The Difference in Clinical Outcomes After Anterior Cervical Fusion, Disk Replacement, and Foraminotomy in Professional Athletes

Use of Publicly Obtained Data in Sports Medicine Research: A Systematic Review and Bibliometric Analysis

BACKGROUND

Publicly obtained data (POD) have recently been utilized frequently by sports medicine researchers to describe injury patterns, risk factors, and outcomes in elite athletes. The relative ease of this type of research that is based solely on internet and media sources has resulted in a near exponential increase in the number of these POD studies.

PURPOSE

To systematically review the sports medicine literature for studies based solely on POD.

STUDY DESIGN

Systematic review and bibliometric analysis; Level of evidence, 4.

METHODS

A systematic review of POD studies published since 2000 was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies of interest were those relying on publicly available injury reports or online media for data acquisition in collegiate, semiprofessional, and professional athletes.

RESULTS

There were 209 POD studies published between 2000 and 2022, with 173 (82.8%) of these studies published after 2016. Studies were published most frequently on athletes participating in North American professional leagues: National Football League (n = 69 [28.4%]), Major League Baseball (n = 56 [23.0%]), National Basketball Association (n = 37 [15.2%]), and National Hockey League (n = 33 [13.6%]). The most common injuries assessed were head injuries/concussions (n = 43 [21.1%]), anterior cruciate ligament injuries (n = 33 [16.2%]), and ulnar collateral ligament injuries (n = 23 [11.3%]). One-quarter of the studies (n = 53 [25.4%]) reported only 1 POD source, and 1 study (0.5%) reported no source. Additionally, 65 studies (31.1%) listed nonspecific POD resources or solely cited previous literature to describe the POD search methodology and data acquisition.

CONCLUSION

POD studies are exponentially increasing in number, particularly across major North American professional sports leagues, with significant variability in the injury of interest, search methodology, and number of data sources. The accuracy of the conclusions reached based on the POD methodology appears highly variable. Given the potential impact of these publications as both contributors to current knowledge and drivers of future research, the sports medicine community should be aware of the inherent biases and limitations of POD injury studies.

Cervical and Lumbar Disk Replacement in Athletes: Is It Safe to Return to Play? A Systematic Review of the Scientific Literature and Lay Press

BACKGROUND AND OBJECTIVES

Cervical/lumbar total disk replacements (TDRs) are often performed for degenerative conditions but rarely in athletes. Therefore, we sought to conduct a systematic review of athletes undergoing TDRs of both the scientific literature and lay press, with an emphasis on contact sport athletes.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, PubMed/Embase/Cochrane/Scopus/Web of Science databases were queried for all primary literature reporting TDRs in athletes, including both cervical/lumbar disk replacements (CDRs/LDRs). Sports were dichotomized into contact vs limited/noncontact. Because of the public nature of injuries in elite athletes, the lay press was also queried.

RESULTS

A total of 488 scientific studies were screened, of which 10 met inclusion criteria. Cervical: seven studies reported CDRs in 53 athletes, of which 7 were professional, 22 semiprofessional, and 24 recreational. Of the seven professional athletes, there was one contact sport athlete (kickboxer). All 7/7 professional and 21/22 semiprofessional athletes successfully returned-to-play at 8-52 weeks without complication. Lumbar: Three studies discussed LDRs in 51 athletes, of which 17 were professional, 6 semiprofessional, and 28 recreational. Of the 17 professional athletes, eight played contact sports (2 boxing, 2 alpine skiing, 2 soccer, judo, rugby). All 17 professional and 6 semiprofessional athletes successfully returned to play at 9-21 weeks. Lay Press: five professional contact sport athletes underwent CDRs, and all returned to play: 3 hockey, 1 mixed-martial arts, and 1 Australian-rules football.

CONCLUSION

The scientific literature and lay press revealed 14 professional contact sport athletes who underwent TDR-6 CDRs and 8 LDRs-all with successful return to play. From the little data that exist, it seems that TDR may be safe in elite athletes; however, the small number of patients highlights the major paucity of data on the safety of TDR in elite contact sport athletes.

Cervical Total Disc Replacement in Athletes: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

To perform a systematic review to describe clinical characteristics, outcomes, and return to play after cervical total disc replacement (cTDR) in athletes.

SUMMARY OF BACKGROUND DATA

The role of cTDR in treating athletes with symptomatic cervical degenerative disc disease is undefined.

METHODS

A systematic search using MEDLINE through PubMed, EMBASE, and the Cochrane Library was conducted to identify all relevant literature. Data regarding study type, country in which the study was conducted, sample size, mean age, sex, type of sport, level of patient participation in sports, surgical indication, levels operated, type of implant, duration of follow-up, reoperations, surgical complications, extent of postoperative return to sports (RTSs), time to RTSs, and outcome notes were extracted from the included studies and analyzed.

RESULTS

Seven studies, including 4 case series and 3 case reports, and a total of 57 cTDR cases, were included. There was significant heterogeneity among the cTDR cases in terms of chosen sport and level of participation. Prestige LP was utilized in 51 out of 57 (89.5%) cases and 53 out of 57 (93%) cases were single-level. No reoperations were noted at a mean follow-up of 51.6 months. All patients returned to sports postoperatively. Return to training and competition occurred at a mean of 10.1 weeks and 30.7 weeks postoperatively, respectively.

CONCLUSIONS

The available evidence regarding cTDR in athletes indicates that these patients RTSs at high rates, with return to training occurring around 10 weeks and return to competition occurring around 30 weeks. Clinical outcomes in these patients are like those reported for the general population. Low-level evidence, small numbers of cases, heterogeneity in chosen sport and participation level, and predominance of a single implant type limit the conclusions that can be drawn from the current literature on this patient population.

The Role of Cervical Disc Arthroplasty in Elite Athletes

PURPOSE OF REVIEW

Cervical disc arthroplasty (CDA) for the treatment of symptomatic cervical disc herniations (CDH) is a promising treatment for professional athletes. In recent years, a number of high-profile athletes have returned to professional play within three months after CDA, raising important questions about the potential of this procedure within this patient group. We provide the first comprehensive review of available literature for the safety and efficacy of CDA in professional contact sport athletes.

RECENT FINDINGS

CDA provides theoretical biomechanical advantages over anterior cervical discectomy and fusion (ACDF) and posterior foraminotomy (PF), as CDA is the only operation for treatment of CDH that provides neural decompression, stability and height restoration, with preserved range of motion. While the comparative long-term results from each procedure are unknown, CDA has provided encouraging promise in its use in professional contact athletes. We aim to aid ongoing discussions regarding the controversies in spine surgery for professional athletes by providing a scientific review of the available evidence-based literature involving cervical disc arthroplasty in this population. In general, we believe that CDA is a viable alternative to ACDF and PF for the contact professional athlete who requires full neck range of motion and desires an expedited return to play. For collision athletes, the short- and long-term safety and efficacy profile of this procedure is promising but still unclear.

Return to sport and active military duty after cervical disc arthroplasty: A systematic review

Introduction

Cervical disc arthroplasty (CDA) has been established as an effective treatment for cervical disc degeneration or herniation in the general population. Return to sport (RTS) outcomes in athletes remain unclear.

Objective

The purpose of this review was to evaluate RTS following single-level, multi-level, or hybrid CDA, with additional return to activity context provided by return to duty (RTD) outcomes in active-duty military.

Methods

Medline, Embase, and Cochrane were searched through August 2022 for studies that reported RTS/RTD after CDA in athletic or active-duty populations. Data was extracted on the following topics: surgical failures/reoperations, surgical complications, RTS/RTD, and postoperative time to RTS/RTD.

Results

Thirteen papers covering 56 athletes and 323 active-duty members were included. Athletes were 59% male with a mean age of 39.8 years and active-duty members were 84% male with a mean age of 40.9 years. Only 1 of 151 cases required reoperation and only 6 instances of surgical complications were reported. Classified as return to general sporting activity, RTS was observed in 100% of patients (n = 51/51) after an average of 10.1 weeks to training and 30.5 weeks to competition. RTD was observed in 88% of patients (n = 268/304) after an average of 11.1 weeks. Average follow-up was 53.1 months for athletes and 13.4 months for the active-duty population.

Conclusion

CDA displays excellent RTS and RTD rates in physically demanding populations at rates superior or equivalent to alternative treatments. Surgeons should consider these findings when determining the optimal cervical disc treatment approach in active patients.

Upper-Extremity Injuries Have the Poorest Return to Play and Most Time Lost in Professional Baseball: A Systematic Review of Injuries in Major League Baseball

PURPOSE

To summarize the incidence of injuries occurring in professional baseball and compare player outcomes reported in the literature.

METHODS

We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines across 3 databases (PubMed, MEDLINE, Embase). Inclusion criteria were studies of injury incidences and/or injury outcomes on active Major League Baseball (MLB) athletes and studies published in the English language. Exclusion criteria were non-MLB players, case series and case report studies with a cohort of ≤3 players, and/or review articles.

RESULTS

A total of 477 articles were identified from the initial search of 3 databases, with 105 studies meeting inclusion criteria. Among these articles, the most common injuries studied were elbow (38%), shoulder (14%), hip/groin (11%), hand/wrist (7%), head/face (7%), knee (7%), spine (5%), and foot/ankle (3%). Injuries with the greatest incidence included hand/wrist (150.3 per year), hamstring (7.8-73.5 per year), ulnar collateral ligament (UCL) tears (0.23-26.8 per year), gastrocnemius strains (24.2 per year), and concussions (3.6-20.5 per year). Lowest rates of return to play were seen following shoulder labral tears (40%-72.5%), rotator cuff tears (33.3%-87%), and UCL tears (51%-87.9%). The injuries leading to most time away from sport included elbow UCL tears (average 90.3 days treated nonoperatively to 622.8 days following revision reconstruction), shoulder labral tears (average 315-492 days), and anterior cruciate ligament (ACL) tears (average 156.2-417.5 days). Following ACL tears, rotator cuff tears, shoulder labral tears, and hip femoroacetabular impingement requiring arthroscopy, athletes had a significantly lower workloads compared with before injury upon return to play.

CONCLUSIONS

Most published investigations focus on elbow injuries of the UCL, with variable return to play and mixed performance following surgery. UCL tears, shoulder labral tears, and ACL tears result in the most missed time. Upper-extremity injury such as shoulder labral tears, rotator cuff tears, and UCL tears had the poorest return to play rates. Workload was most affected following ACL reconstruction, rotator cuff repair, shoulder labral repair, and hip arthroscopy for femoroacetabular impingement.

LEVEL OF EVIDENCE

IV, systematic review of level II-IV studies.

Return to Martial Arts after Surgical Treatment of the Cervical Spine: Case Report and Systematic Review of the Literature for an Evidence-Based Approach

Background: Cervical spine injuries are considered common in athlete populations, especially in those involved in high-contact sports. In some cases, surgical treatment can be necessary, and, therefore, return-to-play (RTP) after surgery represent a notable issue. Methods: We performed a systematic review of literature according to the PRISMA statement guidelines using the following search algorithm: (("ACDF") OR ("cervical spine surgery") OR ("neck surgery") OR ("cervical discectomy") OR ("foraminotomy") OR ("cervical disc replacement")) AND (("return to play") OR ("athlete") OR ("contact sports") OR ("martial arts")). The search was performed on 21 October 2022. We included only articles in which operative treatment for the cervical spine was performed and return to martial art activity was declared in the text. Results: Eight articles were selected, including 23 athletes who practice wrestling (n = 16), kickboxing (n = 1), sumo (n = 1) or other unspecified martial arts (n = 5). We also included the case of a young judoka who underwent anterior cervical discectomy and fusion (ACDF) at our hospital. About 88% (21 of 24 cases) of martial arts practitioners returned to play after cervical spine surgery, and no major complications were reported after RTP. Four patients (16.7%) returned in 0-3 months; 41.7% (10 of 24) returned in 3-6 months; 29.2% (7 of 24) returned after a period longer than 6 months. ACDF is the most used procedure. The level of evidence in the included articles is low: only case reports are available, including some single-case studies. Moreover, a small number of cases have been reported, and the examined data are very heterogeneous. Conclusions: Return to martial arts within one year after cervical spine surgery is generally safe, even if case-by-case evaluation is, however, necessary. Further studies are necessary to corroborate the present findings in a larger population.

Spinal Injuries in the Overhead Athlete

PURPOSE OF REVIEW

Treatment of overhead athletes requires a systematic approach that will make an accurate diagnosis, deliver effective treatment, and make timely and safe return to sport.

RECENT FINDINGS

New data has shown success rates and return to play effectiveness after different types of cervical and lumbar surgery. Cervical foraminotomy has been shown to have the highest rate and fastest return to play, but with the highest incidence of need for revision surgery. Cervical artificial disc replacement has shown promising results in the general population and is being done more commonly in elite athletes, but has an unknown risk for failure. Cervical fusion is a well-established and effective treatment, but has the longest healing time and risk for adjacent level pathology. In the lumbar spine, discectomy has a long and proven track record, fusion is rarely performed but can be effective, and artificial disc replacement is extremely rare in an elite athlete. An effective and comprehensive approach can diagnose, treat, and return overhead athletes to competitive play.

Minimally Invasive Posterior Cervical Foraminotomy Versus Anterior Cervical Fusion and Arthroplasty: Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

Patients with lateral cervical disc and foraminal pathology can be treated with anterior and posterior approaches including anterior cervical discectomy and fusion(ACDF), cervical total disc arthroplasty(TDA), and minimally invasive posterior cervical foraminotomy(MIS-PCF). Although MIS-PCF may have some advantages over the anterior approaches, few comparative studies and meta-analyses have been done to assess superiority.

METHODS

This study includes a systematic review of the literature and meta-analysis of studies directly comparing minimally invasive posterior cervical foraminotomy to either anterior cervical discectomy and fusion or cervical total disc arthroplasty.

RESULTS

In comparing patients undergoing ACDF and MIS-PCF, operative time ranged from 68 to 97.8 minutes in the ACDF group compared to 28 to 93.9 minutes in the MIS-PCF group. Mean postoperative length of stay ranged from 33.84 to 112.8 hours in the ACDF group compared to 13.68 to 83.6 hours in the MIS-PCF group. The total complication rates were 3.72% in the ACDF group and 3.73% in the MIS-PCF group. A random-effects model meta-analysis was carried out which failed to show a statistically significant difference in the complication rate between the two procedures(OR .91; 95% CI 0.13, 6.43; P = .92, I² = 59%). The total reoperation rate was 3.5% in the ACDF group and 5.4% in the MIS-PCF group. A random-effects model meta-analysis was carried out which failed to show a statistically significant difference in the reoperation rate between the two procedures(OR .66; 95% CI 0.33, 1.33; P = .25, I² = 0). In comparing patients undergoing TDA and MIS-PCF, operative time ranged from 90.3 to 106.7 minutes in the TDA group compared to 77.4 to 93.9 minutes in the MIS-PCF group. Mean postoperative length of stay ranged from 103.2 to 165.6 hours in the TDA group and 93.6 to 98.4 hours in the MIS-PCF group. The complication rate ranged from 23.5 to 28.6% in the TDA group and 0 to 14.3% in the MIS-PCF group. The overall reoperation rates were 2.6% in the TDA group and 10.2% in the MIS-PCF group.

CONCLUSIONS

There is no clear superiority between MIS-PCF and ACDF/TDA in terms of operative time, postoperative length of stay, or rate of complications/reoperations. Further studies with increased follow-up intervals >48 months, and higher sample sizes are necessary to determine the true superiority of MIS-PCF and anterior neck approaches in treatment of lateral disc and foraminal pathology.

Validity of Research Based on Public Data in Sports Medicine: A Quantitative Assessment of Anterior Cruciate Ligament Injuries in the National Football League

BACKGROUND

Numerous researchers have leveraged publicly available Internet sources to publish publicly obtained data (POD) studies concerning various orthopaedic injuries in National Football League (NFL) players.

PURPOSE

To provide a comprehensive systematic review of all POD studies regarding musculoskeletal injuries in NFL athletes and to use anterior cruciate ligament (ACL) injuries in NFL players to quantify the percentage of injuries identified by these studies.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review was conducted to identify all published studies utilizing POD regarding ACL injury in NFL athletes from 2000 to 2019. Data regarding player demographics were extracted from each publication. These results were compared with prospectively collected data reported by the teams' medical staff to the NFL Injury Surveillance System database linked to the League's electronic health record. An ACL "capture rate" for each article was calculated by dividing the number of ACL injuries in the POD study by the total number of ACL injuries in the NFL injury database occurring in the study period of interest.

RESULTS

A total of 42 studies were extracted that met the definition of a POD study: 28 evaluated a variety of injuries and 14 dealt specifically with ACL injuries, with 35 (83%) of the 42 studies published during or since 2015. POD studies captured a mean of 66% (range, 31%-90%) of ACL injuries reported by the teams' medical staff. This inability to capture all injury rates varied by position, with 86% capture of ACL injuries in skill athletes, 72% in midskill athletes, and 61% in linemen. POD studies captured 35% of injuries occurring during special teams play.

CONCLUSION

The frequency of studies leveraging publicly obtained injury data in NFL players has rapidly increased since 2000. There is significant heterogeneity in the degree to which POD studies correctly identify ACL injuries from public reports. Sports medicine research relying solely on publicly obtained sources should be interpreted with an understanding of their inherent limitations and biases. These studies underreport the true incidence of injuries, with a bias toward capturing injuries in more popular players.

A Scoping Review of Injuries in Amateur and Professional Men’s Ice Hockey

Background:

Orthopaedic injuries are common in ice hockey at all levels and can result in physical and psychological adverse effects on these athletes.

Purpose:

Primarily, to summarize published data on orthopaedic hockey injuries at the junior through professional level. Secondarily, to characterize the literature based on anatomic site injured, return-to-play rates, cause/mechanism of injury, time lost, and treatments used.

Study Design:

Scoping review; Level of evidence, 4.

Methods:

PubMed, EMBASE, Cochrane library, and SCOPUS were searched using the terms “hockey” and “injuries” using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, and 4163 studies involving orthopaedic injuries were identified. Our inclusion criteria consisted of accessible full-text articles that evaluated orthopaedic injuries in men’s ice hockey athletes of all levels. We excluded case reports and articles evaluating women’s ice hockey injuries, as well as those evaluating nonorthopaedic injuries, such as concussions; traumatic brain injuries; and facial, dental, and vascular injuries, among others. Studies were divided based on level of play and anatomic site of injury. Level of evidence, year published, country of corresponding author, method of data collection, incidence of injury per athlete-exposure, and time lost were extracted from each article.

Results:

A total of 92 articles met the inclusion criteria and were performed between 1975 and 2020, with the majority published between 2015 and 2020. These were divided into 8 anatomic sites: nonanatomic-specific (37%), intra-articular hip (20.7%), shoulder (9.8%), knee (8.7%), trunk/pelvis (7.6%), spine (7.6%), foot/ankle (6.5%), and hand/wrist (2.2%). Of these studies, 71% were level 4 evidence. Data were obtained mostly via surveillance programs and searches of publicly available information (eg, injury reports, player profiles, and press releases).

Conclusion:

This scoping review provides men’s hockey players and physicians taking care of elite ice hockey athletes of all levels with a single source of the most current literature regarding orthopaedic injuries. Most research focused on nonanatomic-specific injuries, intra-articular hip injuries, knee injuries, and shoulder injuries, with the majority having level 4 evidence.

Treatment Outcomes in American Football Players After Intervertebral Disk Herniation: Systematic Review and Meta-Analysis

BACKGROUND

American football players are at increased risk for many forms of spinal injury. Intervertebral disk herniations are particularly concerning as they are the leading cause of days lost to injury and can have long-term effects on player careers. Disk herniation management plays a major role in the likelihood and success of return-to-play (RTP).

OBJECTIVE

To assess the incidence, demographic variables, treatment approaches, outcomes, and RTP rates of disk herniations in American football players.

METHODS

A systematic review of the literature investigating disk herniations in American football players using PubMed, Cochrane Library, and Embase was performed. RTP estimates were calculated by pooling study-specific data using a random-effects model.

RESULTS

Four hundred twenty-two studies were identified, with 18 meeting inclusion criteria. Offensive and defensive linemen were the 2 most commonly injured positions. Players undergoing operations were on average younger, with higher body mass indexes, fewer seasons played, and longer post-treatment careers than nonsurgical counterparts. Postsurgical recovery periods lasted an average 106 d, with a mean RTP duration of 33 games over 2.7 yr and an 8.45% reoperation rate. Operative treatment offered a nonsignificant increase in the likelihood of return-to-play compared with nonoperative treatment (odds ratio = 2.81, 95% CI 0.83-9.51).

CONCLUSION

Disk herniations are a common injury, with surgery potentially improving post-treatment outcomes. The literature suffers from heterogeneous definitions of RTP and varying performance metrics, making it difficult to draw clear conclusions. To better understand the impact of disk herniation and treatment on player health and performance, more studies should be performed prospectively and with standardized metrics.

A Systematic Review of the Orthopaedic Literature on Truncal and Lower Extremity Injuries in Major League Baseball Players

BACKGROUND

Orthopaedic injuries in Major League Baseball (MLB) players can have a tremendous impact on player health, longevity, salaries, and time lost from play.

PURPOSE

To summarize all data published between January 1980 and August 2019 on truncal and lower extremity orthopaedic injuries sustained by MLB players.

METHODS

A literature review of studies examining injuries in MLB was performed using the PubMed and Embase databases. Included studies focused on truncal and lower extremity injuries in professional baseball players. Studies pertaining to nonorthopaedic injuries, and case reports, were excluded.

RESULTS

A total of 41 articles met the inclusion criteria and were selected for the final analysis. Articles were divided based on anatomic region of injury: hip and pelvis (16%), thigh (15%), truncal (14%), knee (13%), and ankle (11%). Most studies (83.7%) were level 3 evidence. Most studies obtained data using publicly available internet resources (29.8%) compared with the MLB Health and Injury Tracking System (22.1%).

CONCLUSION

This review provides physicians with a single source of the most current literature regarding truncal and lower extremity orthopaedic injuries in MLB players. Most research was published on hip and pelvic, truncal, and thigh injuries and consisted of level III evidence.

Cervical Disc Herniations, Radiculopathy, and Myelopathy

The key to successful treatment of elite athletes is optimizing the medical care at every step: injury prevention and sport-specific training; comprehensive history and physical examination; high-quality and complete diagnostic studies; accurate diagnosis; control and completion of rehabilitation program; minimally invasive, safe, and effective surgeries; risk assessment for return to sport; guided and gradual return to sport; and continued rehabilitation and exercise program after return to sport.

Return to Play Guidelines After Cervical Spine Injuries in American Football Athletes: A Literature-Based Review

STUDY DESIGN

Literature-based review.

OBJECTIVE

We sought to evaluate clinical and case studies related to return to play (RTP) after cervical spine injuries in elite American football athletes and to formulate guidelines to help health care practitioners manage these conditions.

SUMMARY OF BACKGROUND DATA

American football athletes are at unique risk of cervical spine injury and appropriate case-by-case management of cervical spine injuries is necessary for these athletes. Despite this need, no standardized guidelines exist for RTP after cervical spine injury.

METHODS

Observational or case-based articles relating to RTP after cervical spine injury in American football athletes were curated from PubMed/EMBASE databases. Primary literature published before December 1, 2019 involving National Football League (NFL) or National Collegiate Athletic Association (NCAA) athletes met inclusion criteria.

RESULTS

The data acquisition process yielded 28 studies addressing cervical spine injuries and RTP in American football athletes. Stingers/burners were the most common injury and placed athletes at higher risk of a more severe re-injury. Transient quadriplegia, cervical stenosis, cervical disc herniation (CDH), and cervical fractures have a more significant impact on the long-term health and career longevity of the American football athlete. As such, the literature offers some guidance for management of these athletes, including average time for RTP in patients treated nonoperatively, thresholds involving cervical stenosis, and postoperative recommendations after spinal decompression and/or fusion surgery.

CONCLUSION

Elite American football athletes are at high risk for cervical spine injury due to the nature of their sport. The decision to allow these athletes to return to play should involve an understanding of the average RTP time, the potential risks of recurrence or re-injury, and individual characteristics such as position played and pathology on imaging.Level of Evidence: 3.

Return-to-Play Outcomes in Elite Athletes After Cervical Spine Surgery: A Systematic Review

CONTEXT

Return-to-play (RTP) outcomes in elite athletes after cervical spine surgery are currently unknown.

OBJECTIVE

To systematically review RTP outcomes in elite athletes after anterior cervical discectomy and fusion (ACDF), cervical disc replacement (CDR), or posterior foraminotomy (PF) surgery.

DATA SOURCES

EMBASE, PubMed, Cochrane, and Medline databases from inception until April 2020. Keywords included elite athletes, return to play, ACDF, foraminotomy, and cervical disc replacement.

STUDY SELECTION

Eligible studies included those that reported RTP outcomes in elite athletes after cervical spine surgery.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Data were extracted by 2 independent reviewers.

RESULTS

The primary outcomes of interest were rates and timing of RTP. Secondary outcomes included performance on RTP. A total of 1720 studies were initially screened. After inclusion criteria were applied, 13 studies with a total of 349 patients were included. A total of 262 (75%) played football, 37 (11%) played baseball, 19 (5%) played rugby, 10 (3%) played basketball, 10 (3%) played hockey, 9 (3%) were wresters, and 2 (1%) played soccer. ACDF was reported in 13 studies, PF in 3 studies, and CDR in 2 studies. The majority of studies suggest that RTP after surgical management is safe in elite athletes who are asymptomatic after their procedure and may lead to higher rates and earlier times of RTP. There is limited evidence regarding RTP or outcomes after CDR or multilevel surgery.

CONCLUSION

The management and RTP in elite athletes after cervical spine injury is a highly complex and multifactorial topic. The overall evidence in this review suggests that RTP in asymptomatic athletes after both ACDF and PF is safe, and there is little evidence for decreased performance postoperatively. Surgical management results in a higher RTP rate compared with athletes managed conservatively.

Performance Outcomes and Return-to-Sport Rate of National Hockey League Athletes Vary After Common Orthopedic Surgical Procedures

OBJECTIVE

Evaluate performance-based outcomes and return-to-sport rate in National Hockey League (NHL) athletes.

DESIGN

Retrospective cohort study.

SETTING

Public records. No direct patient care was provided.

PARTICIPANTS

National Hockey League athletes who underwent different orthopedic procedures were identified using public records. Three hundred thirty-seven athletes met inclusion criteria.

INDEPENDENT VARIABLES

Common orthopedic surgical procedures in NHL athletes.

MAIN OUTCOME MEASURES

Return-to-play and preoperative and postoperative performance measures were collected to calculate a position-specific performance score. Short-term and medium-term outcomes were defined as 1 and 2 to 3 seasons after surgery, respectively.

RESULTS

Three hundred seven athletes (92.6%) successfully returned to play. The number of games played during the first season after surgery compared with baseline was significantly decreased for hip arthroscopy (HA), noninstability shoulder arthroscopy (ie, shoulder arthroscopy procedure to address pathology other than shoulder instability), knee arthroscopy, and sports hernia repair (P = 0.002, 0.009, 0.03, and 0.01, respectively). The number of games played for seasons 2 and 3 after surgery was significantly decreased for both HA and noninstability shoulder arthroscopy (P = 0.01 and 0.001, respectively). Short-term postoperative performance scores were significantly decreased for HA, noninstability shoulder arthroscopy, and anterior cruciate ligament reconstruction (P = 0.00004, 0.02, and 0.02, respectively) while medium-term scores were significantly decreased for HA only (P = 0.009).

CONCLUSIONS

National Hockey League athletes return to play at a high rate after common orthopedic surgeries. However, certain procedures portend poorer performance scores and game participation than others. In particular, HA and noninstability shoulder arthroscopy have the greatest negative effect on NHL careers after surgery.

Transtubular Anterior Cervical Foraminotomy for the Treatment of Compressive Cervical Radiculopathy: Surgical Results and Complications in a Consecutive Series of Cases

Study Design

This was a retrospective review of patients with compressive cervical radiculopathy treated with a minimally invasive anterior cervical foraminotomy (ACF).

Purpose

This study aimed to evaluate the results and complication rates of ACF in a consecutive series of patients and to report our clinical results of ACF as a minimally invasive technique in a series of 45 consecutive patients treated for compressive cervical radiculopathy.

Overview of Literature

ACF is a motion-sparing procedure and an alternative to anterior cervical discectomy and fusion (ACDF) and posterior cervical foraminotomy for direct nerve root decompression in patients with compressive cervical radiculopathy.

Methods

The chart review recorded clinical and radiological features preoperatively and postoperatively and at follow-up (FU). The effect of prognostic factors was analyzed in relation to the clinical outcome.

Results

Between January 2004 and October 2019, 45 patients (15 females and 30 males) with a mean age of 55.9 years (range, 28-78 years) underwent ACF for unilateral cervical radiculopathy. The global clinical outcome according to the MacNab scale was evaluated as excellent in 64.5% of patients (n=29), good in 28.9% (n=13), fair in 4.4% (n=2), and poor in 2.2% (n=1). The radiological FU was available for 73.3% (n=33). The statistical analysis revealed no influence of age, sex, operated level, and side on the clinical outcome. Only one patient (2.2%) exhibited spontaneous bone fusion at the operated level on FU after a right-sided C6-7 ACF with no clinical consequences. No patient presented with signs of delayed segmental instability. The overall reoperation rate of this series was 4.4%.

Conclusions

ACF is a feasible and low-cost alternative to ACDF in selected patients with cervical radiculopathy. The use of tubular retractors in ACF may confer an added advantage that creates a safe corridor for direct cervical root decompression yet minimizing surrounding soft tissue retraction and avoiding unnecessary bone removal.

Prevalence of sports-related spinal injury stratified by competition level and return to play guidelines

Spinal injury is among the most severe and feared injuries an athlete may face. We present an up-to-date review of the recent literature, stratifying recommendations based on injury location (cervical, thoracic, and lumbar spine) and type, as well as, the level of competitive play (high school, collegiate, professional). A literature search was completed to identify all publications reporting return to play guidelines for athletic injuries or injury-related surgery irrespective of the study design. Publication dates were not restricted by year. Search terms used included "return to play" and "spinal injury" on National Library of Medicine (PubMed) and Google Scholar. Selection criteria for literature included axial spine injury guidelines for athletic participation post-injury or post-surgery. Literature found from the search criteria was sorted based on level of competition and location of axial spine injury involved. It was found that professional athletes are more likely to suffer severe spinal injuries, require surgery, and necessitate a longer return to play (RTP), with high school and college athletes usually returning to play within days or weeks. Injuries occur mainly within contact sports and concordance exists between initial and subsequent spinal injuries. Adequate rest, rehabilitation, and protective equipment alongside the education of athletes and coaches are recommended. In conclusion, a multidisciplinary approach to patient management is required with consideration for the emotional, social, and perhaps financial impact that spinal injury may have upon the athlete. Consensus from the literature states that in order for an athlete to safely return to play, that athlete should not be actively suffering from pain, should have a full range of motion, and complete return of their strength in the absence of neurological deficit.

A Systematic Review of the Orthopedic Literature Involving National Hockey League Players

Background

Orthopedic injuries of National Hockey League (NHL) players are common and may significantly affect players’ health and careers. Evidence-based injury management is important in guiding players’ timely return to sport and their ability to play at their pre-injury levels of competition.

Purpose

To summarize all data published between January 1980 and March 2020 on orthopedic injuries experienced by professional ice hockey players competing in the NHL.

Study Design

Systematic review.

Methods

A literature review of studies examining orthopedic injuries in the NHL was performed using the Embase, PubMed, and CINAHL databases. The review included studies focusing on NHL players and players attending the NHL Combine and preseason NHL team camps. Studies pertaining to non-orthopedic injuries and case reports were excluded.

Results

A total of 39 articles met the inclusion criteria and were analyzed. The articles were divided by anatomic site of injury for further analysis: hip and pelvis (24%), general/other (14%), ankle (10%), knee (10%), foot (7%), shoulder (7%), thigh (7%), trunk (7%), spine (6%), elbow (4%), and hand and wrist (4%). The majority of articles were Level IV Evidence (51.3%), followed by Level III Evidence (38.5%). Most studies obtained data from publicly available internet resources (24.7%), player medical records (19.5%) or surveys of team physicians and athletic trainers (15.5%). A much smaller number of studies utilized the NHL Injury Surveillance System (NHLISS) (6.5%) or the Athlete Health Management System (AHMS) (2.6%).

Conclusion

This systematic review provides NHL team physicians with a single source of the current literature regarding orthopedic injuries in NHL players. Most research was published on hip and pelvis (24%) injuries, did not utilize the NHLISS and consisted of Level IV Evidence.

Return to Golf, Tennis, and Swimming After Elective Cervical Spine Surgery

Background

After surgery for degenerative cervical spine problems, most patients hope to return to non-competitive sports and other leisure activities. Limited data are available to counsel patients about return to play (RTP) in non-competitive sports after cervical surgery.

Methods

Participants had cervical surgery for degenerative diagnoses from April 1, 2007, to April 1, 2018. Demographic data were collected, and participants were asked to complete a survey regarding sports participation before and after cervical surgery. 

Results

Of the 73 participants who responded to the study, the majority (81.1%) were able to return to one or multiple hobby sports after elective spine surgery. RTP rates at 12 months for golf, tennis, and swimming were 67.6%, 31.2%, and 81.6%, respectively. Younger age and lack of preoperative motor deficit were significant predictors of return to swimming after surgery. After surgery, 54.3% of golfers reported similar or improved levels of play. 

Conclusions

After elective cervical spine surgery, the majority of hobby athletes can expect to return to athletics. The majority of golfers returned to play with similar or improved frequency and quality of play compared to preoperative levels. Future prospective studies will further elucidate factors predicting RTP after different types of elective cervical surgeries.

Performance-based outcomes following patellar tendon repair in professional athletes

Objectives: There are limited data on the impact of a patellar tendon repair to a professional athlete's career. The purpose of this study was to determine differences return to play (RTP) rate, career length, and performance-based outcomes after a patellar tendon repair in professional athletes of four different sports.Methods: Participants met inclusion criteria if initial reports of the date and type of surgery were corroborated by at least two independent sources of information through a well-established protocol of public newspaper archives, team injury reports, and player profiles. Players with other concomitant injuries of the knee or treated nonoperatively were excluded. One hundred and three athletes across professional baseball, basketball, American football, and soccer athletes were identified and met inclusion criteria. RTP rate, career length, and sports-specific performance statistics (i.e. player efficiency rating (PER) for professional basketball players) before and after surgery were collected for each athlete.Results: Seventy-nine (76.7%) professional athletes successfully RTP. American football athletes had the lowest RTP rate and the largest drop in performance in post-operative season 1 (P < 0.001). These athletes also experienced the shortest adjusted career lengths (P = 0.003) compared to players in the other sports. Basketball athletes played significantly less games through post-operative seasons 1 to 3 (P < 0.05). Soccer athletes had less goals and assists per game and played fewer games (P < 0.05) in post-operative season 1 that recovered to baseline by seasons 2 and 3.Conclusion: A patellar tendon rupture is a potentially devastating injury for the professional athlete. American football players appeared to have the worst postoperative outcome with the lowest RTP rate and a most significant decrease in performance in the first postoperative season. This procedure also had a significant short-term impact on soccer athletes who sustained decreases in short-term game performance. These findings are likely explained by the unique physical demands imposed by each sport.

Controversies in the Management of Cervical Spine Conditions in Elite Athletes

Cervical spine injuries in elite athletes can have detrimental consequences, which makes return to play for professional athletes after cervical spine injury controversial. Although most athletes can return to sport under some circumstances, such as single-level anterior cervical diskectomy and fusion for cervical disk herniation, return to play after cervical disk arthroplasty and multilevel fusion for cervical disk herniation remains controversial. Allowing athletes to return to play after a finding of cervical stenosis and in the incidence of pseudarthrosis remains unclear. This review provides a systematic framework to guide return-to-play decision-making in common cervical conditions in elite athletes. [Orthopedics. 2019; 42(4):e370-e375.].

Prognosis Following Hip Arthroscopy Varies in Professional Athletes Based on Sport

PURPOSE

To evaluate return to play (RTP) and performance-based outcomes in professional athletes across 4 major North American team sports following hip arthroscopy.

METHODS

Professional athletes of the National Football League, Major League Baseball (MLB), National Basketball Association, and National Hockey League (NHL) who underwent hip arthroscopy were identified using an established protocol of public reports. Sport-specific statistics were collected before and after hip arthroscopy for each athlete, leading to a performance score. RTP was defined as the first regular or postseason game played following surgery.

RESULTS

A total of 151 arthroscopic hip procedures were performed on 131 professional athletes. The overall RTP rate after arthroscopic hip surgery was found to be 88.7% (134 of 151 arthroscopic hip surgeries), with no significant difference between sports. The median number of seasons played after hip arthroscopy were 2.7, 2.3, 1.1, and 0.9 for the National Football League, National Basketball Association, MLB, and NHL cohorts, respectively, with no significant difference between sports. MLB and NHL cohorts experienced a decrease in games played in the first season following hip arthroscopy (P = .04, P = .01), whereas NHL players also experienced a decrease in games played in seasons 2 and 3 postoperatively (P = .001). Performance scores decreased in the NHL cohort for all seasons postoperatively (P < .001, P = .003). No other statistically significant differences were found when comparing players of different sports.

CONCLUSIONS

Although professional athletes demonstrate a high rate of RTP following hip arthroscopy across the 4 major North American team sports, hockey players demonstrate the worst prognosis following hip arthroscopy, with sustained decreases in games played and performance in the first 3 seasons postoperatively.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

A Comprehensive Return-to-Play Analysis of National Basketball Association Players With Operative Patellar Tendon Tears

Background:

Patellar tendon tears impart potentially debilitating sequelae among professional basketball athletes.

Hypothesis:

Professional basketball athletes with patellar tendon tears have decreased return-to-play performance in seasons after injury compared with preinjury statistics.

Study Design:

Case series; Level of evidence, 4.

Methods:

Patellar tendon tears among National Basketball Association (NBA) athletes from the 1999-2000 to 2014-2015 seasons were identified. Player performance statistics for players who underwent operative patellar tendon repair were compared from 1 season before injury to 1 season after injury and 2 seasons before injury to 2 seasons after injury using the primary outcome of player efficiency rating (PER). Secondary performance outcomes were also analyzed.

Results:

A total of 13 patellar tendon tears (10 complete, 3 partial) were identified among 12 NBA athletes. Three players (25%) did not return to play in the NBA. No significant differences were found in PER in comparisons of 1 season before and after injury (16.6 ± 1.5 vs 14.3 ± 1.7; P = .20) or in comparisons of 2 seasons before and after injury (15.8 ± 0.8 vs 6.3 ± 2.3; P = .49). Diminished performance outcomes were noted for total minutes played (2598 ± 100 vs 1695 ± 78; P = .01), games played (74.8 ± 1.9 vs 60.5 ± 1.4; P = .04), and minutes per game (34.8 ± 1.5 vs 28.2 ± 1.8; P = .02) in comparisons of 1 season before and after injury. Total minutes played per season (2491 ± 190 vs 799 ± 280; P = .045) decreased in comparisons of 2 seasons before and after injury.

Conclusion:

Patellar tendon tears were not associated with diminished efficiency-adjusted performance, as measured by PER, games played, minutes per game played, points per 36 minutes, and rebounds per 36 minutes. However, decreases in total minutes played were observed following patellar tendon tear. Orthopaedic surgeons may be better prepared to counsel basketball athlete patients with patellar tendon tear given these findings.