this could potentially be attributed to a lack of statistical power impacting this comparison because only 14 (25%) of our female athletes did not undergo capsular closure. It is now standard practice at our institution to perform capsular closure for all cases of arthroscopic hip labral repair.

A recent study by Ferrer-Rivero et al¹¹ analyzed whether hip arthroscopic surgery was an effective treatment option for high-level female athletes (defined as patients who participated in professional, collegiate, or high school sports) compared with low-level female athletes (defined as patients with a Tegner Activity Scale score ≤6). In their high-level group, which included 11 female athletes, they demonstrated an RTS rate of 63.6% at 1 year, while their low-level group of 18 patients had an RTS rate of 85.7%. Their finding in high-level athletes is lower than previously reported rates for combined male and female athletes of 79% to 93%^{16,21,26,27,30} and comparable with our finding of 68%. High school athletes made up the majority of our cohort, with 48% of included patients, which may have skewed our results toward a lower overall RTS rate. At the high school level, the relatively lower RTS rate (52%) was partially attributed to graduating from high school (4/11), loss of interest (2/11), and not having time (2/11). This is important to consider, given that some of these athletes may have not intended to return to sport or been unable to return to preoperative sport (ie, graduation), thus making the overall RTS rate in our cohort lower. One consideration is that at higher levels of competition and with significant motivation, athletes may be more likely to return to their preoperative sport, although it is difficult to draw this conclusion, given that the numbers of collegiate and professional athletes in our cohort were smaller (n = 4 and 2, respectively). Interestingly, our results suggest that a higher proportion of dancers achieved RTS. Similarly, in a systematic review, Ifabiyi et al¹⁵ demonstrated that flexibility sport athletes (dancers/gymnasts) had RTS rates >75.9% after hip arthroscopic surgery; one reason for this may be that the level of attrition after high school is lower in dancers. Another consideration is that in solo sports such as dance, athletes may find more opportunities to continue participation (ie, joining a dance studio) compared with team sports in which it may be more difficult to access organized leagues. These findings support that sport-specific differences may influence RTS outcomes among female athletes.

Our study demonstrated improvements on PROMs when comparing preoperative and postoperative scores for patients with available data. Further, female athletes who returned to sport had significantly higher postoperative Tegner Activity Scale, HOS-ADL, HOS-SSS, and HOS Total scores compared with those who did not return to sport. Fenn et al¹⁰ analyzed high-level athletes at 5 years after surgery and found durable improvements in PROM scores, consistent with our findings. Similarly, in their cohort of runners, Chen et al⁵ demonstrated significant improvements in PROM and VAS scores across all athletes, but those who did not achieve RTS had significantly lower PROM scores at final follow-up. Our study supports these findings that RTS rates positively correlate with the durability of PROM scores but that even for patients who do not achieve RTS, they still are likely to experience significant improvements on PROMs compared with preoperatively. This highlights that the maintenance of satisfactory PROM scores may not always correlate with female athletes’ decisions to continue sport. Patients may still attribute sport discontinuation to their hip, despite having acceptable or improved validated PROM scores. Our findings also suggest that the current PROMs may lack sensitivity to detect residual symptoms or other values that may influence RTS and long-term sport continuation.

At a mean final follow-up of 8.4 years, 73% of patients in our cohort had discontinued sports. Of the patients who discontinued, 36% cited their hip as the reason for discontinuation. Lamba et al¹⁸ reported on RTS in male and female athletes and found a continuation of sports in 61% at an average of 8.5 years postoperatively, with 24% of athletes citing their hip as their reason for discontinuing sports, although the authors did not stratify by sex. Our findings suggest higher rates of discontinuing sports in female athletes as well as an increased number of patients who attribute hip-related reasons for discontinuing sports at longer-term follow-up. Given that only 1 (2%) patient underwent revision arthroscopic surgery and 1 (2%) patient went on to undergo THA, subsequent postoperative complications or failures cannot completely account for sport discontinuation. Importantly, this low revision rate is similar to other rates in the literature of 1% to 2%.^6,7,10 As mentioned, patients also had significant durable improvements in PROM scores at final follow-up, which suggests that they had subjectively continued improvement in their hip pain and functionality. Even though outcomes remained positive, these patients may have felt that their pain, motion, or overall function, as well as the psychological effect of their injury/surgery/rehabilitation, was not sufficient to maintain their competitive level of sport, although their hip was not a hindrance to daily activities. It is worthwhile to consider that the majority of the patients who discontinued sports in our cohort cited non–hip-related reasons pertaining to time constraints, loss of interest, non–hip-related injuries, and other nonspecified reasons besides their operative hip. It has been widely reported that there are many factors associated with an athlete’s decision to return to sport that range beyond physical constraints relating to their injury or surgical intervention, and it is reasonable to conclude that some of these same factors would likely contribute to retention in sport even after achieving RTS.^9,12,25,31 Tjong et al³⁵ conducted a qualitative assessment of RTS after hip arthroscopic surgery for FAI in their cohort of patients, of whom 57% returned to sport. They found a myriad of influences on patients’ RTS relating to their self-motivation, aging, encouragement from others, and adaptations to physical limitations.³⁵ Likewise, in their systematic review of qualitative studies assessing RTS after hip arthroscopic surgery, Ko et al¹⁶ described self-efficacy, social support, and resetting expectations as 3 themes that are crucial components of a patient’s successful rehabilitation and ultimate RTS after hip arthroscopic surgery. Combining qualitative data with our findings suggests that there may be psychosocial elements that influence sport continuation in our female athletes, while keeping in mind that many patients will still discontinue sports for reasons unrelated to injuries or innate coping mechanisms.

Limitations

There are several limitations in this study. First, there exists a risk of recall bias, given the retrospective nature of the study. This is particularly important when considering patients’ reasons for sport discontinuation if there was a significant lag time between sport cessation and their survey response. There is also a risk of selection bias, given that all patients in the cohort were from a single tertiary academic medical center. This may decrease the generalizability of these results to female athletes from larger geographic distributions. Furthermore, more than half of the patients in the study did not have preoperative PROM scores available. However, collecting postoperative scores for the entire cohort did allow us to compare outcomes between those who successfully returned to sport and those who did not. Additionally, Beighton scores and other nuanced sport participation scores (such as University of California, Los Angeles scores) were not routinely collected during the initial study period and thus could not be analyzed. Future clinical studies should routinely collect Beighton scores and comprehensive sport participation scores. Given the smaller sample size, our multivariate analysis was likely underpowered. Although we consider it a strength to have included athletic female patients of all levels, as physical activity and returning to play can be important to patients, regardless of their level of competition, it is important to note that there are varying levels of talent, investment, and motivation between athletes, and the subjective nature of this is difficult to capture in a study. The nuanced differences could influence an athlete’s RTS but should not influence the treatment team’s perception of how important returning to play is for that patient. Additionally, we were unable to capture athletes returning to a different type of physical activity in our definition of returning to preoperative sport, which could skew our results. Despite these limitations, our analysis evaluated a larger patient cohort at midterm follow-up compared with previous studies involving competitive female athletes undergoing hip arthroscopic surgery for FAI.

Conclusion

Female athletes who underwent primary hip arthroscopic surgery for FAI had significant improvements in PROM scores and moderate RTS rates at a minimum 5-year follow-up. Most athletes discontinued sports because of non–hip-related factors, although hip-related issues were also cited. Our analysis highlights the need for thorough perioperative counseling and establishing appropriate patient expectations for female athletes before hip arthroscopic surgery.

Footnotes

Final revision submitted June 7, 2025; accepted July 1, 2025.

One or more of the authors has declared the following potential conflict of interest or source of funding: B.A.L. has received nonconsulting fees, consulting fees, travel and lodging, and royalties from Arthrex; owns stock or stock options in COVR Medical; and is an editorial or governing board member of the Journal of Knee Surgery, Knee Surgery, Sports Traumatology, Arthroscopy, and Orthopedics Today. M.H. has received support for education from Smith & Nephew, Medwest Associates, Arthrex, and Foundation Medical; has received honoraria from Encore Medical; has received consulting fees from Vericel; has received a grant from Medical Device Business Services; has other professional activities with DJO, Moximed, and Stryker; and is an editorial or governing board member of the Journal of Cartilage and Joint Preservation. A.J.K. has received nonconsulting fees, consulting fees, royalties, travel and lodging, and a grant from Arthrex; is a paid consultant for Arthrex; is an editorial or governing board member of The American Journal of Sports Medicine; and is a board or committee member of the Arthroscopy Association of North America, the International Cartilage Repair Society, and Springer. K.R.O. is a paid consultant for Arthrex and Smith & Nephew; has received consulting fees and nonconsulting fees from Smith & Nephew; has received travel and lodging from Smith & Nephew and Synthes; and has received speaking fees from Synthes. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Ethical approval for this study was obtained from Mayo Clinic.

ORCID iDs

Mario Hevesi

Aaron J. Krych

Kelechi R. Okoroha

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