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Hi Everyone! I was hoping to start a discussion/get advice about a patient population that I do not have a lot of experience with! I appreciate any input!
45 yo F, Scientist for VA Dept of Agriculture – work is split between sitting and standing throughout the day. Has 2 children, 14 and 17 yo.
History: Diagnosed with hip dysplasia in 2016 (reported that she did not have hip pain before then), tried PT and steroid injections without any lasting relief of symptoms. Used to ride horses for years.
Current Condition: Right Periacetabular Osteotomy on 12/28/2017 (Eval on 2/2/2018), was 25% WB (started week of IE) and to progress to 50% WB after 2 weeks.
Initial primary complaint: right posterior hip from PSIS to greater trochanter, achy to shooting pain, I, V. highest level pain 4-5/10, lowest 0/10. With increased activity – feels pain from anterior lateral hip to proximal third of thigh, shooting initially to achy pain.
N/T proximal anterior thigh, great toe tingling (gradual improvement since surgery)
Aggs – walking with RW more than 2-3 laps around her house, laying on her back to more than an hour, glute exercises (with HH therapist)
Eases – change in position in bed or resting after walking pain intensity eases quickly, but can remain achy
ROM – 90 deg hip flexion, 5 deg hip extension, 18 degrees abduction
MMT – Glute medius 3-/5, gluteus maximus 3+/5, iliopsoas 3-/5
Neuro – Patient reporting changes in sensation of the proximal anterior thigh and plantar aspect of the foot.
***Now 11 weeks post op: FWB weaning off of SPC. Discomfort now I, V, in proximal anterior hip with inc in walking.
ROM: 10 deg extension, 30 deg abduction, 9 degrees adduction, 35 degrees IR, 50 degrees ER, 105 deg flexion.A few questions I had initially…as most of the return to activity/sport with PAO is done on younger patients:
1. What is your success with older patient receiving hip preservation surgeries? The research I found (30 year retrospective study, pts 13-56 yo) found 29% hips had good-excellent results with no progression of OA/conversion to THA. 70% developed progressive OA and hip THA (with preoperative age, preop limp, and limited IR being some factors that inc likelihood).
2. Other research I’ve read found that it is possible to restore gait mechanics to near “normal” compared to controls, but I have found that she continues to have weakness of hip flexors and has felt anterior hip discomfort (mild so not a huge concern for her) as she increases weight-bearing status.
-She wants to d/c AD (and has been cleared to do so), but I am worried that she will be stuck in the cycle of psoas inhibition/fatigue leading to increased TFL and adductor activation/hypertonicity. What advice would you give this patient or what strategies would you take? -
Hi Sarah,
I’ve never worked with a patient status post PAO, so I can’t offer any personal anecdotes.
In terms of D/Cing her cane – What does her gait look like now with the cane? Has it normalized or do compensations persist?
If the patient is eager to ditch the cane, but her gait is still antalgic, I may consider showing her video on the ipad of her gait before and after increased activity. Or perhaps you could set a benchmark distance/time that she needs to be able to walk without increased pain/worsening gait before discharging the cane. -
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Hey Sarah,
I do not have any experience with pt’s s/p PAO either, so I cannot offer any personal anecdotes. When deciding whether or not I is appropriate to d/c a cane, I generally look at how well the patient is able to control the pelvis in the frontal plane when walking with and without the cane. If they are able to ambulate with minimal-to-no trendelenberg, then I am generally fine with letting them d/c the cane. However, I would be sure that she is sure to bring the cane with her when she is going to be walking longer distances so that she can use it when she becomes fatigued. It is all about graded exposure to walking without the cane.
I have had a few patients with anterior hip discomfort following arthroscopy that appear to have components of psoas pathology as well as intra-articular hip pathology, so I’m curious to hear other people’s strategies for managing your patient’s anterior hip pain as well. This is always something that I have had some trouble with.
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Hey Sarah!
I am in the same situation as Justin and Tyler in the sense of I have not worked with this population before. I loved Justin’s idea of taking a video and giving he a goal to work toward. I find sometimes breaking down the gait cycle and going step by step can help her see what compensatory strategies she has developed and give her the opportunity to correct these. Sorry I don’t have more to offer! -
Alright so since no one is very helpful for Sarah and this case.
Big “gap in Knowledge” here.
What a perfect opportunity to work on some “Clinical Questions/Searching the Evidence” to answer patient specific questions.
So before I jump in in my thoughts, and steer this discussion.
I would like each resident to come up with a PICO question related to this case; search the evidence, review a related article, and post clinical thoughts/applicability.
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From the Non Arthritic Hip CPG – newer updated articles out there as well.
Maeyama A, Naito M, Moriyama S, Yoshimura I. Periacetabular
osteotomy reduces the dynamic instability of dysplastic
hips. J Bone Joint Surg Br. 2009;91:1438-1442. http://dx.doi.
org/10.1302/0301-620X.91B11.21796Another more recent article with author to know (Clohisy JC)
Intermediate-Term Hip Survivorship and Patient-Reported Outcomes of Periacetabular Osteotomy: The Washington University Experience.
Wells J, Schoenecker P, Duncan S, Goss CW, Thomason K, Clohisy JC.
J Bone Joint Surg Am. 2018 Feb 7;100(3):218-225. -
Hey Sarah,
To add to the general consensus. I have not seen this either. I would agree with Justin about the gait in regards to d/c AD. In the literature I’ve encountered with pts s/p hip labral repair and FAI arthroscopy, the major components for progressing through the protocol phases are pain-free uncompensated gait. I feel like although the surgical intervention is not the same, the same philosophy may be applied. In addition to Justin’s suggestion of videoing the patient, I find that part-task breakdowns of gait are helpful once the patient understands what/why you are working on something, such as hip flexion.
I also wonder about her joint mobility. If she has some posterior capsule tightness and/or anterior capsular hypermobility, she may have increased stress to the (already weak) psoas as it crosses the anterior capsule, similar to patients with hypermobile-FAI leading to increased anterior hip pain. Joint mobs might have an added effect of some increased neural input to the psoas…
Keep us posted!
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Sarah, these articles look interesting, thanks for the synopsis of them. Ill try to read them in more depth soon. I recently evaluated a female in her 30’s s/p traumatic labral tear during child birth that was surgically repaired and we have started some quadruped work too. I think there will be some good carryover between these two patients in regards to treatments and gait training. Did your MD provide some sort of protocol for PAO? I’ve never seen this and I am interested in how the rehab differs from other hip arthroscopies.
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Hey Sarah,
I looked into some articles on gait with PAO. PICO: “In patients with PAO, what parameters of gait are most affected at >1 year post-op?”. I found the two articles you posted while doing my literature search and read over them a little. Additionally, I found an article by Pederson et al. (“Walking pattern in 9 women with hip dysplasia 18 months after periacetabular osteotomy”) talking about gait mechanics pre- vs. post- operatively. They discuss the improvements in upright gait pattern following PAO as evidenced by increased knee extension throughout stance phase of gait and increased hip extension torque. They also found a reduced hip flexor moment, which was similar to their pre-operative findings.
I wonder if, similarly to what we discussed about posterior hip joint mobility to take pressure off of the anterior structures (hip flexor), if you emphasized hip extensor moment, that would also aid in the anterior hip pain she is experiencing?
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Hey Sarah,
Sorry for the late response. My PICO was, “In patients who undergo PAO, which gait characteristics are most affected between pre-operative and post-operative analyses?” I’ve attached the article I found below.
Karam MD, Gao Y, Mckinley T. Assessment of walking pattern pre and post peri-acetabular osteotomy. Iowa Orthop J. 2011;31:83-9.
The researchers used a GaitRite gait analysis system pre and post-operatively to measure changes in gait as well as pedometers to measure activity level. Data from an average of 11.5 months post-op showed a 5% increase in gait velocity, a small improvement in cadence, and a 4.5% increase in stride length compared to pre-operative data. At 9.5 months post-op, there was an 8.75% decrease in overall physical activity level (measured by pedometer), though there was a significant increase on the physical component score on the SF-36.
The mean age of patients in this study was 28.5, so definitely younger than your patient. However, if you choose to use this data with your patient, you can use this data to encourage her that she may be able to walk better than before.
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