Hello, everyone. My name is Steve Aoki. I am faculty at the University of Utah. Today I'll be going over a lecture for the ANNA toolkit series on hip arthroscopy, when to rehab and when to revise. I appreciate the opportunity to present this talk and would like to thank the ANNA staff for their time and commitment to this series. As with any hip arthroscopy for femoral acetabular impingement, our priority is to perform a surgery that addresses the soft tissue and bony morphology, which in most cases is referring to fixing the labrum and reshaping the femur and or the acetabulum. We try to accomplish this task as best as possible while minimizing damage to the surrounding tissues. After performing a hip sculpt, the rehabilitation process begins. Most rehab protocols have a component of both time and criteria-based advancements, although there are no universal agreements as to the ideal protocol. The reality is that an ideal rehab protocol should probably be tailored to the patient. I've included my protocol for your reference. When looking at general principles, most hip arthroscopy protocols incorporate both a functional and time progression. As with any orthopedic PT protocol, there is a little bit of wriggle room for slowing or speeding up the rehab process according to how the patient is progressing. However, too much of a deviation away from the recommendations can lead to potential problems. There's a balance between doing too little and doing too much. If doing too little, the patient may experience deconditioning, stiffness, weakness, and a decrease in function. On the flip side, doing too much may lead to pain, inflammation, stress reactions, and potentially other injuries. For me, the first step in assessing a patient's progression, particularly if they're not doing as well as expected, is to identify what are they doing for rehab, and are they maintaining a reasonable program that is staying on task? Getting back to the question of when to rehab and when to revise, I think the first question that we have to ask ourselves is, why are we asking the question in the first place? Is the patient not hitting their expectations? Is the patient not reaching my expectations? When we look at measurements like the minimally clinically important difference, substantial clinical benefit, and patient acceptable symptomatic state, it may help us in measuring a clinically meaningful outcome, although the numbers don't do a very good job of evaluating the individual patient. If a patient is reaching the MCID, SCB, and PAS, and they are still unable to reach the function of the level of activity that they want to participate in, then they aren't meeting their expectations. When trying to understand the recovery processes after a hip scope, it's important to look at the literature. Now, this is an early 2017 systematic review with meta-analysis of 26 studies investigating the recovery curve after a hip arthroscopy for FAI. The important take-home points from this study are that pain and ADL improvements occur around the three- to six-month window, and sports typically improve around the six- to 12-month window. One other important take-home point from this article is that pain, ADLs, and sports function, while slow, they continue to improve up to two years out from the surgery. So this gives us a pretty decent idea of what to expect with a typical patient. Another study published in 2018 looking at recovery curves shows very similar findings with MCID and substantial clinical benefit being reached by six months, with outcome improvements continuing to improve up to two years after surgery. A couple other interesting points noted in this manuscript was that there were differences in the patient's recovery curves with older male patients and those with out-of-reach one or greater taking longer to improve. Also those patients with higher preoperative PROs took longer to achieve the MCID and SCB as well. Another study out of Shane Nose Group at Rush looked at MCID, SCB, and PAS at one-, two-, and five-year intervals. Again, similar findings with continued improvement out to two years out. Interestingly, they also found that outcomes did slightly fall at the five-year mark. If your patient isn't doing as well as expected, it's important to gather the information as to why. Is this a pain issue? Do they hurt with activity progression, or is this a problem where they hurt at baseline? Do they feel weak? Does the hip feel too stiff or too loose? Are they frustrated because they have unreasonable expectations and they expected to be doing their sports earlier than your protocol allowed? Was there an injury that set this all off? Was there an event where you went from doing well to doing poorly quickly? Can the patient identify any particular reason in the post-op recovery process that they can attribute to not doing well? I'm going to break the case scenarios into three main groups of people that I see after hip arthroscopy. The first scenario is the person that continues to return to clinic. They're continuing to improve, but the process is slower than expected. They typically notice that the hip is allowing them to do more as time progresses, but their expectations are not being met. In these situations, the question as to when to rehab is always. I'm not a big fan of using strong adverbs of frequency like always in my vocabulary, but in this case, it's hard to change course if someone is improving, even if the process is slow. In these cases, I try to get the patients to focus on any non-surgical treatments that may be helping. First, working with a therapist or trainer to focus on comfortable strengthening and conditioning that targets progression of activity in a way that minimizes pain. It's also important to assess how far away the patient is from reaching their goals. There's a big difference in the patient that is wanting to be more comfortable with their daily housework versus that patient who is looking to get back to aggressive competitive sport. One other point that I would make here is that anytime I have a patient that is not hitting expectations, as painful as it may be, I see them back more frequently so I can have a better sense of their trajectory. I wanted to briefly review some of the literature supporting being patient with the rehab process in the post-operative setting, and it's important to maximize the muscular strengthening because it can take a little bit of time. Here are just a few of the studies showing that muscle strength is not normal, even one to two years out from a hip arthroscopy. The studies also support that those with better neuromuscular control tend to have better outcomes as well. Now in scenario number two, this is the patient that is behind in expectations. Despite being compliant with PT and having reasonable expectations of progression of activity, they continue to plateau in their improvement. In these situations, it's important to identify how far behind, severity of symptoms, and are there any objective reasons for continued symptoms. I'll start off with first assessing the activity level, and is it time appropriate? Are they doing a reasonable job with their rehab progression? Are there any aspects to their history or physical that are pointing towards a mixed picture with other pathology potentially present? And if needed, we'll start considering re-imaging with a post-operative MR arthrogram. Ideally, I would like to wait at least six months before considering obtaining a post-operative MRA. I tell patients that we as orthopedists tend to be more successful at making a person better after surgery if we can identify a structural problem prior to considering a surgery. If you think the problem is soft tissue, I would try my best to continue to push a non-surgical program. Then we need to target in our workup, why do we think the patient isn't improving like expected? Was the osteoplasty inadequate? Are we still dealing with labral pathology? Was there more chondral damage than expected at the time of the first surgery? Any identifiable adhesions or underlying stiffness? Is there a stability issue in a potential failed capsule? Are there any surgical complications that have affected recovery? Are there any other diagnoses that can be causing the pain? OK, so we decide to go back in, and it's time to start considering doing a revision. It's important to consider at this point, would a hip arthroscopy revision or would a different approach be more helpful? If revising, do you have something structural that you can address, or are you considering going back in just because the patient isn't doing well? There's a better chance of making someone better if you have something objective to address at the time of surgery. If the patient is mildly dysplastic, it may be better to consider a PAO, especially in the setting of a capsular insufficient patient. Look for excessive version. Consider age and chondral health. Would it be better to move in the direction of a total hip? Also consider the other diagnoses that may occur in this patient population. Was your patient struggling with a core muscle injury that was overlooked? My last scenario is the patient that is doing well, has a traumatic slip or fall, and feels an immediate change in symptoms. These are the patients that come back and are noticeably different. They go from looking great to they are back to where they started or even worse off. They can be catastrophic problems that can occur like fractures. Luckily, these are uncommon. More commonly in my practice are the patients that slip and fall, particularly they get their leg caught in an extended position. They may or may not feel a pop. In these clinical scenarios, I am thinking capsular failure is the primary diagnosis in almost all of them. The first example, this is a well-done osteoplasty that was done in my area. The patient was bending over and had a slight slip and his hip gave way. He ended up fracturing his hip and requiring an RAF. I've only seen a couple of these patients over the years. I would caution that the ones that I have seen are typically larger patients. Whenever I have a patient with a higher BMI, I have these patients use crutches for a longer duration in the postoperative recovery process. Here's another patient from over a decade ago in my practice. The patient had an osteochondroplasty, a labral repair. They're mildly dysplastic. I did an interportal capsulotomy with capsular repair. She had fallen and got her leg caught behind her in an extended position. She felt a pop. My first few patients that had this story, I watched them. Now if I have a patient with this story, I move on them quickly given that the story fits well with the traumatic capsular failure. Here's her MR arthrogram demonstrating a wide open capsule. In her situation, she was mildly dysplastic, so I repaired her capsule. But I also augmented the capsule with dermal allograft to help protect the tissue. This is her traumatic capsular tear. And then this is just after repairing her capsule back into place and getting it opposed, I floated a graft down and did a dermal allograft augmentation. So for my final pearls, I can summarize this talk into five main points. If you're thinking about when to rehab and when to revise, I really do feel like it's hard to pull the trigger to do another surgery if a patient is improving, even if that process is a slow process for the person. I would identify aspects of the recovery process that could be improved and target those if you're working on a conservative program in the recovery process. I would follow those patients that aren't doing well or not hitting their expectations more closely if they're not on track. If worsening or they're plateaued, then I'd start identifying those potential objective causes for continued symptoms. And when you consider a revision, consider potentially a hip arthroscopy, but consider other surgical options or other diagnoses that may be helpful in trying to figure out what's really going on with this patient. So thank you again for listening to this talk. And again, I want to thank the Anna staff for putting together this toolkit series.

hip arthroscopy

rehabilitation

surgery recovery

patient outcomes

capsular failure