Rehabilitation after hip femoroacetabular impingement arthroscopy

Hip arthroscopic techniques to repair labral tears and address femoroacetabular impingement (FAI) are evolving. This article discusses the different phases of rehabilitation and the rehabilitation protocol. Although there is evidence to support arthroscopic procedures to address labral tears and FAI, there are few published evidence-based rehabilitation studies dedicated to postoperative rehabilitative care. It is thought that by following the restrictions set by the physician while performing early circumduction, using the minimal criteria to advance through each subsequent phase, and allowing patients to perform functional sport progressions throughout the rehabilitation athletes will be able to return to sport smoothly and effectively.     

Outcome after hip arthroscopy for femoroacetabular impingement in 289 patients with minimum 2-year follow-up

Femoroacetabular impingement (FAI) is a common cause of hip pain and dysfunction. The purpose of this study was to report outcome 2 years after the arthroscopic treatment of FAI using validated outcome measurements. Two hundred and eighty-nine patients (males = 190, females = 99) with a mean age of 37 years underwent arthroscopic surgery for FAI. Patients were included consecutively in a hip arthroscopy registry. The cohort was evaluated using online web-based validated health-related patient-reported outcomes measurements, including the iHOT-12, HAGOS, EQ-5D, HSAS for physical activity level, VAS for overall hip function and overall satisfaction. The mean follow-up time was 25.4 months. Pre-operative scores compared with those obtained at follow-up revealed statistically and clinically significant improvements (P < 0.05) for all measured outcomes; iHOT-12 (43 vs 66), VAS for global hip function (50 vs 71), HSAS (2.9 vs 3.6), EQ-5D index (0.58 vs 0.75), EQ-VAS (67 vs 75) and HAGOS different subscales (56 vs 76, 51 vs 69, 60 vs 78, 40 vs 65, 29 vs 57, 33 vs 58). At the 2-year follow-up, 236 patients (82%) reported they were satisfied with the outcome of surgery. We conclude that arthroscopic treatment for FAI resulted in statistically and clinically significant improvements in outcome parameters.     

High rate of return to tennis after hip arthroscopy for patients with femoroacetabular impingement syndrome

ObjectiveThe purpose of this study was to evaluate return to sport (RTS) outcomes in tennis athletes following hip arthroscopy for femoroacetabular impingement syndrome (FAIS). It was hypothesized that there would be a high rate of return to tennis after hip arthroscopy.Study designLevel IV, Retrospective Analysis.SettingOutpatient sports medicine clinic at a single institution.ParticipantsA total of 28 patients (60.8% female; mean age, 36.2 ± 9.2 years; mean BMI, 22.8 ± 2.1 kg/m²) with self reported tennis activity prior to hip arthroscopy.Main outcome measuresA postoperative return to sport and minimum two-year patient reported outcomes.ResultsThere was a high rate of return to tennis, with 78% of patients eventually returning to tennis. An additional 9% of patients had the necessary hip function to return, but did not return due to lack of interest or resources. The patients returned to tennis at an average of 8.0 ± 3.3 months after surgery. The majority of athletes (66.7%) were able to continue competing at the same or higher levels following surgery.ConclusionsPatients return to tennis 78% of the time at a mean of 8.0 ± 3.3 months following hip arthroscopy for FAIS.     

Altered gait mechanics are associated with severity of chondropathy after hip arthroscopy for femoroacetabular impingement syndrome

BackgroundSuboptimal patient-reported function and movement impairments often persist after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Individuals with FAIS with preoperative cartilage pathology (ie. chondropathy) demonstrate distinct movement patterns and have worse post-operative outcomes. It is unknown whether the presence of chondropathy after surgery negatively affects movement and function.Research questionDo sagittal plane gait mechanics differ based on chondropathy severity following arthroscopy for FAIS?MethodsA cross-sectional walking gait analysis was performed for 25 participants post-arthroscopy (2.48 ± 1.38y) and 12 healthy controls (HCs). Peak total support moment (TSM) and relative contributions of the hip, knee, and ankle were calculated during loading response. The Hip Osteoarthritis MRI Scoring System was used to categorize the FAIS group into no-mild or moderate-severe chondropathy groups based on 3 T magnetic resonance imaging of their surgical hip. The interactions of group by limb were evaluated for kinetic variables, covaried by gait speed.ResultsGroups did not differ based on age, BMI and sex distribution (P ≥ 0.14). 13 participants with FAIS presented with moderate-severe chondropathy and 12 presented with no-mild chondropathy. Participants with moderate-severe chondropathy walked significantly slower than both other groups (P = 0.006) and demonstrated lower peak TSM than those with no-mild chondropathy (P = 0.002). Participants with no-mild chondropathy demonstrated lower hip (61.5 %) and greater ankle (17.7 %) contributions to the TSM on the involved limb compared to the moderate-severe group (hip:73.4 %, P = 0.07; ankle:10.5 %, P = 0.007).SignificanceSlower gait speed alone did not explain the lower TSM strategy in participants with moderate-severe chondropathy. Interestingly, the joint contribution strategy of this group was not different than HCs. Participants with no-mild chondropathy demonstrated a TSM strategy that shifted the demand away from their hip and toward their ankle. Given the small sample size, and large variability in joint strategies, future work needs to examine whether these alterations in gait strategy, with or without advanced chondropathy, impact patient function.     

Hip arthroscopy with labral repair for femoroacetabular impingement: short-term outcomes

Purpose

The purpose of this study was to examine the progression of clinical outcomes 3, 6 and 12 months after hip arthroscopy with labral repair for femoroacetabular impingement (FAI).

Methods

From May 2009 to December 2011, 87 consecutive patients [55 females (median age 38, range 17–63) and 32 males (median age 38, range 15–59)] underwent hip arthroscopy and labral repair, by the same experienced surgeon. Standardised, but unstructured, post-operative rehabilitation instructions were provided. Function and pain were evaluated using modified Harris Hip Score (mHHS) and visual analogue scale (VAS) pre-operatively and post-operatively at 3, 6, and 12 months.

Results

A main effect of time was seen for mHHS and pain (VAS) at 3, 6, and 12 months (p < 0.001). Mean (SE) mHHS improved significantly from 59.9 (1.9) pre-operatively to 74.5 (1.9) after 3 months (p < 0.001), and again from 3 to 6 months from 74.5 (1.9) to 80.1 (1.9) (p = 0.004), with no additional changes from 6 to 12 months [80.1 (1.9)–78.7 (1.9), (n.s.)]. Also, the mean (SE) VAS improved significantly from pre-operative 57.9 (2.6) to 30.0 (2.6) after 3 months (p < 0.001), and from 30.0 (2.6) to 22.6 (2.6) (p = 0.017), after 6 months with no additional changes from 6 to 12 months [22.6 (2.6)–27.9 (2.6), (n.s.)].

Conclusions

Improvements in function (mHHS) and pain (VAS) were seen in patients after hip arthroscopy with labral repair for FAI at 3, 6, and 12 months. While significant improvements occurred from 3 to 6 months, no further improvements were seen from 6 to 12 months.

Level of evidence

Prospective case series, Level IV.     

Surgical indications for treatment for femoroacetabular impingement with surgical hip dislocation

Purpose

There is a lack of detailed information about the indications of surgical treatment for femoroacetabular impingement (FAI), particularly using open surgical dislocation. The purpose of this review was to systematically review the reported indications for surgical dislocation of the hip for FAI.

Methods

Two databases (MEDLINE and EMBASE) were screened for clinical studies involving the treatment for FAI with surgical hip dislocation. We conducted a full-text review and the references for each included paper were hand-searched for other eligible studies. Papers published until September 2011 were included in this review. Two individuals reviewed all identified studies independently, and any disagreement was resolved through consensus.

Results

Fifteen studies met the eligibility criteria, which included a total of 822 patients. We identified a lack of consensus for clinical and radiographic indications for surgical hip dislocation to treat FAI. The most common clinical indications reported were clinical symptoms such as hip pain in 10 papers (67 %), a positive impingement sign in 9 papers (60 %), painful/reduced range of motion in 9 papers (60 %), activity-related groin pain in 4 papers (27 %), and non-responsive to non-operative treatment in 4 papers (27 %). The most commonly reported radiographic indicators for surgical hip dislocation were a variety of impingement findings from radiographs in all 15 included papers (100 %), a combination of radiographs and MRA in 5 papers (33 %) or radiographs and MRI in 3 papers (20 %).

Conclusions

These results showed that that there was an inconsistency between the clinical and radiographic indications for surgical hip dislocation as a treatment for femoroacetabular impingement. This review suggests that there is a need for the development of standardized clinical and radiological criteria that serve as guidelines for surgical treatment for FAI.

Level of evidence

Systematic review, Level IV.     

CT assessment of asymptomatic hip joints for the background of femoroacetabular impingement morphology

PURPOSE

The purposes of this study were to assess the presence of cam and pincer morphology in asymptomatic individuals with a negative femoroacetabular impingement test, and to determine and compare the ranges of alpha angle using two measurement methods.

MATERIALS AND METHODS

In total, 68 consecutive patients who underwent abdominopelvic computed tomography (CT) for reasons other than hip problems were the patient population. Patients who had a positive femoroacetabular impingement test were excluded. Alpha angle measurements from axial oblique (A_N) and radial reformat-based images (A_R) from the anterior through the superior portion of the femoral head-neck junction, as well as femoral head-neck offset, center-edge angle, acetabular version angle measurements, and acetabular crossover sign assessment, were made.

RESULTS

Overall prevalences of cam (increased alpha angle, decreased femoral head-neck offset) and pincer morphology (increased center-edge angle, decreased acetabular version) were 20.0%, 26.8%, 25.8%, and 10.2% of the hips, respectively. The mean A_R ranged from 41.64°±4.23° to 48.13°±4.63°, whereas A_N was 41.10°±4.44°. The values of A_R were higher than A_N, and the difference was statistically significant (P < 0.001). The highest A_R values were measured on images from the anterosuperior section of femoral head-neck junction.

CONCLUSION

In asymptomatic subjects, higher alpha angle values were obtained from radial reformatted images, specifically from the anterosuperior portion of the femoral head-neck junction compared with the axial oblique CT images. Other measurements used for the assessment of cam and pincer morphology can also be beyond the ranges that are considered normal in the general population.Femoroacetabular impingement (FAI) is a recognized risk factor for the development of osteoarthritis (1, 2). Morphological abnormalities of the proximal femur and/or acetabulum result in abnormal contact between the femur and acetabulum during hip motion, especially during flexion and internal rotation. The resulting abnormal stress on the acetabular labrum and articular cartilage can cause degeneration and tearing of the labrum, damage the adjacent acetabular cartilage, and eventually lead to osteoarthritis (1).Morphological variations and measurements demonstrating such alterations in the proximal femoral head and acetabulum that might be responsible for the development of FAI have become a research focus (2–7). The alpha angle (AA) is a parameter that demonstrates the degree of focal femoral epiphyseal overgrowth and reflects insufficiency of the anterolateral femoral head-neck offset and asphericity of the femoral head (5, 7). Since the concept of FAI was proposed, the AA measurement has become a widely used method to quantify osseous deformity at the femoral head-neck junction (5). However, there has been some controversy regarding its validity in clinical use, because of the substantial overlap in AA measurements between volunteers and symptomatic patients with cam-type deformity (8, 9).Our purposes in this prospective study were to determine the range of AA values in radial reformatted computed tomography (CT) images, to assess the prevalence of cam and pincer morphology in asymptomatic patients with a negative hip impingement test, and to compare the AA values using two measurement methods.     

A review of femoroacetabular impingement in athletes

There are a multitude of well recognized hip and groin injuries that commonly affect athletes; however, a more recently recognized and possibly often overlooked cause of hip pain is that of femoroacetabular impingement (FAI). FAI is characterized by abutment of the femoral neck against the acetabular rim, which may occur by two mechanisms known as 'CAM' or 'pincer' impingement, although most commonly by a mixture of both. CAM impingement is characterized by abutment of the femoral neck against the acetabulum due to a morphological abnormality of the femoral head-neck junction. Pincer impingement occurs where an abnormality of the acetabulum results in impingement against an often normal femoral neck. Both CAM and pincer impingement are known to result in pathological consequences of cartilage delamination and labral lesions, leading to significant pain and disruption to athletic performance and activities of daily living in athletes. There are currently several methods of assessing the degree of impingement by use of CT and magnetic resonance imaging scans, which can be used in conjunction with magnetic resonance arthrography and arthroscopy to assess the damage caused to the underlying structures of the hip. Both open and arthroscopic surgical methods are used, with recent reports in athletes showing excellent results for lifestyle improvement and frequency of returning to sport. In cases of hip and groin pain in athletes, it is important to remember to look for typical history, and examination and imaging findings that may suggest a diagnosis of hip impingement. This article goes some way to explaining the principles, consequences and management of FAI.     

Femoral neck fractures after arthroscopic femoral neck osteochondroplasty for femoroacetabular impingement

Purpose

The objective of this study was to evaluate the rate, associated risk factors and outcome of insufficiency femoral neck fractures following arthroscopic femoral neck osteochondroplasty for femoroacetabular impingement.

Methods

Between 2005 and 2009, a consecutive series of 376 arthroscopic femoral osteochondroplasties for femoroacetabular impingement were performed and analysed. Seven postoperative fractures were found and comprise the fracture group. The amount of femoral head-neck bone resected as assessed on follow-up cross table lateral views, as well as age, gender, height, weight and BMI, was compared between the fracture group and the entire collective. Subjective outcome was recorded using the WOMAC score.

Results

Seven fractures (1.9 %) were identified. All occurred in males at an average of 4.4 weeks postoperatively and were considered insufficiency fractures. The fracture group had a significantly higher mean age (p = 0.01) and height (p = 0.013). Within the fracture group, alpha angles were lower (p = 0.009) and resection depth ratios were higher (p < 0.001). The femoral offset was significantly higher (p = 0.016) in the fracture group and in male patients (p < 0.001). The cut-off value for resection depth ratio on cross table lateral radiograph was 18 % of the femoral head radius. After a mean follow-up of 20 months, an inferior WOMAC (p = 0.030) was recorded in the fracture group.

Conclusion

Femoral neck insufficiency fractures were identified in 1.9 % of our arthroscopic femoral osteochondroplasty cases. Significant new pain following a period of satisfactory recovery after arthroscopic femoral neck osteochondroplasty should alert the surgeon to the possibility of this complication. If a resection depth ratio of more than 18 % is recognized on the postoperative cross table lateral view, particularly in male patients with a high femoral head-shaft offset, the risk of postoperative insufficiency fracture is increased. This study not only defines the complication rate, but also identifies associated risk factors and determines the influence on the postoperative subjective short-term result. Important information for both the patient and orthopaedic surgeon is provided and may have a direct consequence on the postoperative protocol.

Level of evidence

IV.     

Pulmonary embolism after hip arthroscopy

A case of pulmonary embolus after elective hip arthroscopy is reported. The incidence of thromboembolic events after such procedures is currently unknown, and the decision regarding whether to provide prophylaxis rests on anecdotal evidence.     

The effectiveness of hip arthroscopic surgery for the treatment of femoroacetabular impingement syndrome: A systematic review and meta-analysis

ObjectiveTo determine the effectiveness of hip arthroscopic surgery for the treatment of femoroacetabular impingement syndrome (FAI).DesignSystematic review with meta-analysis.Data sourcesWe performed electronic database searches in MEDLINE, Embase, SPORTDiscus, CINAHL, Cochrane Central Register for Controlled Trials (CENTRAL), Web of Science, Scopus, the WHO International Clinical Trials Registry Platform and ClinicalTrials.gov from their inception to July 10th 2019.Eligibility criteria for selecting studiesWe included randomised controlled trials (RCTs) comparing hip arthroscopic surgery to a placebo/sham surgery and other non-operative comparators (e.g. no intervention, physiotherapy, etc.). Two authors independently selected studies, rated risk of bias, extracted data, and judged overall certainty of evidence using GRADE. Hip-specific quality of life (QoL) at 12 months was the primary outcome.ResultsWe identified three RCTs (n = 650 participants). There is high certainty evidence from three RCTs (n = 574 participants) that hip arthroscopic surgery provided superior outcomes compared to non-operative care for hip-specific QoL at 12 months (mean difference (MD): 11.02 points, 95% CI 4.83–17.21). Low quality evidence suggests that arthroscopic surgery provided similar outcomes to non-operative care for hip-specific QoL at 24 months (MD: 6.3, 95% CI ?6.1 to 18.7).ConclusionHip arthroscopic surgery for FAI provides superior outcomes compared to non-operative care at 12 months, but not at 24 months. Placebo trials are needed to establish the efficacy of hip arthroscopic surgery.