Did COVID-19 restrictions affect post-operative rehabilitation of patients who underwent arthroscopic management of femoroacetabular impingement?

INTRODUCTION

Femoroacetabular impingement (FAI) is a clinical syndrome resulting from bone overgrowth that develops around the femoral head and along the acetabulum. Continuous or repetitive loading may cause abnormal contact on bony prominences, the labrum, and articular cartilage and may precipitate labral damage and cartilage degeneration.^[1]

FAI is classified into three categories: Cam type, which results from bony growth at the femoral head-neck junction; pincer type, which is caused by extra bone growth at the acetabular side; and mixed type, which involves both types of FAI; the cam and pincer.^[2]

The diagnosis of FAI is based on clinical and radiographic parameters, including patient history, physical examination findings, and radiological parameters. Plain radiographs are applied to assess bony morphologies, while magnetic resonance arthrography (MRA) diagnoses acetabular labral tears and articular cartilage pathology. Alpha angles are used to quantify the concavity of the femoral head-neck junction, where cam deformity is diagnosed when the alpha angle is >50°.^[3]

In the past 30 years, the field of hip arthroscopy has changed tremendously. In a short time, it has progressed from adjunctive tools with clinical applications limited to diagnosis and pathology resection to safe, anatomic reconstructive procedures.^[4] Hip arthroscopy for treating FAI associated with labral tear through osteochondroplasty and labral repair is the approach of choice because it is safe, minimally invasive, and requires a shorter recovery time than open surgery.^[5]

Recently, many specific rehabilitation programs have been developed that usually divide the recovery of patients into different stages, focusing on restoring function, and improving the joint’s range of motion to facilitate a safe return to usual activity.^[5-9] However, programs may vary significantly considering post-operative restrictions, rehabilitation activities, and the time points for the activities.^[10] Therefore, comparative studies are needed to guide post-operative rehabilitation and conduct a standardized program after arthroscopic management of FAI.^[5,6,8] As consequences of the COVID-19 pandemic, partial lockdown and associated strict social restrictions may have influenced the recovery of those patients due to restricted access to medical services, reduced or absent physiotherapy, exercises, support from relatives and friends, and face-to-face follow-up.

The primary aim of this study was to design and evaluate the impact of a home-based exercise rehabilitation protocol for patients who underwent arthroscopic management of FAI in comparison to the routine physiotherapy protocol. The secondary aim was to evaluate the impact of social restrictions imposed due to the COVID-19 pandemic on rehabilitation and outcomes as perceived by the patients and whether these affected their satisfaction rates.

The researchers hypothesized that patients following arthroscopy for FAI would have limited access to supervised post-operative rehabilitation with concerns that the COVID-19 restrictions would negatively affect recovery.

MATERIALS AND METHODS

Data collection tools

Patients’ assessment sheet

This was used to assess demographic data, comorbidities, body mass index (BMI), and sports level.

Modified Harris hip score (mHHS)

It was developed by Byrd and Jones (2000) to assess patient-reported outcomes in hip arthroscopy surgery.^[11] It is a valid and reliable tool demonstrating excellent test/retest reliability (intraclass correlation coefficient [ICC], 0.91) and construct validity.^[9] It contains eight items that represent the different aspects of pain and function. The total score ranged from “0” = worst functional outcome and maximum pain level to “100” = best functional outcome and least pain level. The interpretation of the outcome is as follows: <70 = poor result, 70–79 = fair result, 80–89 = good result, and >90 = excellent result.

International hip outcome tool-12 (iHOT-12) score

This was developed by Griffin et al. (2012) to assess patient-reported measures of health-related quality of life in hip surgery. It is a valid and reliable tool demonstrating good test/ retest reliability with an ICC of 0.89. It contains 4-domains (12 items) representing symptoms and functional limitations, sports and recreational activities, job-related concerns, and social, emotional, and lifestyle concerns. It is scored on a visual analog scale from 0 to 100, with 100 indicating the best function and the fewest symptoms.^[12]

Surgical satisfaction questionnaire

It is a valid and reliable 8-item questionnaire developed by Haff et al. (2011) to assess patient satisfaction following pelvic surgery. The internal consistency reliability by Cronbach’s alpha was 0.79. The response to the first six questions was graded using a 5-point Likert scale from 1 = very unsatisfied to 5 = very satisfied. The last two questions answers were 1 = never and 5 = yes.^[13]

COVID-19 rehabilitation questionnaire

It is an 8-question questionnaire developed by MacDonald et al. (2021). It was modified by the researchers to be six questions to assess the responses of the study group toward the effect of COVID-19 restriction on their recovery. The researchers removed two questions that did not fulfill the criteria of our patients, as all patients underwent surgery and received home-based exercise. The response to each question was recorded as yes or no.^[14]

Procedure

All patients diagnosed with FAI associated with labral tears scheduled for primary arthroscopy were recruited from the arthroscopy unit in Assiut University Hospitals. All eligible patients who agreed to participate in the study for 1 year (July 2020–June 2022) and were followed up for 1 year ending in June 2022 were included (study group). A matched-pair control group was collected from the registry system from June 2018 to June 2020, including 1-year data collection and 1-year follow-up. All patients’ diagnoses were confirmed by pelvic radiographs (anteroposterior/lateral) and MRA.

Patients of the study group with COVID-19 restrictions were educated and encouraged by the researchers to manage daily living activities, home-based exercises (teaching booklet), and mobilization. Patients were, then, reviewed at 2 weeks postoperatively in the outpatients’ clinic for removal of sutures and continuation of post-operative rehabilitation protocol. The researchers reinforced the importance of the commitment to the post-operative rehabilitation protocol and reviewed patients by phone and/or e-mail every month and in the outpatients’ clinic if patients’ conditions necessitated that. Patients were, then, followed up at 6 and 12 months postoperatively for clinical and radiological evaluation. Radiological evaluation was done with a pelvic radiograph.

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Flow diagram of study sample recruitment

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According to the registry, patients of the cohort control group before COVID-19 restrictions were referred to different physiotherapy centers to complete their post-operative rehabilitation period. They performed exercises under the supervision of physiotherapists. All follow-up appointments were conducted with the attendance of patients at the outpatients’ clinic 2 weeks, 6 weeks, 3 months, 6 months, and 12 months postoperatively. Clinical and radiological evaluations were recorded using the same study evaluation methods.

All patients were evaluated at 6 and 12 months postoperatively for their different aspects of pain and function using mHHS and for quality of life and abilities to return to an active lifestyle using the iHOT-12 score. Patients in both groups reported their satisfaction with their outcomes after 12 months postoperatively using a surgical satisfaction questionnaire to evaluate the impact of arthroscopic management and post-operative rehabilitation on their satisfaction level.

Patients in the study group were evaluated at 6 and 12 months postoperatively for their responses toward the effect of the COVID-19 pandemic and social restrictions on the care received, recovery, and mental health. Patients were asked if they felt that the COVID-19 pandemic limited their recovery after arthroscopic management of FAI associated with a labral tear and the reasons behind it. Furthermore, they were asked whether they received physiotherapy, had access to health-care services during recovery if diagnosed with COVID-19 after surgery, if any mental health deterioration occurred, and if they encountered anxiety and/or depression. This was addressed by the COVID-19 rehabilitation questionnaire.

RESULTS

The means of the age of the control and study groups were 37.13 ± 6.75 and 28.42 ± 7.72 years, respectively [Table 1]. Over three-quarters of the control and study groups were males (76.7% and 76.9%, respectively). Less than two-thirds of the control and study groups had a normal BMI (63.3% and 61.5%, respectively).

Control and study groups were matched and similar regarding the baseline assessment. All the studied patients in both groups were diagnosed with FAI with a labral tear in MRA [Table 2]. The right side was affected in 50% of the study group patients and 36.7% of the control group. Furthermore, 36.7% of control group patients and 19.2% in the study group had bilateral FAI. Cam-type was found in 40% of patients in the control group and 23.1% in the study group. Pincer type was found in 11.5% of patients in the study group. Sixty percentages of patients in the control group and 65.4% in the study group had both cam and pincer forms of FAI (mixed type). The mean duration of symptoms for patients in the control and study groups was 22.5 ± 19.36 and 16 ± 0 months, respectively. More than half (56.7%) of the patients in the control group and less than two-thirds (61.5%) of patients in the study group had positive flexion, abduction, and external rotation (FABER) test. Most patients (96.7%) in the control group and all patients (100%) in the study group had positive flexion, adduction, and internal rotation (FADDIR) test [Table 2].

Regarding pre-operative and post-operative alpha angles, the mean pre-operative alpha angles for patients in control and study groups were 63.18 ± 9.06 and 61.58 ± 6.19, respectively. The mean post-operative alpha angle for patients in control and study groups was 45.58 ± 4.97 and 53 ± 2.32, respectively. Regarding Tönnis classification of hip arthritic changes, the mean Tönnis classification of hip arthritic changes was 1.17 ± 2.98 for patients in the control group and 2.31 ± 4.06 for patients in the study group. All the studied patients (100%) in both groups were treated with arthroscopic management through osteochondroplasty (pincer resection, cam resection, or both according to the deformity type) and labral repair using anchor suturing. The majority of patients in the study group (88.46 %) and more than half of patients in the control group (56.66%) had two anchor sutures repair [Table 2].

No statistically significant difference (P = 0.059) was found between the control and study groups in pre-operative mHHS. Improvement in mHHS throughout the rehabilitation periods (6 and 12 months postoperatively) was observed in control (85.5 ± 17.04, 93.95 ± 5.78) and study (93.32 ± 12.41, 96.63 ± 4.71) groups. However, no statistically significant difference was observed in mHHS at 6 and 12 months postoperatively (P = 0.058, P = 0.064, respectively).

A statistically insignificant difference (P = 0.051) was found between the control (34.83 ± 20.94) and study (46.7 ± 23.13) groups in pre-operative iHOT 12 scores. A statistically significant improvement was observed (6 and 12 months postoperatively) through iHOT 12 score in control (58.03 ± 23.89, 62.1 ± 19.52) and study (72 ± 22.33, 80.85 ± 13.46) groups (P = 0.029, P < 0. 001, respectively).

A high statistically significant difference was found between the control (31.33 ± 0.48) and study (29.54 ± 1.98) groups through surgical satisfaction questionnaire score (P < 0.001) [Figure 1]. Both groups were satisfied with their outcomes, but the control group showed a higher satisfaction score than the study group.

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Figure 1:

(a) Surgical satisfaction questionnaire for patients of the study group and (b) surgical satisfaction questionnaire for patients of the control group.

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In the study group, all patients were very satisfied with the questions concerning whether, looking back, they would repeat surgery, were satisfied with pain control at home after surgery, and recommended the surgery to someone else. All patients reported neutral responses regarding the time to return to daily activities and work. Sixty-two percentages of patients were very satisfied with pain control at the hospital after surgery and were satisfied with the results of surgery and rehabilitation. Non-applicable responses were reported in 61.5% of patients to concerns about time to return to normal exercises after surgery due to COVID-19 restrictions [Figure 1a].

All patients in the control group were very satisfied with the question concerning whether, looking back, they would repeat surgery, were satisfied with pain control at home after surgery, and would recommend surgery to someone else. Two-thirds of patients (66.7%) were very satisfied with pain control at the hospital after surgery and the results of surgery and rehabilitation. They had a neutral response to the question concerning the time to return to normal exercises after surgery. All patients reported neutral responses regarding the amount of time to return to daily activities and return to work [Figure 1b].

As illustrated in [Figure 2], all patients in the study group reported limited recovery due to the COVID-19 pandemic. All of them reported that they had limited recovery due to limited access to care or rehabilitation centers and restrictions of partial lockdown. All patients reported having access to health-care services about concerns while recovering. Twenty-one (80.8%) were diagnosed with COVID-19 after surgery and felt anxious. All patients in the study group did not have mental health deterioration or depression during the partial lockdown.

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Figure 2:

Responses of the study group patients for COVID-19 rehabilitation questionnaire.

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A statistically significant improvement was found between non-COVID-19 patients and COVID-19-affected patients of the study group by the iHOT 12 scores (P = 0.028). The mean (±SD) iHOT 12 score for patients diagnosed with COVID-19 after surgery was 78.48 (±13.47) versus 90.8 (±8.43) for patients not diagnosed with COVID-19 after surgery. The same significant improvement was found regarding mHHS (P = 0.038). The mean (±SD) mHHS for patients diagnosed with COVID-19 after surgery was 96.03 (±5.0) versus 99.14 (±1.9) for patients not diagnosed with COVID-19 after surgery.

DISCUSSION

This study demonstrated that the designed home-based exercise rehabilitation protocol showed improvement at 6 and 12 months postoperatively, with more obvious improvement after 12 months as regards the functional outcomes, health-related quality of life, and pain for patients in the study group. Patients in both the study and control groups were satisfied with the outcome of the arthroscopic management of FAI. However, patients in the study group still felt that their recovery had been affected by the restrictions imposed by the partial COVID-19 lockdown.

Post-operative rehabilitation was significantly affected during the COVID-19 pandemic as the clustering risk was higher in outpatients than in inpatient rehabilitation due to uncontrolled exposure.^[18] Therefore, the health education of patients undergoing arthroscopic management of FAI is an important issue, which was the reason for designing a home-based exercise rehabilitation protocol.^[19,20]

In the present study, a comparison of patients’ demographic and baseline characteristics, including pre-operative data, clinical and radiological findings, and operative data, showed that both groups were similar. It demonstrated that FAI associated with labral tears occurs in young adults, mostly males, with positive FABER and FADDIR tests and some arthritic changes. All types, cam, pincer, or mixed, were treated with arthroscopic intervention. This result is similar to that of Müller-Torrente et al. (2021), who conducted a study on 90 patients who underwent hip arthroscopy (45 in the control group and 45 in the experimental group) and stated that the demographic and baseline data of the patients were similar.^[21] They reported that FAI occurs in young adults, mostly males with positive FABER and FADDIR tests and all patients were treated with hip arthroscopy.

In the pre-operative measurement, the mean scores obtained from the mHHS in the control and study groups were close, indicating poor pre-operative conditions, and there was a statistically non-significant difference between them. This result demonstrated that both groups had similar scores and characteristics. Both groups had improvement in mHHS from preoperatively to 6 and 12 months postoperatively after rehabilitation, with significant improvement in the study group. This result is similar to that of Müller-Torrente et al. (2021). They stated that the baseline pre-surgery mHHS was poor in both the experimental and control groups.^[21]

In the pre-operative measurement, the mean scores obtained from the iHOT 12 score in the control and study groups were close, indicating poor pre-operative status, and there was a statistically insignificant difference between them. This result clarified that both groups had similar scores and characteristics. Both groups had improvement in iHOT 12 scores from preoperatively to 6 and 12 months postoperatively after rehabilitation, with significant improvement in the study group. This is similar to the result of Horton et al. (2021), who conducted a study on 51 patients divided into three groups (17 patients in each group) who underwent hip arthroscopy and reported no statistical difference in the mean score of pre-operative iHOT 12.^[19] Postoperatively, after rehabilitation, all groups significantly improved their iHOT-12 scores from pre-operative to 3-month post-operative evaluations.

From the researchers’ point of view, the better improvement in outcomes of patients in the study group regarding mHHS and iHOT 12 scores could be due to the effect of the home-based rehabilitation protocol, continuous follow-up by the researchers through phone and e-mail communication, and outpatient clinic visits when patients’ conditions necessitated that.

In the present study, both groups were satisfied with their post-operative outcomes after rehabilitation, with statistically significant differences. Patients in the study group demonstrated less satisfaction with their outcomes due to their inability to return to normal exercise routines, which responded to this question as not applicable due to COVID-19 restrictions. A statistically significant relationship was found between patients’ satisfaction and the mHHS and iHOT-12 scores in both groups. This result is in agreement with MacDonald et al. (2021), who conducted a study on 48 patients who underwent primary total hip arthroplasty and 57 patients who underwent total knee arthroplasty to evaluate the effect of social restrictions of COVID-19 on their outcomes and satisfaction. They reported that social restrictions due the COVID-19 pandemic limited recovery, with worse outcome measure scores and lower patient satisfaction rates.^[14]

The present study demonstrated that all patients in the study group reported limited recovery due to the COVID-19 pandemic. They reported that they had limited recovery due to limited access to care or rehabilitation centers and the restrictions of partial lockdown. They all reported having access to health-care services when concerns arose while recovering. Most of them were diagnosed with COVID-19 after surgery.

Before and after surgery, patients should access sufficient information and support from the arthroscopy staff as well as their friends and families. Post-operative recovery and rehabilitation plans should start before surgery to keep patients alert about their recovery phases and reduce their anxiety levels.^[22,23] However, the COVID-19 pandemic may have diminished access to support services during postoperative rehabilitation and recovery. Due to the restrictions of partial lockdown, patients felt unable to connect with the health team and have a face-to-face follow-up. This is supported by reasons given by the patients in the study group who felt that recovery and rehabilitation were limited as a result of the restrictions of the COVID-19 pandemic.

Despite the perceived limitations on the recovery and rehabilitation of patients in the study group during the partial lockdown, the mHHS and iHOT-12 scores were significant compared to patients in the control group. Patients in this group showed better outcomes regarding the mHHS and iHOT-12 scores than patients in the control group.

According to the COVID-19 rehabilitation questionnaire, all patients in the study group received support from friends and family and did not have mental health deterioration or depression during the partial lockdown, in contrast to MacDonald et al. (2021), who stated that the COVID-19 pandemic resulted in a lack of support from friends and family during the post-operative rehabilitation and recovery period. Despite the same improvement in function and satisfaction levels, it profoundly affected patients’ mental health and perception of recovery during the follow-up period following arthroplasty. Patients felt the social restrictions enjoined by the COVID-19 pandemic limited recovery and rehabilitation and were associated with worse Oxford hip scores, Oxford knee scores, quality of life scores, and a lower satisfaction rate. However, compared to the control cohort group, no difference was found in outcomes, such as the Oxford hip score, the Oxford knee score, or the satisfaction rate after total hip or knee arthroplasty.^[14]

CONCLUSION

The rehabilitation protocol following arthroscopic management of FAI proposed to patients in the study group achieved better benefits than the usual hospital physiotherapy rehabilitation protocol in terms of better functional outcomes, health-related quality of life, and pain reduction (mHHS, iHOT-12).

AUTHORS’ CONTRIBUTIONS

MAA and RAA shared the study conception, study design, material preparation, data collection, data analysis, and the first draft of the manuscript. MAA performed the surgical operations for both groups of patients. All authors carefully reviewed and approved the final draft of the manuscript and were responsible for the content.

ETHICAL APPROVAL

The research design was reviewed and approved by the Ethics Review Board Committee at the Faculty of Nursing, Assiut University, Assiut, Egypt, with registration number 4210031 on 28-5-2020. Informed consent from patients was taken and all data were kept confidential.

USE OF ARTIFICIAL INTELLIGENCE (AI)-ASSISTED TECHNOLOGY FOR MANUSCRIPT PREPARATION

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.