Clinical Pearl #11: Hip Arthroscopy
What happens if all conservative measures have been exhausted related to your hip pain? Surgery, hip arthroscopy, is now the consideration for your hip to address your FAI and cartilage damage.
CONSIDERATIONS WITH HIP ARTHROSCOPY:
Two small incisions are commonly used in the procedure to access the joint. Do not be fooled by the size of these incisions related to the amount of work within the joint which can be performed within the surgery! Many patients see these small incisions, or portals, and think they should, or could, do more than allowed given the number and size of the portals following surgery.
The joint needs to be distracted in order for the surgeon to have the space to be able to “fix” issues with the joint. Examples for creating joint distraction include a perineal post stabilizing the pelvis so the femur can be distracted from the acetabulum or a “boot” at the foot by which long axis traction can be placed through the hip. Be sure to ask your surgeon what he or she uses and potential side effects, including numbness, or other nerve issues, post operatively. Inquiring about the integrity of articular cartilage is important to help identify any potential weight bearing precautions, or limitations, after surgery and for how long. A microfracture may be indicated due to articular cartilage damage, and this effects weight bearing after surgery. Should labral damage be extensive, a labral reconstruction may be indicated, and inquiring what impact this has on healing and outcome is helpful.
COMMON POST OPERATIVE PRECAUTIONS AFTER HIP SCOPE:
Let’s talk about some commonalities with post op recovery from surgery. Although this is a huge topic itself, the information here is broad enough to cover many post operative protocols.
For at least a week or two, sometimes up to 4 weeks, there will be range of motion restrictions/precautions. A common one is not bending the hip more than 90 degrees. Then, how do you put shoes and socks on? If there are family members in your home, ask for assistance. If it is the summer, consider slip on shoes and avoid using socks. I recommend avoiding flip flops so not to cause a trip hazard. If you live alone, and both socks and shoes are needed, I recommend using a grabber and/or shoe horn.
Many surgeons will limit the amount of external rotation after surgery. 2-4 weeks is average. This means that crossing the ankles, or trying to sit criss-cross applesauce will not be welcomed, nor will sleeping on your back or belly with the knee outward.
Some surgeons will limit hip extension for 2-4 weeks. What does this mean? Think about walking. Every time you push off, the hip should ideally extend. Thus, a full cycle of walking and pushing off will be limited, and it will likely be uncomfortable. Lying on your belly may also be limited due to his precaution.
The length of time these precautions exist vary according to the surgeon. There are variances amongst surgeons with the use of a post operative hip brace, CPM (continuous passive motion) machine, or other passive motion machines, and ice machines after surgery. Be sure to inquire about these to assist in the preparation for post operative care, and the set up at home to accommodate. Some surgeons will allow full weight bearing immediately after surgery using crutches, while others may wait a few weeks and allow partial weight bearing instead. A microfracture may be involved, a procedure where drilling into bone below the surface of articular cartilage to “fix” local damage to articular cartilage. If this is involved, it is likely there will be a significant weight bearing precaution, or non-weight bearing, for 4-6 weeks to allow greater healing potential within the joint.
POST OPERATIVE REHABILITATION AFTER HIP SCOPE:
Most surgeons have protocols by which to follow after surgery to help guide your rehabilitation process. Although these appear as "recipes" to follow during the post operative process, they are not a "one size fits all" approach. Over time, patients can, and will, develop different deficits, issues and/or compensations. Being able to work with a skilled PT who not only is knowledgeable about your procedure, but able to identify these deficits will be key in your recovery. I tell people it takes a while to get to the point of surgery, and time to master compensations related to hip dysfunction. Surgery alone does not fix these compensations, but repetitions of appropriate activities to help retrain the body is key. And, these take time and consistency!