SAN FRANCISCO — A reduction in the rate of
adhesions following
hip arthroscopy can be achieved through changes in
rehabilitation protocol, according to a study presented at the
2011 Annual Meeting of the Arthroscopy Association of North
America.
“Revision hip arthroscopy has been described as
part of the learning curve in the advancement of the treatment of multiple
intra-articular problems,” study author S. Clifton Willimon, MD, said
during his presentation. “Intra-articular adhesions have been reported as
a cause of continued pain after both open and arthroscopic procedures of the
hip.”
Willimon noted that although these adhesions have been
reported, the risk factors that could lead to an increased rate of adhesions
had not been identified.
Factors for adhesions
Willimon and colleagues analyzed data from the
experience of Marc M. Philippon, MD, with primary hip arthroscopies performed
between 2005 and 2009. Cases were analyzed individually to see if adhesions
were the primary cause of hip revision — a factor determined by patient
reports or patients returning to their surgeons. If no contact could be made to
determine if a revision had occurred, the patient’s data were excluded
from the study. Data examined included age, gender, labral treatment,
microfracture of chondral surfaces and rehabilitation
protocol.
The investigators followed more than 1,200 hip cases.
Fifty-seven (4.5%) of hips required revision arthroscopy, 153 hips underwent
labral debridement and 1,196 underwent labral repair. Six of the 153 labral
debridements had adhesions, while 57 hips of the 1,196 hips that underwent
labral repair were found to have adhesions — numbers which indicate no
difference in adhesion prevalence between labral debridements and labral
repairs.
Willimon reported that his group also discovered that 5%
of patients who did not undergo microfracture were found to have adhesions,
while 3% of those who underwent microfracture had adhesions. Certain
patient-specific factors also played a part, he added.
“In our results, we found that age between the
adhesion and non-adhesion group was statistically significant,” Willimon
said.
Rehabilitation
The hip rehabilitation program used in the study was
modified to include
hip circumduction in November 2008. Willimon noted that 1,067
hips did not undergo circumduction and 291 hips underwent these exercises. Four
cases in the circumduction group demonstrated adhesions, while compared to 61
in non-circumduction group — leading to a 4.4 times higher risk for
adhesions among the non-circumduction group.
“This study has identified both patient- and
rehabilitation-specific factors that contribute to an increased risk of
adhesion formation,” Willimon concluded. “We feel strongly that
circumduction exercises play a critical role in minimizing the risk of adhesion
formation. Thorough analysis … revealed that rehabilitation factors,
patient characteristics and operative techniques may play a role in adhesion
formation following hip arthroscopy.” – by Robert Press
Reference:
- Willimon SC, Philippon MJ, Briggs KK. Risk factors for adhesions
following hip arthroscopy. Paper SS-39. Presented at the 2011 Annual Meeting of
the Arthroscopy Association of North America. April 14-16. San Francisco.
- S. Clifton Willimon, MD, can be reached at Children’s
Orthopaedics of Atlanta, 5445 Meridian Mark Road, Suite 250 Atlanta, GA 30342;
email: cliff.willimon@gmail.com
- Disclosure: Willimon has no relevant financial disclosures.
The authors do an excellent job of statistically
dissecting their experience with adhesions following hip arthroscopy. They have
some unexpected observations that a number of intuitively suspected risk
factors were actually not a problem. They noted the introduction of their
circumduction exercises reduced the incidence of adhesions, but this, compared
to a historical control group introduces the risk that other factors, such as
improved surgical technique, may represent confounding variables.
It seems all patients undergoing repeat arthroscopy were
found to have adhesions. Thus, is it possible that these types of adhesions
might simply be present among some patients who did not require repeat
arthroscopy? Also, did the authors have any data or impressions about whether
removing the adhesions improved their patients’ results? This information
would be necessary in order to support their postulation that the adhesions
were the source of pain.
Lastly, it appears patients who were not able to be
contacted were excluded from their data. This number of lost to follow-up is
important in order to better appreciate the validity of their observations.
— J.W. Thomas Byrd, MD
Session moderator
Disclosure: Byrd is a consultant to Smith & Nephew and A2
Surgical,
receives research support from Smith & Nephew
and holds
stock in A2 Surgical