Srino Bharam, MD David Bertone, PT, DPT, OCS

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1 Fall Conference American Physical Therapy Association of NJ October 25 th, 2014 Srino Bharam, MD David Bertone, PT, DPT, OCS Srino Bharam, MD Board certified Orthopedic Surgeon Lennox Hill Hospital, NY, Valley Hospital, NJ Fellowship trained in hip arthroscopy with Dr. Marc Philippon Univ. of Pittsburgh Center for Sports Medicine. Fellowship trained in orthopedic trauma at Harvard Mass. General Hospital. Director of Hip Arthroscopy, attending surgeon orthopaedic residency and sports medicine fellowship, Lenox Hill Hospital, Manhattan. Hip preservation practice, offices in Manhattan and Bergen County National and International lecturer and author in peer reviewed journals on hip arthroscopy and orthopaedic research. David Bertone, PT, DPT, OCS Board certified orthopedic clinical specialist since years of experience in orthopedic rehabilitation President/Owner of db Orthopedic Physical Therapy, PC Member, NJ Board of Physical Therapy Examiners since 2012 Adjunct Instructor, Rutgers, The State University of New Jersey, Doctoral Physical Therapy program. Srino Bharam, MD Arthroscopy Association of North America Research Committee Smith and Nephew Endoscopy Paid Consultant David Bertone, PT, DPT, OCS Member NJBPTE Bharam Bertone Hip Arthroscopy & Rehab

2 Review the pertinent anatomy of the hip joint and surrounding structures. Understand the pathomechanics of hip labral injuries and femoroacetabular impingement (FAI). Interpret clinical and radiographic findings to identify hip dysfunction. Learn conservative management of hip labral tears and FAI. Understand the role of hip arthroscopy for symptomatic FAI. Develop a postoperative rehabilitation program following hip arthroscopy. Understand post operative precautions and progression guidelines. Learn manual and exercise techniques used in recovery/rehabilitation process. Understanding hip anatomy Normal vs pathologic Anatomic variations Role of hip arthroscopy Bharam Bertone Hip Arthroscopy & Rehab 2014 Constrained ball and socket 1.8 to 3.5x body weight during gait cycle Increases 5 to 8x during athletic activity Bharam Clin Sports

3 27 muscles cross hip joint Primary flexors Extensors Abductors Adductors External rotators Dense capsular envelope 3 thickened capsular ligaments Iliofemoral Pubofemoral Ischiofemoral Diarthrodial Constrained Acetabulum triradiate cartilage 45 abd, 15 ant Covers 170 FH Femoral head neck/shaft angle anteversion 3

4 Central Peripheral Peritrochanteric Space Fibrocartilaginous, horse shoe shaped Dimensions Widest anteriorly Thickest superiorly Attachments Ant/pos: transverse ligament Peripheral: capsule Articular side Zone of calcified cartilage Anterior: Well defined chondrolabral junction Anterior: collagen fibers are parallel Posterior: fibers are perpendicular 4

5 Circumferential fibers Capsular side Extends acet coverage 22%, Acet volume 33% Free nerve endings Propioceptive role? Unmyelinated fibers in the ant and sup quadrant Kim 1995 Vascularity Kelly Arthroscopy 2005 No Microvascularity in labral substance Poroelastic finite element model Ferguson et al J Biomech 2000 Labrum intact enhances joint congruity Absent labrum 40% increase cartilage consolidation Increase frictional surfaces Increase subsurface strain and stresses Center of contact shift lateral to acet rim 5

6 Ferguson et al J Biomech human hip joints without labrum 22% early cart degradation Decrease hydrostatic pressurization Ferguson et al J Orthop Res 2001 Bovine labrum compared to meniscus/cart Labrum Low permeability (sealant effect) Increase tensile strength (increase joint stability) Hypoplastic Hyperplastic vs Labral sulcus Cleft between labrum and adjacent cartilage Posterior Can also see anterior cleft 6

7 Insidous onset Traumatic vs repetitive injury During /after activities During/after intercourse Locking/catching Difficulty with walking, sitting, standing, stairs Intra articular vs extra articular??? Labral tear FAI Loose body Chondral injury Ligamentum teres tear Rotatory Instability Femoral neck stress fracture Avascular necrosis Intraarticular Majority anterior superior McCarthy Arthroscopy 2001 Associated with adjacent art cart damage 7

8 Traumatic Degenerative Capsular laxity Philippon 2001 Femoroacetabular impingement Leuning CORE, 2001 Dysplasia 8

9 Concept of FAI Ganz and colleagues 2004 Head neck region reshaped using osteotomes 19 pts mean 36 y/o (21 52), 4.7 yr f/u good results, no osteonecrosis 9

10 Case presentation MGH: 55 y/o female housekeeper hip pain Impingement of the femoral neck on the anterior acetabular margin Focal Prominent ant wall Global Coxa profunda Coxa protusio Iliac spine sign 10

11 Cam Lesion Abnormal Shear Forces Anterior- Superior Labral Tears Chondrolabral Separation Cartilage Delamination 11

12 Osseous bump Pistol grip deform SCFE LCPD Retroversion Typical males s Restriction in motion prior to symptoms Mechanical pain with activity, sports, sitting Gait Standing Seated Supine Lateral Prone 12

13 6 8 stride length Stance, stride length, pelvic rotation Abductor dysfunction Trendelenburg Antalgic Intra articular: short stance Ischiofem impingement : short stride Foot angle progression IR: fem anteversion, torsion ER: fem retroversion, effusion, ligament injury Body habitus, posture Generalized laxity Thumb to forearm Hyperextension elbows, kness Palms to floor Lumbar deformity Hyperlordosis Scoliosis One legged stance One legged squat Crossley et al AJSM

14 Snapping ITB Trendelenburg test Pelvis drop from unsupported side secondary weak abduct Neurologic DTR, sensory, motor Seated SLR Lower ext pulses Skin and lymphatics Passive IR/ER Resisted Adduction 14

15 Passive Flex/ext (110/0) Abd/add (45/30) IR/ER (30/50) Flexion contracture Contralateral side held in full flexion Passive extension examined side Palpation pubic symphysis, lower abd exam adductor tubercle Resisted sit up Anterior Impingement hip flexion 90º, adduction and maximal IR FABER (Patrick) Ant pathology Ant instability SI Joint 15

16 Posterior Impingement Stinchfield test Log roll test Anterior instability Extension and ER Dynamic internal rotatory impingement DIRI Dynamic external rotatory impingement DEXRIT Martin et al 2014 Philippon, et al ESSKA patients performed preop exam Confirmed + test correlated with capsular laxity found intraop 16

17 17

18 1.5 Tesla, hip coil Arthro vs plain mri: 8% vs 42% FN 10% vs 20% FP Intra artic injection: 7% FN Byrd et al AJSM 2004 Coronal PD Kawan et al CORE pts with FAI symptoms Axial oblique: 53.5 Radial:

19 Activity modification NSAIDs Physiotherapy Injections Guided Diagnostic/Anesthetic Therapeutic Steroid Viscosupplementation PRP Avoid significant DJD Avoid significant dysplasia No relief with conservative tx Manage patient expectations 19

20 Supine Position Anterior Anterolateral MidAnterior DALA Posterolateral Anterolateral Anterior labrum Ant acet wall Ant loaded fem head Mid Anterior View other portal placement(s) Lateral labrum 20

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23 Traction removed Hip flexed 45 degrees 70 degree scope redirected head/neck jct (or accessory 2 3cm distal to anterolateral) Systematic exam Dienst Counterclockwise 23

24 Bharam Bertone Hip Arthroscopy & Rehab

25 Anderson et al JBJS % delam of 64 FAI pts during open sx Associated with males and CAM type MRA 22% sen, 100% spec Best seen on sag T1, PD images Pffirmann et al Radiology pts with isolated CAM (m 30.7 y/o) 52% delam avg 7.6mm, range 2 30mm MRA: 22% sen, 95% spec 25

26 Bedi, Zaltz, Kelly AJSM 2011 Level 3 evidence 60 pts under 40 y/o with CAM Arthroscopic grp Correction: 17.2 Lat, 12.6 AP Surgical hip dislocation grp Correction: 21.2 Lat, 20.1 AP Open surgery may be considered for posterior and proximal femoral head deformity. 26

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28 Athlete #1 Athlete #2 Soft tissue Impingement Psoas impingement Bony Impingement AIIS overgrowth 28

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30 45 professional athletes with FAI 93% return to play with arthroscopic decompression Fabricant et al CORR 2012 Level 4 24/27 athletes cam resection Alpha angle improved 64 to yr f/u Improved HOS and MHHS Javed, O Donnell JBJS pts (60 82, mean 65 y/o) Avg f/u 30 months (12 54) Improved MHHS (19 pts) Improved HOS (15 pts) High patient satisfication 7 pts underwent THR 30

31 Proper patient selection Appropriate imaging Patient expectations Future: Long term outcomes History, Mechanism of Injury Surgical procedures get detail, precautions Past Medical History, Medication Functional goals Use of Outcome measures: International Hip Outcome Tool (ihot 33) Hip Outcome Scale (HOS) Copenhagen Hip and Groin Outcome Score (HAGOS) Modified Harris Hip Score (mhhs) Lower Extremity Functional Scale (LEFS) Symptom scores Subjective complaints ADL status Occupation/Sports Objective Posture evaluation Gait assessment Skin, post op wound status AROM, MMT caution with iliopsoas Clear lumbar spine Palpation Flexibility 31

32 Dippman et al 2014 clinical outcomes 3, 6 and 12 months after hip arthroscopy with labral repair for FAI. 87 patients (55 female, 32 male 38mean age) mhhs and 100pt VAS pre post op intervals Precautions 90 flexion, 25 abd, PMB 4weeks 26 page HEP and training manual (Dutch) Stalzer et al rehab progression model Mobility, stability, strength, return to sports mhhs VAS 32

33 Improvement in function and pain can be expected within first 3months of surgery. Post op WB ing needs to be studied. 4 weeks PWB for femoral osteoplasty Modification of rehab program after 3months may change outcome scores. Need standardization of outcome tools. Phase 1 (MOBILITY) 0 4 weeks Protect repaired tissue Restore ROM within restrictions CPM?, bike, PROM, AROM Decrease pain and inflammation Ice, NSAIDS, IFES Prevent muscle inhibition isometrics Precautions Do not push through hip flexor pain! Observe ROM restrictions Avoid SLR flexion WB ing restrictions Phase 2 (STABILITY) 4 6weeks Continue to protect repaired tissue Restore FULL ROM Restore NORMAL gait pattern Increase muscle strength Precautions No forced stretching or ballistic movements Avoid hip flexor irritation No treadmill use? 33

34 Phase 3 (STRENGTH) 6 8weeks Restore muscle endurance/strength Restore CV endurance Optimize neuromuscular control/balance/prop Precautions No forced stretching or ballistic movements Avoid hip flexor irritation No contact activities No treadmill use? Phase 4 (RETURN TO SPORT) 8 16weeks Criteria for FULL return to competition FULL pain free ROM Hip strength > 85% Ability to perform sport specific drills at full speed painfree Completion of functional sports test Labral repair majority ant/sup labrum Hip flexion to 90 deg 10 days Hip abd to 25 deg 3 weeks Hip ER to 25 deg 3 weeks Osteoplasty Avoid hip impingement positions and inflammation of iliopsoas. Limit impact with significant femoral neck shaving. Hip to 90 deg 10 days 34

35 Microfracture Be aware of size and location of chondral lesion Hip flexion to 90 deg 10 days Strict adherence to WB ing per MD. Avoid compression/shear exercises CPM critical Capsular repair Majority in ant. capsule Caution with ER and ext 3 weeks Bracing to restrict ER Willimon, Briggs and Philippon in 2014 Retrospective study of 1264 hip arthroscopies during 4 year period. Risk factors for adhesions <30 years of age 5.9 times more likely mhhs < times Microfracture procedure 3.1 times Circumduction exercises performed passively 3 times/day reduced risk! CPM use 8hrs/day, 2 4 weeks 15 Femoral acetabulum joint hypomobility Adhesive capsulitis Psoas tendinopathy Myofascial trigger points Can develop with delay in early post op joint mobilization. Overly aggressive strength training. 3 35

36 Psoas, Iliacus and Inguinal ligament Apply deep manual pressure to improve muscle play and length tension relationship. 3 Thumb contact/reinforced opposite hand. Pressure based on depth of muscle and patient tolerance. Direction parallel to fibers of targeted muscle to remove tissue slack. Active or AA movement of limb, muscle from shortened to lengthened position. Hand pressure opposite to movement direction. Several repetitions of pattern 3sec mvmt, 3 sec hold at end. 4 Cashman G, Mortenson W, Gilbert M. Myofascial treatment for patients with acetabular labral tears: a single subject research design study. JOSPT. 2014; 44(8):

37 Improve passive accessory motion of the hip joint capsule and to decrease central nociceptive excitability. 3 Enhance cartilage healing? 5 Hip stability modulated by deep local muscles 11 Gluteus minimis Abd, flex, IR RTC Attaches sup aspect of capsule Quadratus femoris Gemelli ER Obturator internus/externus Iliocapsularis Anteromedial hip capsule/inf border of AIIS to lesser trochanter tighten ant capsule? Deep fibers of iliopsoas Stabilize late phase of gait 37

38 Retchford T et al. Can local muscles augment stability in the hip? A narrative literature review. J Musculoskeletal Neuronal Interact. 2013; 13(1): Deep ER muscles Secondary stabilizers Prime movers 38

39 39

40 Pre op evaluation to identify motor control, stability deficits when possible. 5 Protect soft tissue repair and reduce inflammation early. Restoration of normal ROM and correct muscle firing patterns EARLY is critical. Mid phase joint mobilization to prevent capsular adhesions. Close monitor symptoms with load progression Caution with ER capsule repair Avoid toe touch WB ing irritation of iliopsoas Eliminate crutches normal gait pattern Upright bike better than recumbent Watch hip flexion >90 early No resistance, progress time Individualize the rehab program NO PROTOCOLS but guidelines! AVOID hip flexor/adductor irritation. DON T be overly aggressive! 40

41 1. Burman M. Arthroscopy or the direct visualization of joints. J Bone Joint Surg. 1931;4: Dienst M, Godde S, Seil R, Hammer D, Kohn D. Hip arthroscopy without traction: In vivo anatomy of the peripheral hip joint cavity Arthroscopy. 2001; 17: Voos JE, Rudzki JR, Shindle MK, Martin H, Kelly BT. Arthroscopic anatomy and surgical techniques for peritrochanteric space disorders in the hip Arthroscopy. 2007;23:1246.e Byrd JW. Hip arthroscopy by the supine approach. Instr Course Lect. 2006;55: Glick JM. Hip arthroscopy by the lateral approach. Instr Course Lect. 2006;55: Lynch TS, Terry MA, Bedi A, Kelly BT. Hip arthroscopic surgery: patient evaluation, current indications, and outcomes. Am J Sports Med May;41(5). 7. Dienst M, Seil R, Kohn DM. Safe arthroscopic access to the central compartment of the hip. Arthroscopy Dec;21(12): Dorfmann H, Boyer T. Arthroscopy of the hip: 12 years of experience. Arthroscopy Jan Feb;15(1): Byrd JW Avoiding the labrum in hip arthroscopy. Arthroscopy Oct;16(7): Robertson WJ, Kelly BT. The safe zone for hip arthroscopy: a cadaveric assessment of central, peripheral, and lateral compartment portal placement. Arthroscopy Sep;24(9): Byrd JW, Pappas JN, Pedley MJ. Hip arthroscopy: An anatomic study of portal placement and relationship to the extra articular structures. Arthroscopy. 1995;11: Badylak JS, Keene JS. Do iatrogenic punctures of the labrum affect the clinical results of hip arthroscopy? Arthroscopy Jun;27(6): Aoki SK, Beckmann JT, Wylie JD. Hip arthroscopy and the anterolateral portal: avoiding labral penetration and femoral articular injuries. Arthrosc Tech Aug 17;1(2):e Byrd JWT. Complications associated with hip arthroscopy. JWT Byrd (Ed.), Operative Hip Arthroscopy, Thieme, New York (1998), pp J.W.T. Byrd, K.S. Jones Hip arthroscopy for labral pathology: Prospective analysis with 10 year follow up. Arthroscopy. 2009;25: Bharam Bertone Hip Arthroscopy & Rehab Byrd JW. Hip arthroscopy. J Am Acad Orthop Surg. 2006;14(7): Bond JL, Knutson ZA, Ebert A, Guanche CA. The 23 point arthroscopic examination of the hip: basic setup, portal placement, and surgical technique. Arthroscopy Apr;25(4): Grothaus MC, Holt M, Mekhail AO, Ebraheim NA, Yeasting RA. Lateral femoral cutaneous nerve: An anatomic study. Clinic Orthop Relat Res. 2005: Sussmann P, Zumstein M, Hahn F, Dora C. The risk of vascular injury to the femoral head when using the posterolateral arthroscopy portal: Cadaveric investigation. Arthroscopy. 2007;23: Sevitt S, Thompson RG. The distribution and anastomoses of arteries supplying the head and neck of the femur. J Bone Joint Surg Br Aug;47: E. Gautier, K. Ganz, N. Krugel, T. Gill, R. Ganz Anatomy of the medial femoral circumflex artery and its surgical implications J Bone Joint Surg Br. 2000;82: Ilizaliturri VM Jr. Complications of arthroscopic femoroacetabular impingement treatment: a review. Clin Orthop Relat Res. 2009;467(3): Bedi A, Galano G, Walsh C, Kelly BT. Capsular management during hip arthroscopy: from femoroacetabular impingement to instability. Arthroscopy Dec;27(12): Martin HD, Savage A, Braly BA, Palmer IJ, Beall DP, Kelly B. The function of the hip capsular ligaments: A quantitative report. Arthroscopy.2008;24(2): Sampson TG. Complications of hip arthroscopy. Clin Sports Med. 26. Bartlett CS, DiFelice GS, Buly RL, Quinn TJ, Green DS, Helfet DL. Cardiac arrest as a result of intraabdominal extravasation of fluid during arthroscopic removal of a loose body from the hip joint of a patient with an acetabular fracture. J Orthop Trauma. 1998;12(4): Fowler J, Owens B. Abdominal compartment syndrome after hip arthroscopy. Arthroscopy. 2010;26(1): Ladner B, Nester K, Cascio B. Abdominal fluid extravasation during hip arthroscopy. Arthroscopy. 2010;26(1): Ayeni OR, Bedi A, Lorich DG, Kelly BT Femoral neck fracture after arthroscopic management of femoroacetabular impingement: A case report. J Bone Joint Surg Am. 2011;93(9). 30. Hewitt JD, Glisson RR, Guilak F, Vail TP. The mechanical properties of the human hip capsule ligaments. J Arthroplasty Jan;17(1): Moss SG, Schweitzer ME, Jacobson JA, Brossmann J, Lombardi JV, Dellose SM, Coralnick JR, Standiford KN, Resnick D. Hip joint fluid: detection and distribution at MR imaging and US with cadaveric correlation. Radiology Jul;208(1): Deinst M, Seil R, Kohn DM. Safe Arthroscopic Access to the Central Compartment of the Hip. Arthroscopy Dec;21(12):15: Bharam Bertone Hip Arthroscopy & Rehab

42 1. Bharam S. Labral tears, extra articular injuries, and hip arthroscopy in the athlete. Clinics Sports Med. 2006; 25(2): Pierce C et al. Ice hockey goaltender rehabilitation, including on ice progression, after arthroscopic hip surgery for femoroacetabular impingement. JOSPT. 2013; 43(3): Lebeau R, Nho S. The use of manual therapy post hip arthroscopy when an exercise based therapy approach has failed: a case report. JOSPT. 2014; 44(9): Cashman G, Mortenson W, Gilbert M. Myofascial treatment for patients with acetabular labral tears: a single subject research design study. JOSPT. 2014; 44(8): Orbell S, Smith T. The physiotherapeutic treatment of acetabular labral tears, a systematic review. Adv in Physiotherapy. 2011; 13: Nawabi D et al. The demographic characteristics of high level and recreational athletes undergoing hip arthroscopy for femoroacetabular impingement: a sports specific analysis. Arthroscopy: Journal of Arthroscopic and Related Surgery. 2014; 30(3): Bennell K et al. Efficiacy of a physiotherapy rehabilitation program for individuals undergoing arthroscopic management of femoroacetabular impingement the FAIR trial: a randomized controlled trial protocol. BMC Musculoskeletal Disorders. 2014; 15:58: Tijssen et al. Diagnostics of femoroacetabular impingement and labral pathology of the hip: a systematic review of the accuracy and validity of physical tests. Arthroscopy: Journal of Arthroscopic and Related Surgery. 2012; 28(6): Tibor L Sekiya J. Differential diagnosis of pain around the hip joint. Arthroscopy: Journal of Arthroscopic and Related Surgery. 2008; 24(12): Ayeni O et al. A painful squat test provides limited diagnostic utility in CAM type femoroacetabular impingement. Knee Surg Sports Traumatol Arthrosc. 2014; 22: Retchford T et al. Can local muscles augment stability in the hip? A narrative literature review. J Musculoskeletal Neuronal Interact. 2013; 13(1): Alzaharani A et al. The innervation of the human acetabular labrum and hip joint: an anatomic study. BMC Musculoskeletal Disorders. 2014; 15:41: Stalzer S, Wahoff M, Scanlan M. Rehabilitation following hip arthroscopy. Clin Sports Med. 2006; 25: Willimon S, Briggs K Philippon M. Intra articular adhesions following hip arthroscopy: a risk factor analysis. Knee Surg Sports Traumatol Arthrosc. 2014; 22: Enseki K. et al. The hip joint: arthroscopic procedures and postoperative rehabilitation. JOSPT. 2006; 36(7): Dippmann C et al. Hip arthroscopy with labral repair for femoroacetabular impingement: short term outcomes. Knee Surg Sports Traumatol Arthrosc. 2014; 22: Smith M et al. A biomechanical analysis of the soft tissue and osseous constraints of the hip joint. Knee Surg Sports Traumatol Arthrosc. 2014; 22: Spencer Gardner L et al. A comprehensive five phase rehabilitation programme after hip arthroscopy for femoroacetabular impingement. Knee Surg Sports Traumatol Arthrosc. 2014; 22: Bharam Bertone Hip Arthroscopy & Rehab

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