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REHABILITATION HIP IMPINGEMENT
the femoral head–neck junction. The area of resection is marked with a radiofrequency probe; a burr is used to cut through about 5 mm deep. The bone resection is then carried out laterally on to the femoral neck to reshape the head–neck junction. It is important that the hip is assessed dynamically in order to ensure adequate clearance has been obtained.
CHONDRAL LESION Andreas Fontana found that the average chondral defect in a group of 30 patients (average age 36.8 years) was 2.6 cm2
(40). The
severity of cartilage abnormality correlated with the severity of BMO (32). Patients with degenerative labral pathology are 2.9 times more likely to have a large femoral head chondral defect. Significantly, hips with cam impingements are 7.5 times more likely to have acetabular chondral defect.
Microfracture to treat chondral defects of the hip is seen as safe and effective. Early results show significant improvement in functional outcomes and decreased pain in the majority of patients (42). Marc Philippon showed seven of nine patients with 100% fill and that average fill on second-look arthroscopy following microfracture is 91% (45).
The quality of the literature
assessing clinical outcome after open or arthroscopic treatment of FAI is limited. Historically, the open surgical dislocation with osteoplasty has been the gold standard. The scientific data do not show that this has superior outcomes to arthroscopic techniques (46).
REHABILITATION
Thomas Byrd, one of the forefathers of hip arthroscopy, said recently that the “best operation will fail with poor rehab but an average surgery will turn out pretty well with good, structured, supervised rehab” (44). Philippon et al. (45) showed a strong correlation between time from injury to surgery and return to full playing: less than 1 year – 3 months, and more than 1 year – 4.8 months.
Figure 4: Passive external rotation stretch – it is vital to block the knee and the foot. Be aware of any previous knee pathology which maybe stressed. I try to avoid adducting the hip as this is the position of impingement
The period of rehabilitation post- surgery is dependent on the type and amount of work performed. Generally, a hip arthroscopy without microfracture will be weight-bearing immediately. If the acetabulum or the femoral head has required microfracture, then the patient is flat-foot weight-bearing (10kgs) for 6–8 weeks. Continous Passive Motion (CPM) is preferred and can be prescribed for 8–12 hours a day for a 4-week period in some cases. This gives the newly recruited mesenchyme stem cells the optimal physical environment (47). Early passive motion is essential for
all patients. It is worth noting, especially in patients who have had labral repair, that certain ranges do not put any stress on the anterosuperior labral, which covers the majority of lesions: n Flexion: 0–90o n Abduction: 0-25o n Lateral rotation: 0-25o
.
Figure 5: Seatbelt lateral distraction – I use many seatbelt techniques, this being one of the most powerful.
In side lying,
place the belt high up in the groin. Fix the iliac crest and the knee, whilst laterally distracting the hip
Daily cycling with no resistance is started on the day of surgery. Aquatic walking begins on day one. Chondroplasty requires avoidance of impingement of the hip while restoring full range. It is also important to limit
impact work for 8 weeks in order to minimise the risk of femoral neck fracture. At the Sports Hip Surgery meeting in 2008, only one of the experienced surgeons there had had a case of femoral neck fracture post- chondroplasty.
During the non-weight-bearing
stage, the psoas can cause discomfort due to the isometric contraction required to support the limb during ambulation. Its distal attachment into the lesser trochanter can develop a typical tendinopathy pattern, occasionally needing infiltration. There area number of techniques such as seatbelt lateral distraction and passive external rotation than help maintain range and prevent adhesions forming post-arthroscopy (figures 4 and 5). Lewis et al. report that when patients with anterior hip and subtle hip instability perform prone hip extension, only minimal contraction of the gluteal muscles is noted (48). In contrast, significant contraction of the hamstring muscles, especially medially (mainly semimembranosis), is noted. They also suggest that during supine hip flexion the hip medially rotates due to the dominant action of tensor fascia lata (TFL) over the iliopsoas, increasing the anterior glide of the femoral head. Once the patient is able to bear
weight, general conditioning to allow the patient to return to full function is progressed gradually. It is essential to maintain a leg-strength programme throughout, ideally alternating running and strengthening in the process.
THE FUTURE It is important that we continue to develop the rehabilitation protocols, as surgical procedures that advance the athletes we deal with are already pushing the limits of the protocol to enable them to return to competition. As with our understanding of the knee joint, preservation of labral tissue may improve the overall integrity of the joint and prevent early OA (12). Surgery for FAI is continually evolving, with surgeons now frequently performing iliotibial band (ITB) labral reconstructions and autologous chondrocyte implantations.
Although the bony structure of the acetabulum may be able to withstand forces up to four times body weight, the soft tissue structures of the anterior hip joint may become injured at much
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