Two-year outcomes after arthroscopic surgery compared to physical therapy for femoracetabular impingement: A protocol for a randomized clinical trial.

BACKGROUND: As the prevalence of hip pathology in the younger athletic population rises, the medical community continues to investigate effective intervention options. Femoracetabular impingement is the morphologically abnormal articulation of the femoral head against the acetabulum, and often implicated in pre-arthritic hip conditions of musculoskeletal nature. Arthroscopic surgical decompression and non-surgical rehabilitation programs focused on strengthening and stability are common interventions. However, they have never been directly compared in clinical trials. The primary purpose of this study will be to assess the difference in outcomes between these 2 commonly utilized interventions for femoracetabular impingement. METHODS: The study will be a single site, non-inferiority, randomized controlled trial comparing two different treatment approaches (surgical and nonsurgical) for FAI. The enrollment goal is for a total of 80 subjects with a diagnosis of Femoracetabular impingement that are surgical candidates and have failed 6 weeks of conservative treatment. This will be a convenience sample of consecutive patients that are Tricare beneficiaries and seeking care at Madigan Army Medical Center. Patients that meet the criteria will be screened, provide written consent before enrollment, and then randomized into one of two arms (Group I = hip arthroscopy, Group II = physical therapy). Group I will undergo hip arthroscopy with or without labral repair. Group II will follow an impairment based physical therapy program consisting of 2 sessions per week for 6 weeks. The primary outcome will be the Hip Outcome Score and secondary measures will include the International Hip Outcome Tool and the Global Rating of Change. Measures will be taken at baseline, 6 months, 1 and 2 years. Hip-related healthcare utilization between both groups will also be assessed at the end of 2 years. DISCUSSION: The current evidence to support both surgical and conservative interventions for femoroacetabular impingement is based on low-level research. To date, none of these interventions have been directly compared in a randomized clinical trial. Clinical trials are needed to help establish the value of these interventions in the management of femoracetabular impingement and to help define appropriate clinical pathways. TRIAL REGISTRATION: NCT01993615 30 October 2013.

Advanced technologies in the radiotherapy clinic: system fundamentals.

The radiotherapy treatment process is undergoing rapid development at every step from planning through delivery, and each step is increasingly automated and assisted by new imaging, positioning, contouring and treatment tools. Plan delivery and verification is now aided using an increasing range of image guidance technologies, and imaging at treatment now brings broad opportunities for dose guidance and adaptation for improving overall treatment quality. While these many tools bring exciting opportunities for exact, reliable and efficient targeting of radiation dose, a consistently high level of accuracy must be achieved at every step to achieve the desired results. This level of workmanship requires thorough understanding of the basic methods involved in each step, including the opportunities and limitations, by both the clinicians and the planning/delivery staff alike. These processes and their clinical implementation are discussed in depth throughout this volume. Here, we overview their integration and guiding background concepts, as well as a range of workday efficiencies for clinical practice.

Image guidance and the new practice of radiotherapy: what to know and use from a decade of investigation.

Over the past decade, fundamental advances in image-guided radiation therapy (IGRT) have been made that are now being implemented in clinical practice. Imaging technologies to direct and confirm beam accuracy at the time of radiotherapy delivery have been intensively researched and developed. More recently, these imaging data have been used to evaluate and even modify the daily dose delivery of intended treatment plans. The rationale for the use of IGRT, to improve tumor control while limiting normal tissue toxicity, is a universal goal in radiotherapy. Avoidance of unexpected under- or overdosing during treatment is the most important benefit of IGRT, and has led to its integration into the use of advanced radiotherapy planning/delivery technologies for many clinical applications. Evidence-based strategies to effectively use IGRT in the clinic are still emerging. The evolving role of IGRT and some proposed strategies to exploit its potential benefits in the clinic will be presented, emphasizing the perspective of the radiation clinician. Practical strategies will be proposed to exploit the potential benefits of IGRT technologies in the clinic.

Motion management and image guidance for thoracic tumor radiotherapy: clinical treatment programs.

Managing target motion first requires understanding the nature of the motion characteristic of the tumor in the individual patient. It is important to have effective immobilization and patient training strategies to help reduce motion, and then to design appropriate margins and compensation for the residual motion that is quantified. Especially when considering complex, technically demanding treatments that require a degree of patient cooperation, careful patient selection is needed to ensure that the potential benefits of the treatment design are actually realized. Finally, accurate treatment hinges critically on verification - of overall positioning, of target and organ motion at the time of treatment, and of the performance of the selected treatment strategy. Properly selected imaging methods are central to this verification process. This discussion will present practical solutions for motion management and image guidance of radiotherapy for thoracic tumors, and most of these concepts are widely applicable to treatment of other tumor sites as well.

Intensity-modulated radiotherapy for breast cancer: advances in whole and partial breast treatment.

Intensity-modulated radiotherapy (IMRT) can improve dose distributions through the treated breast and also reduce radiation doses to adjacent normal tissues including the contralateral breast, heart and lung with appropriate planning. Analyses demonstrate that the quality of radiation dose distribution does affect clinical results, and that outcomes are enhanced through improved planning and dose delivery methods. To achieve these results, it is essential to carefully define tissue volumes for treatment or avoidance, select technologies that can potentially conform fields to those volumes, use comprehensive planning methods, and assess their results in terms of objective dose constraints. IMRT can also be used to boost the region of tumor excision concurrently with whole breast treatment, an approach now being evaluated in on-going clinical studies. Partial breast irradiation (PBI) has been proposed as an alternative to irradiation of the entire breast for early-stage breast cancer patients undergoing breast conservation treatment. Numerous single institution phase II studies have demonstrated promising results, and the American Society of Radiation Oncology (ASTRO) has defined a suitable group of low-risk patients for PBI treatment off protocol at this time. IMRT has been proposed as an alternative to 3D conformal radiotherapy (3DCRT) for external beam PBI to improve the dose conformality to target volumes and the sparing of normal tissues. There are an increasing number of institutions evaluating and using IMRT instead of 3DCRT for PBI because of the potential treatment advantages for the breast cancer patient.

Image-guided, adaptive radiotherapy of prostate cancer: toward new standards of radiotherapy practice.

The development and acceptance of new image-guided radiotherapy (IGRT) technologies have often been initiated with the treatment of prostate cancer. Imaging and tracking of the prostate during a treatment course has yielded a great deal of information about the motion and deformation of the gland during radiotherapy, and has led the way toward the development of more accurate treatment methods including dose-guided and adaptive strategies. Now, there is long-term experience with the use of fiducials and electromagnetic implantable beacons that give high-quality tracking of prostate motion. From analyzing these extensive tracking data sets, a clear understanding of prostate motion and its dosimetric significance has developed. This knowledge can now be used to define current expectations and guidelines for clinical care. The random nature of prostate motion requires daily localization if treatment is to be delivered with small margins. Interfraction motion can have a significant impact on prostate gland dosimetry, and even more of an impact on the seminal vesicles and possibly intraprostatic tumor areas. The dosimetric impact on normal structures (bladder/rectum) is less clear, and there are significant individual variations. Interfraction and intrafraction rotations and deformations of the prostate are routinely detected. The dosimetric impact of these motions of the prostate gland is minimal when daily localization is used, even when the treatment margins are small. However, deformations of the seminal vesicles, rectum and bladder are much more pronounced. The dosimetric impact of deformation of the rectum and bladder is highly variable among patients, and the clinical consequences remain unclear. Daily volumetric imaging and dosimetry may become quite important for these volumes. Due to the random nature of motion/deformation during prostate radiotherapy, adaptive radiotherapy ideally would be performed as an on-line process. On-line adaptive radiotherapy requires robust deformable registration and replanning programs. These are beginning to emerge in useful clinic applications.

The expanding roles of stereotactic body radiation therapy and oligofractionation: toward a new practice of radiotherapy.

The range of clinical applications for stereotactic body radiation therapy (SBRT) continues to expand based on clinical outcomes data from prospective trials and carefully analyzed institutional experiences. As a result of this strong scientific foundation, there has been burgeoning implementation of SBRT and other forms of hypofractionated radiation therapy in the practice of radiation oncology worldwide. In spite of the clinical successes achieved thus far - or, perhaps, because of them - fundamental questions about SBRT remain and have come into greater focus. Where and when is SBRT optimally integrated into the range of evolving modern multidisciplinary cancer treatment programs? What scientific insights (biological, technical and medical) might lead to further improvements in the efficacy of SBRT? What efficiencies are needed to achieve greater availability of SBRT? These and many other questions, fueled by the clinical accomplishments of SBRT to date, provide compelling directions for further exploration in scientific and clinical studies and further contributes to discoveries already transforming the practice of radiation oncology.

Stereotactic body radiation therapy for thoracic cancers: recommendations for patient selection, setup and therapy.

Advanced technologies have facilitated the development of stereotactic body radiation therapy (SBRT) programs capable of delivering ablative radiation doses for the control of lung cancers. To date, experience with these programs has been highly favorable, as reflected in the results of careful clinical trials. The medically inoperable lung cancer patient, lacking more effective options, has served as the initial clinical base to test SBRT; the therapeutic outcomes have confirmed a significant role for this approach. For many patient groups, SBRT may become a noninvasive alternative to some thoracic surgeries, especially ones with more limited therapeutic goals such as wedge resection. Despite these results, long-term evaluation of the cases treated is required to allow greater understanding of the limitations and contributions of this new modality. The successful delivery of SBRT requires the development of a comprehensive, specialized clinical program providing advanced technology and the technical expertise of physicians, physicists and therapists specially trained in SBRT applications. To achieve successful clinical outcomes, careful patient selection and attention to therapy design and delivery are required since exacting clinical procedures are involved. This chapter will outline many details essential for establishing an effective SBRT program in clinical practice.

Identification of abnormal hip motion associated with acetabular labral pathology.

STUDY DESIGN: Resident's case problem. BACKGROUND: Recent literature has suggested that acetabular labral pathology secondary to femoroacetabular impingement (FAI) may be a precursor to early-onset hip osteoarthritis. The purpose of this resident's case problem was to explore the extent to which abnormal movement at the hip is a possible contributor to acetabular labral pathology. DIAGNOSIS: The patient was a 25-year-old female with a 4-year history of anterior-medial groin pain. Based on a combination of the clinical examination and magnetic resonance imaging findings, she was given a diagnosis of acetabular labral tear by her orthopaedic surgeon and referred to a physical therapist for assessment. Movement analysis during a single-leg step down, running, and a drop jump maneuver revealed excessive hip adduction and internal rotation on the involved side, which reproduced her symptoms. Application of a hip-strapping device resulted in decreased hip adduction and internal rotation, and an immediate decrease in symptoms. DISCUSSION: The reduction in pain secondary to controlling hip motion suggests that excessive frontal and transverse plane hip motions may contribute to FAI. Accordingly, physical therapy intervention aimed at controlling and reducing hip adduction and internal rotation during activities may be indicated in patients who present with this movement pattern associated with anterior hip/groin pain.

Prostate cancer: image guidance and adaptive therapy.

Image-guided radiation therapy implies the use of a variety of imaging techniques in the treatment room to determine the location of target areas with the patient in the treatment position. This is particularly relevant for prostate cancer radiation therapy since the prostate gland can differ in its position within the pelvis from one treatment to another. The different imaging techniques include transabdominal ultrasound, in-room X-rays with and without the use of intraprostatic implanted fiducials, kilovoltage and megavoltage CT techniques, and even in-room MRI. The workflow and capabilities of each imaging system need to be evaluated and investigated individually.

Lung cancer: a model for implementing stereotactic body radiation therapy into practice.

Primary and metastatic tumors to the lung have been principle targets for the noninvasive high-doseper- fraction treatment programs now officially called stereotactic body radiation therapy (SBRT). Highly focused treatment delivery to moving lung targets requires accurate assessment of tumor position throughout the respiratory cycle. Measures to account for this motion, either by tracking (chasing), gating, or inhibition (breath hold and abdominal compression) must be employed in order to avoid large margins of error that would expose uninvolved normal tissues. The treatments use image guidance and related treatment delivery technology for the purpose of escalating the radiation dose to the tumor itself with as little radiation dose to the surrounding normal tissues as possible. Clinical trials have demonstrated superior local control with SBRT as compared with conventionally fractionated radiotherapy. While late toxicity requires further careful assessment, acute and subacute toxicity are remarkably infrequent. Radiographic and local tissue effects consistent with bronchial damage and downstream collapse with fibrosis are common, especially with adequate doses capable of ablating tumor targets. As such, great care must be taken when employing SBRT near the serially functioning central chest structures including the esophagus and major airways. While mechanisms of this injury remain elusive, ongoing prospective trials offer the hope of finding the ideal application for SBRT in treating pulmonary targets.