Posts tagged FAI
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.

Altered Functional Performance Found Among Patients With Hip Impingement
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Hip impingement or Femoroacetabular Impingement is a common condition among athletes caused by abnormal contact within the hip joint.  Contributing factors include structural changes in the ball (Cam lesion) and/or socket (Pincer lesion), as well as, weakness in the hip musculature.  The powerful glut muscles act as both movers and stabilizers of the hip joint.  Many athletes with hip impingement remain asymptomatic if they maintain adequate glut strength and hip stability.  Conversely, hip impingement symptoms often worsen in the presence of glut weakness due decreased joint control and increased joint contact forces.  

A recent study in the Journal of Orthopedic and Sports Physical Therapy examined the biomechanical differences between patients with hip impingement (N=20) and their healthy peers (Lewis, C. et al. 2018).  Authors assessed biomechanical differences during a commonly used step down test.  Consistent with our Boulder Physical Therapy clinic's findings, patients with hip impingement demonstrated greater hip flexion and anterior pelvic tilt compared to their asymptomatic peers.  In addition, authors found decreased performance among females compared to male participants.  This study highlights the importance of regaining both glut strength and functional stability to restore function in patients with hip impingement.  

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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.