Feasibility of interdisciplinary evaluation in non-arthritic hip pain: A randomized trial.

BACKGROUND: Physical therapy and orthopaedic surgery are two common treatments for non-arthritic hip pain. Interdisciplinary evaluation across these disciplines may produce a more supportive treatment-planning process; however, the feasibility of such an evaluation remains unknown. HYPOTHESIS OBJECTIVE: To assess the feasibility of an interdisciplinary evaluation with an orthopaedic surgeon and physical therapist for non-arthritic hip pain. STUDY DESIGN: Observational feasibility study of a randomized controlled trial. METHODS: Participants were randomized to an interdisciplinary (surgeon + physical therapist) or standard (surgeon) evaluation in a hip preservation clinic. Recruitment rate was recorded. Retention rate was calculated for all variables of interest. Enrollment and refusal reasons were recorded as patient quotes and categorized by a single grader. Time spent in clinic was compared across groups using Mann Whitney U tests (P ≤ 0.05). Study clinicians were interviewed, and responses were categorized based on pre-determined themes. RESULTS: Eighty-one percent of eligible patients enrolled over a 15-month recruitment period. Willingness(n = 16), urgency to resolve pain(n = 10), financial compensation(n = 1), interest in research(n = 42), physical therapy(n = 6), or multiple-provider care(n = 15) were participants' enrollment reasons; reason was not recorded for 22 participants. Time(n = 11), preference for single-provider care(n = 6), current physical therapy treatment(n = 1), and disinterest in physical therapy(n = 7) or research(n = 2) were refusal reasons of patients who did not enroll. Retention for primary variables of interest was 100% in both groups. Participants spent, on average, 23.5 min more time in clinic for the interdisciplinary evaluation compared to the standard (P < 0.001). CONCLUSIONS: An interdisciplinary evaluation for patients with non-arthritic hip pain that included a physical therapist and orthopaedic surgeon in a hip preservation clinic was feasible and may better inform the treatment planning process.

Repair of Full-Thickness Gluteus Maximus Tear With Suture Anchors.

Gluteal tendon tears are a common cause of hip pain. Most commonly, tears occur in the gluteus medius and minimus, and there are well-established nonoperative or operative treatment pathways. In this Technical Note, we describe our technique for repair of a full-thickness gluteus maximus tendon tear using anchor fixation.

Modified Loop Suture Technique in Arthroscopic Labral Repair of the Hip.

Hip arthroscopy is rapidly increasing in case volume annually in the United States. However, it remains a challenging surgery with a steep learning curve. Labral repair is commonly performed to preserve the labrum rather than labral debridement or reconstruction. Many techniques have been described for labral repair. In this technical note, we describe our technique for a modified loop suture technique for arthroscopic labral repair of the hip.

Patient-specific factors, but neither regional anesthesia nor hip-specific cryotherapy, predict postoperative opioid requirements after hip arthroscopy for femoroacetabular impingement (FAI) syndrome.

Background: We sought to determine whether regional nerve block, cryotherapy variant, or patient-specific factors predict postoperative opioid requirements and pain control following hip arthroscopy. Methods: 104 patients underwent hip arthroscopy with (n = 31) or without (n = 73) regional block and received cryotherapy with a universal pad [joint non-specific; no compression (n = 60)] or circumferential hip/groin wrap with intermittent compression (n = 44). Outcomes included total opioid prescription amounts, requests for refills, and unplanned clinical encounters for postoperative pain within 45 days of surgery. Multivariate modeling was used to determine the effect of perioperative regional nerve block and type of cryotherapy device on outcomes after adjusting for patient demographics, previous opioid use, mental health disorder history, and surgery length. Results: The average amount of 5 mg oxycodone pill equivalents prescribed within 45 days of surgery was 40.5 (SD 14.8); 36% requested refills, 20% presented to another physician, and 21% called the surgeon's office due to pain. Neither the hip-specific cryotherapy pad nor regional block was predictive of opioid amounts prescribed, refill requests, or unplanned clinical encounters due to pain. Refill requests within 45 days were more common with baseline opioid use (p < 0.001), increased age (p = 0.007), and mental health disorder history (p = 0.008). Total opioid amounts prescribed within 45 days were higher with workers compensation (p = 0.03), a larger initial opioid prescription (p < 0.001), baseline opioid use (p < 0.001), history of mental health disorder (p = 0.02), and increased age (p = 0.02). Together, these variables explained 61% of the variance in opioid amounts prescribed. Conclusion: Patient factors are strong predictors of postoperative opioid requirements after hip arthroscopy. Postoperative opioid prescription amounts, opioid refill requests, and pain-related calls or office visits were not affected by use of a perioperative regional nerve block or type of cryotherapy delivery system. Level of evidence: III, retrospective cohort study.

Treatment of Chronic Proximal Hamstring Tendinopathy with Surgical Debridement and Suture Anchor Repair.

We evaluated outcomes following surgical debridement and suture anchor repair of chronic proximal hamstring tendinopathy without sciatic nerve decompression. Chart review identified eight patients (one bilateral) who met study requirements. All eight patients were available for follow-up at a mean of 6.7 years and none underwent re-operation on the index hip during the follow-up period. Seven patients completed patient-reported outcome scores. The mean LEFS score was 81.1, and the mean SANE score was 74.9. The mean Marx activity score was 2.8, and the mean Custom Marx score was 23.3. Pain relief was excellent. The mean numeric pain score at rest was 0.6, while the mean numeric pain score with activity was 4.0. Treatment of chronic, recalcitrant proximal hamstring tendinopathy with surgical debridement and suture anchor repair without exploration of the sciatic nerve results in excellent pain relief, good function, and low re-operation risk. (Journal of Surgical Orthopaedic Advances 31(1):061-064, 2022).

Editorial Commentary: Low-Radiation Dose 3-Dimensional Computed Tomography Scan Reconstruction Is the Best Way to Visualize the Anterior Inferior Iliac Spine-For Now.

Femoroacetabular impingement comes in several anatomic variations that may coexist, and subspine impingement is a commonly discussed cause of indirect extra-articular hip pathology. Although a classification system to identify and understand anterior inferior iliac spine morphology has been in place for some time, attempts have been made to visualize and understand the anatomy based on other imaging modalities. Standard radiographs are a common part of the initial patient evaluation pathway, along with thorough history taking and physical examination findings. Magnetic resonance imaging scans are obtained typically to evaluate the soft tissue, muscle, ligaments, articular cartilage, and labrum for pathology. For many hip preservation surgeons, a computed tomography scan with 3-dimensional reconstruction is standard protocol for patients who progress along the treatment pathway toward a surgical procedure because understanding the complex hip anatomy is key to successful surgical treatment. Many hip arthroscopy patients are in their young adult years, and we always attempt to reduce the amount of radiation exposure. Eliminating this computed tomography scan and using standard-of-care magnetic resonance imaging to simplify patient care, reduce radiation, and reduce health care costs would certainly be beneficial to our hip preservation patients.

Treating Knee Osteoarthritis With Platelet-Rich Plasma and Hyaluronic Acid Combination Therapy: A Systematic Review.

BACKGROUND: Platelet-rich plasma (PRP) and hyaluronic acid (HA) are injectable treatments for knee osteoarthritis. The focus of previous studies has compared their efficacy against each other as monotherapy. However, a new trend of combining these 2 injections has emerged in an attempt to have a synergistic effect. PURPOSE: To systematically review the clinical literature examining the combined use of PRP + HA. DESIGN: Systematic review. METHODS: A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using PubMed and Embase. The following search terms were used: knee osteoarthritis AND platelet rich plasma AND hyaluronic acid. The review was performed by 2 independent reviewers who applied the inclusion/exclusion criteria and independently extracted data, including methodologic scoring, PRP preparation technique, HA composition, and patient-reported outcomes (PROs). RESULTS: A total of 431 articles were screened, 12 reviewed in full, and 8 included in the final analysis: 2 case series, 3 comparative, and 3 randomized studies. Average follow-up was 9 months. The modified Coleman Methodology Score was 38.13 ± 13.1 (mean ± SD). Combination therapy resulted in improved PROs in all studies. Of the comparative and randomized studies, 2 demonstrated that combination therapy was superior to HA alone. However, when PRP alone was used as the control arm (4 studies), combination therapy was not superior to PRP alone. CONCLUSION: Combination therapy with PRP + HA improves PROs and is superior to HA alone but is not superior to PRP alone.

Prevalence of low back pain and related disability in patients with femoroacetabular impingement syndrome.

BACKGROUND: Low back pain (LBP) has been associated with worse hip function for persons with femoroacetabular impingement syndrome (FAIS). Reports are limited to surgical populations and based on the presence or absence of LBP, regardless of pain severity. OBJECTIVES: To report the prevalence of clinically significant LBP for persons with FAIS; compare demographics, pain, and function between those with and without clinically significant LBP; and evaluate relationships between hip function and both LBP-related disability and LBP severity. We hypothesized that participants with LBP would be older, have higher body mass index (BMI), and report worse groin pain, longer symptom duration, and worse hip function. We hypothesized that worse LBP-related disability and LBP severity would be related to worse hip function. DESIGN: Observational cross-sectional study. SETTING: Hip preservation clinic. PARTICIPANTS: 158 persons with FAIS. INTERVENTIONS: n/a MAIN OUTCOME MEASURE(S): Visual analog pain scales (VAS 0-100) were used to categorize participants with (≥30) and without (<30) clinically significant LBP. Age, sex, BMI, pain severity and duration, and hip function (33-item Hip Outcome Tool [iHOT33]) were compared between those with and without clinically significant LBP. Correlations were evaluated between the modified Oswestry Disability Index (ODI) and iHOT33, ODI and groin pain severity, LBP severity and iHOT33, and LBP and groin pain severity. RESULTS: Sixty percent of participants reported clinically significant LBP (n = 95). These participants reported worse iHOT33 scores (mean difference: 10.1 points) than those without clinically significant LBP (p = .001). Worse ODI scores were associated with worse iHOT33 scores (P < .001; ρ = -0.74). Significant relationships were also observed between (1) ODI and groin pain, (2) LBP and iHOT33, and (3) LBP and groin pain, but the magnitudes of these correlations were weak (ρ ≤ 0.36). CONCLUSIONS: Clinically significant LBP is highly prevalent in persons with FAIS and is associated with worse hip function. Worse LBP-related disability, but not LBP severity, was strongly associated with worse hip function.

Use of continuous passive motion device after arthroscopic hip surgery decreases post-operative pain: A randomized controlled trial.

BACKGROUND: We sought to determine whether continuous passive motion (CPM) usage improves outcomes following arthroscopic hip surgery involving acetabular labral repair. Our hypothesis is that CPM usage reduces pain and pain medication use and improves quality of life in individuals who undergo hip arthroscopy. METHODS: We created a randomized controlled trial consisting of 54 patients who underwent arthroscopic acetabular labral repair. Patients were randomized to two groups, one with CPM use post-operatively and one without. Primary outcomes measured were pain level, patient satisfaction, and quality of life. Parameters used to measure these outcomes were self-reported pain scores on Likert scale, frequency of analgesic medication use, and self-reported scores on Hip Outcome Score Activity of Daily Living (HOS ADL). These parameters were compared between the two randomized groups using t-test for statistical analysis. RESULTS: There was no statistical difference between the treatment and control groups in terms of patient characteristics. There was no statistical difference between the two groups in terms of HOS ADL scores, although the patients in the control group demonstrated a trend toward higher HOS ADL scores. The patients in the CPM group had a statistically significant decrease in pain levels after surgery compared to patients in the control group. The total morphine equivalent dose consumed in the first two post-operative weeks was higher in the control group compared to the CPM group, although this difference was not statistically significant. CONCLUSIONS: Use of CPM resulted in lower pain level scores in patients after hip arthroscopy. Although there is no statistical difference in quality of life or quantity of analgesics consumed post-operatively, patients who used CPM tended to have lower HOS ADL scores (which is desirable) and less consumption of pain medication. A study with a larger sample of patients might elucidate more differences between the two groups. LEVEL OF EVIDENCE: II, therapeutic.

Associations Between Movement Impairments and Function, Treatment Recommendations, and Treatment Plans for People With Femoroacetabular Impingement Syndrome.

OBJECTIVE: The purpose of this study was to describe movement impairments for persons with femoroacetabular impingement syndrome and their association with function, treatment recommendations, and treatment plans. METHODS: This report is a secondary, observational analysis of a clinical trial dataset in which participants received an interdisciplinary evaluation from a surgeon and physical therapist. The therapist documented frontal and sagittal plane movement impairments across 6 functional tasks. Associations between number of impairments in each plane and function (33-item International Hip Outcome Tool [iHOT33]) were evaluated using Pearson or Spearman correlations. Joint provider recommendations (physical therapist and surgeon) and participant-reported treatment plans were dichotomized based on the inclusion of physical therapy or not. Logistic regressions were used to examine the effects of (1) iHOT33, total movement impairments, and previous physical therapist treatment on joint provider recommendation and (2) these same variables along with joint provider recommendation on participant treatment plan; prevalence ratios and 95% CIs were reported for significant contributors. RESULTS: Thirty-nine participants demonstrated an average iHOT33 of 35.0 (SD = 19.5) and presented with a median 5 frontal and 3 sagittal plane impairments. More frontal plane impairments were associated with worse iHOT33 scores. Twenty-seven participants received a joint provider recommendation that included physical therapy; no significant contributors to these recommendations were identified. Twenty-four of the 27 participants with a physical therapist recommendation included physical therapy in their treatment plan. Two additional participants did not receive a physical therapist recommendation but included physical therapy in their plan. Joint provider recommendation was the only significant contributor to the participant-reported plan (prevalence ratio = 7.06; 95% CI = 3.25-7.97). CONCLUSION: Persons with femoroacetabular impingement syndrome displayed clinically observable movement impairments that were associated with worse function. Joint provider recommendations strongly influenced participants' treatment plans to pursue physical therapy. IMPACT: Physical therapists contribute new information to surgical examinations regarding movement. Joint recommendations from the physical therapist and the surgeon can influence patients' decisions to pursue physical therapy.

A Comparative Analysis of the Quadratus Lumborum Block Versus Femoral Nerve and Fascia Iliaca Blocks in Hip Arthroscopy.

PURPOSE: To evaluate the effect of the single-shot quadratus lumborum (QL) block versus femoral nerve and fascia iliacus (F/FI) blocks performed preoperatively on perioperative opioid requirements, subjective pain scores, and time to discharge. METHODS: Patients who underwent hip arthroscopy for femoroacetabular impingement and had a preoperative nerve block between January 2017 and August 2019 at our institution were identified. Patients were separated into 2 groups: those who either received a preoperative single-shot QL block or a preoperative single-shot F/FI block. All patients received general anesthesia. Intraoperative, postanesthesia care unit (PACU), and total morphine equivalents were analyzed using unpaired t test. Secondary outcome measures including total time in PACU and block-related complications were recorded and analyzed as well. RESULTS: One hundred one patients were retrospectively reviewed. Forty-three patients received preoperative QL blocks, and 58 patients received preoperative F/FI blocks. Demographics and operative characteristics were similar between the 2 groups. Patients receiving a QL block required significantly lower total morphine equivalents (63.1 vs 87.0, P < .001). Patients receiving a QL block also had shorter PACU stays (116 vs 148 minutes, P < .001) and lower subjective pain scores at the time of discharge (3.27 vs 4.98, P < .001) compared with the F/FI block group. There were also significant decreases in the number of intraoperative opioids (42.1 vs 58.4, P < .001) and PACU opioids (20.7 vs 28.7, P = .03) used when analyzed separately. Two patients in the femoral nerve block group had noted a fall postoperatively while the block was in effect. No patients in the QL block group had a block-related complication. CONCLUSIONS: Patients receiving a preoperative QL block for hip arthroscopy demonstrated lower total opioid requirements, shorter PACU stay, and lower pain scores at discharge than patients receiving preoperative F/FI blocks with no reported adverse events. LEVEL OF EVIDENCE: Level III, retrospective comparative trial.

Utility of Percutaneous Ultrasonic Tenotomy for Tendinopathies: A Systematic Review.

CONTEXT: Chronic tendinopathy is a challenging problem that can lead to significant disability and limitation in not only athletics but also activities of daily living. While there are many treatment techniques described for this overuse injury, no single modality has been proven superior to all others. With recent advances in medical technology, percutaneous ultrasonic tenotomy (PUT) for tendinosis has gained traction with promising results. OBJECTIVE: To examine the data published on PUT for treatment of tendinopathy, analyze the outcomes of the procedure, including duration of pain relief and patient-reported outcomes, and assess the rate of complications associated with the procedure. DATA SOURCES: PubMed, MEDLINE, EMBASE, and Google Scholar. STUDY SELECTION: The following combination of keywords was entered into the electronic search engines: ultrasonic tenotomy, ultrasound tenotomy, Tenex, and ultrasonic percutaneous tenotomy. The search results were screened for studies relevant to the topic. Only English-language studies were considered for inclusion. Studies consisting of level 4 evidence or higher and those involving human participants were included for more detailed evaluation. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: Articles meeting the inclusion criteria were sorted and reviewed. Type of tendinopathy studied, outcome measures, and complications were recorded. Both quantitative and qualitative analyses were performed on the data collected. RESULTS: There were a total of 7 studies that met the inclusion criteria and quality measures-5 studies involving the treatment of elbow tendinopathy and 1 study each involving the management of Achilles tendinopathy and plantar fasciitis. PUT resulted in decreased pain/disability scores and improved functional outcome scores for chronic elbow tendinopathy and plantar fasciitis. Results for Achilles tendinopathy showed modest improvement in the short term, but long-term data are lacking. CONCLUSION: PUT is a minimally invasive treatment technique that can be considered in patients with tendinopathy refractory to conservative treatment measures. Further higher quality studies are necessary to accurately assess the comparative effectiveness of this treatment modality.

Percutaneous ultrasonic tenotomy effectively debrides tendons of the extensor mechanism of the knee: A technical note.

BACKGROUND: Percutaneous ultrasonic tenotomy (PUT) is a minimally-invasive method of treating patellar tendinosis, but its immediate effect on tendon structure has never been studied. Given the crucial nature of the extensor mechanism of the knee, it is important to understand the procedure's effect on tendon structure prior to clinical implementation. The aim of this study was to analyze the tendon structure of the extensor mechanism of the knee after PUT in a cadaveric model. METHODS: Four fresh-frozen cadaveric specimens (two patellar and two quadriceps tendons) underwent PUT. The tendons were then sectioned and stained with hematoxilin & eosin (H&E). The sections were analyzed for a clear area of debridement. The area of debridement was calculated as an average of three measurements. RESULTS: All four tendons demonstrated a clear area of debridement limited to the treatment area without damaging any surrounding tissue. The area of debridement for the patellar and quadriceps tendons treated was 2.89 mm2, 1.5 mm2, 2.98 mm2 and 7.29 mm2, respectively. CONCLUSIONS: Percutaneous ultrasonic tenotomy effectively debrided the treatment area in all tendons without damaging surrounding tissue. Further work is needed to report clinical outcomes, assess the risk of post-procedure tendon rupture and define return-to-sport progression.

CrossFit-related hip and groin injuries: a case series.

To provide descriptive data on injury presentation and treatment and to identify risk factors for requiring surgical treatment for athletes presenting with CrossFit-related hip and groin injuries. CrossFit-related injuries (n = 982) were identified within a single hospital system from 2010 to 2017, with 83 (8.5% of total) identified hip or groin injuries. Patient demographics, injury diagnosis, surgical procedure and rehabilitation were assessed. Independent predictors of requiring surgery were analyzed via multivariate logistic regression analysis. Patients with hip or groin injuries were more often female (hip injuries: 63%; all injuries: 50%; P < 0.001) with mean age 34.3 years (standard deviation 10.9). Median symptom duration was 4 months with 70% reporting insidious onset. Most common diagnoses were femoral-acetabular impingement syndrome (34%), hamstring strain (11%), non-specific hip/groin pain (imaging non-diagnostic) (11%), hernia (7%) and iliotibial band syndrome (6%). Most (90%) required physical therapy (median 2 months). Surgery occurred in 24% (n = 12 hip arthroscopy, n = 5 inguinal hernia repair, n = 3 total hip arthroplasty), with 100% return to sport after arthroscopy or hernia repair. The only predictor of surgery was complaint of primarily anterior hip/groin pain (82% surgical patients, 46% non-surgical) (odds ratio 5.78, 95% confidence interval 1.44-23.1; P = 0.005); age, sex, body mass index, symptom duration and symptom onset (insidious versus acute) were non-significant (P > 0.25). CrossFit athletes with hip and groin injuries often present with prolonged symptoms with insidious onset. Most patients require several months of physical therapy and approximately one quarter require surgery. Patients presenting with primarily anterior hip/groin pain are at increased risk for requiring surgery. LEVEL OF EVIDENCE: IV, case series.

Physical Therapists and Physicians Evaluate Nonarthritic Hip Disease Differently: Results From a National Survey.

BACKGROUND: Physical therapy and surgery are viable treatment options for nonarthritic hip disease (NAHD). Interdisciplinary collaboration can help patients make informed treatment decisions. Understanding how each provider can contribute is a critical first step in developing collaborative evaluation efforts. OBJECTIVE: The objective of this study was to describe the current evaluation of NAHD by both physical therapists and physicians, and evaluate national use of expert-recommended evaluation guidelines. DESIGN: A national survey study distributed in the United States was implemented to accomplish the objective. METHODS: A survey was distributed to 25,027 potential physical therapist and physician respondents. Respondents detailed their evaluation content for patients with NAHD across the following domains: patient-reported outcomes, patient history, special tests, movement assessment, clinical tests, and imaging. Respondents ranked importance of each domain using a 5-point Likert scale (not important, slightly important, important, very important, or extremely important). Odds ratios (ORs [95% CIs]) were calculated to identify the odds that physical therapists, compared with physicians, would report each evaluation domain as at least very important. Fisher exact tests were performed to identify statistically significant ORs. RESULTS: Nine hundred and fourteen participants (3.6%) completed the survey. Physical therapists were more likely to indicate movement assessment (OR: 4.23 [2.99-6.02]) and patient-reported outcomes (OR: 2.56 [1.67-3.99]) as at least very important for determining a diagnosis and plan of care. Physical therapists had lower odds of rating imaging (OR: 0.09 [0.06-0.14]) and special tests (OR: 0.72 [0.53-0.98]) as at least very important compared with physicians. LIMITATIONS: This survey study did not include many orthopedic surgeons and thus, primarily represents evaluation practices of physical therapists and nonsurgical physicians. CONCLUSIONS: Physical therapists were more likely to consider movement assessment very important for the evaluation of patients with NAHD, whereas physicians were more likely to consider imaging and special testing very important.

Bone marrow lesions: etiology and pathogenesis at the hip.

Bone marrow lesions (BML) are painful changes in subchondral bone which can be reliably identified on magnetic resonance imaging and have been identified in patients suffering from hip osteoarthritis (OA) and related conditions. Created via repetitive microdamage at the articular surface and dysregulated subchondral healing, BML have been linked to traumatic, inflammatory, degenerative, metabolic and neoplastic processes. While BML are known to be a common pathology throughout the body, BML at the hip have not been extensively studied in comparison to those at the knee. Due to the hip's unique biomechanical architecture, function and loading, and independent risk factors leading to hip OA, hip BMLs must be independently understood. The identification of BML in the setting of a pre-osteoarthritic condition may provide a target for treatment and prevention of joint degeneration. By continuing to define and refine the relationships between BML, subchondral bone cysts and OA, prevention, diagnosis and treatment of OA could shift, leading to an improved quality of life and increased longevity of individuals' native hips.