Jeffrey S. Grzybowski

Rehabilitation Following Hip Arthroscopy – A Systematic Review

Context Rehabilitation following hip arthroscopy is an integral component of the clinical outcome of the procedure. Given the increase in quantity, complexity, and diversity of procedures performed, a need exists to define the role of rehabilitation following hip arthroscopy. Objectives (1) To determine the current rehabilitation protocols utilized following hip arthroscopy in the current literature, (2) to determine if clinical outcomes are significantly different based on different post-operative rehabilitation protocols, and (3) to propose the best-available evidence-based rehabilitation program following hip arthroscopy. Data sources Per PRISMA guidelines and checklist, Medline, SciVerse Scopus, SportDiscus, and Cochrane Central Register of Controlled Trials were searched. Study selection Level I–IV evidence clinical studies with minimum 2-year follow-up reporting outcomes of hip arthroscopy with post-operative rehabilitation protocols described were included. Data extraction All study, subject, and surgery parameters were collected. All elements of rehabilitation were extracted and analyzed. Descriptive statistics were calculated. Study methodological quality was analyzed using the modified Coleman methodology score. Results Eighteen studies were included (2,092 subjects; 52% male, mean age 35.1 ± 10.6 years, mean follow-up 3.2 ± 1.0 years). Labral tear and femoroacetabular impingement were the most common diagnoses treated and labral debridement and femoral/acetabular osteochondroplasty the most common surgical techniques performed. Rehabilitation protocol parameters (weight-bearing, motion, strengthening, and return to sport) were poorly reported. Differences in clinical outcomes were unable to be assessed given heterogeneity in study reporting. Time-, phase-, goal-, and precaution-based guidelines were extracted and reported. Conclusion The current literature of hip arthroscopy rehabilitation lacks high-quality evidence to support a specific protocol. Heterogeneity in study, subject, and surgical demographics precluded assimilation of protocols and/or outcomes to generate evidence-based guidelines. Strengths and limitations in the literature were identified. Future studies should recognize and report the essentials of rehabilitation following hip arthroscopy.

High Rate of Return to Running for Athletes After Hip Arthroscopy for the Treatment of Femoroacetabular Impingement and Capsular Plication

Background: Femoroacetabular impingement (FAI) is most commonly diagnosed in athletes who sustain repetitive flexion loading to their hips. No studies to date have focused solely on patients’ return-to-running ability after hip arthroscopy. Purpose: To evaluate patients’ ability to return to running after hip arthroscopy for FAI and capsular plication. Study Design: Case series; Level of evidence, 4. Methods: Clinical data were retrospectively retrieved for 51 consecutive patients with FAI (22 men, 29 women) who had undergone hip arthroscopy for the treatment of FAI and identified themselves as recreational or competitive runners on intake forms. Two-year outcome measures included the modified Harris Hip Score (mHHS) and the Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sport-Specific (HOS-SS) subscales. A postoperative return-to-running survey was used to obtain running-specific information. Results: Patient age and body mass index (BMI) were a mean (±SD) of 26.3 ± 7.8 years and 23.7 ± 3.3 kg/m2, respectively. Before surgery, patients had refrained from running because of pain for a mean of 8.1 ± 5.7 months. After surgery, 48 patients (94%) returned to running at a mean of 8.5 ± 4.2 months. Patients who had discontinued running for more than 8 months before surgery had a longer return-to-running time than did those who had stopped for less than 8 months (10.6 ± 4.2 vs 7.6 ± 4.1 months; P = .01). After 2 years, mean preoperative distance had decreased significantly (P < .01) from 9.5 ± 6.5 miles per week when healthy to 6.4 ± 5.8 miles postoperatively. Despite decreased mileage, all 2-year outcomes scores improved significantly (P < .001). Conclusion: Recreational and competitive runners with FAI returned to running 94% of the time at a mean of 8.5 months after hip arthroscopy. However, runners should be counseled before their surgery that they may run fewer miles than when they were pain free. Additionally, patients with a higher BMI and/or longer preoperative lull may have a longer recovery time.

All-Endoscopic Single-Row Repair of Full-Thickness Gluteus Medius Tears.

Abductor tendon tears typically develop insidiously in middle-aged women and can lead to debilitating lateral hip pain and a Trendelenburg limp. The gluteus medius tendon is most commonly torn and may show fatty degeneration over time, similar to the rotator cuff muscles of the shoulder. Endoscopic repair offers a therapeutic alternative to traditional open techniques. This article describes the workup, examination, and endoscopic repair of a full-thickness gluteus medius tear presenting as lateral hip pain and weakness. The surgical repair for this case used a single-row suture anchor technique. In addition, the indications and technique for a double-row repair will be discussed.

Capsular Plication for Treatment of Iatrogenic Hip Instability

The most commonly reported reasons for persistent hip pain after hip arthroscopy are residual femoroacetabular impingement, dysplasia and dysplasia variants, or extra-articular impingement. There are some cases in which the underlying osseous pathomorphology has been appropriately treated, and the cause of persistent hip pain can be soft-tissue injuries such as chondrolabral tears or capsular abnormalities. Capsular defects after hip arthroscopy may suggest an alteration of the biomechanical properties of the iliofemoral ligament and lead to iatrogenically induced hip instability. There are a growing number of biomechanical and clinical studies showing the importance of capsular management during hip arthroscopy. We describe the workup, examination under anesthesia, diagnostic arthroscopy, and technique of capsular plication for iatrogenic instability of the hip.

Diagnosis, Evaluation, and Endoscopic Repair of Partial Articular Gluteus Tendon Avulsion

In addition to trochanteric bursitis, gluteus medius and minimus tears (GMMTs) can be a common source of insidious lateral hip pain and dysfunction. Partial-thickness GMMTs are much more common than full-thickness GMMTs but are frequently overlooked by both radiologists and orthopaedic surgeons. GMMTs are commonly identified on magnetic resonance imaging ordered for lateral hip pain unresponsive to conservative management. Imaging can show that high-grade partial articular gluteus tendon avulsion (PAGTA) can occur as either an isolated gluteus medius tear, an isolated gluteus minimus tear, or a combined GMMT. We describe how to identify PAGTA injuries with intraoperative assessment and identification of the interval between the gluteus medius and minimus tendons to allow access to the PAGTA without violating the bursal side of the tendon. PAGTAs can be repaired arthroscopically by single- or double-row suture anchor fixation depending on the size of the tear. The purpose of this article is to guide orthopaedic surgeons in the recognition of PAGTA with magnetic resonance imaging and dynamic examination to allow for accurate repair of GMMTs.

Outcomes for Hip Arthroscopy Based on Sex and Age: A Comparative Matched-Group Analysis

Objectives: The purpose of this study was to compare the clinical outcomes of patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) based on sex and age. Methods: A total of 150 patients undergoing hip arthroscopy for FAI by a single fellowship-trained surgeon were prospectively analyzed, with 25 patients categorized in each of the following groups: A) females ≤30 years,B) females 31-45 years, C) females >45 years, D) males ≤30 years, E) males 31-45 years and F) males >45 years. Primary clinical outcomes included the Hip Outcome Score Activity of Daily Living (HOS-ADL) and Sport-Specific Subscales (HOS-SS), the modified Harris Hip Score (mHHS), and clinical improvement at final follow-up. Statistical analysis was performed utilizing ANOVA with post-hoc Tukey HSD tests, with P<0.05 considered significant. Results: One-hundred forty of 150 patients (93%) were available for follow-up at an average 2.72±0.43 years (minimum, 2 years), with no differences in follow-up rates between the 6 groups (P<0.05). All groups demonstrated significant improvements in HOS-ADL, HOS-SS, and mHHS outcomes at final follow-up (P<0.001). Females >45 scored significantly worse on the HOS-ADL, HOS-SS, and mHHS compared to females ≤30 (P<0.0001, P=0.001, P<0.0001 respectively) and females 30-45 (P=0.015, P<0.0001, P=0.001 respectively). Similarly, males >45 scored significantly worse on the HOS-ADL, HOS-SS, and mHHS compared to males ≤30 (P=0.012, P=0.015, P=0.022 respectively) (Figure 1). Males >45 scored significantly better than females >45 on the HOS-SS (P=0.013) and the mHHS(P=0.024). Incorporating both sexes, patients >45 scored significantly worse on the HOS-ADL, HOS-SS, and mHHS compared to patients ≤30 (P<0.0001, P<0.0001, P<0.0001, respectively) and patients 30-45 (P=0.005, P<0.0001, P=0.008, respectively). Conclusion: While all patients had significant improvements in all outcomes following hip arthroscopy for FAI, patients >45 years performed worse compared to patients in younger age groups, with females >45 years demonstrating the poorest outcome scores. This data can be used to counsel patients preoperatively and to individualize care to optimize outcomes following hip arthroscopy for FAI.