Adhesions after Hip Arthroscopy | Treatment and prevention
Welcome back to my 3-part blog series on adhesions after arthroscopic hip surgery. In Part 1, we checked on the evidence around how big a problem this is, and the potential impacts of excessive capsular fibrosis following a hip scope. In Part 2, we looked at the risk factors and diagnosis of adhesions after hip arthroscopy and, here in Part 3, we’ll dive into the action topics - treatment and prevention of adhesions after hip arthroscopy. There is exciting potential for impact in this space, especially in preventative strategies. Physiotherapists and other rehab health professionals have a great opportunity to help our patients and our surgical colleagues with delivering the best possible outcomes after arthroscopic hip surgery.
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Part 3 will cover the following topics:
Treatment of post-operative hip adhesions
Post-operative adhesions are one of the most common reasons for failed hip arthroscopy and subsequent revision surgery.1,2,3,4,5 The evidence for efficacy of treatment strategies for problematic adhesions after hip arthroscopy is still in its infancy, but the information available to date is summarised for you below.
Surgical treatment of adhesions after hip arthroscopy
The most frequently reported treatment for post-operative hip adhesions, is surgical lysis during a revision arthroscopy. The challenge is that additional surgery may incite the development of further adhesions. The application of a capsular spacer has been used in some patients, placed between the labrum and the capsule to reduce the chances of re-adhesion and to address labral eversion to maintain or restore the labral seal.1
Non-surgical treatment options for post-surgical hip adhesions
Non-surgical techniques are always preferable to repeat surgery, but what non-surgical options are available? Non-surgical options in the literature include pressure injection for periarticular adhesions, manipulation under anaesthesia and exercise.
High pressure injections for periarticular hip adhesions
For peri-articular adhesions of the deep surface of the hip flexors to the joint capsule, one study described a high-volume injection (10-12ml) of local anaesthetic into the adhesion plane between the capsule and hip flexor planes, using ultrasound guidance.6 The aim was to try to separate the tissues. This was followed with 1mm of corticosteroid to reduce post-procedure inflammation and re-scarring. Twelve of 21 patients showed positive response to the injection, although improvements in pain intensity (reduction of 2.5/10) and function (8-10% improvement in Hip Outcomes Scores) were quite modest.6
Manipulation under anaesthesia for post-operative hip adhesions
One other technique study reported Manipulation under Anaesthesia (MUA) as a potential solution to post-operative peri-capsular adhesions following hip arthroscopy.7 The procedure is described as gentle flexion and then repeated motions into hip abduction and external rotation, akin to wide circumduction. Impingement positions and motions are avoided. The authors noted that the technique was most helpful for peri-articular rather than intra-articular adhesions, but outcomes were not presented. Research is required to establish the efficacy of such a technique.
Exercise in the management of hip adhesions after arthroscopy
Exercise is warranted for joint health regardless and may be helpful for reducing pain and loss of range of motion associated with adhesions. As with MUA, exercise is likely to be more helpful with peri-articular adhesions, particularly after scar maturation. Caution should be taken to avoid positions of impingement or overly aggressive stretching which may cause inflammation and further fibrosis or aggravate other co-existing pathologies.
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Prevention of problematic post-operative adhesions
Considering the modest effects likely to be achieved with non-surgical treatments for hip adhesions after arthroscopy, and the risks of repeat surgery, the primary focus in managing this issue should be placed on prevention strategies. As we discussed in the risk factors blog, what happens in early rehabilitation appears to be more impactful than the actual surgical procedures utilised. Rehabilitation strategies are therefore of high importance. Pharmacological or biological solutions are also being explored.
Rehabilitation strategies for preventing adhesions after hip arthroscopy
General principles are to initiate early and regular motion but avoid overly aggressive early rehabilitation. Excessive inflammation or bleeding will increase the chances of excessive fibrosis. Adequate patient education around post-operative load management will therefore also be essential.
The strongest evidence for prevention is for regular circumduction. Willimon et al (2014) commented on the ‘precipitous reduction in the revision arthroscopy rate’ when they added regular passive circumduction (small circles at around 70 degrees of hip flexion) to their post-operative protocol.3 As we mentioned above, patients who were provided with regular circumduction were 4.1 times less likely to develop post operative adhesions!
Regular use of Continuous Passive Motion (CPM) machines for 6 weeks also appeared to reduce risk of developing post-operative adhesions.3 CPM machines are not necessarily in widespread use these days after arthroscopy, in favour of a more active approach. This means that most patients will not have easy access to a CPM machine post-operatively unless they hire one themselves. If a patient does not have a partner, family member or friend able to assist with regular passive circumduction, hiring a CPM machine is something that should be considered.
What we know is that regular early motion is critical. Physiotherapists or rehab therapists should develop a post operative plan with the patient, preferably pre-operatively and in consultation with the surgeon. Decisions can be made about how and who will provide mobilisation techniques.
Early active motion is also important, ensuring the healing capsule is protected – early stretching into external rotation and extension is not recommended. Stimulus of the peri-articular muscles will be particularly important to provide direct gentle mobilisation of the capsule and adhesions that are naturally forming in the healing process. Stimulus of these muscles is also important to restore dynamic joint protection mechanisms after surgery. Target muscles would include the iliocapsularis, iliopsoas, gluteus minimus, as well as the rectus femoris with some caution. Inclusion of exercises that move the pelvis on the femur and vice-versa is also important.
Resistance-free stationary cycling can usually be started on day 1 or 2, and when cleared for the pool, active motion in the pool is recommended.2
Pharmacological strategies for preventing hip adhesions
Medications and biologics are also under consideration and some are in early use in prevention strategies to reduce the risk of problematic adhesions following hip arthroscopy. The medication most frequently mentioned is Losartan, an angiotensin II type receptor blocker. Losartan is used to block the activation of TGF-b1, a key cytokine active in the formation of fibrosis. Although some efficacy has been shown in healing of musculoskeletal tissues and reducing fibrosis in PRP or stem cell treatments,1,2 evidence for the usefulness of Losartan in prevention of post-operative adhesions after arthroscopy is currently lacking. Future research in the field of pharmacology and biologics is expected.
Concluding thoughts on adhesions after hip arthroscopy
Intra-articular and peri-articular adhesions are very common following hip arthroscopy, particularly after arthroscopic surgery for FAIS. Adhesions are a normal part of healing but excessive fibrosis and adherence of the capsule to intra and extra-articular tissues may contribute to persistent post-operative pain in some patients.
Regardless of pain, adhesions may be one explanation for a lack of post-operative range improvement despite removal of bony sources of impingement.8 The potential impact of post-operative adhesions on long term joint health also remains worthy of consideration and should underpin our efforts to reduce the development of excessive post-operative adhesions. Early post-operative rehabilitation strategies play a central role in adhesion prevention.
If you are a physiotherapist or other health professional involved in post-operative rehabilitation, if you are not already aware of potential risks of post operative adhesions and doing something about it, it’s time to update your protocols.
I hope you’ve enjoyed this series. If you’d like to learn more about prevention and management of adhesions after hip arthroscopy, we talked in detail on this topic recently in one of our live Hip Academy Member Masterclasses. The recording of the masterclass is available for all members. Join us in Hip Academy to take advantage of the wealth of learning resources available for health professionals, and live interaction with other hip lovers and hip learners from all around the world!
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This blog was written by Dr Alison Grimaldi
Dr Alison Grimaldi is a physiotherapist, researcher and educator with over 30 years of clinical experience. She has completed a Bachelor of Physiotherapy, a Masters of Sports Physiotherapy and a PhD, with her doctorate topic in the hip region. Dr Grimaldi is Practice Principal of PhysioTec Physiotherapy in Brisbane and an Adjunct Senior Research Fellow at the University of Queensland. She runs a global Hip Academy and has presented over 100 workshops around the world.
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References
- Ruzbarsky JJ, Soares RW, Comfort SM, Arner JW, Philippon MJ. Adhesions in the setting of hip arthroscopy. EFORT Open Rev. 2023 Nov 1;8(11):792-797.
- Philippon MJ, Ryan M, Martin MB, Huard J. Capsulolabral adhesions after hip arthroscopy for the treatment of Femoroacetabular Impingement: Strategies during rehabilitation and return to sport to reduce the risk of revision. Arthrosc Sports Med Rehabil. 2022 Jan 28;4(1):e255-e262. doi: 10.1016/j.asmr.2021.10.031. PMID: 35141559; PMCID: PMC8811550.
- Willimon SC, Briggs KK, Philippon MJ. Intra-articular adhesions following hip arthroscopy: a risk factor analysis. Knee Surg Sports Traumatol Arthrosc. 2014 Apr;22(4):822-5.
- Den Hartog TJ, Leary SM, Schaver AL, Parker EA, Westermann RW. The incidence and outcomes following treatment of capsulolabral adhesions in hip arthroscopy: A systematic review. Iowa Orthop J. 2023 Dec;43(2):146-155. PMID: 38213862; PMCID: PMC10777703.
- Keogh JAJ, Keng I, Ifabiyi M, Patel M, Duong A, Malviya A, Wuerz TH, Ayeni OR. Adhesions after hip arthroscopy are associated with revision but show poorly defined criteria for diagnosis and operative management: a systematic review. Arthroscopy. 2024 Apr 30:S0749-8063(24)00303-7. doi: 10.1016/j.arthro.2024.04.008. Epub ahead of print. PMID: 38697325.
- M V Reddy S, Ayeni O, Vatturi SS, Yu H, Choudur HN. Ultrasound-guided release of post-arthroscopy extra-articular hip adhesions in femoroacetabular impingement: a novel technique. Skeletal Radiol. 2021 Dec;50(12):2541-2548. doi: 10.1007/s00256-021-03766-z. Epub 2021 Apr 12. PMID: 33844029; PMCID: PMC8038923.
- Gaio NM, Turner EHG, Spiker AM. Hip manipulation under anesthesia for post-hip arthroscopy pericapsular scarring: Indications and techniques. Arthrosc Tech. 2023 May 29;12(6):e983-e989. doi: 10.1016/j.eats.2023.02.036. PMID: 37424664; PMCID: PMC10323974.
- Hansen L, de Raedt S, Jørgensen PB, Mygind-Klavsen B, Rømer L, Kaptein B, Søballe K, Stilling M. Hip joint motion does not change one year after arthroscopic osteochondroplasty in patients with Femoroacetabular Impingement evaluated with dynamic radiostereometry. J Exp Orthop. 2022 Jan 5;9(1):4. doi: 10.1186/s40634-021-00427-x. PMID: 34985680; PMCID: PMC8733129.
