Evaluating Return to Sports Following Total Hip Arthoplasty With Custom Stems in Professional and Recreational Table Tennis Players

Abstract

Background:

Table tennis players execute short explosive movements, along with continuous hip flexion, abduction, and rotation, increasing their risk of injury. Previous studies reported a rate of return to sports (RTS) of 20% to 80% in athletes following total hip arthroplasty (THA). There are no studies reporting RTS in table tennis players following THA.

Purpose:

To evaluate the clinical outcomes and RTS following custom THA in professional, ex-professional, and recreational table tennis players.

Study design:

Case series; Level of evidence, 4.

Methods:

Patients who underwent primary THA between April 2013 and January 2022 were retrospectively reviewed (n = 2977). Table tennis players of any level that received a custom femoral stem were included in the study (N = 17). At a minimum follow-up of 2 years, all players were assessed using the Oxford Hip Score (OHS), Forgotten Joint Score (FJS), and the University of California Los Angeles (UCLA) activity score, as well as with a sports-specific questionnaire that included questions related to their table tennis practice. Descriptive statistics, including medians and interquartile ranges, were used to summarize the data.

Results:

All 17 players (22 hips) were available at ≥2 years, of which 3 were professional (5 hips), 4 were ex-professional (6 hips), and 10 were recreational (11 hips). The median OHS was 44.0 (IQR, 44.0-48.0) in professional, 48.0 (IQR, 48.0-48.0) in ex-professional, and 48.0 (IQR, 45.0-48.0) in recreational players. The median FJS was 92.0 (IQR, 88.0-98.0) in professional, 98.0 (IQR, 98.0-98.0) in ex-professional, and 100.0 (IQR, 93.0-100.0) in recreational players. The median UCLA activity score was 10.0 (IQR, 9.0-10.0) in professional, 9.0 (IQR, 9.0-9.8) in ex-professional, and 8.0 (IQR, 5.5-9.0) in recreational players. The rate of RTS was 100% for professional and ex-professional players, and 80% for recreational players. The hours played before onset of symptoms was higher than following surgery for professional (30.0 [IQR, 25.0-30.0] vs 20.0 [IQR, 16.0-22.5] h/week) and ex-professional players (19.5 [IQR, 11.0-29.3] vs 3.0 [IQR, 2.0-5.5] h/week), while it was constant for recreational players (4.0 [IQR, 2.3-4.0] vs 4.0 [IQR, 3.8-4.5] h/week).

Conclusion:

Our retrospective analysis demonstrated that at a minimum follow-up of 2 years THA using custom stems provided good to excellent clinical outcomes in professional, ex-professional, and recreational table tennis players. All professional and ex-professional players, as well as 80% of recreational players, were able to return to play table tennis, although both professional and ex-professional players reduced their number of hours of play compared with before surgery. These findings could be used to help set expectations for table tennis players who are scheduled to undergo THA.

High-level athletes often start their career at a young age and must perform repetitive movements to progress.^25,41 More specifically, table tennis players frequently execute short explosive movements, ²⁹ in addition to continuous hip flexion, abduction, and rotation. This results in high strains applied on their lower limb joints, which can lead to hip and groin injuries.^19,56

The incidence of hip and groin injuries has been reported to vary between 5% and 72% in athletes that play soccer, hockey, rugby, and cycling,^{9,15,18,26,42,43,49} which may result in various hip pathologies, such as femoroacetabular impingement (FAI). The incidence of FAI in athletes ranges from 17% to 79%.^5,7,23,52 Furthermore, FAI may lead to secondary osteoarthritis (OA),^1,17 which could require surgical interventions, such as total hip arthroplasty (THA).

A recent systematic review showed a pooled proportion of return to sports (RTS) following THA of 56% (range, 20%-80%) in athletes that practiced high-intensity sports including hiking, running, tennis, and skiing, ⁴⁰ although none of the included studies reported on table tennis players. Another systematic review ⁴⁷ found that return to table tennis following THA was considered safe in one of the included studies, ⁵¹ but was allowed only with experience in another included study. ¹⁰

There are no studies reporting outcomes of custom THA in table tennis players. Therefore, the purpose of the present study was to evaluate the clinical outcomes and RTS following THA in professional, ex-professional, and recreational table tennis players at a minimum follow-up of 2 years. Our null hypothesis was that there would be no differences in RTS across the 3 groups.

Methods

Study Design and Participants

All patients that underwent primary THA between April 2013 and January 2022 by 1 of 2 surgeons (A.N. and I.T.) were retrospectively reviewed (n = 2977). Patients that played table tennis at any level before surgery and received a custom (also termed individualized) femoral stem were included in the present study (N = 17). None of the patients had previous hip surgeries (arthroscopy, osteotomy, or arthroplasty). All custom stems were metaphyseal-engaging, conventional length, made of titanium alloy, and coated with hydroxyapatite in the proximal two-thirds. The surgeons systematically implanted custom stems in active patients to restore both the intra- and the extra- medullary femoral architecture, including reproducing the native femoral offset and anteversion, which has been shown to provide excellent clinical outcomes and high rates of RTS in athletic populations (Figure 1).^35,36,53 One recreational player had surgery via the lateral approach because the patient had a gluteal muscle enthesopathy and required reattachment of the gluteal muscles. All other players had surgery via direct anterior approach (modified Hueter). ⁴⁴ Immediately after surgery, partial weightbearing with the use of crutches was allowed. Within the first 4 weeks, passive rehabilitation was started progressively. After 4 to 6 weeks, active progressive weightbearing rehabilitation was started, and after 8 weeks, functional training specific to table tennis could be initiated. All patients provided informed consent for their data to be used for research and publication purposes, and institutional review board approval was obtained.

Figure 1.

Preoperative (A) and postoperative (B) pelvic radiographs of a professional male table tennis player, aged 26 years.

Definitions

Professional players were defined as table tennis players who competed at national and/or international competitions prior to THA. Ex-professional players were defined as table tennis players that had retired from competing at national and/or international competitions but were coaches or playing recreationally before THA. Recreational players were defined as table tennis players who did not compete at national and/or international competitions before THA, but practiced the sport ≥2 hours per week, before the onset of symptoms.

Postoperative Assessment

At a minimum follow-up of 2 years, all players were assessed using the Oxford Hip Score (OHS), ¹³ Forgotten Joint Score (FJS), ²⁷ 12-item Short Form Health Survey (SF-12) Quality of Life subscore, ¹⁶ and University of California Los Angeles (UCLA) activity score ⁵⁷ per operated hip, as well as with a sports-specific questionnaire that included questions related to their table tennis practice per player (see Supplemental Material Figure S1, available separately).

Statistical Analysis

Descriptive statistics were used to summarize the data. Due to the small cohort size, continuous variables were presented as medians and interquartile ranges, while categorical variables were presented as proportions. Comparisons between groups were not conducted due to the small cohort size. Statistical analyses were conducted using R Version 4.3.1 (R Foundation for Statistical Computing).

Results

Patient Characteristics

Seventeen table tennis players (22 hips) were included in the study, of which 3 were professional (5 hips), 4 were ex-professional (6 hips), and 10 were recreational (11 hips). The proportion of male patients was 100% in professional players, 67% in ex-professional players, and 73% in recreational players (Table 1). The median age was considerably lower for professional players (median, 25.8; IQR, 23.3-42.9), compared with ex-professional (median, 47.3; IQR, 45.2-57.0) and recreational players (median, 57.3; IQR, 53.7-62.7). The most common indication for THA was secondary OA due to dysplasia for professional players (60%), and primary OA for ex-professional (83%) and recreational (73%) players.

Table 1.

Characteristics and Surgical Data for Hips in Initial Cohort (n = 22) ^a

	Professional (n = 5 hips)		Ex-Professional (n = 6 hips) b		Recreational (n = 11 hips)
Age, y	25.8	(23.3-42.9)	47.3	(45.2-57.0)	57.3	(53.7-62.7)
BMI, kg/m2	22.9	(21.7-25.2)	26.1	(24.0-26.8)	25.4	(24.7-28.7)
Sex, male	5	(100)	4	(67)	8	(73)
Bilateral	2	(40)	2	(33)	1	(9)
Etiology
Primary OA			5	(83)	8	(73)
Secondary OA due to dysplasia	3	(60)			2	(18)
Secondary OA due to dysplasia and FAI	1	(20)	1	(17)
Severe chondropathy with dysplasia	1	(20)
Avascular necrosis					1	(9)
Dysplastic acetabular morphology	3	(60)			1	(9)
Acetabular cup diameter
46-48			3	(50)	4	(36)
50-52	2	(40)	3	(50)	5	(45)
54-56	3	(60)			2	(18)
Femoral head diameter
28 M					1	(9)
32 M			2	(33)	5	(45)
36 M	5	(100)	4	(67)	5	(45)

^aData are presented as median (IQR) or n (%). BMI, body mass index; FAI, femoral acetabular impingement; M, medium offset; OA, osteoarthritis.

^bFive of the 6 hips belonged to ex-professional players who were table tennis coaches.

Preoperative Data

The median waiting period between the onset of symptoms and surgery was 24.0 months (IQR, 24.0-60.0) in professional, 66.0 months (IQR, 33.0-96.0) in ex-professional, and 18.0 months (IQR, 10.5-33.0) in recreational players (Table 2). The number of hours of play before surgery was partially or completely reduced in all 3 of 3 (100%) professional players, 4 of 4 (100%) ex-professional players, and 6 of 10 (60%) recreational players.

Table 2.

Table Tennis Questionnaire for Each Player in the Final Cohort (N = 17) ^a

	Professional (n = 3 players)		Ex-Professional (n = 4 players) b		Recreational (n = 10 players)
Time between onset of symptoms and surgery, mo	24.0	(24.0-60.0)	66.0	(33.0-96.0)	18.0	(10.5-33.0)
Years played before surgery	15.0	(12.5-23.5)	38.0	(34.8-41.8)	14.0	(6.5-37.5)
Hours played per week before onset of symptoms	30.0	(25.0-30.0)	19.5	(11.0-29.3)	4.0	(2.3-4.0)
In the waiting period immediately before surgery, were you able to play
table tennis at your usual pace?
Yes, there was no change in my ability to play	0	(0)	0	(0)	4	(40)
No, I had to reduce my pace/number of hours of play	3	(100)	1	(25)	4	(40)
No, I had to completely stop playing	0	(0)	3	(75)	2	(20)
Return to play table tennis following surgery	3	(100)	4	(100)	8	(80)
Pain on VAS (0, no pain; 10, extreme pain)
Right hip	1.0	(0.5-1.5)	0.0	(0.0-0.3)	0.0	(0.0-1.0)
Left hip	1.0	(0.5-1.5)	0.0	(0.0-0.0)	0.0	(0.0-0.0)
Spine	1.0	(0.5-2.0)	1.0	(0.0-2.5)	1.5	(0.0-4.5)
Right knee	0.0	(0.0-2.0)	0.0	(0.0-0.3)	0.0	(0.0-2.3)
Left knee	0.0	(0.0-0.5)	0.0	(0.0-0.3)	2.0	(0.0-2.8)
Right ankle	0.0	(0.0-1.5)	0.0	(0.0-0.3)	0.0	(0.0-0.0)
Left ankle	0.0	(0.0-0.0)	0.0	(0.0-0.0)	0.0	(0.0-0.0)
Right foot	0.0	(0.0-1.5)	0.0	(0.0-0.0)	0.0	(0.0-0.0)
Left foot	0.0	(0.0-1.0)	0.0	(0.0-0.0)	0.0	(0.0-0.0)
Satisfaction with surgery (1, not at all satisfied; 10, extremely satisfied)	9.0	(8.0-9.5)	10.0	(9.8-10.0)	10.0	(10.0-10.0)

^aData are presented as median (IQR) or n (%). VAS, visual analog scale.

^bThree of the 4 ex-professional players were table tennis coaches.

Postoperative Assessment

All 17 table tennis players were available at a minimum follow-up of 24 months. The OHS tended to be lower in professional players (median, 44.0; IQR, 44.0-48.0) compared with ex-professional (median, 48.0; IQR, 48.0-48.0) and recreational (median, 48.0; IQR, 45.0-48.0) players (Table 3). The FJS tended to be lower in professional players (median, 92.0; IQR, 88.0-98.0), compared with ex-professional (median, 98.0; IQR, 98.0-98.0) and recreational (median, 100.0; IQR, 93.0-100.0) players. The SF-12 Physical component was higher in professional (median, 90.0; IQR, 70.0-95.0) and ex-professional (median, 95.0; IQR, 91.3-95.0) players compared with recreational (median, 70.0; IQR, 47.5-92.0) players. The SF-12 Mental component tended to be lower for professional (median, 83.3; IQR, 70.8-87.5) and recreational (median, 79.2; IQR, 75.0-93.8) players compared with ex-professional (median, 91.7; IQR, 76.0-91.7) players. The UCLA activity score tended to be higher in professional (median, 10.0; IQR, 9.0-10.0) players compared with ex-professional (median, 9.0; IQR, 9.0-9.8) and recreational (median, 8.0; IQR, 5.5-9.0) players. Satisfaction with surgery tended to be lower in professional (median, 9.0 points; IQR, 8.0-9.5) players compared with ex-professional (median, 10.0 points; IQR, 9.8-10.0) and recreational (median, 10.0 points; IQR, 10.0-10.0) players (Table 2).

Table 3.

Clinical Outcomes for Hips in Final Cohort (n = 22) ^a

		Professional (n = 5 hips)		Ex-Professional (n = 6 hips) b		Recreational (n = 11 hips)
Follow-up, y		4.9	(3.4-5.4)	6.2	(4.6-8.4)	6.0	(3.9-7.7)
OHS		44.0	(44.0-48.0)	48.0	(48.0-48.0)	48.0	(45.0-48.0)
FJS		92.0	(88.0-98.0)	98.0	(98.0-98.0)	100.0	(93.0-100.0)
SF-12	Physical	90.0	(70.0-95.0)	95.0	(91.3-95.0)	70.0	(47.5-92.5)
SF-12	Mental	83.3	(70.8-87.5)	91.7	(76.0-91.7)	79.2	(75.0-93.8)
UCLA activity score		10.0	(9.0-10.0)	9.0	(9.0-9.8)	8.0	(5.5-9.0)

^aData are presented as median (IQR). One patient had an SF-12 Physical component of 20 and a UCLA score of 2.0 because of an issue with the knee. This patient had an OHS of 48 and FJS of 100. FJS, Forgotten Joint Score; OHS, Oxford Hip Score; SF-12, 12-item Short Form Health Survey; UCLA, University of California Los Angeles.

^bFive of the 6 ex-professional players were table tennis coaches.

Professional players reported slight pain on visual analog scale in the operated hip (1.0; IQR, 0.5-1.5) and the spine (1.0; IQR, 0.5-2.0), ex-professional players reported slight pain in the spine (1.0; IQR, 0.0-2.5), and recreational players reported slight pain in the spine (1.5; IQR, 0.0-4.5) and left knee (2.0; IQR, 0.0-2.8) (Table 2).

Return to Sports

The proportion of players who returned to play table tennis was 100% (n = 3) in the professional group, 100% (n = 4) in the ex-professional group, and 80% (n = 8) in the recreational group (Table 2). Of note, all bilateral patients returned to sports, and they were able to RTS between their 2 surgeries.

Of the 3 professional players who returned to table tennis, all (100%) resumed playing at a professional level, though only 1 (33%) was at his best level since surgery. Two (67%) professional players reported that the time taken to reach best level following surgery was “shorter than expected” or “as expected,” and these same players reported the best level achieved was “somewhat better than expected” or “as expected.” For the 3 professional players, the time taken to reach the player's best level following surgery was 15.0 months (IQR, 8.5-16.5) (Table 4). Furthermore, the hours played before onset of symptoms was greater than following surgery (30.0 vs 20.0 hours/week) (Tables 2 and 4).

Table 4.

Players that Returned to Play Table Tennis Following Surgery (n = 15)

	Professional (n = 3 players)		Ex-Professional (n = 4 players) a		Recreational (n = 8 players)
After surgery, you were able to resume playing table tennis …
Recreationally			3	(75)	7	(88)
Professionally	3	(100)			1	(13)
Recreationally and as a coach			1	(25)
Are you currently at your best level since surgery?
Yes	1	(33)	1	(25)	7	(88)
No	2	(67)	3	(75)	1	(13)
After surgery, the time it took you to reach your best level was…
Much shorter/faster than expected	1	(33)			2	(25)
Somewhat shorter/faster than expected					1	(13)
As expected	1	(33)	3	(75)	5	(63)
Somewhat longer/slower than expected	1	(33)	1	(25)
Your best level is/was…
Much better/higher than expected					1	(13)
Somewhat better/higher than expected	1	(33)			1	(13)
As expected	1	(33)	4	(100)	4	(50)
Somewhat worse/lower than expected	1	(33)			2	(25)
Time to return to best level of table tennis postoperatively, mo	15.0	(8.5-16.5)	11.0	(10.5-11.5)	4.5	(3.0-6.0)
Hours per week played when at best level postoperatively, hr	20.0	(16.0-22.5)	3.0	(2.0-5.5)	4.0	(3.8-4.5)

^aData are presented as median (IQR) or n (%). Three of the 4 ex-professional players were table tennis coaches.

Of the 4 ex-professional players who returned to table tennis, all (100%) resumed playing at a recreational level, with only 1 (25%) at best level since surgery, and another (25%) also returning as a coach. Three (75%) ex-professional players reported that the time taken to reach their best level following surgery was “as expected” and all 4 (100%) reported their best level achieved was “as expected.” The time taken to reach their best level following surgery was 11.0 months (IQR, 10.5-11.5). Furthermore, the hours played before onset of symptoms was lower than following surgery (19.5 vs 3.0 hours/week) (Table 4).

Of the 8 recreational players who returned to sports, 1 (13%) resumed playing as a professional and 7 (88%) were at their best level since surgery. All eight (100%) recreational players reported that the time taken to reach their best level following surgery was “shorter than expected” or “as expected” and 6 (75%) reported their best level achieved was “better than expected” or “as expected.” The time taken to reach their best level following surgery was 4.5 months (IQR, 3.0-6.0). Furthermore, the hours played before onset of symptoms was the same as following surgery (4.0 vs 4.0 h/week) (Table 4). Of note, professional players (median, 25.8; IQR, 23.3-42.9) were considerably younger than ex-professional (median, 47.3; IQR, 45.2-57.0) and recreational players (median, 57.3; IQR, 53.7-62.7) (Table 1), which may have affected their ability to RTS.

Discussion

The most important findings of the present study were that THA using custom stems provided good to excellent short-term clinical outcomes in table tennis players, regardless of their level. Furthermore, all professional and ex-professional players, as well as 80% of recreational players, were able to return to play table tennis following THA, although both professional and ex-professional players reduced their number of hours of play compared with before surgery, thus only partially confirming our null hypothesis. These findings could be used to help set expectations for table tennis players that are scheduled to undergo THA with custom stems.

Several studies^{11,21,30,34,54} have reported on RTS following THA in professional and recreational players; however, none has focused on table tennis players. A systematic review reporting on sports participation following THA pooled data from 14 studies that included players of various levels and sports and found that RTS to presymptomatic level was 82%. ⁴⁰ The systematic review also reported a tendency for patients to shift from high-impact sports to low-impact sports following THA. ²⁰ Another systematic review summarizing athletic activity following THA in patients who participated in sports such as swimming, skiing, and biking at various levels found an RTS rate ranging from 54% to 98%. ²² Last, a systematic review reporting on RTS following THA in 250 golfers found that the rate of return to golf was 90% at a mean time of 4.5 months. ⁴⁵ The present study reported an RTS rate in the high end of those in previous publications, with all (100%) professional and ex-professional players returning to table tennis and 80% of recreational players returning to table tennis.

Interestingly, a recent survey of 510 European Hip Society members revealed that 65% of surgeons allowed unrestricted table tennis participation between 3 and 6 months following THA, 19% of surgeons allowed table tennis participation with experience, 10% did not allow it, and 6% had no opinion. ⁴⁸ The consensus of the survey stated that table tennis should be allowed at 3 months following THA. The authors of the present study believe that return to table tennis can be allowed without restriction at 3 months following THA, if the 3-dimensional architecture of the hip has been accurately restored by the implants.

Navas et al ³⁴ found that athletes significantly increased the number of sports sessions per week following THA compared with before the onset of symptoms (3 days/week vs 1 day/week; P < .0001). Additionally, they reported a significant increase in the minimum session length following THA compared with before the onset of symptoms (82 ± 40.8 minutes vs 23 ± 31.6 minutes; P < .0001). ³⁴ In contrast, the present study found that professional and ex-professional players reduced the number of hours played per week following THA compared with before THA (professional players, 20 vs 30 h/week; ex-professional players, 3.0 vs 19.5 h/week), while the number of hours played per week stayed constant for recreational players (4.0 vs 4.0 h/week). This could be due to professional and ex-professional players’ nearing the end of their career or due to their older age. Nonetheless, all players in the present study were very satisfied with surgery (range, 8.0-10.0 points). Furthermore, 5^4,6,24,30,33 of the 37 studies included in the systematic review by Hoorntje et al ²⁰ reported that time to RTS ranged from 4 to 7 months, while the present study reported a similar median time to return to best level of 4.5 months in recreational players, but a higher median time to return to their best level of 15 and 11 months, respectively, in professional and ex-professional players. Of note, the present study only recorded the time it took for players to return to their best level of play, and not the time it took for players to RTS. Additionally, the time to return to best level of play may have been higher for professional players, due to the high volume of hours and intensity of play. It is also important to note that all professional and ex-professional players returned to play, while only 80% of recreational players returned to play.

A study investigating sports activity following THA with short stems in 68 patients who participated in high-, intermediate-, and low-impact sports found that at a mean follow-up of 2.7 years, the UCLA activity score was 7.6 ± 1.9. ⁴⁶ Another study reporting on outcomes and sports activity following THA in 36 patients <40 years old found that at a follow-up of 3.9 ± 1.3 years, UCLA activity score was 7.6 ± 1.5 and modified Harris Hip Score was 92.6 ± 12.3. ³⁴ The present study found that at a minimum follow-up of 2 years, median UCLA activity scores were 10.0 in professional, 9.0 in ex-professional, and 8.0 in recreational table tennis players. Additionally, FJS (median, 92-100) and OHS (median, 44-48) scores were good to excellent following THA, regardless of player level.

Twenty of the 22 hips included in the present study underwent THA for primary or secondary OA. Of these, 5 table tennis players presented with secondary OA due to dysplasia, while 2 presented with secondary OA due to dysplasia and FAI. An alternative treatment for dysplasia is periacetabular osteotomy (PAO)^2,8; however, PAO is not recommended in cases with OA. ³⁹ A recent systematic review on outcomes of PAO in competitive athletes found that postoperative sports participation ranged from 63.7% to 85.7% in low-impact sports, 4.3% to 25.4% in moderate impact sports, and 5.1% to 10.8% in high-impact sports, and time to RTS ranged from 8.8 to 12.8 months. ¹² An alternative treatment for FAI is hip arthroscopy ¹⁴ ; however, arthroscopy is not recommended in cases with OA.^3,28,31 A systematic review on RTS following hip arthroscopy in patients participating in various sports such as football, rowing, biking, and swimming reported a pooled rate of RTS to the patients’ preoperative level of 82% at 5.7 months. ³² Although arthroscopy can provide good outcomes in patients with FAI, it should not be performed on patients with severe dysplasia.^38,50,55

All players in the present study underwent THA with custom stems, which allows accurate restoration of the native hip anatomy, including femoral anteversion, femoral offset, and limb length. ³⁷ A recent systematic review ³⁷ has shown that custom stems grant good clinical outcomes, low complication rates, and excellent survival. Additionally, custom stems have been shown to provide excellent clinical outcomes and high rates of RTS in athletic populations, such as ballet dancers.^35,36,53 We believe that when custom stems are implanted by a minimally invasive muscle-sparing direct anterior approach, they can provide the best outcomes in high-demanding athletic patients, such as table tennis players, because this combination can allow optimal balance of the muscles through restoration of the extramedullary anatomy. Furthermore, it could be interesting to compare outcomes and rate of RTS of robotic-assisted THA versus manual THA.

Limitations

The present retrospective study has several limitations. First, the cohort size was small, as it focused only on table tennis players who underwent THA. In addition, all patients were operated on by 1 of 2 experienced orthopaedic surgeons; thus, outcomes may not have been generalizable to any surgeon. Furthermore, post hoc comparison tests between groups were not performed due to the limited cohort size. Second, the present study reported only short-term outcomes, and it is therefore not possible to extrapolate these results to the long term. Third, 29% of the cohort underwent bilateral THA, which could have influenced the mean age of the cohort and clinical outcomes. Additionally, the presence of bilateral THA further reduces the size of the cohort; hence, further studies on larger cohorts are needed to confirm these findings. Fourth, the present study only recorded the time it took for players to return to their best level of play, and not the time it took for players simply to return to play, which makes it more difficult to compare with other studies in the literature. Fifth, there was no comparative group of table tennis players who underwent surgery with off-the-shelf stems or using another surgical approach.

Conclusion

Our retrospective analysis demonstrated that at a minimum follow-up of 2 years, THA using custom stems provided good to excellent clinical outcomes in professional, ex-professional, and recreational table tennis players. All professional and ex-professional players, as well as 80% of recreational players, were able to return to play table tennis; although both professional and ex-professional players reduced their number of hours of play compared with before surgery. These findings could be used to help set expectations for table tennis players who are scheduled to undergo THA.