Brian R Neri, MD - Board Certified Orthopaedic Surgeon New York Islanders Pro Health Care
Brian R Neri, MD - Board Certified Orthopaedic Surgeon: 516-622-6040
Brian R Neri, MD - Board Certified Orthopaedic Surgeon
 
Patient Info

Hip

Hip Arthroscopy

Hip Arthroscopy is a relatively new surgical technique that can be effectively employed to treat a variety of Hip conditions.

General Info

Hip Arthroscopy

Hip arthroscopy is utilized to address various pathologies, such as, Femoro Acetabular Impingement (FAI), labral tears and internal snapping hip inside the hip joint.

Arthroscopy, in general, involves the use of small incisions to allow the entrance of a camera and tools into a joint. For hip arthroscopy, the hip is first distracted to allow space for the arthroscopic instruments to enter. Secondly, two to three incisions are made at the lateral aspect of the hip to perform the surgery. Through this technique, the entirety of the hip joint can be visualized to confirm and address various pathologies.

The labrum is a rim of cartilage that extends off the edge of the socket of the hip. Due to acute trauma, genetic make up or the type of sports or activities you partake in, the labrum can be damaged. This can range from fraying of the tissue to an actual complete tear. While in the joint, the tissue can be “cleaned up.” This entails shaving the frayed labral tissue down to stable, healthy tissue. In the case of an actual tear in the labrum, this can be repaired with the use of anchors and sutures to

In cases where FAI or “extra bone” is an issue, the problem areas are sculpted to resemble a more anatomically normal hip, thus eliminating the bony impingement on the labrum.

Hip Endoscopy

Hip Endoscopy entails accessing the space outside the hip joint with a camera and tools through small incisions. This procedure is used to address pathologies of the proximal iliotibial band (IT band), as well as the trochanteric bursa. We call the combination of these conditions Greater Trochanteric Pain Syndrome.

For this surgery, you are placed on your side. There is no need to distract your hip, as the surgery does not take place within the joint. The camera and surgical instruments are used to visualize the structures outside of the hip that are causing your problem. A diamond shaped “window” is made in the IT band, where it overlies the prominence of your hip, the greater trochanter. This eliminates the friction that is causing a lot of your pain. The inflamed bursal tissue is also removed during this surgery.

Terminology

Hip Arthroscopic/Endoscopic Procedures

Labrum Debridement

Performed to address diseased, frayed and/or degenerative irreparable labral tissue by excising the tissue with a motorized shaver device.

Labrum Repair

Reattachment of the labrum tissue to the acetabular (cup) rim.  Typically this is performed by use of small anchors placed into bone.

Labrum Reconstruction

In cases of diseased, calcified or diminished labral tissue, the labrum is reconstructed using tissue from the iliotibial band (ITB) and anchored in place.

Chondroplasty

Shaving of diseased articular cartilage, typically done in cases of arthritis where frayed cartilage tissue is encountered.

Synovectomy

Excising inflamed synovium (lining) of the joint to reduce pain.

Microfracture

Technique of filling in areas of cartilage loss by making small holes in the bone to achieve bleeding and healing with scar cartilage.  This necessitates crutches for 6-8 weeks.

Rim Resection

Performed for patients with femoroacetabular impingment (FAI) with acetabular (cup) overcoverage.  The rim of the acetabulum is trimmed to achieve more clearance with hip movement.

Osteoplasty (Cam resection, osteochondroplasty)

Also performed for patients with FAI due to cam lesions (bony bumps) on the femur.  These can lesions cause abnormal contact between the femur and acetabulum resulting in cartilage/labrum tearing.  The osteoplasty procedure is performed using a high-speed burr to resect this area of bone under xray guidance.

Iliopsoas lengthening

Done in cases of internal snapping hip (pain from tendon popping over hip joint) or severe tendonitis where the tendon is lengthened utilizing a heat probe.

Iliotibial band release

A thick band of tissue running along the side of your hip is released to treat snapping or pain from irritation to the bursa.  Procedure is done endoscopically using a heat probe.

Ligamentum teres

Ligament connecting the femoral head (ball) to acetabulum (socket) which can be a source of pain and possible instability if torn.

Capsular plication

The hip capsule is a thick tissue encompassing the joint.  This is performed in cases of hip instability or looseness.  The capsule is tightened by shrinkage with a heat probe or stitched to decrease volume.

Postoperative Rehabilitation Protocol and Exercises

PHASE I OF REHABILITATION

MAXIMUM PROTECTION AND MOBILITY

GOALS:

  1. PROTECT THE INTEGRITY OF THE REPAIR
  2. REDUCE PAIN AND SWELLING
  3. INITIATE ROM
  4. RE‐ESTABLISH GLUT ACTIVATION
  5. HEP

RESTRICTIONS:

Range of Motion: protect the capsule and labral repair

  1. FLEXION 0‐70 FOR 10 DAYS, PROGRESS AS TOLERATED
  2. ABDUCTION 0‐45 FOR 2 WEEKS, AVOID LATERAL HIP PAIN
  3. ER 0 FOR: DEPENDS ON PROCEDURE
  4. EXTENSION 0 FOR: DEPENDS ON PROCEDURE
  5. IR : NO LIMITS
  6. ADD: NOLIMITS

WEIGHT BEARING (WB) STATUS:

NON MICROFRACTURE:

  • 20#FFWB FOR 3 WEEKS (2 crutches)
  • 50% WB FOR 1 WEEK (1 crutch) THEN WEAN TO FWB

MICROFRACTURE:

  • 20#FWB FOR 6 WEEKS ( 2 crutches)
  • 50% FOR 1 WEEK ( 1 crutch) THEN WEAN TO FWB

PHASE 1 MAXIMUM PROTECTION AND MOBILITY

TREATMENT STRATEGIES

  1. CPM 30‐70 4‐6 HOURS PER DAY
  2. ICE / COMPRESSION / GAME READY
  3. SOFT TISSUE MASSAGE / RETROGRADE / LYMPHATIC DRAINAGE
  4. ISOMETRICS
  5. PROM / CIRCUMDUCTION
  6. INITIATE STRETCHING PROGRAM
  7. CORE ACTIVATION
  8. GENTLE MUSCLE STRETCHING
  9. NON RESISTANT STATIONARY BICYCLING
  10. GAIT TRAINING
  11. INITIATE SHORT CRANK BIKE/REGULAR BIKE AS TOLERATED 10‐15 MIN, NO RESISTENCE

CRITERIA TO ADVANCE TO PHASE II

  1. MINIMAL C/O PAIN WITH PHASE I EXERCISES
  2. PROPER MUSCLE ACTIVATION WITH PHASE I EXERCISES
  3. MINIMAL C/O PINCHING IN THE FRONT OF THE HIP BEFORE 100 DEGREES FLEXION
  4. FULL WB IS ALLOWED AND IS TOLERATED

PHASE II OF REHABILITATION: CONTROLLED STABILITY

GOALS:

  1. NORMALIZE GAIT
  2. RESTORE FULL ROM
  3. IMPROVE NEUROMUSCULAR CONTROL, BALANCE, PROPRIOCEPTION
  4. INITIATE FUNCTIONAL EXERCISES MAINTAINING CORE AND PELVIC STABILITY

PRECAUTIONS:

  1. AVOID HIP FLEXOR AND ADDUCTOR IRRITATION
  2. AVOID JOINT IRRITATION: balance intensity and volume of therex with proper rest
  3. AVOID BALLISTIC OR AGGRESSIVE STRETCHING
  4. DO NOT PUSH FLEXION AND ER MOTION

TREATMENT STRATEGIES:

  1. WEAN OFF CRUTCHES PER WB GUIDELINES
  2. GAIT TRAINING WITH EMPHASIS ON CORE CONTROL AND GLUT ACTIVATION
  3. SOFT TISSUE MASSAGE AND MOBILIZATIONS / ITB / HIP FLEXOR / TFL
  4. NON RESISTANT CYCLING
  5. PROM / CIRCUMDUCTION
  6. PAIN FREE STRETCHING HIP FLEXOR / ITB / TFL / HAMSTRING / QUAD
  7. FULL A/PROM
  8. CORE STABILITY
  9. WEIGHT BEARING / PROPRIOCEPTIVE ACTIVITIES
  10. MOVEMENT PREP
  11. CARDIOVASCULAR AND UPPER BODY EXERCISES
  12. INITIATE BEGINNING OF FUNCTIONAL EXERCISES AT THE END OF PHASE II

CRITERIA TO ADVANCE:

  1. NORMAL PAIN FREE GAIT
  2. FULL ROM WITH MINIMAL STIFFNESS INTO EXTERNAL ROTATION
  3. NO JOINT INFLAMMATION, MUSCLE IRRITATION, OR PAIN
  4. ACHIEVE ADVANCEMENT TO FUNCTIONAL EXERCISES WITHOUT PAIN AND GOOD

NEUROMUSCULAR CONTROL

PHASE III OF REHABILITATION: FUNCTIONAL TRAINING

GOALS:

  1. RESTORE NORMAL STRENGTH
  2. RESTORE NORMAL PROPRIOCEPTION
  3. BEGIN PLYOMETRIC PROGRAM
  4. BEGIN AGILITY AND RUNNING PROGRAM
  5. PREPARE FOR RETURN TO SPORTS

TREATMENT STRATEGIES:

  1. DYNAMIC WARMUP / MOVEMENT PREP
  2. FELDENKRAIS ROLLING
  3. HIP ACTIVATION EXERCISES
  4. FUNCTIONAL SPORTS CORD EXERCISES
  5. DYNAMIC STRENGTH TRAINING
  6. AGILITY TRAINING
  7. ADVANCED PROPRIOCEPTION EXERCISES
  8. SPORT SPECIFIC TRAINING

CRITERIA TO RETURN TO SPORTS:

  1. COMPLETION OF THE FUNCTIONAL HIP SPORTS TEST WITH PASSING SCORE
  2. PAIN FREE RETURN TO PRACTICE ENVIROMENT
  3. FORMAL CLEARANCE BY SURGEON
Professional - Orthopedic and Sports Physcial Therapy
PHASE I
A. Prone Glut Set
  • Tighten buttock while pushing pelvis toward table
Prone Glut Set
B. Prone Quad Set
  • Place foam roll under ankle tighten quad and extend the knee
Prone Quad Set
C. Prone ER Isometric
  • Bend knees to 90 degrees, place foam between feet and squeeze
Prone ER Isometric
D. Adduction Isometric
  • Place foam between knees and squeeze to activate adductors
Adduction Isometric
E. Abduction Isometric
  • Place belt around thighs and push out to activate abductors
Abduction Isometric
F. Faber Slide
  • In supine slide foot up into flexion while leg falls out into abduction and ER
Faber Slide
G. Pelvic Tilt
  • Flatten back by tightening abdominal muscles and buttocks
Pelvic Tilt
H. Fallout
  • In hooklying, let the legs fall out into abduction
Fallout
I. Reverse Fallout (IR)
  • In hooklying separate feet wider than shoulders and touch knees together
Reverse Fallout (IR)
J. Bridge
  • Start in hook lying position raise buttock toward the ceiling squeezing gluts at the top of range
Bridge
K. Cat/ Camel
  • In quadruped initiate AROM L/S flexion and extension
Cat/ Camel
L. Quadruped Rock
  • Starting in quadruped sit back toward heels and then rock forward into prone press up position
Quadruped Rock
M. Prone IR AROM
  • Lying prone bend knees to 90 and let leg fall out to side achieving IR
Prone IR AROM
N. Prone Hip Extension
  • Lying on table with legs extended off the edge, glut squeeze and lift leg to table height
Prone Hip Extension
O. Stool Rotation
  • Place knee of involved leg on stool, rotate foot away from the body without moving trunk (IR)
Stool Rotation
P. Standing Abduction with IR
  • In standing position rotate toes in and abduct leg
Standing Abduction with IR
PHASE I - Stretching Program:
A. Supine Hamstring Supine Hamstring
B. Supine ITB Supine ITB
C. Prone Quad Prone Quad
D. Supine Modified Hip Flexor Supine Modified Hip Flexor
E. F.A.B.E.R. Stretch F.A.B.E.R. Stretch
F. Fencer Hip Flexor Stretch Fencer Hip Flexor Stretch
G. Standing TFL Standing TFL
Phase II:
A. S/L Clam
  • In side lying position knees bent to 90 with hip flexed to 45 degrees open slowly open legs up
  • Open and open leg
S/L Clam
B. Physiobridge Series
(Toes/Heels/Bent knees)
  • 3 separate positions lift hips toward ceiling
Physiobridge Series
C. Band walk
  • With band around ankle feet shoulder width apart step out to side keeping constant tension
Band walk
D. Step Down Step Down
E. Ball Squat
  • Ball behind the small of back squat to 70 degrees knee flexion
Ball Squat
F. Lunge Hold SLS
  • Standing in lunge position involved knee bent to 30 degrees lift back foot off the floor
Lunge Hold SLS
Phase III:
A. Pitchers Squat
  • With involved leg in the front start with knee bent at 30 degrees and squat to 70 degrees
Pitchers Squat
B. Pitchers Squat Rotation
  • Same as above adding in trunk rotation while holding plyoball
Pitchers Squat Rotation
C. Unilateral RDL
  • Standing on the involved leg with knee slightly flexed hinge at the hip lowering the ball to floor
Unilateral RDL
D. Single Leg Cord Rotation
  • Standing on the involved leg knee flexed to 30 while holding theraband rotate hip while pulling back on band
Single Leg Cord Rotation
Phase III: Abdominal Progression:
A. PPT with Unilateral March Abdominal Progression
B. PPT with Extension A. B Abdominal Progression
C. PPT with Bilateral March Abdominal Progression
D. Side Plank Abdominal Progression
E. Front Plank Abdominal Progression

Videos

Arthroscopic Hip Labral Repair

Hip Labral Repair

Hip Arthroscopy - Brian R Neri, MD - Orthopaedic Surgeon
Shoulder and Elbow Arthroscopy - Brian R Neri, MD - Orthopaedic Surgeon
Sports Medicine - Brian R Neri, MD - Orthopaedic Surgeon
Sports Medicine - Brian R Neri, MD - Orthopaedic Surgeon
You Tube Twitter Facebook Linked In
Bookmark and Share
Your Practice Online
Shoulder Arthroscopy Elbow Arthroscopy