Effects of Resistance Training Prior to Total Hip or Knee Replacement on Post-operative Recovery in Functional Performance: A Systematic Review and Meta-Analysis.

Objective: To evaluate the effectiveness of pre-operative resistance training in patients allocated to TJR surgery on selected post-operative outcomes, via a meta-analysis of studies using exercise modalities and loading intensities objectively known to promote gains in muscle size and strength in adults of young-to-old age. Design: A systematic review and meta-analysis. Literature Search: Cochrane Central, MEDLINE, EMBASE, and PEDro were searched on August 4th 2021. Study Selection: Randomized Controlled Trials (RCTs) were included if (i) they compared pre-operative lower-limb-exercises before elective TJR with standard care, (ii) explicitly reported the exercise intensity, and (iii) reported data on functional performance. Data Synthesis: This systematic review and meta-analysis is reported in accordance with the PRISMA reporting guidelines. A random effects model with an adjustment to the confidence interval was performed for pooling the data. Results: One thousand studies were identified. After applying exclusion criteria, five RCTs were located including 256 participants (mean age ranged from 61 to 72 years, 54% women). Moderate-to-large improvements in functional performance and maximal knee extensor strength were observed at 3 months after surgery along with small-to-moderate effects 12 months post-operatively. For patient-reported outcomes, small-to-moderate improvements were observed at 3 months post-operatively with no-to-small improvements at 12 months. Conclusion: Prehabilitation efforts involving progressive resistance training provides an effective means to improve post-operative outcomes related to functional performance, knee extensor strength and patient-reported outcome in patients undergoing TJR. Due to large methodological diversity between studies, an optimal loading intensity remains unknown. Systematic Review Registration: Prospero ID: CRD42021264796.

Five-Year Follow-up After Hip Arthroscopic Surgery in the Horsens-Aarhus Femoroacetabular Impingement (HAFAI) Cohort.

Background: Patients with femoroacetabular impingement syndrome (FAIS) are offered hip arthroscopic surgery to decrease hip pain, improve their function, and decrease development of hip osteoarthritis (OA). Nonetheless, long-term follow-up data are few. Purpose: To investigate patient-reported outcomes, clinical tests, reoperations, and radiographic status 5 years after primary hip arthroscopy in patients with FAIS. Study Design: Case series; Level of evidence, 4. Methods: A total of 60 patients (age, 36 ± 9 years; 63% female) diagnosed with FAIS were included in the study and followed for 5 years after hip arthroscopy. Follow-up included Copenhagen Hip and Groin Outcome Score (HAGOS); Hip Sports Activity Scale; and clinical tests (flexion, adduction, internal rotation [FADIR]; flexion, abduction, external rotation [FABER]; and psoas muscle/tendon major pain provocation). Radiographic evaluation included lateral joint-space width (LJSW) and Tönnis classification for hip OA. Reoperations and conversion to total hip replacement (THR) were recorded. We calculated the proportion of patients who exceeded the minimal important change (MIC), achieved the Patient Acceptable Symptom State (PASS), and were within the 95% reference interval of age- and sex-matched persons with no hip problems. Changes were investigated using paired t tests. Results: Compared with preoperatively, all HAGOS subscales were improved substantially 5 years after surgery (mean, ≥21 points; P < .001), and 67% to 89% of patients reported improvements exceeding MIC. Between 56% and 80% achieved PASS, but only 7% to 24% reached the 95% reference interval for the HAGOS subscales. A total of 36% had a positive FADIR test and 25% had a positive FABER test, which were improvements compared with preoperatively (P < .001 for both). Patients with a positive FADIR test had significantly worse HAGOS subscales. Six patients (10%) had a THR since their primary hip arthroscopy. In the remaining patients, the mean LJSW was decreased (-0.4 mm; P = .043), and hip OA had worsened in 9 patients (23%; P = .003). Conclusion: Five years after surgery, the majority of patients experienced HAGOS improvements exceeding MIC while also showing an acceptable PASS. However, clinical tests, participation in physical activities, and quality of life indicated that many patients still experience hip problems. Registration: NCT04590924 (ClinicalTrials.gov identifier).

Does Daily Physical Activity Differ Between Patients with Femoroacetabular Impingement Syndrome and Patients with Hip Dysplasia? A Cross-Sectional Study in 157 Patients and 60 Healthy Volunteers.

BACKGROUND: The clinical presentation of femoroacetabular impingement syndrome (FAIS) and acetabular hip dysplasia (HD) are similar. However, the groups seem to differ regarding physical activity (PA) and sport. PURPOSE: The aim was to compare PA between three groups; patients with FAIS, patients with HD, and healthy volunteers. A secondary purpose was to compare self-reported function in sport and recreation (sport/recreation) between patients with FAIS and HD. STUDY DESIGN: This study is a cross-sectional study on 157 patients with FAIS or HD and 60 healthy controls. METHODS: PA was measured with accelerometer-based sensors, and sport/recreation was measured with the Copenhagen Hip and Groin Outcome Score (HAGOS). Data on patients with FAIS or HD and healthy volunteers were collected in other studies and merged for comparison in this study. RESULTS: Fifty-five patients with FAIS (20 males; mean age 36 years), 97 patients with HD (15 males; mean age 30 years) and 60 healthy volunteers (24 males; mean age 31 years) were included. Compared with patients with HD, patients with FAIS spent more time on very low intensity PA (mean 73 minutes (95% CI: 45;102)) and less time on low intensity PA per day (mean -21 minutes (95% CI: -37;-6)). Both groups spent less time on high intensity PA per day compared with healthy volunteers (p≤0.03). However, sport/recreation did not differ between the two groups (FAIS: median 34 points (IQR: 22;50) and HD: median 38 points (IQR: 25;53), p=0.16). CONCLUSION: Patients with FAIS appear to be less physical active compared with patients with HD. However, both groups seem to perform less high intensity PA compared with healthy volunteers. This is interesting, as self-reported function in sport/recreation does not differ between patients with FAIS and HD. Thus, high intensity PA seems to be a key outcome in the management of patients with FAIS and HD. LEVEL OF EVIDENCE: Level 2b.

Despite patient-reported outcomes improve, patients with femoroacetabular impingement syndrome do not increase their objectively measured sport and physical activity level 1 year after hip arthroscopic surgery. Results from the HAFAI cohort.

PURPOSE: Patients with femoroacetabular impingement syndrome (FAIS) are young and middle-aged persons living physically active lives including sports activities. However, measurements of the physical activity level before and after hip arthroscopic surgery in patients with FAIS using both self-reported and objective accelerometer-based measures are lacking. Furthermore, comparing patients with a reference group of persons reporting no hip problems and conducting subgroup analyses investigating changes in physical activity level and self-reported outcomes according to pre-surgery activity level may further highlight the activity pattern for patients. METHODS: Sixty patients with FAIS eligible for hip arthroscopic surgery were consecutively included in a prospective cohort study (HAFAI cohort) together with 30 reference persons reporting no hip problems. Participants completed the Copenhagen Hip and Groin Outcome Score (HAGOS) together with questions regarding their sports activities. Furthermore, participants wore a three-axial accelerometer for five consecutive days during waking hours. The accelerometer-based data were analysed and presented as total activity and type, frequency and duration of activities. RESULTS: Patients experienced significant and clinically relevant changes in all HAGOS scores. 88% of patients participated in some kind of sports activity 1 year after surgery. Overall, objectively measured physical activity did not change from before to 1 year after surgery. However, subgroup analyses of the most sedentary patients preoperatively revealed significant changes towards a more active pattern. Compared to reference persons, patients performed less bicycling and running. CONCLUSION: Despite clinically relevant changes in self-reported outcomes, patients did not increase their overall physical activity level 1 year after surgery. Physical activity levels were lower in patients than in the reference group and patients continued bicycling and running less compared with the reference group. LEVEL OF EVIDENCE: II.

High relative reliability and responsiveness of the forgotten joint score-12 in patients with femoroacetabular impingement undergoing hip arthroscopic treatment. A prospective survey-based study.

The forgotten joint score-12 (FJS-12) may be an advantageous questionnaire in young patients with high hip function and a low level of pain. We investigated the reliability and the responsiveness of the FJS-12 in patients with femoroacetabular impingement undergoing hip arthroscopic treatment. Fifty patients were included in the reliability study and 34 patients were included in the responsiveness study. Test-retest reliability was assessed with intraclass correlation coefficient (ICC), standard error of measurement (SEM) and minimal detectable change (MDC). Responsiveness was assessed from testing correlations between the FJS-12 and the Copenhagen Hip and Groin Outcome Score (HAGOS) of the change score, effect size (ES) and standardized response mean (SRM). Floor and ceiling effect were defined as present if the number of patients obtaining the maximum (100) and minimum score (0) exceeded 15%. The relative reliability was high (ICC = 0.9, 95% CI: 0.8-0.9) and the absolute reliability was low (SEM = 11, MDCindividual = 32, MDCgroup = 4.5). The responsiveness was high, and the change score was highly correlated with the subscale 'pain' from the HAGOS and moderately correlated with the subscale 'ADL'. Furthermore, the FJS-12 exceeded or equalled the HAGOS subscales in ES and SRM. Below 15% of the patients scored the maximum or minimum score. The FJS-12 has high reliability, high responsiveness to change and shows no floor or ceiling effect.

Editorial Commentary: The Gain in Pain After Hip Arthroscopic Surgery: What Is Clinically Relevant, and Is Pain Related to Function in Patients With Femoroacetabular Impingement Syndrome?

Hip arthroscopic surgery improves patient-reported outcomes in patients with femoroacetabular impingement syndrome and/or hip chondropathy. The minimal clinically important change on a pain visual analog scale has now been calculated in this patient group, and the pain level 1 year after surgery has been related to function. Next step: identifying what causes pain and decreased function 1 year after surgery.

Progressive resistance training in patients with hip dysplasia: A feasibility study.

OBJECTIVES: To examine whether progressive resistance training is feasible in patients with symptomatic hip dysplasia scheduled for periacetabular osteotomy. A secondary objective was to investigate patient-reported outcomes, functional performance and hip muscle strength. DESIGN: Feasibility study. PATIENTS AND METHODS: Seventeen patients (median age 28 years, range 22-40 years) performed 8 weeks (20 sessions) of supervised sessions of progressive resistance training. Training-adherence, number of dropouts and adverse events, and visual analogue scale scores on pain were registered. Patients completed the Hip and Groin Outcome Score, performed 2 hop-tests, and hip peak torque was assessed by isokinetic dynamometry. RESULTS: Training-adherence was 90.3±9%. Few and minor adverse events were observed, one patient dropped out and acceptable pain levels were reported during the intervention. Scores on 4 out of 6 subscales on patient-reported outcome improved (p <0.05), as did standing distance jump (12.2%, 95% confidence interval (CI) [1.3, 23.0]), countermovement jump (25.1%, 95% CI [1.3, 48.8]). Isokinetic concentric hip flexion peak torque showed significant improvements (16.6%, 95% CI [4.6, 28.6]) on the affected side while isometric hip flexion (10.9%, 95% CI [0.3, 21.6]) improved on the non-affected side. CONCLUSION: Supervised progressive resistance training is feasible in patients with hip dysplasia. The intervention may improve pain levels, patient-reported outcomes, functional performance and hip flexion muscle strength.

Arthroscopic Surgical Procedures Versus Sham Surgery for Patients With Femoroacetabular Impingement and/or Labral Tears: Study Protocol for a Randomized Controlled Trial (HIPARTI) and a Prospective Cohort Study (HARP).

Study Design Study protocol for a randomized controlled trial and a prospective cohort. Background The number of arthroscopic surgical procedures for patients with femoroacetabular impingement syndrome (FAIS) has significantly increased worldwide, but high-quality evidence of the effect of such interventions is lacking. Objectives The primary objective will be to determine the efficacy of hip arthroscopic procedures compared to sham surgery on patient-reported outcomes for patients with FAIS (HIP ARThroscopy International [HIPARTI] Study). The secondary objective will be to evaluate prognostic factors for long-term outcome after arthroscopic surgical interventions in patients with FAIS (Hip ARthroscopy Prospective [HARP] Study). Methods The HIPARTI Study will include 140 patients and the HARP Study will include 100 patients. The international Hip Outcome Tool-33 will be the primary outcome measure at 1 year. Secondary outcome measures will be the Hip disability and Osteoarthritis Outcome Score, Arthritis Self-Efficacy Scale, fear of movement (Tampa Scale of Kinesiophobia), Patient-Specific Functional Scale, global rating of change score, and expectations. Other outcomes will include active hip range of motion, hip muscle strength tests, functional performance tests, as well as radiological assessments using radiographs and magnetic resonance imaging. Conclusion To determine the true effect of surgery, beyond that of placebo, double-blinded placebo-controlled trials including sham surgery are needed. The HIPARTI Study will direct future evidence-based treatment of FAIS. Predictors for long-term development and progression of degenerative changes in the hip are also needed for this young patient group with FAIS; hence, responders and nonresponders to treatment could be determined. J Orthop Sports Phys Ther 2018;48(4):325-335. doi:10.2519/jospt.2018.7931.

Acute and chronic effects of early progressive resistance training on knee pain and knee joint effusion after unicompartmental knee arthroplasty.

To investigate if progressive resistance training initiated one week after unicompartment knee arthroplasty affect knee pain and knee joint effusion. Data from the progressive resistance training intervention group of a previous randomized control trail study was analysed. Knee pain was measured using a visual analogue scale, and knee circumference was used as an indication of knee joint effusion. Comparisons were made between the early (session 1+2) and late (session 15+16) phase of the 8-week intervention (chronic) and between the pre and post levels of single training sessions (acute). Chronic effects : A significant decrease in pre- (55% SD 44% ; p=0.004) and post-training (47% SD 53% ; p = 0.002) pain was observed. Also, a significant decrease in pre- (4.1% SD 3.3% ; p = 0.0001) and post-training (2.9% SD 2.7% ; p = 0.0004) circumference was observed. Acute effects : A significant increase in pain was observed in session 5, while a significant increase in circumference was observed in session 6-8, 10 and 13-16. Progressive resistance training initiated in the early post-operative phase following unicompartment knee arthroplasty does not increase the pain level immediately after a training session, despite frequent increases in joint effusion. Furthermore, pre- and post levels of pain and joint effusion dropped significantly following the intervention period.

Impaired hip muscle strength in patients with femoroacetabular impingement syndrome.

OBJECTIVES: Patients with femoroacetabular impingement (FAI) experience hip pain as well as decreased function and lowered quality of life. The aim was to compare maximal isometric and isokinetic muscle strength (MVC) during hip flexion and extension and rate of force development (RFD) during extension between patients with FAI and a matched reference group. Secondary, the aim was to compare patient hips and subgroups defined by gender and age as well as to investigate associations between hip muscle strength and self-reported outcomes. Design Cross-sectional, comparative study Methods Sixty patients (36±9 years, 63% females) and 30 age and gender matched reference persons underwent MVC tests in an isokinetic dynamometer. RESULTS: During hip flexion and extension, patients' affected hip showed a strength deficit of 15-21% (p<0.001) and 10-25% (p<0.03) compared with reference MVC, respectively. The affected hip of the patients was significantly weaker than their contralateral hip. RFD was significantly decreased for both patient hips compared to the reference group (p<0.05). While age had less effect on MVC, female patients were more affected than male patients. Self-reported measures were associated with isometric hip muscle strength. CONCLUSIONS: Patients with FAI demonstrate decreased hip flexion and extension strength when compared to (1) reference persons and (2) their contralateral hip. There seems to be a gender specific affection which should be investigated further and addressed when planning training protocols. Furthermore, self-reported measures were associated with isometric muscle strength, which underlines the clinical importance of the reduced muscle strength.

The efficacy of early initiated, supervised, progressive resistance training compared to unsupervised, home-based exercise after unicompartmental knee arthroplasty: a single-blinded randomized controlled trial.

OBJECTIVE: To examine if supervised progressive resistance training was superior to home-based exercise in rehabilitation after unicompartmental knee arthroplasty. DESIGN: Single blinded, randomized clinical trial. SETTING: Surgery, progressive resistance training and testing was carried out at Aarhus University Hospital and home-based exercise was carried out in the home of the patient. SUBJECTS: Fifty five patients were randomized to either progressive resistance training or home-based exercise. INTERVENTION: Patients were randomized to either progressive resistance training (home based exercise five days/week and progressive resistance training two days/week) or control group (home based exercise seven days/week). MAIN MEASURES: Preoperative assessment, 10-week (primary endpoint) and one-year follow-up were performed for leg extension power, spatiotemporal gait parameters and knee injury and osteoarthritis outcome score (KOOS). RESULTS: Forty patients (73%) completed 1-year follow-up. Patients in the progressive resistance training group participated in average 11 of 16 training sessions. Leg extension power increased from baseline to 10-week follow-up in progressive resistance training group (progressive resistance training: 0.28 W/kg, P= 0.01, control group: 0.01 W/kg, P=0.93) with no between-group difference. Walking speed and KOOS scores increased from baseline to 10-week follow-up in both groups with no between-group difference (six minutes walk test P=0.63, KOOS P>0.29). CONCLUSIONS: Progressive resistance training two days/week combined with home based exercise five days/week was not superior to home based exercise seven days/week in improving leg extension power of the operated leg.

Pain, activities of daily living and sport function at different time points after hip arthroscopy in patients with femoroacetabular impingement: a systematic review with meta-analysis.

AIM: To investigate pain, activities of daily living (ADL) function, sport function, quality of life and satisfaction at different time points after hip arthroscopy in patients with femoroacetabular impingement (FAI). DESIGN: Systematic review with meta-analysis. Weighted mean differences between preoperative and postoperative outcomes were calculated and used for meta-analysis. DATA SOURCES: EMBASE, MEDLINE, SportsDiscus, CINAHL, Cochrane Library, and PEDro. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies that evaluated hip pain, ADL function, sport function and quality of life before and after hip arthroscopy and postoperative satisfaction in patients with symptomatic FAI. RESULTS: Twenty-six studies (22 case series, 3 cohort studies, 1 randomised controlled trial (RCT)) were included in the systematic review and 19 in the meta-analysis. Clinically relevant pain and ADL function improvements were first reported between 3 and 6 months, and sport function improvements between 6 months and 1 year after surgery. It is not clear when quality of life improvements were first achieved. On average, residual mild pain and ADL and sport function scores lower than their healthy counterparts were reported by patients following surgery. Postoperative patient satisfaction ranged from 68% to 100%. CONCLUSIONS: On average, patients reported earlier pain and ADL function improvements, and slower sport function improvements after hip arthroscopy for FAI. However, average scores from patients indicate residual mild hip pain and/or hip function lower than their healthy counterparts after surgery. Owing to the current low level of evidence, future RCTs and cohort studies should investigate the effectiveness of hip arthroscopy in patients with FAI. TRIAL REGISTRATION NUMBER: CRD42015019649.

The Horsens-Aarhus Femoro Acetabular Impingement (HAFAI) cohort: outcome of arthroscopic treatment for femoroacetabular impingement. Protocol for a prospective cohort study.

INTRODUCTION: During the past decade, it has become increasingly more common to offer hip arthroscopic surgery when treating people with femoroacetabular impingement (FAI). Nevertheless, the latest reviews conclude that it still remains to be properly investigated how surgery affects the patients. Specifically, detailed information on the functional, muscular and mechanical impact of surgery in larger groups is lacking. Furthermore, the long-term outcome of the surgery is still to be investigated. METHODS AND ANALYSIS: In this prospective cohort study, a total of 60 patients with FAI scheduled for arthroscopic surgery will be followed and tested preoperatively, and again after 3, 6, 9 and 12 months. Assessment includes isokinetic dynamometry evaluating hip flexion and extension; evaluation of functional capacity in a three-dimensional motion laboratory; pain assessment; self-reported function, quality of life, expectation and satisfaction with the surgery; recording of previous and present sporting activities and accelerometry. In addition, data on surgical procedure, rehabilitation progress, adverse events and failure will be recorded. Patients will be compared with an age-matched and gender-matched reference group of 30 persons with no hip, knee, ankle or back problems. Long-term follow-up of this cohort may evaluate possible reoperations and development of hip osteoarthritis. Furthermore, analysis on how subgroups respond to the treatment could be performed together with identification of possible "non-responders". ETHICS AND DISSEMINATION: The study is approved by the Central Denmark Region Committee on Biomedical Research Ethics (Journal No 1-10-72-239-14). The results from this study will be presented at national and international congresses and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT02306525.

Pelvic movement strategies and leg extension power in patients with end-stage medial compartment knee osteoarthritis: a cross-sectional study.

INTRODUCTION: During movement tasks, patients with medial compartment knee osteoarthritis use compensatory strategies to minimise the joint load of the affected leg. Movement strategies of the knees and trunk have been investigated, but less is known about movement strategies of the pelvis during advancing functional tasks, and how these strategies are associated with leg extension power. The aim of the study was to investigate pelvic movement strategies and leg extension power in patients with end-stage medial compartment knee osteoarthritis compared with controls. MATERIALS AND METHODS: 57 patients (mean age 65.6 years) scheduled for medial uni-compartmental knee arthroplasty, and 29 age and gender matched controls were included in this cross-sectional study. Leg extension power was tested with the Nottingham Leg Extension Power-Rig. Pelvic range of motion was derived from an inertia-based measurement unit placed over the sacrum bone during walking, stair climbing and stepping. RESULTS: Patients had lower leg extension power than controls (20-39 %, P < 0.01) and used greater pelvic range of motion during stair and step ascending and descending (P ≤ 0.03, except for pelvic range of motion in the frontal plane during ascending, P > 0.06). Furthermore, an inverse association (coefficient: -0.03 to -0.04; R (2) = 13-22 %) between leg extension power and pelvic range of motion during stair and step descending was found in the patients. CONCLUSIONS: Compared to controls, patients with medial compartment knee osteoarthritis use greater pelvic movements during advanced functional performance tests, particularly when these involve descending tasks. Further studies should investigate if it is possible to alter these movement strategies by an intervention aimed at increasing strength and power for the patients.