Femoroacetabular Impingement and Hip Arthroscopy Surgery

Understanding Femoroacetabular Impingement

Femoroacetabular impingement (FAI) is a condition characterised by abnormal contact between the femoral neck and the acetabulum. It can affect individuals of all ages and is often caused by structural abnormalities in the hip joint, particularly those who are active. The impingement can lead to hip pain and joint damage. Initially, this damage involves tears of the labrum (fibrocartilagenous structure) and damage to the cartilage that lines the joint surfaces. If left untreated, the impingement will continue to cause pain through ongoing damage to the joint, leading to the onset of arthritis.

Treatment of Femoroacetabular Impingement [1]

The primary treatment approaches for femoroacetabular impingement include:

Non-operative Treatments

• Physical Therapy: Involves tailored activities to improve strength and neuromuscular control, as well as flexibility in the hip joint. Strengthening exercises for the muscles of the hip and lumbosacral spine can improve weakness and muscle imbalance.

• Activity Modification: Avoiding activities that exacerbate symptoms, such as deep squats or high-impact sports. Physiotherapy interventions need to try to avoid movements that provoke symptoms and should be executed in a pain-free manner that does not create additional joint irritation.

• Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) to manage pain and inflammation.

• Injections: Corticosteroid injections to reduce inflammation and relieve pain temporarily.

Surgical Treatments

• Arthroscopy: Minimally invasive surgery to reshape the femoral head or acetabulum to improve joint mechanics, repair the labrum and remove any loose bodies.

• Total Hip Replacement: In severe cases with significant joint damage, a total hip replacement may be necessary.

Understanding the treatment options for femoroacetabular impingement and being prepared for the journey ahead can positively impact outcomes and overall quality of life.

Understanding the Condition

• Knowledge of FAI helps patients recognize symptoms and seek timely medical attention.

• Awareness of treatment options empowers patients to make informed decisions regarding their care.

Setting Realistic Goals

• Preparation allows patients to set achievable rehabilitation and recovery goals.

• Understanding the timeline and potential outcomes helps manage expectations.

Enhancing Recovery

• Being prepared with a structured rehabilitation plan can facilitate a smoother recovery process.

• Engagement in pre-operative conditioning can improve surgical outcomes and reduce recovery time.

Improving Communication with Healthcare Providers

• Being well-informed enables patients to ask relevant questions and discuss concerns with their healthcare team.

• Effective communication fosters a collaborative approach to treatment and recovery.

Hip Arthroscopy Surgery

Hip arthroscopy is a minimally invasive surgical procedure used to diagnose and treat various hip joint conditions. It involves the use of a small camera (arthroscope) and specialized instruments inserted through tiny incisions. It is usually performed as a day case procedure.

Preparation plays a crucial role in effectively managing femoroacetabular impingement. Here are some key reasons why being prepared is significant:

Pre-Surgery Preparation

 - Consultation with Your Surgeon: Discuss your medical history, symptoms, and any medications you are taking.

- Imaging Tests: X-rays or MRIs may be required to provide a clear picture of the hip joint.

Physical Preparation

 - Strengthening Exercises: Engage in physical therapy to strengthen the muscles around the hip and lumbosacral spine while maximising the function.

- Weight Management: Maintaining a healthy weight can reduce stress on the hip joint.

Post-Surgery Planning

 - Arranging Transportation: Have someone available to drive you home after the procedure.

- Home Setup: Prepare your living space for a comfortable recovery, including easy access to essentials.

Emotional Readiness

 - Mental Preparation: Understand the recovery process and set realistic expectations for your rehabilitation.

- Support System: Inform family and friends about your surgery to ensure you have adequate support during recovery.

Post Operative Recovery After Hip Arthroscopy

The initial days following surgery are crucial for recovery. Here’s what you can anticipate:

1. Pain Management

It is normal to experience some pain and discomfort after the procedure. Your surgeon will prescribe pain medications to help manage this.

2. Swelling and Bruising

Swelling and bruising around the hip area can occur. Applying ice packs can help reduce swelling.

3. Wound care

Keep the surgical site clean and dry. Follow the specific instructions provided by your healthcare team regarding dressing changes and signs of infection. Stitches need to be removed by your practice nurse around two weeks after the surgery

4. Physical Therapy

Physical therapy usually begins within a few days after surgery to help restore mobility and strength. Follow your therapist's guidance closely. International Society for Hip Preservation has suggested the following post-operative regime [1]:

Guidelines for post-operative rehabilitation.

Stage	Estimated timea (length in weeks)	Rehabilitation goals	Progression criteria
Immediate post-operative	2–4	Pain control Appropriate gait within weight-bearing status (assistive device if needed)	90 degrees of asymptomatic flexion 10 degrees hip extension Tolerate all prescribed exercises
Early impairment	2–4	Symmetrical gait pattern ROM sufficient for ADLs Re-establish neuromuscular control for ADLs	Tolerance of progressive exercise programme Establish full weight-bearing status Symmetrical gait pattern ROM >80% of opposite hip in all planes of motion
Late impairment	2–6	ROM symmetrical to non-surgical side Return to low and moderate level ADLs Return to non-labour occupation activities	ROM symmetrical to opposite hip Strength >75% of opposite hip in all planes of motion Maintain single-leg stance × 30 s Continuous ambulation >10 min or 1 mile
Functional restoration	2–8	Return to all ADLs Low to moderate fitness activities as aligned with patient goals	Strength >75% of opposite hip in all planes of motion HOS S >85% for ADL subscale

^a Time frames are estimated and do not supersede progression criteria.

Post-operative Physical Therapy recommendations (outlined to aid patients and physiotherapists involved in post-operative care - for more information refer to the article referenced at the end).

Pre-operatively (2 weeks prior to surgical procedure)
Education	− Provide an opportunity to ask questions regarding post-operative rehabilitation
Exercise	− Provide an opportunity to review pre-operative exercises (i.e. core, deep hip rotators and gluteal strengthening) as well as exercises that will be performed immediately post-op
Phase One (1–14 days post-operatively) 1 and 2 visits Precautions: Avoid hip flexion beyond 90° during ADL (i.e. putting on shoes and socks) to minimize irritation of the anterior capsule Avoid sitting low chairs or positions of increased flexion Avoid prolonged standing, pivoting or twisting (i.e. car transfer), negotiating public transportation and return to work
Analgesia	− Adequate pain control is necessary to allow for early rehabilitation − Paracetamol and non-steroidal anti-inflammatory medication for pain control in the early weeks
Muscle activation exercises	− Encourage activation of deep hip rotators (DHR) to reduce Trendelenburg gait pattern
ROM	− Progressed based on healing properties of the involved tissues, including bone, labrum, capsuloligamentous structures and cartilage
Gait	− Facilitation of normal gait pattern is critical for appropriate loading of the hip joint and to avoid compensatory patterns that may increase load through healing tissue
Hydrotherapy	− With adequate wound healing (around 10–14 days post-operatively), consider use of aqua therapy for early ambulation and normalizing gait
Soft tissue mobilization (STM)	– Focused on the psoas, rectus femoris, tensor fascia latae, adductors and glutei to improve muscle activation and flexibility – Monitor lumbar spine mobility to facilitate appropriate joint loading
Phase Two (3–6 weeks post-operatively) 1–2×/week Precautions: Avoid repetitive hip joint flexion beyond 90°, especially in the setting of a labral repair Avoid aggressive compressive forms of loading, such as running on hard surfaces, squats, lunges, skipping and mini-trampoline Consider modification of these exercises during the healing period
Therapeutic exercise	− Initiate cycling with a high seat to avoid hip flexion beyond 90° − Progression of DHR stability programme − Prone, four-point kneeling with resistance band Initiate activation and strengthening of gluteal musculature − To facilitate local hip stability, begin in weight bearing with use of a belt starting with a quadriceps femoris contraction followed by an isometric contraction of the hip abductors
Proprioceptive training	− Initiate proprioception exercises encouraging gluteal activation
Hydrotherapy	− Initiate deep water running, limiting gravity, to progress towards over ground running
STM	− Continue to address soft tissue limitations and spinal mobility
Phase Three (7–12 weeks post-operatively) 1–2×/week Precautions: Progressive joint loading and RTS-specific exercise
Education	− Importance of regular exercise throughout sport-specific phase to maintain gluteal strengthening and cardiovascular endurance − Emphasis on maintenance of strength for injury prevention
Therapeutic exercise	− Global strengthening − Unilateral loading with emphasis on quadriceps control and improving global muscular support − Core stability programme to promote coordinated limb movement
Proprioceptive training	− To promote hip stability and skill execution, progression of DHR strengthening with co-contraction of gluteus medius and minimus in varying degrees of hip flexion − Consider utilization of real time ultrasound for feedback in standing, single leg and associated movements
Sport-specific training	Initiate running, jumping and figure eight drills with a heavy emphasis on DHR endurance
Phase Four - Return To Sports

5. Follow-Up Appointments

Attend all scheduled follow-up appointments to monitor your recovery progress and make any necessary adjustments to your rehabilitation plan.

7. Gradual Return to Activities

As you recover, gradually resume normal activities as advised by your healthcare provider. Avoid high-impact activities until cleared.

Following these guidelines can help ensure a smoother recovery process after hip arthroscopy.

8. Driving.

Return to driving should be considered when you feel you are ready. Usually, this would be around 6-8 weeks after the surgery. Trial your driving ability on a quiet road. Inform your insurance company that you have had the surgery and recovered from it before re-starting the driving.

Managing Expectations

Understanding that recovery is a gradual process can help you stay positive. Here are some common experiences:

• Fluctuating Pain Levels: It’s normal to have good days and bad days. Be patient with yourself.

• The pace of recovery is very individual and varies between cases.

[1] A. Takla, et al. The 2019 International Society of Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of femoroacetabular impingement syndrome (FAIS): an international consensus statement. J Hip Preserv Surg. 2021 Mar 19;7(4):631–642. doi:10.1093/jhps/hnaa043