Patient-Perceived Outcomes Improve Faster Than Hip Strength in Recovery After Surgical Correction for Symptomatic Femoroacetabular Impingement

Maxwell A Konnaris; Lucas M Junginger; Elizabeth R Sibilsky Enselman; Richard D Bell; Tristan Maerz; Asheesh Bedi

doi:10.1177/15563316221093614

. 2022 May 25;19(1):97–106. doi: 10.1177/15563316221093614

Patient-Perceived Outcomes Improve Faster Than Hip Strength in Recovery After Surgical Correction for Symptomatic Femoroacetabular Impingement

Maxwell A Konnaris ¹, Lucas M Junginger ², Elizabeth R Sibilsky Enselman ², Richard D Bell ¹, Tristan Maerz ², Asheesh Bedi ^2,^✉

PMCID: PMC9837412 PMID: 36776512

Abstract

Background: Patients with symptomatic femoroacetabular impingement (FAI) have hip strength deficits, instability, and increased risk for concomitant injury. While surgical intervention is an effective method of treatment for FAI, more information is needed about the recovery process. Purposes: We sought to understand how patients with FAI recover from surgical correction in the short term. Do patients’ perceptions of improvement correspond with measured improvements in hip strength? Methods: We conducted a prospective cohort study of 17 patients (11 male, age range: 16–38 years) who were diagnosed with symptomatic FAI at a single surgeon’s practice. Hip strength (flexion, extension, and abduction) was measured preoperatively and at 14, 26, and 52 weeks postoperatively. Patient-reported outcomes using the modified Harris Hip Score (mHHS) and Hip Outcome Osteoarthritis Score (HOOS) subscales were measured at the same time points and at 2 weeks postoperatively. Results: Compared with preoperative values, there was a significant increase in postoperative values at 26 and 52 weeks in normalized isokinetic hip extension (29% and 38%, respectively) and normalized hip abduction (48% and 55%, respectively). No differences in strength were observed at 14 weeks. Modified Harris Hip Score and all HOOS subscales were decreased by 2 weeks postoperatively, and by 14 weeks mHHS improved by 21%, and HOOS subscales improved as well (activities of daily living by 18%, pain by 34%, quality of life by 69%, sport and recreation by 36%, and symptoms by 28%). Conclusion: We observed that patient-reported outcomes including symptoms, function, and satisfaction improved at 14 weeks, while objective measures of hip strength improved at 26 weeks following surgical correction of FAI. More rigorous study is indicated.

Keywords: femoroacetabular impingement, hip strength, recovery, return to play, patient-reported outcomes

Introduction

Femoroacetabular impingement (FAI) syndrome is a symptomatic hip disorder caused by proximal femoral and/or acetabular pathomorphology [4]. Patients with FAI experience groin pain, labral tears, and articular cartilage damage resulting in strength, stability, and functional deficits of the hip [9,17,26]. Consequently, FAI may delay or prevent a successful return to play [17,33] and increase the risk of developing secondary osteoarthritis (OA) in the nondysplastic hip [2,4,34]. Surgical intervention as a treatment for FAI may restore athletic performance [18], reduce the progression of hip OA [20,21], and lower the risk of total hip arthroplasty (THA) [1]. Patients have high expectations for return to full activity following surgical correction of FAI [11]; although favorable postoperative clinical outcomes for patients with FAI have been reported [5,6,32], how objective measures of hip strength compared with subjective patient-reported outcomes after surgical correction of FAI is not well understood.

Patients with symptomatic FAI have strength deficits in all planes of movement [17,26], and athletes with underlying muscle weakness are at a greater risk of injury [29]. Therefore, understanding postoperative changes in strength and patient-reported outcomes in an integrated manner could improve understanding of the postoperative recovery process, inform return-to-play decisions, and guide patient expectations of recovery. The purpose of this study was to characterize the recovery of hip strength and patient-reported outcomes in patients with symptomatic FAI who underwent an arthroscopic correction and a standardized postoperative rehabilitation program. We hypothesized that these interventions would significantly increase measures of hip strength and patient-reported outcomes by 26 weeks after surgery.

Methods

Between September 2012 and April 2016, 75 to 100 male and female surgical patients seeking treatment for hip or groin pain at a single surgeon’s practice were screened per year for possible inclusion in this study. Patients between 16 and 40 years of age were eligible for enrollment if they had a symptomatic cam lesion or head/neck offset with or without focal rim impingement confirmed by computed tomography scan, physical examination, and a diagnostic intra-articular fluoroscope-guided injection of an anesthetic and corticosteroid [7]. To be included they had to consent to undergo FAI arthroscopic surgical correction and agree to perform a supervised postoperative rehabilitation program. Subjects were excluded if any of the following were present: previous hip surgery; previous history of hip, knee, or ankle injury; evidence of global over-coverage deformity; hip dysplasia; radiographic changes greater than Tonnis grade 1; type 1 or 2 diabetes mellitus; myopathy; cancer; endocrine disorder; autoimmune disorder; major medical illness; body mass index >35 kg/m²; pregnancy; or lidocaine allergy.

Patients who consented to undergo surgical correction of symptomatic cam impingement FAI agreed to perform a supervised postoperative rehabilitation, preoperative and postoperative bilateral hip strength testing, and patient-reported outcome surveys within the short-term recovery leading up to 52 weeks postsurgery (Fig. 1, Table 1). Hip strength was measured preoperatively and at 14, 26, and 52 weeks postoperatively. Patient-reported outcomes were measured at the same time points as well as 2 weeks postoperatively. Measurements were performed to the nearest whole 1°.

Fig. 1. — Study design: (a) Patients with cam impingement symptomatic FAI often have labral tears, cartilage defects, and groin pain that result in functional deficits such as pain-inhibited muscle strength and reduced range of motion, (b) In this study, we measured hip strength and patient-reported outcomes before, (c) patients are treated with surgical correction of FAI with postoperative rehabilitation, and (d) Patients were then characterized by measuring hip strength and patient-reported outcomes through the short-term recovery up to 1 year. Hip strength was measured at 14, 26, and 52 weeks postoperatively. Patient-reported outcomes were additionally measured at 2 weeks postoperatively. *FAI* femoroacetabular impingement.

Table 1.

Inclusion and exclusion criteria.

Inclusion criteria	Exclusion criteria
• Male or female • 16 to 40 years of age • Consented to undergo FAI arthroscopic surgical correction • Symptomatic cam lesion or head/neck offset with or without focal rim impingement confirmed by CT scan and physical examination • Agreed to perform supervised postoperative rehabilitation	• Previous hip surgery • Previous history of hip, knee, or ankle injury • Global over-coverage deformity • Hip dysplasia • Tonnis grade >1 • Type 1 or 2 diabetes mellitus • Myopathy, cancer, endocrine disorder, or autoimmune disorder • Major medical illness • BMI (kg/m²) ≥35 • Pregnancy • Lidocaine allergy

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FAI femoroacetabular impingement, CT computerized tomography, BMI body mass index.

Surgical intervention was performed by a single, fellowship trained, sports medicine orthopedic surgeon (Supplemental Table 1). A rim osteoplasty was performed to correct cephalad retroversion and eliminate focal rim impingement lesions as assessed by labral pathologic changes and intraoperative fluoroscopy. Labral refixation was performed in all cases. A T-capsulotomy along the anterior femoral neck was performed in cases with significant distal extension of cam deformity to improve proximal-distal and medial-lateral visualization of the entire cam lesion and to ensure optimal restoration of offset in all safely accessible locations between the superior and the inferior retinacular (epiphyseal) vessels. In all cases, the capsulotomy was repaired at the conclusion of the procedure. Intraoperative fluoroscopy was used to confirm restoration of offset on the extended-neck lateral radiograph and proximal-distal correction from the physeal scar to the intertrochanteric line.

Patients completed a standardized postoperative rehabilitation program in a single sports medicine center with a certified physical therapist who had significant experience in the rehabilitation of hip preservation patients. The rehabilitation program was based on protocol reported by Enseki and colleagues [13] and the known healing properties of osseous tissues, emphasizing preservation of the blood supply to the head and neck of the femur. Early postoperative rehabilitation began with a 2-week restriction of excessive hip flexion, abduction, and internal rotation to avoid progression of inflammation caused by a compression of acetabular rim with the femoral head-neck. Patients completed ankle-and-knee muscle strengthening exercises, rode a stationary bicycle, and carried out passive range of motion (ROM) and hip isometric exercises. For the first 3 weeks, patients were partial weight-bearing. Gradual increases were initiated over the first 2 to 6 weeks, incorporating balance and aquatic exercises, lumbopelvic stabilization, full passive ROM, and gentle stretching of the hip musculature as tolerated. Strength exercises of the hip began at 4 to 6 weeks, generally emphasizing hamstring, quadriceps, and gluteal muscles. At 6 to 8 weeks, full weight-bearing endurance exercises, such as stepper and elliptical machines, were initiated. These gradually progressed to aerobic exercise, such as jogging at 12 weeks. From weeks 12 to 20, functional exercise began, including squats and single-leg stability exercises. Agility and plyometric training began at week 20. This increased in complexity and intensity as patients passed functional tests demonstrating appropriate gait and motor control until, ultimately, they were able to return to full sports and competitive activity.

Isometric and isokinetic hip flexion, extension, and abduction of both the involved and the uninvolved hip were measured in a Biodex system 3 dynamometer. Isometric measurements were performed at 45° and 90° of hip flexion and extension, and 45° of hip abduction. Isokinetic measurements were performed at a speed of 60°/s from a range of 0° to 60° of hip flexion, extension, and abduction.

The Veterans RAND 12-Item Health Survey (VR-12) [36] was used to measure health-related quality of life. The VR-12 results are summarized in 2 scores: the physical component score (PCS) and the mental component score (MCS). The modified Harris Hip Score (mHHS) [31] survey was used to measure hip-related function and satisfaction; postoperative mHHS has been shown to strongly correlate with patient satisfaction following hip arthroscopy [3]. The Hip Disability and Osteoarthritis Outcome Score (HOOS) [30] was used to evaluate symptoms and functional limitations related to the hip by assessing 5 separate patient domains including pain, symptoms including stiffness and ROM, limitations in activities of daily living (ADL), sport and recreation function, and quality of life relating to the hip. A ceiling effect was established if 15% of the total patients reached the maximum score of a particular survey [33].

Four patients were missing measurements of hip strength or patient-reported outcomes at 1 of the postoperative time points. In addition to absolute force of injured legs, normalized values were calculated by dividing the value of the involved limb by the preoperative value of the contralateral, uninvolved limb. Due to technical errors at the preoperative visit, 2 patients were omitted from the normalized strength analysis. One additional patient was removed from the normalized isokinetic hip abduction measures due to highly variant fold changes from preoperative values.

Statistical Analysis

Data is presented as mean ± 95% confidence intervals, and we report significance at P <.05. Mixed-effects models were used to determine the differences over time compared with preoperative values, and also between involved and uninvolved hip at each time point. Values at baseline measurements between involved and uninvolved hip were compared using t-tests. Minimal clinically important difference (MCID) scores [16] were calculated for patient-reported outcomes to determine changes presurgery and postsurgery at 52 weeks. Patient-acceptable symptomatic state (PASS) scores [10] were calculated for mHHS preoperatively and at 52 weeks postoperatively. Cohen’s d was calculated [24] to determine effect size of hip strength values. Pearson coefficients were calculated to determine the correlation between the change in alpha angle from baseline and various patient outcomes. Statistical analysis was performed using Prism (Version 8.0) and JMP (Version 16.0). Multivariate statistical analysis was performed to investigate potential relationships between strength outcomes and patient radiographic and demographic data.

Results

Seventeen patients (N = 11 male, N = 6 female) met the inclusion criteria and consented to participate in this study (Table 2).

Table 2.

Baseline subject demographics.

	Male	Female	Total
N	11	6	17
Age (years)	27.4 ± 7.3 (16–38)	21.2 ± 6.3 (16–32)	25.2 ± 7.4 (16–38)
BMI (kg/m²)	25.6 ± 3.8 (20.0–33.6)	21.6 ± 2.3 (18.1–24.4)	24.2 ± 3.8 (18.1–33.6)

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BMI body mass index.

At 26 weeks postoperatively, absolute isokinetic hip extension strength increased by 19% (P = .084, d = 0.407) and hip abduction by 28% (P = .036, d = 0.637; Fig. 2). At 52 weeks postoperatively, strength continued to significantly improve as hip extension increased by 28% (P = .002, d = 0.601) and hip abduction increased by 34% (P = .006, d = 0.759) compared with preoperative values. Normalized isokinetic strength exhibited similar trends, but with larger improvements for hip extension and abduction (Fig. 2). By 26 weeks, patients showed a 29% gain in hip extension strength (P = .216, d = 1.249) and a 48% gain in hip abduction strength (P = .002, d = 0.742) compared with preoperative values. We observed greater improvements in strength at 52 weeks postoperatively as hip extension increased by 38% (P = .026, d = 1.663) and hip abduction by 55% (P < .001, d = 0.868). There were no significant differences in isokinetic hip flexion or isometric hip strength at any time point (Figs. 2 and 3). We investigated the multivariate relationship between age, sex, body mass index, preoperative isokinetic hip strength, and preoperative alpha angle and found no significant relationship with 26-week postoperative isokinetic hip strength for both absolute abduction and normalized abduction (Supplemental Table 2).

Fig. 3. — Isometric strength measurements: Hip (a–c, j–l) Flexion, (g–i) Abduction, and (d–f, m–o) Extension (45° baseline N = 17, 14 weeks N = 16, 26 weeks N = 16, 52 weeks N = 15 and 90° baseline N = 16, 14 weeks N = 15, 26 weeks N = 16, 52 weeks N = 15). Normalized values are displayed as relative to the preoperative uninjured leg measure. Values are mean ± 95% CI. *Significantly different (P < .05) compared with the preoperative value. CI confidence interval.

We measured VR-12, mHHS, and HOOS outcome surveys (Fig. 4). Veterans RAND 12-Item Health Survey PCS subscale score decreased at 2 weeks after surgery, and at 14 weeks values exceeded preoperative scores by 14% (P = .069, d = 0.722). Patients had no significant changes in VR-12 MCS over the study period. By 26 weeks, there was an improvement in VR-12 PCS of 36% (P < .001, d = 2.459) compared with preoperative values. Average mHHS decreased by 2 weeks, but by 14 weeks it increased by 21% (P = .001, d = 1.163) compared with baseline. A total of 25% of patients reached the maximum mHHS value as early as 14 weeks after surgery. All HOOS subscale scores decreased 2 weeks postoperatively, and by 14 weeks ADL improved by 18% (P = .002, d = 0.832), pain by 34% (P < .001, d = 1.279), quality of life by 69% (P = .001, d = 1.455), sport and recreation by 36% (P = .013, d = 0.904), and symptoms by 28% (P = .001, d = 0.948) compared with preoperative values. These improvements in HOOS subscales persisted for the duration of the study period. Ceiling effects were also observed for all HOOS subscales, and by 14 weeks postoperatively 25% of patients had reached maximum scores for HOOS ADL. The change in percentage of patients who reached the MCID value was calculated for mHHS and HOOS subscales at 52 weeks compared with baseline values (Table 3). Patients who attended their preoperative (N = 17) and 52 weeks postoperative visits (N = 15) were included in the analysis. About 69% of patients reached the mHHS MCID value at 52 weeks following surgery. The percentage of patients who reached the MCID for HOOS subscales all increased substantially at 52 weeks postoperatively including HOOS ADL (77%), pain (77%), and symptoms (85%). In addition, the change in mHHS PASS score was assessed for patients both preoperatively and at 52 weeks postoperatively (Table 3). About 54% of patients preoperatively achieved mHHS PASS scores which increased to 87% of patients at 52 weeks following surgery.

Table 3.

MCID and PASS in patient-reported outcomes.

Outcome	52 weeks
mHHS (MCID)	73%
mHHS (PASS)	33%
HOOS subscales (MCID)
ADL	80%
Pain	80%
Quality of life	100%
Sport and recreation	100%
Symptoms	87%

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Percentage of patients who achieved a MCID and PASS in patient-reported outcomes by 52-week postoperative visits. MCID is displayed for mHHS; HOOS: ADL, pain, quality of life, sport and recreation, and symptoms. PASS is displayed for mHHS. Values are represented as a change from baseline for the percentage of patients that reached the 52-week postoperative visit.

MCID minimal clinically important difference, PASS patient acceptable symptomatic state, mHHS Modified Harris Hip Score, HOOS Hip Disability and Osteoarthritis Outcome Score, ADL activities of daily living.

Discussion

In this cohort study, hip strength and patient-reported outcome measures improved within 26 weeks postoperatively for patients undergoing surgical correction and postoperative physical rehabilitation for FAI. Hip strength exceeded preoperative values at 26 weeks and continued to significantly increase 52 weeks postoperatively. We are unaware of an established MCID for hip strength in FAI patients, but our observations of effect size show a range of d = 0.407 to 1.663, which is generally considered to be a meaningful effect. In addition, our objective was to explore patient-reported outcomes along with strength measurements to gain insight into subjective patient recovery following surgery. As seen with other procedures such as anterior cruciate ligament (ACL) surgery, improvements in patient-reported outcomes preceded the recovery of strength with scores exceeding preoperative measures as early as 14 weeks. A comprehensive understanding of hip strength postoperatively can improve our ability to clinically manage athletes with FAI, potentially reducing the risk of reinjury and optimizing performance when returning to play.

Our study has limitations. This prospective observational study included symptomatic patients with FAI from a single surgeon’s cohort, and it lacks healthy age- and activity-matched controls, although we provided measures on the contralateral hip of each patient. We observed ceiling effects in each of the patient-reported outcome measures, but other studies [12,14] demonstrated similar results; this suggests a need for a more sensitive outcome survey for patients with FAI.

Patients with FAI often have deficits in hip muscle strength and instability [26,17], which can increase their risk of further chondral injury [35]. Symptomatic FAI patients report hip weakness often attributed to pain-related neuromuscular inhibition [19] and hip muscle atrophy [23]. As a result of a combination of passive connective tissue and active muscle components, FAI patients exhibit femoral head instability [27]. Consequently, repetitive shear forces and increased contact stresses wear the connective tissue of the hip [28], which frequently results in hip OA [22,34] and accompanying weakness [22]. We observed that patients with FAI who underwent surgical treatment and completed postoperative rehabilitation recovered or exceeded their preoperative values for hip abductor and extensor strength as soon as 26 weeks and continued to increase in strength through 52 weeks postoperatively. However, these patients had hip flexion weakness through 52 weeks following surgery compared with preoperative values. Our observations are consistent with prior studies that reported hip strength increases at 1 and 2.5 years following surgery [8,18], but also identified that these strength changes occur earlier than 1 year. We compared isokinetic and isometric hip strength values and observed minimal changes in isometric hip strength values, which suggests that isometric measurements are not an accurate assessment of strength changes of the hip.

In addition to weakness, patients with FAI often report pain, functional deficits, and reduced quality of life [4]. Surgical correction attempts to restore functional and symptomatic deficits of the hip [18]. We observed that patients with FAI who underwent surgical correction and postoperative rehabilitation improved in measures of perceived hip-related pain, quality of life, symptoms, function, and satisfaction as soon as 14 weeks following surgery compared with preoperative values. Prior studies have shown that patients with FAI often experience symptomatic and functional improvements within 1 year following surgical correction [12,14]. We observed similar results, although we used an integrated approach to further understand when patients recover from strength deficits, as well as improve in pain, quality of life, symptoms, and function postoperatively. Most patients reached the MCID values for mHHS and HOOS subsets and improved by 33% from baseline to 52 weeks postoperatively for PASS mHHS. Despite the improvement in subjective outcome measures at 14 weeks, patients continued to have a substantial deficit in force production compared with preoperative measures. Therefore, the study supports the notion that objective improvements in strength and muscle function lag behind patient-perceived functional recovery. Similar observations have been made from patients with ACL reconstruction, in which changes in patient-perceived function generally precede noticeable objective measures of improvement in quadriceps strength [15,25]. More specific patient-reported outcomes that do not display ceiling affects and provide greater sensitivity in functional outcome measurements could help better guide the treatment and prognosis of patients with FAI.

In conclusion, patients with FAI who underwent surgical correction and completed postoperative rehabilitation recovered hip strength by 26 weeks and improved in perceived outcomes of pain, function, and quality of life as soon as 14 weeks postoperatively. Understanding that objective measures of hip strength may not improve as quickly as patient-reported measures of function and recovery may aid clinicians in managing patients’ successful return to sport or high-impact activity and guide the postoperative expectations of patients with FAI who are undergoing surgical correction. Future studies should investigate the use of additional therapies that aid in the recovery process, limit the progression of hip OA, lower the risk of THA, and successfully manage a healthy return to activity for patients with FAI.

Supplemental Material

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Acknowledgments

Illustration created with BioRender software.

Footnotes

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Asheesh Bedi, MD, reports relationships with Arthrex, Inc, and Springer. The other authors declare no potential conflicts of interest.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the American Orthopedic Society for Sports Medicine and discretionary funds from Dr Asheesh Bedi at the University of Michigan.

Human/Animal Rights: All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013.

Informed Consent: Informed consent was obtained for all patients included in this study.

Level of Evidence: Level IV, prospective cohort study

Required Author Forms: Disclosure forms provided by the authors are available with the online version of this article as supplemental material.

ORCID iD: Maxwell A. Konnaris Inline graphic https://orcid.org/0000-0003-4893-1413

Supplemental Material: Supplemental material for this article is available online.

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PERMALINK

Patient-Perceived Outcomes Improve Faster Than Hip Strength in Recovery After Surgical Correction for Symptomatic Femoroacetabular Impingement

Maxwell A Konnaris, BS

Lucas M Junginger, BS

Elizabeth R Sibilsky Enselman, MEd, ATC

Richard D Bell, PhD

Tristan Maerz, PhD

Asheesh Bedi, MD

Abstract

Introduction

Methods