Course Faculty Objectives - Azata

1 Hip Arthroscopy for Labral Tears and Femoral Acetabular impingement : The Latest Thank You Azata !! in Post-Surgical Rehabilitation. Course Faculty Objectives Scott Cheatham PT, DPT, PhD(c), OCS, ATC, CSCS At the conclusion of this presentation the participant Assistant Professor, Division of Kinesiology will be able to: California State University Dominguez Hills, Carson CA. Discuss common arthroscopic techniques for intraarticular hip pathology. Discuss post-operative intervention programs after hip arthroscopy. Discuss the latest evidence on risk factors and suggested strategies for reducing future pathology.

2 Discuss emerging diagnoses classified as external hip impingement . Types of FAI Progression of Hip Labral Pathology Excessive loading of the labrum (FAI). Global labral and Fraying of the articular articular cartilage margin of the anterior degeneration labrum Delamination of the articular cartilage from Tearing along the the articular margin articular margin of the adjacent to the labral anterior labrum lesion McCarthy JC, Noble PC, Schuck MR, et al. The Otto E Aufranc Award the role of labral lesions to development of early degenerative hip disease. Clin Orthop. 2001;393:25 37. 1. Types of Acetabular Labral Tears Hip Arthroscopic Surgery Overview Orthopedic Table: Patient Positioning OSI PROfx Orthopaedic Table.

3 Available at Types of Arthroscopic Surgery osteoplasty Rim Trimming Hip Arthroscopy Capsular osteoplasty Acetabular Chondroplasty Microfracture Plication and Rim Trimming Labral Repair Closure 2. Chondroplasty & osteoplasty Microfracture Open Procedure: Measuring the Femoral Head Arthroscopic: Reshaping of the Femoral Head Hip Labral Refixation Refixation Arthroscopic Repair Open Repair Autograft or Allograft Hip Labral Resection Capsular Plication 3. CEBM Levels of Evidence Levels of Evidence Grading Criteria A: Systematic Review of RCT's Level 1 B: Individual RCT with narrow CI. Post-Operative Rehabilitation C: Series of cases (all or none).

4 A: Systematic review of cohort studies Level 2 B: Individual cohort study, RCT with drop outs >20%. The Evidence C: Outcomes Research or ecologic studies Level 3 A: Systematic Review of case-control studies B: Individual case-control Level 4 Case Series Level 5 Expert's opinion OCEBM Levels of Evidence Working Group*. "The Oxford Levels of Evidence ". Oxford Centre for Evidence-Based Medicine. Systematic Reviews Systematic Reviews Level of Evidence Cheatham SW, Enseki KR, Kolber MJ. Post-Operative Cheatham et al. 2014. Rehabilitation after Hip Arthroscopy: A Search for the Level 4 evidence (N=6). Evidence.

5 J Sports Rehab. 2014; Nov 12. [Epub Ahead of Print] Included only research that measured post-operative rehabilitation Grzybowski JS, Malloy P, Stegemann C, Bush-Joseph C, Found 20 clinical commentaries on post-operative rehabilitation Harris JD, Nho SJ. Rehabilitation Following Hip Arthroscopy - A Systematic Review. Front Surg. 2015;2:21-25. Grysbowski et al. 2015. Level 1 evidence (N=1). Level 3 evidence (N=2). Level 4 evidence (N=15). Included research that reported post-operative rehabilitation Systematic Review Summary A paucity of evidence exists regarding post-operative rehabilitation after hip arthroscopy.

6 Most of the literature comes from: Post-Operative Rehabilitation Case reports/series (level 4 evidence). Clinical commentaries (level 5 evidence). A consensus on the best program has yet to be determined. Criterion Based Protocol The existing evidence suggests that a 4 to 5 stage program with an initial period of weight-bearing and mobility precautions is efficacious in regard to function, patient satisfaction, and return to competitive level athletics. 4. Hip Arthroscopic Rehabilitation Protocol Special Considerations Case Report 2012. Procedure PROM WB CPM Brace osteoplasty Rim No limits FWB X 21 days 4-6 hrs (3 days) then 1- 21 days Trimming then 50% (1 2 hrs (wks).)

7 Wk). Chondroplasty No Limits WBAT 4-6 hrs (3 days) then 1- None 2 hrs (wks). Microfracture No Limits FFWB (6-8 wks) 4-6 hrs (6-8 wks) None Labral Repair Flexion up to 120 NA 4-6 hrs (3 days) then 1- 17-21 days Cheatham SW, Kolber MJ. Rehabilitation after Hip ABD up to 45. No ER (17-21 days). 2 hrs (wks) Arthroscopy and Labral Repair in a High School Football No Ext > 0 (17-21 days) Athlete. Int J Sports Phys Ther. 2012 April; 7(2): 173 184. Capsule Plication Flexion up to 120 NA 4-6 hrs (3 days) then 1- 17-21 days and Capsule ABD up to 45 2 hrs (wks). Closure No ER (17-21 days). No Ext > 0 (17-21 days). * CPM- May still be prescribed.

8 Primarily used to move the LE for nutrition and maintain ROM. Case History Mixed impingement Patient: 18- year-old senior male high school athlete Combined. Combined impingement just means that both the pincer 210 lbs. with muscular build and excess body fat and cam types are present. Mechanism: Insidious onset of deep anterior groin pain for one year prior to diagnosis. Intermittent groin pain during and after physical activity which eventually became more severe. Diagnosis: Left mixed cam-pincer femoroacetabular impingement with an anterosuperior labral tear. Confirmed by MRA. Surgical Intervention: Acetabular and femoral head osteoplasty & chondroplasty, capsular synovectomy, plication, and an anterior superior labral repair.

9 Post-Surgical Orders: Evaluate and treat with crutch ambulation (WBAT). *Please see publication for more details Assessment Pain: (4-5/10) with left hip flexion/adduction Posture & Gait: Compensatory right trunk shift in an effort to unload the affected left limb in standing and gait ambulation with crutches. Post-Operative Program ROM: Decreased left hip ROM in all planes due to pain and apprehension by the patient. Four (4) Criterion Based Phases Strength & Muscle Length: General weakness (3/5) and decreased length of the left hip musculature (rectus femoris, hamstrings, abductors/ITB). Palpation: Tenderness in the anterior hip musculature.

10 Pelvic and LE Neurovascular Screen: (-) for medical red flags . 5. Phase I: Guidelines Focus: Protect the repaired tissue, restore ROM, control pain & inflammation, and restore neuromuscular control. Criteria to advance to Phase II: Full weight bearing, minimal Phase I pain with phase I activity, ROM 75% of the uninvolved side, and proper muscle firing patterns. Precautions: Avoid hip flexor pain and following ROM &. weight bearing restrictions. An external brace may be worn. Phase I: Parameters Phase I: Manual Therapy Range of Motion: AAROM/AROM/PROM. Upright bike riding, ankle pumps, towel slides, prone lying, quadruped Circumduction rocking, and standing IR/ER with chair Beck (2008) found adhesion formation between the joint Strengthening: capsule and the resected Isometrics for the hip and leg muscles, resisted prone IR/ER, three way femoral neck which may lead leg raises, sidelying clams, double leg bridges, leg press.