Posts in Hip Injuries
Pre Operative Expenses Linked To Post Operative Expenses After Hip Surgery
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Arthroscopic hip surgery is one of the fastest growing orthopedic surgical procedures today. This procedure is commonly utilized to treat hip impingement and hip labral tears. The rapid growth of surgery for this condition is thought to result from both an increase in surgeons trained in hip arthroscopic surgery, as well as, the increased utilization of MRI scans. Experts have expressed concern over these increases in surgical rates due to the large numbers of pain free athletes and patients who show impingement and labral tears on MRI, but remain asymptomatic. One of the key indications for surgery remains failure of conservative treatments including high level, evidence based Physical Therapy. Patients who are unable to return to a desired level of activity or play may opt for the surgery after completion of this Physical Therapy program. A recent study reports on the pre and post operative costs associated with this procedure.

Clewley and colleagues performed a retrospective analysis of pre and post operative costs in 1850 patients who elected for hip arthroscopic surgery over a 12 year period (JOSPT. 2018). Authors found significant differences in costs and health care use between high and low health care utilization groups. In addition, authors found patients who utilized greater amounts of care before the procedure were more likely to use greater amounts of healthcare after the procedure. As expected, the higher utilization group spent significantly greater amounts of money for their associated care compared to their lower utilization peers. Future research is needed to determine the psychosocial and behavioral traits associated with higher health care expenditures.

Increased Medical Risks of Chronic Pain and Mental Health Disorders Found After Elective Hip Surgery
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Inherent risks, such as infection and blood clots, are associated with orthopedic surgeries and should be considered in decision making between surgical and conservative treatments for musculoskeletal diagnoses. In addition to these inherent risks, patients should also consider other hidden or less common risks after surgery including increased healthcare costs (office visits, additional surgeries, hospitalization) and changes in disability after surgery. A recent study examined additional risks found in patients who elected for arthroscopic hip surgery.

Rhon and colleagues followed 1870 patients treated in the military health system up to 2 years after elective arthroscopic hip surgery to determine their subsequent healthcare utilization (Br J Sp Med. 2018). Specifically, the authors assessed for seven co morbidities (mental health, chronic pain, substance abuse, cardiovascular disoders, metabolic syndrome, systemic arthropathy, and sleep disorders) associated with poor outcomes in the management of musculoskeletal disorders. The incidence of these seven co morbidities at 1 and 2 year follow up was compared to each patient’s pre operative status. Authors reported a statistically significant increase in all seven co morbidities following the surgical procedure. Specifically, authors found significant increases in the following

Chronic Pain - 166%

Systemic Arthropathy - 132%

Sleep Disorders - 111%

Metabolic Syndrome - 86%

Mental Health Disorders - 84%

Cardiovascular Disorders - 71%

Authors concluded, “major clinical co morbidities increased substantially after elective hip surgery compared to preoperative status”.

Previous studies have not shown significant differences in outcomes between Physical Therapy and arthroscopic hip surgery. Thus, patient’s must consider surgical risks in their decision making.

Physical Therapy Reduces Healthcare Costs and Opioid Utilization After Hip Surgery
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Arthroscopic hip surgery rates have dramatically increased in the last decade due in part to increased MRI imaging.  MRIs are very sensitive, but lack specificity in many musculoskeletal disorders with high rates of false positives among asymptomatic populations.  Hip pathologies such as impingement (cam or pincer) and labral tears can be found in up to 68% of patients without hip pain.  As we described in our previous blog posts, many patients with these pathologies are able to improve pain and function with Physical Therapy alone.  Further, authors report no differences in long term outcomes between surgery and Physical Therapy.  A new study highlights the importance of post operative Physical Therapy in patients who do not respond to conservative treatments.  

Rhon and colleagues followed patients who underwent hip arthroscopic surgery between 2004 and 2013 to determine their outcomes and healthcare utilization (Physical Therapy. 2018).  The authors reported on 1870 patients of which 83% received Physical Therapy alone, 72% received opioid medication, and 56% received both Physical Therapy and opioid medication.  Authors reported a $5000 savings on healthcare expenditure, a reduction in subsequent hip surgeries, and opiod utilization among patients receiving Physical Therapy first.  Not surprisingly, patients receiving opioids first utilization more medication, over a longer period of time compared to patients receiving Physical Therapy.

Click Here to learn more on how MEND can help accelerate your recovery after hip surgery

Should I choose PT or surgery for my hip impingement or labral tear?
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The labrum is a dense connective and fibrocartilage tissue lining the socket of the hip joint.  It functions to deepen the hip socket and improve stability and weight bearing during functional activities.  The labrum is highly innervated on top and front portions of the joint and often refers to the front of the hip when symptomatic.  Labral tear diagnosis is on the rise due to more surgeons being trained in hip arthroscopic surgery and increased utilization of MRI scans.  Experts note caution is warranted when interpreting these findings because up to 68% of pain free individuals will have a labral tear after MRI testing.

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Hip labral tears  and femoral acetabular impingement are common diagnoses among < 40 year old patients especially those involved in rotational sports such as hockey and tennis.  As stated previously, many of the positive MRI findings are also present in pain free athletes.  Researchers are still determining which of these findings indicate pathology vs. a natural adaptation to the sport similar to what we see in pitcher's shoulders. 

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Physical Therapy treatments including manual therapy and exercise are very effective for both hip impingement and labral tears.  Goals of treatment include pain reduction and improving patient function including return to sport and activity.  Interventions are designed to increase space and avoid abnormal contact at the hip joint.  Most importantly, patients are trained to re establish hip strength and coordination to allow a safe return to sport without the classic hip pinch or catch.  Two studies have compared the effectiveness of Physical Therapy to surgical interventions and both have found significant patient improvement, but no significant differences between groups.  Thus, patients are encouraged to utilize Physical Therapy first for their hip symptoms.  Early Physical Therapy may also help identify patients who require surgical intervention after conservative treatment.  

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No Difference Between Surgery or Physical Therapy for Hip Impingement
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Hip impingement, or the compression of the soft tissue or bony structures of the hip joint, has become the flavor of the week in orthopedic surgery.  Surgical rates have risen 18 fold over the past ten years outpacing the available research on the condition.  Previous research has shown up 68% and 67% of asymptomatic hips will show labral tears and hip deformities, respectively.  The high rates of findings in asymptomatic patients, especially athletes, requires further research to determine if these changes are truly pathology or natural changes in athletic patient's hip joints.  Further, there has been no quality randomized trials between surgery and high quality Physical Therapy interventions until now.

Mansell and colleagues examined 80 patients with femoroacetabular impingement (FAI) syndrome over a 2 year period (Am J Sp Med. 2018).  Patients were randomized to receive either arthroscopic hip surgery with post operative Physical Therapy or Physical Therapy (twice per week x 12 weeks).  Both groups demonstrated improvements in pain and function, but no significant differences were found between groups were found at 2 year follow up.  Twenty patients from the Physical Therapy group eventually elected to have surgery but further analysis found this cross over did not alter the results.

This study highlights the importance of using Physical Therapy first for hip impingement.  To schedule your first appointment with the experts at MEND click here. 

Physical Therapy Improves Outcomes After Hip Impingement Surgery
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Hip impingement, femoracetabular impingement, is a common source of pain for patients.  Much research is needed on this more recent diagnosis secondary to the high rates of impingement found in pain free athletes.  In addition, more research is needed on the comparison of conservative versus surgical management of the condition.  Patient's undergoing arthroscopic surgery to resurface the joint and remove the bony impingement often are prescribed a formal post operative Physical Therapy program.  A recent randomized, controlled trial compared the effectiveness of this program to a general, unsupervised exercise program.

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Bennell and colleagues in the British Medical Journal compared these two programs in 30 patients who underwent surgery for hip impingement (2017).  The Physical Therapy group included 1 pre operative and 6 post operative sessions focused on manual therapy and progressive exercise.  The control group did not receive post operative rehabilitation.  The authors reported a superior recovery for the patients in the PT group at 14 weeks post operatively, but these changes were insignificant at 6 months.  Similar to other post operative Physical Therapy trials, PT has been shown to accelerate the recovery of patients undergoing surgery by allowing them to return to activities sooner than patients not receiving the same care.