Variation in rehabilitation setting after uncomplicated total knee or hip arthroplasty: a call for evidence-based guidelines.

BACKGROUND: High-level evidence consistently indicates that resource-intensive facility-based rehabilitation does not provide better recovery compared to home programs for uncomplicated knee or hip arthroplasty patients and, therefore, could be reserved for those most impaired. This study aimed to determine if rehabilitation setting aligns with evidence regardless of insurance status. METHODS: Sub-study within a national, prospective study involving 19 Australian high-volume public and private arthroplasty centres. Individuals undergoing primary arthroplasty for osteoarthritis participated. The main outcome was the proportion participating in each rehabilitation setting, obtained via chart review and participant telephone follow-up at 35 and 90 days post-surgery, categorised as 'facility-based' (inpatient rehabilitation and/or ≥ four outpatient-based sessions, including day-hospital) or 'home-based' (domiciliary, monitored or unmonitored home program only). We compared characteristics of the study cohort and rehabilitation setting by insurance status (public or private) using parametric and non-parametric tests, analysing the knee and hip cohorts separately. RESULTS: After excluding ineligible participants (bilateral surgeries, self-funded insurance, participation in a concurrent rehabilitation trial, experience of a major acute complication potentially affecting their rehabilitation pathway), 1334 eligible participants remained. Complete data were available for 1302 (97%) [Knee: n = 610, mean age 68.7 (8.5) yr., 51.1% female; Hip: n = 692, mean age 65.5 (10.4) yr., 48.9% female]; 26% (158/610) of knee and 61% (423/692) of hip participants participated predominantly in home-based programs. A greater proportion of public recipients were obese and had greater pre-operative joint impairment, but participated more commonly in home programs [(Knee: 32.9% (79/240) vs 21.4% (79/370) (P = 0.001); Hip: 71.0% (176/248) vs 55.6% (247/444) (P <  0.001)], less commonly in inpatient rehabilitation [Knee: 7.5% (18/240) vs 56.0% (207/370) P (< 0.001); Hip: 4.4% (11/248) vs 33.1% (147/444) (P <  0.001], and had fewer outpatient treatments [Knee: median (IQR) 6 (3) vs 8 (6) (P < 0.001); Hip: 6 (4) vs 8 (6) (P < 0.001)]. CONCLUSIONS: Facility-based programs remain the norm for most knee and many hip arthroplasty recipients with insurance status being a major determinant of care. Development and implementation of evidence-based guidelines may help resolve the evidence-practice gap, addressing unwarranted practice variation across the insurance sectors.

Differences in hip torque ratios between individuals with femoroacetabular impingement syndrome and asymptomatic individuals: A cross-sectional study.

BACKGROUND: Hip torque ratios are considered a useful measure for patients with hip pain. However, evidence regarding this measure for patients with femoroacetabular impingement syndrome is scarce. The primary aim of this study was to compare hip external-internal rotation and abduction-adduction torque ratios between patients with femoroacetabular impingement syndrome and asymptomatic individuals. The secondary aim was to compare hip torque ratios between the asymptomatic group and femoroacetabular impingement syndrome patients grouped according to the severity of symptoms and functional limitations. METHODS: Hip abduction-adduction and external-internal rotation torque ratios of 134 individuals with femoroacetabular impingement syndrome and 134 asymptomatic matched controls was assessed through isokinetic testing. Severity of symptoms and functional limitations was assessed through the iHOT-33. Mann Whitney U and Kruskall-Wallis tests were used to compare hip torque ratios between asymptomatic individuals and patients with femoroacetabular impingement syndrome and to patients with femoroacetabular impingement syndrome with different severities of symptoms and functional limitations. FINDINGS: No differences were identified in hip abduction-adduction (U = 7659.5, p = 0.192) and external-internal rotation (U = 8787.5, p = 0.764) torque ratios between patients with femoroacetabular impingement syndrome and asymptomatic individuals. Hip abduction-adduction torque ratio was higher (p = 0.0127) in patients with a severe state (median = 1.80, IQR = 0.61) when compared to asymptomatic individuals (median = 1.52, IQR = 0.45) (moderate effect size, r = 0.45). INTERPRETATION: Patients with severe symptoms and functional limitations related to FAI syndrome presented greater hip abduction-adduction torque ratio than asymptomatic individuals, suggesting a decreased adduction torque capacity relative to abduction torque in this subgroup of femoroacetabular impingement.

Knee and hip dynamic muscle strength in individuals with femoroacetabular impingement syndrome scheduled for hip arthroscopy: A case-control study.

Background The primary aim of this study was to compare knee and hip dynamic muscle strength of individuals with femoroacetabular impingement (FAI) syndrome scheduled for hip arthroscopy with healthy controls. Our secondary aim was to compare hip and knee muscle strength between male and female patients with FAI syndrome. Methods One hundred and thirty-four individuals with femoroacetabular impingement syndrome scheduled for hip arthroscopy and 134 healthy controls matched for sex and age (within 5 years range) underwent an isokinetic assessment of knee extension and flexion and hip abduction, adduction, external rotation and internal rotation dynamic muscle strength. Two MANOVAs were conducted to compare isokinetic peak torque and total work between groups and sexes. Findings Individuals with femoroacetabular impingement syndrome demonstrated lower values of all variables representing knee and hip isokinetic peak torque and total work measures when compared to healthy controls, with differences ranging from 0.09 Nm/kg (95%CI: 0.06-0.12 Nm/kg) to 0.64 Nm/kg (95%CI: 0.49-0.79 Nm/kg). Female participants from both FAI syndrome and control group showed less knee and hip muscle strength compared to male participants. There was no significant interaction between group and sex regarding knee or hip isokinetic peak torque and total work (p > 0.05). Interpretation Individuals with femoroacetabular impingement syndrome scheduled for hip arthroscopy present impairments in knee or hip dynamic muscle strength when compared to controls. Female participants present less knee and hip muscular strength compared to male participants, these between-sex differences are similar for both FAI syndrome and control group participants.

Therapeutic Exercise Approaches to Nonoperative and Postoperative Management of Femoroacetabular Impingement Syndrome.

Femoroacetabular impingement syndrome (FAIS) is characterized by premature contact of the femur and acetabulum during hip motion. Morphologic variations of FAIS present as either aspherical femoral deformity (cam femoroacetabular impingement) or overcoverage (pincer femoroacetabular impingement) or both. Patients with FAIS often describe discomfort with hip flexion, adduction, and internal rotation. The use of hip arthroscopy to treat FAIS has risen substantially over the last 15 years. Given that one practice domain of the athletic training profession involves injury prevention and wellness protection, optimal FAIS treatment and management strategies warrant discussion. Sports medicine professionals often help patients with FAIS explore nonoperative exercise strategies and direct rehabilitation exercises for those who pursue surgery. Both approaches demonstrate key pillars of exercise program design, which include postural control, core stabilization, hip strength and motor control, and mobility. The purpose of this article is 2-fold: to present an overview of FAIS, including common diagnostic strategies, and commonalities in therapeutic approaches between nonoperative and postoperative rehabilitation for the treatment and management of patients with FAIS.

Physical Therapy Protocol After Hip Arthroscopy: Clinical Guidelines Supported by 2-Year Outcomes.

CONTEXT: Femoroacetabular impingement (FAI) was first described by Ganz in 2003 and is a significant cause of decreased function and mobility. Femoroacetabular impingement must be treated in an individualized, goal-oriented, stepwise fashion. This protocol was developed with biomechanical considerations of soft tissue and bony structures surrounding the hip joint. EVIDENCE ACQUISITION: The PubMed database was searched for scientific and review articles from the years 2000 to 2015 utilizing the search terms: hip rehabilitation, femoroacetabular impingement, and arthroscopy. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 5. RESULTS: Five hundred ninety-five of 738 patients were available for follow-up showing improvement from preoperative to 2-year follow-up of 61.29 to 82.02 for modified Harris Hip Score (mHHS), 62.79 to 83.04 for Hip Outcome Score-Activities of Daily Living (HOS-ADL), 40.96 to 70.07 for Hip Outcome Score-Sport-Specific Subscale (HOS-SSS), and 57.97 to 80.41 for Non-Arthritic Hip Score (NAHS); visual analog scale (VAS) scores decreased from 5.86 preoperatively to 2.94 postoperatively. CONCLUSION: Following a structured, criteria-based program, appropriate patients undergoing hip arthroscopy may achieve excellent outcomes and return to full independent activities of daily living as well as sport.

Rehabilitation After Hip Arthroscopy: A Movement Control-Based Perspective.

Adequate control of movement is essential for patients to return to unrestricted function after hip arthroscopic surgery. Mobility, muscle performance and stability, and neuromuscular control are vital aspects addressed in rehabilitation to help re-establish control of movement for function. Initial joint protection is a hallmark for all patients after hip arthroscopy to prevent intra-articular and extra-articular soft tissue irritation of healing tissues. It is essential to tailor exercises of each phase to patients' specific functional demands. Each phase of rehabilitation should be monitored so that patients are not advanced too quickly, which can lead to setbacks and delays in return to normal function.

Examining the effects of altering hip orientation on gluteus medius and tensor fascae latae interplay during common non-weight-bearing hip rehabilitation exercises.

BACKGROUND: Improving activity and strength of the gluteus medius muscle is a common goal among clinicians aiming to rehabilitate lower extremity and low back injuries. The functional anatomy of the hip is complex, particularly how position-dependent the activity and strength of many muscles surrounding the hip are, and the optimal exercise technique to isolate gluteus medius remains controversial. The objective of this study was to quantify the effect of altering hip orientation during side-lying clamshell and hip abduction exercises on the relative muscle activation profiles of gluteus medius and tensor fascae latae. METHODS: The ratio of gluteus-medius-to-tensor-fascae-latae peak electromyography signal amplitude of 13 healthy, male participants was compared across variations of the clamshell and abduction exercises. The hip flexion angle was varied from 30°, 45°, and 60° for the clamshell, while hip rotation orientation was varied from internal, neutral, and external rotation for the abduction exercise. FINDINGS: Varying hip angle - flexion in the clamshell exercise and internal/external rotation in the abduction exercise - did not significantly affect the interplay between gluteus medius and tensor fascae latae activation levels. Both exercises remained gluteus medius-dominant across all variations, but the gluteus-medius-to-tensor-fascae-latae ratio was far greater for the clamshell than for the abduction exercise; the clamshell may be the preferred rehabilitative exercise to prescribe when minimal tensor fascae latae muscle activation is desired by the clinician. INTERPRETATION: These findings provide information for clinical decision-making pertaining to effective gluteus medius activation in lower extremity and low back exercise rehabilitation programs.

Postoperative rehabilitation guidelines for hip arthroscopy in an active population.

CONTEXT: With the evolution of hip arthroscopy has come an increased recognition of intra-articular hip pathologies and improved techniques for their management. Whereas mechanical problems can often be corrected through surgery, functional deficits must be corrected through the rehabilitation process. Therefore, the evolution of hip arthroscopy has necessitated a progression in hip rehabilitation to ensure optimal postsurgical results. EVIDENCE ACQUISITION: Literature review was conducted with PubMed, EMBASE, and PEDro (1992 to 2009) with the terms hip, rehabilitation, and physical therapy. RESULTS: Although it is generally accepted that rehabilitation after hip arthroscopy is important, there is limited evidence-based research to support the rehabilitative guidelines. CONCLUSION: The common goal of hip rehabilitation should remain focused on the return to pain-free function of the hip joint. Outcome data indicate that this goal is being met; however, further data are required to completely validate the long-term success of hip rehabilitation after arthroscopy.

Avaliação de resultados subjetivos de pacientes submetidos a artroplastia total de quadril pelo questionário WOMAC / Self-reported outcomes of patients undergoing total hip replacement surgery assessed by the WOMAC questionnaire

Objective: To assess pain, stiffness and physical function outcomes among patients undergoing total hip replacement using the Western Ontario and McMaster Universities Osteoarthritis Index. Methods: From January 2009 to July 2010, 64 male and female patients were assessed using the WOMAC questionnaire at baseline, hospital discharge, 3-month follow-up, and 6-month follow-up; one group of patients with primary hip osteoarthritis (n = 42) and another group with hip fracture (n = 22). Results: Changes in the total scores of the osteoarthritis group were statistically significant comparing baseline, hospital discharge, 3-month and 6-month assessments, demonstrating continued improvement over time up to 6-month follow-up. The total scores of the hip fracture group demonstrated a worsening from baseline to discharge, followed by improvement. The differences were statistically significant between baseline and discharge, as well as between discharge and the 6-month assessment. No statistically significant differences were found between baseline values and the 3-month assessment or baseline values and the 6-month assessment, demonstrating that the patients returned to their baseline health status after 3 months and maintained this status up to 6-month follow-up. Conclusion: The Western Ontario and McMaster Universities Osteoarthritis Index questionnaire detected changes in outcome following hip replacement surgery among patients with primary diagnoses of hip osteoarthritis and hip fracture, with differences in the pattern of changes between the two groups.

Objetivo: Avaliar resultados referentes a dor, rigidez e função física de pacientes submetidos à artroplastia total de quadril utilizando o questionário Western Ontario and McMaster Universities Osteoarthritis Index. Métodos: De Janeiro de 2009 a Julho de 2010, 64 pacientes homens e mulheres foram avaliados utilizando o questionário WOMAC no momento pré-operatório, na alta hospitalar, com 3 meses e 6 meses de seguimento; um grupo de pacientes com osteoartrite primária de quadril (n = 42) e outro grupo com fratura de quadril (n = 22). Resultados: Mudanças nos escores totais do rupo de osteoartrite foram estatisticamente significantes comparando-se a avaliações de pré-operatório, alta hospitalar, com 3 meses e 6 meses, demonstrando melhora contínua com o decorrer do tempo até o seguimento de 6 meses. Os escores totais para o grupo com fratura de quadril demonstraram uma piora entre o momento pré-cirúrgico e a alta, seguida por uma melhora nos demais seguimentos. As diferenças foram estatisticamente significantes entre o pré-operatório e a alta, assim como entre a avaliação da alta e de 6 meses. Não houve diferença estatisticamente significante entre a avaliação pré-operatória e a de 3 meses ou entre a avaliação préoperatória e a de 6 meses, demonstrando que os pacientes retornaram ao seu estado de saúde pré-cirúrgico após 3 meses, mantendo esse estado até 6 meses de seguimento. Conclusão: O questionário Western Ontário and McMaster Universities Osteoarthritis Index detectou mudanças após a cirurgia entre os pacientes com diagnóstico primário de osteoartrite de quadril e fratura de quadril, com diferenças nos padrões de mudança entre os dois grupos.