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Rehabilitation Guidelines for Hip Arthroscopy Procedures

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Rehabilitation Guidelines for Hip Arthroscopy Procedures JUSTIN D. HUDSON, MD Orthopaedic Surgery and Sports Medicine JustinHudsonMD.com [email protected] P: (541) 242-4812 F: (541) 242-4813 Rehabilitation Guidelines for Hip Arthroscopy Procedures Lunate surface of acetabulum Articular cartilage Anterior superior iliac spine The hip is a ball-and-socket joint. Head of femur Anterior inferior iliac spine The socket is formed by the Iliopubic eminence acetabulum, which is part of the Acetabular labrum large pelvis bone. The ball is the Greater trochanter (fibrocartilainous) femoral head, which is the upper Fat in acetabular fossa (covered by synovial) end of the femur (thighbone).The hip Neck of femur Obturator artery joint allows flexion and extension as well as rotation of the thigh and Anterior branch of leg. Because the hip is responsible Intertrochanteric line obturator artery Posterior branch of for transmitting the weight of the obturator artery upper body to the lower extremities, Obturator membrane the joint is subjected to substantial Ischial tuberosity forces. Walking transmits 1.3 to Round ligament Acetabular artery (ligamentum capitis) Lesser trochanter Transverse 5.8 times body weight through the acetabular ligament joint. Running and jumping can generate forces across the joint Figure 1 Hip joint (opened) lateral view equal to 6 to 8 times body weight. The acetabulum is ringed by strong fibrocartilage called the labrum. The labrum forms a gasket around the socket, Spine creating a tight seal and helping to provide stability to the joint. The iliopsoas tendon lays across the anterior hip joint and connects the Iliopsoas muscle-tendon fibers of the psoas major and iliacus muscles to the proximal femur (lesser Iliopectineal trochanter). It can become irritated bursa when there is inflammation deeper in the hip caused by inflamed structures Bursa (see figure 2). Hip joints of athletes are exposed to extremes of motion. Pelvic bone Femur These forces are absorbed by and can injure the labrum. It is currently thought that the labrum may also be injured by impingement of the hip, also called femoroacetabular impingement, or FAI. Figure 2: Diagram of the iliopsoas muscle-tendon and bursa. FAI is a condition in which extra bone grows along the bones that form the hip joint. Because the bones do not fit together perfectly, they rub against each other during movement. This friction can damage the joint, causing pain and limiting activity. There are three types of FAI: • Pincer. This occurs when extra bone extends out over the normal rim of the acetabulum. The labrum can be crushed under the prominent rim of the acetabulum. • Cam. the femoral head is not round and cannot rotate smoothly inside the acetabulum. A bump forms on the edge of the femoral head that grinds the Figure 3: Frog leg radiograph: The thin arrow on your left indicates the area of “flattening” of the cartilage inside the acetabulum. right femoral head and lack of the normal femoral head-neck offset. The thick arrow on the right Figure 3 demonstrates the boney indicates the more normal, rounded contour of the left femoral head. abnormality associated with cam impingement of the right with sitting is common with patients indicated that the hip pain is likely hip; note the difference in the who have FAI. Patients will often due to the labral tear. Labral repair shape of the femoral head. describe a deep discomfort in the restores the normal suction seal of anterior groin while sitting. The the hip joint. Hip arthroscopy is • Combined. Combined pain can also be directly lateral or performed on an outpatient basis impingement just means deep within the buttocks. Flaps under general anesthesia. The hip is that both the pincer and from damaged articular cartilage placed in traction to open the joint cam types are present. may cause mechanical symptoms enough to allow for the insertion Cam and pincer impingement often causing pain during or after of the instruments. After marking can co-exist. When the normal weight bearing and impact activities, out the anatomical landmarks with ball and socket function is lost, such as running and jumping. x-ray guidance, three to four small impingement may occur as the incisions are made in the area of Non-operative treatment of painful hip is flexed toward its end range. the hip joint. One incision is used labral tears is usually not successful, This is often made worse with to insert a camera that displays the but 33-69% of young adults and adduction and internal rotation. inside of the hip joint on a monitor 73% of people over age 50 have Repetitive impingement can cause and the other incisions are used to labral tears seen on MRIs, with no labral tears and fracturing of the insert the surgical instruments used symptoms. In pediatric patients acetabular articular cartilage. Labral for repairing labral tears, debriding (aged 2-18 years) the rate of tears can cause sharp, catching defective cartilage, removing asymptomatic labral tears is quite pain, popping or locking during bone spurs associated with pincer low, about 1.4%. Somebody in that activities including running, kicking impingement and removing loose age group is unlikely to have a or changing directions. Most people bodies. The anterior hip joint labral tear that does not cause them with this injury will also experience capsule is entered using a small some pain. Arthroscopic repair of a more subtle, dull, activity-induced incision called a capsulotomy. The labral tear is suggested when clinical positional pain while sitting. Pain FAI is then treated using a burr tests and imaging studies have 2 to reshape the femoral head-neck Rehabilitation of the hip begins the offset. This is called a proximal day after surgery. The rehabilitation femoral osteoplasty. The goal guidelines are presented in a is to restore the normal ball on criterion-based progression and socket function so that the hip can each patient will progress at a move through the full range of different rate depending on the motion without impingement. Hip specific procedure performed, age, arthroscopy can also be used to preinjury health status and rehab treat articular cartilage lesions inside compliance. The patient may also the joint and the pain generators have postoperative hip and thigh directly outside of the hip joint pain which can slow the recovery including mechanical symptoms Figure 4: T2 MR image showing abductor rate. This can be caused by traction that come from the iliopsoas tendon tendon tears (yellow arrows) at the greater on the hip during surgery. There trochanter of the femur. as it crosses the front of the joint may also be reflex inhibition and hip abductor tendon tears. The iliopsoas can snap over the and poor control of the muscles Treatment of articular cartilage iliopectineal eminence and bursae that stabilize the hip immediately lesions is done by creating small (Figure 2). While the snapping can following hip arthroscopy. holes in the subchondral bone of be painful, anterior hip pain due Aggressive range of motion (ROM) the defect to promote the inflow of to iliopsoas bursitis and tendonitis is avoided in order to protect the blood and stem cell in the hopes may occur without snapping of repaired labrum, the repair of that these elements will lead to the tendon. It should be noted that the capsulotomy, and the now the growth of fibrocartilage to fill asymptomatic snapping can be sensitive bony areas that have been the chondral defect. Although the common in hypermobile athletes. recontoured. It is important to use fibrocartilage is not as strong as the Non-operative treatment (physical crutches for the first two to three original hyaline cartilage, it does act therapy and basic psoas bursa weeks after surgery to minimize to create continuity of the surface. injections) is successful in getting forces on the back and pelvic joints while developing pain control, Hip arthroscopy has allowed for almost two thirds of patients with protecting repaired structures and the repair of hip abductor (gluteus painful snapping hips back to full avoiding compensatory habits that medius and minimus) tendon activity. When these measures fail, can prolong post-operative pain. tears. Figure 4 shows an image of an arthroscopic management of the All exercises should be performed an abductor tendon tear. Suture iliopsoas tendon may be performed within pain tolerance. Pushing to anchors are placed in the greater and does provide long-term relief extremes of motion beyond pain tuberosity and then the sutures are of the snapping and pain. This tolerance does not enhance function passed through the torn tendon can include surgical lengthening of but rather increases discomfort and the tendons are brought back the iliopsoas tendon or deepening and prolongs rehabilitation. Rehab to their anatomic location on the the groove beneath the tendon to in the first 6 weeks following hip femur. This is similar to a rotator potentially help limit its movement arthroscopy emphasizes muscle cuff repair in the shoulder. To as a means of reducing irritation. activation and hip stability, working allow the tendon to heal back While up to 80% of patients who within range of motion restrictions. to the bone after this procedure, have a lengthening procedure for weight bearing and strengthening the tendon report improvement exercises will be limited in the first in symptoms of painful snapping, post-operative rehabilitation phase. there is a possibility of chronic hip flexor weakness and pain Iliopsoas tendon dysfunction is following this procedure. a source of anterior hip pain. 3 Rehabilitation Principals: Frequently asked questions: 1. Patients may stand and walk 1. When can I shower? 6. When can I drive? with 20% of their body weight You will be able to shower 72 You must be off all opioid pain on their surgical leg for hours after surgery.
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