I've actually been in the course long enough now that I've had to re-cert twice. So I think it's 10 or 11 years old and I've had my boards twice during this thing. So the talks are excellent as always. And again, relax. Honestly, you just coming to this course is going to help you take your re-certification or the CAQ exam. So I want to thank Chris and Tom for inviting me again. And I'd like to thank the entire AOSSM staff. Without them, they do such a phenomenal job in terms of getting you guys prepared. I've got nothing to disclose in my presentation. And if you need to contact me, please feel free to give me an email or find Chris or Tom and they can get a hold of me. In terms of the talk itself, everything you need to know about the HIP is truly in this lecture. You have a long syllabus. You've got 60 questions. I learned a lot when I grew up with Jiminy Cricket and Walt Disney and the fact that they used to always have that bouncing ball with different colored things for you to remember. Well, in my talk, I've got things outlined in yellow, which were pertinent things that have come across in terms of talks. So if you just follow my talk in circle, you'll find in your outline this is a really easy talk to follow. The hip joint itself is made up of the acetabulum and the proximal femur. For test question purposes, the decreased neck shaft angle or version can predispose to a femoral neck stress fracture. That's really the only questions that have come across in terms of that hip joint. Now, the hip joint itself has changed quite a bit. We talk about compartment anatomy now and the central compartment, the peripheral compartment, and the peritrochanteric or the outside, the hip joint compartment. Things to understand and recognize is that the labrum and pincer lesions are found centrally. Peripherally, the femoral neck and cam lesions are found. And in the peritrochanteric space are most of the other problems that can come across in hip joint questions. The hip joint itself is highly constrained and is much less mobile than the other joints. The labrum is the mainstay of the hip joint itself that most of the questions come from. And we'll talk about that a little bit later on. The ligamentum teres does provide a limited blood supply to the head and has also been indicated in terms of instability. But again, questions to this test pertaining to the hip joint are ones with which mostly revolve around anatomy, physical examination, and well-done paper and published studies, which unfortunately for us hip arthroscopists is not a lot. Hip joint capsule, the anterior capsule is formed by the iliofemoral ligament, which is the strongest of the three pelvofemoral ligaments. If cut and left uncut, there's potential for a question that the hip will rest in an increased external rotation position. The pubofemoral ligament and the posterior capsule make up the other two ligaments. Important in understanding of the ligaments that make up the capsule is that the hip joint and the capsule itself is taught in extension and external rotation and is lax with flexion and internal rotation. The importance of that is that as we move from the central compartment to the peripheral compartment to work on FAI or CAM procedures, we have to flex and internally rotate the hip to get into that space. Labral anatomy attaches to the transverse acetabular ligament. And basically what you need to know is the majority of the pathology for labrum is found anterior and superior, where the labrum is the widest and the thickest. The function of the labrum is it helps with joint congruity. It deepens the socket. It enhances stability, decreases the coefficient of friction, and helps out with proprioception. Neurovascular structures, again, what you need to know about the hip joint is that it's innervated by L3 nerve root. There are anterior structures that we know, the femoral artery, nerve, and vein. The lateral femoral cutaneous nerve exits under the inguinal ligament near the ASIS and is important in terms of portal placements for hip arthroscopy and having problems after the hip scope. Posteriorly, we'll talk about some of these other nerves. Femoral head blood supply. The majority of the femoral head blood supply is from the lateral ascending branch of the medial femoral circumflex artery. This is important because when you're doing a hip arthroscopy, you've got to watch out going laterally in terms of affecting this blood supply to the femoral head. Range of motion. The key in the examination when they give you range of motion is a loss of internal rotation. Once you have a loss of internal rotation, it's usually indicative of somebody having FAI, and that's the way the questions are phrased. Internal rotation is the key. Soft tissue injuries we'll go over right now. Bursitis, repetitive friction of nearby muscles causing injury to surrounding tissue. Trochanteric bursitis, which is friction of the IT band over the greater troch. The key to the questions in the tests are it's commonly associated with a wide pelvis, a leg discrepancy, foot pronation, and activity on banked or uneven surfaces. For most test purposes, the treatment is conservative. Ischial bursitis, hamstring syndrome. These patients will complain of having problems sitting. It's oftentimes in hockey players, skaters, and distant runners. And again, the treatment is non-operative. Iliopsoas bursitis, and we'll talk about the iliopsoas. Tendon is coming up. The key to this is that it's the snapping hip syndrome, which we'll talk about. And again, this is generally treated in a conservative care fashion. Iliopectineal bursitis is iliopsoas bursitis, but just higher up in the pelvis. The snapping hip or coccyx sultans, there are three types. The two that you have to worry about are external and internal snapping. Intraarticular is slowly going by the wayside. I just mentioned it. External is usually called by the IT band. Internal by the psoas tendon. So internal snapping hip exam, a favorite question on all tests. It is elicited by moving from an abducted, externally rotated and flexed position to an adducted, internally rotated and extended position. The importance to this is that the examiner will hear a clunk or a pop. As seen in this bottom picture, the patient will pop as to where the point to where this actually bothers them. So you can hear internal snapping. External snapping, on the other hand, is the patient will come in and they'll tell you my hip is actively dislocating. And basically what that is is the IT band is coming up and over the greater troch. And the test that's important for that is the OBRA test, which is an abducted, extended hip and the knee is flexed. And the patient cannot adduct past midline. Imaging in the snapping hip, the key here is now the dynamic ultrasound. And you can see the snapping hip on exam. And basically what you see here is the psoas tendon snapping over the iliacus. Primitive management is recommended for all of these in avoidance of aggravating activities. Treatment, if it fails, is in general arthroscopic. And we do a psoas release. You need to think about these tendons as to the amount of tendon versus muscle. And basically we now are all releasing these in the mid-portion. The key to this, which can be asked in a test, this is a capsulotomy between the anterior labrum and the femoral head. And the 50-50 rule is that you release the tendon and 50% of the muscle is still there. External snapping hip can either be done open in a Z-plasty type of fashion or arthroscopically. And again, we try to create that same type of Z-plasty when these are released. Gluteal tears. Moving on to an area of the, quote-unquote, the rotator cuff of the hip. The gluteus medius tendon is the most commonly implicated tendon in terms of tearing for this area. Oftentimes described as weakness or a sudden pop or injury. Six and seven decades. And the key is the physical examination again. Weakness with hip abduction, a Trendelenburg gait, and tenderness on the superior lateral or anterior facet of the greater troch. Trendelenburg gait is remembers the pelvis drops when the contralateral foot is lifted off the ground. And test questions that have been written involve where does the gluteus medius attach. And it attaches on the lateral facet as well as the superior lateral facet of the greater troch. Very important. Gluteal manual muscle testing. The medius and the minimus are both tested with the knee in extension. But one has hip abduction, hip extension, and external rotation, which is the medius. Where the minimus is hip abduction, extension, and neutral rotation. So these will be found in the question as you do it. The patient has weakness in abduction, extension, and external rotation of the hip joint. You know they're trying to lead you to the gluteus medius. Gluteal tears can oftentimes be treated in a conservative fashion. If operative intervention needs to be done, it can be done open or endoscopically. And there's been no study out there showing one more effective than the other. So it's unfair to ask that question other than do they need to be fixed. Contusions are the most common athletic hip injury. They may be superficial or deep. And the general treatment, again, for these is to get rid of the inflammatory component. The iliac crest contusion is called a hip pointer. And, again, the treatment is directed to decreasing the swelling with ice elevation and compression. Quadriceps contusion, this is a favored question to ask on all the exams. The importance of this is to try to prevent hematoma formation in myositis ocificans. To do so, you want to treat your athletes, immobilize them in flexion to maintain range of motion and decrease the bleeding. Again, in flexion. And the most commonly given number is 120 degrees of flexion. Myositis ocificans occurs in areas of deep soft tissue injury and presents as painful injury and loss of motion. The key to all myositis questions are that the treatment is based solely on clinical findings, not based on x-rays, based on clinical findings. Again, you want to avoid increased bleeding, loss of range of motion, and surgery, if needed, is delayed for a long period of time. Muscle and ligament strains, the most important question that's ever asked is violent eccentric forces. And what's key to understanding these eccentric forces is that the most commonly injured muscles and ligaments across the thigh and hip are muscles across two joints. Two joints are more susceptible. So, adductor longus, again, two joints. And it is the most commonly injured adductor tendon. It's very common in athletic pubalgia, sports hernia, core muscle injury, or angle disruption. The flavor of your choice is dependent upon the year that they write the papers on. But again, adductor longus. External oblique strains, very common in hockey and baseball players. Forceful contraction when the trunk is to the opposite side. Hamstring injury, again, sprinters, hip flexion and knee extension. Non-surgical management, in general for all these questions, is a single tendon avulsion with retraction less than two centimeters. Surgical repair are for single tendons greater than two centimeters, or any three-tendon avulsion. Oftentimes, these are maximal and will be well over five centimeters. Rectus femoris strain, again, is the tendon with which travels over two joints, commonly injured. And the one that's commonly injured, which you'll be asked, is the reflected head is most commonly involved. Rectus femoris strains, again, MRIs will show edema and fluid. And currently, one of the newer impingements are the subspinous impingements. And subspinous impingements occur from AIIS avulsions, which is where this reflected head of the rectus comes from. Hernias, abdominal pain above the hip joint can be both inguinal and femoral. Currently, in 2017, Gilmore's groin sports hernia, peripubic pain syndrome, athletic pubalgia, inguinal disruption is now known as a core muscle injury. So they may use any of these terms, but it's all the same term. It's exertional, chronic, inguinal, or peripubic pain in athletes. And it involves areas of injuries of the rectus abdominis and the adductor longus. Clinical history, these are usually hyperextension injuries around an abducted hip. Physical examination, the patients will have pain to palpation over the peripubic area, the symphysis pubis, or the adductor area. And basically, it's stimulated by firing the rectus abdominis muscle. You also must perform a full hip examination. Imaging, again, you must rule out other causes of pain, which include femoral acetabular impingement. Treatment algorithm, again, for pre- or mid-season athletes is always conservative. However, post-season are people that have had pain greater than six to eight months. Surgical intervention may be necessary. In general, they will ask you, will be, if you're considering surgeon, to refer to a general surgeon. Not white type of surgery needs to be done. Here's an explanation of the different types of stuff that can be done. However, the importance is you want to refer them for operative intervention if greater than eight to ten weeks of conservative care have failed. So questions. Again, I have 60 questions in your handout. I'm not going to give all 60 questions while we're talking. They're all there. We're going to highlight a few of them. Your high school running back takes a direct blow to the anterior thigh by another player's helmet. You've ruled out compartment syndrome. Due to the severe injury to the quadriceps contusion, he's unable to continue to play. What should be included in your initial management? Thigh contusion, think about immobilizing the knee and 120 degrees of flexion. Which of the following best describes athletic pubalgia, spore ternia, core muscle injury? This is a syndrome, as we discussed, of lower abdominal and adductor pain. What injury mechanism is postulated in the result of a core muscle injury or athletic pubalgia? Traumatic repetitive extension and abduction. Again, it's an extended pelvis and abduction of the hip joint, which puts pressure across the symphysis pubis, giving your abdominal and adductor area tension. What is the most common adductor groin strain? Adductor longus. Question number eight, what is the most common quadriceps tendon? Again, which is the one that crosses two joints? Rectus femoris. What type of muscle contraction force is the leading cause of most muscle strains? This is a commonly asked question, and the key to this is understanding that it is eccentric. Initial treatment of myosinus ossificans should be guided by which of the following primarily? Again, we talked about this. It's not by any radiographic measures. It's done by clinical findings. Question 11, you see a first-time marathon runner the day after her race. She complains of lateral hip and knee pain bilaterally. Her OBRA test is positive. The diagnosis of iliotibial band syndrome is made. What are the factors that have contributed to her condition? Again, we talked about this. Varus mechanical alignment, pronated feet, and a wide pelvis. A 20-year-old college football running back sustained a hip flexion injury. You plan operative intervention with the MRI and figure 14, which I'll show you. Here's the figure. We're looking at the pelvis. We're comparing it, and we're noticing the significant hamstring injury here. And the question just asks, which are the ones which are vulsed off of the pelvis? The majority of the rectus femoris strain involve what portion of the tendon? Indirect, proximal, direct, and reflected. And again, Dr. Kading will talk to you about how to take these tests, but basically you're trying to eliminate the ones which don't make sense, and a reflected head is the one which makes the most sense. During hip arthroscopy, the surgeon performs a capsulotomy of the anterior and anterolateral portals, or an interportal capsulotomy. The patient complains arbitrarily that the foot rests in an externally rotated position. This is an injury to the main ligament of the capsule, and that's the iliofemoral ligament. A 24-year-old runner developed popping in the anterior hip. She has no pain with internal rotation in the flexed hip. So loss of internal rotation in a flexed hip is that FAI examination. There is no pain or visible popping laterally with the OBRA test. What is the next best diagnostic test for this patient is to take a look to see what's going on with that psoas tendon. Finally, a 58-year-old female presents with refractory left-sided pain. She's been treated for six months. She has reproducible pain in flexion, abduction, and external rotation, positive Trendelenburg sign. She has strong and symmetric single leg raises, non-painful with flexion, adduction, and internal rotation. Based on the examination findings, what's the most likely? A gluteus medius tear. Okay, traumatic injuries, bone injuries. There are lots of them. They're oftentimes frightening on the sidelines when you see them. Traumatic fractures, again, are high energy with increased soft tissue damage. Hip dislocations, the majority are posterior, and the patients will be held in a flexed, adducted, and internally rotated position. Of hip dislocation, the key things you need to know, the most common complication is AVN. The least common complication is recurrence, and morbidity is dependent upon time to reduction. Again, what you want to do is get these reduced as soon as possible. Stress fractures are very common in our athletes, and MRIs are usually the treatment that's seen the most. They can occur in the rami. They can occur in the sacrum. Femoral stress fractures are the most commonly asked questions, and again, the goal for treatment of femoral stress fractures, again, are to prevent displacement. The location of these are very important, and the fact that the medial or compressive cortex stress fracture is stable and you treat with crutches, the lateral or tensile surface is more likely to displace, and these need to be fixed. So conservative management for all, except for the lateral or tensile stress fractures, and you want to fix these as soon as you can. Avulsion injuries commonly seen in adolescents. All of these avulsion injuries are just understanding anatomy. Sites of occurrence we'll talk about. The anterior superior iliac spine is associated with the sartorius tendon. The anterior inferior iliac spine is associated with rectus femoris. This is oftentimes associated also with subspinous impingement. Issue of tuberosity avulsions are a result of hamstring contractions. Greater troch avulsions, again, from the gluteus medius. Importantness is that this affects the blood supply to the laterally ascending branch and therefore can be a cause of AVN in the femoral head. Lesser troch avulsions is the iliopsoas tendon, and the key here is it's the only avulsion injury that moves proximally. Treatment, again, is conservative. It's very rare that these are treated in an operative fashion, even despite what the x-rays look like. Osteitis pubis, where it used to be a single entity, now people are talking about this being a result of the imbalance of both your abdominal muscles and your hip abductors. The treatment, again, is conservative with core strengthening and balancing out the pelvis. Degenerative joint disease, a seven times increased risk of DJD with high-impact activity sports. Important to understand the newest, well, not newest, but the radiographic guidelines that people are using are the tonus classification, zero showing no signs of arthritis, one showing mild, two showing moderate with small cysts, and three being severe. The importance of this is the results of hip arthroscopy are poor if their tone is two or more, and we'll talk about that a little bit later. Osteonecrosis, again, multiple causes for this. Imaging is done by MRI, and again, the FECAT staging, with which you guys should be aware of for other things such as total joints. Tumors, remember that the pelvis and the hip account for 10% to 15% of all primary musculoskeletal tumors. So be aware of them when you're looking on the x-ray. What is the most common direction of a traumatic hip dislocation? Posterior. Question 23, a 32-year-old marathon runner complained to five weeks of increasing pain in the left groin. An MRI demonstrates a linear signal at the medial 50% of the femoral neck. What is the best management of this? Remember, medial is good, compressive, non-weight-bearing. A serious complication associated with an avulsion of the greater troch is osteonecrosis of the femoral head. A 28-year-old man is involved in a head-on motor vehicle accident while going to their athletic event. That's how it got into as a sports question. The least common complication of a posterior dislocation of the hip joint is recurrent dislocation. A 13-year-old male hurrer has an acute pop in his right buttock, unable to finish the race, has an apotheosial avulsion, which is 1.5 by 2 centimeters and 1.3 displaced. What is the most common recommended treatment for this injury? This non-operative treatment is likely to produce a return to normal functioning. Pelvic avulsion injuries, this is just a game of matching. ASIS is sartorius, AIS is rectus, lesser troch is psoas, greater troch is gluteus, initial tuberosity is hamstring. A 36-year-old female has been training for the Boston Marathon. Fifth week she's trained, she's developed left inguinal hip pain. She can't walk. She has groin pain with hip flexion and rotation. MRI shows this picture. What is the management? Tensile fracture. Fix. I'm sorry to remove this. An important point on your test taking is that during this now, they have these multiple question things where question 36 will be, you'll give a response and then there's a part two to question 36. You're not on the test going to be able to go back to the one that's beforehand. So when you do this, make sure you don't mark it off to go back to because you won't be able to go back. So when you have these test questions that have multiple options, answer the question. The other ones you can go back to, but the ones they don't, that's just a secret thing that's in the small writing when you're doing this. I was banging my mouse last year trying to get back to that question. A 22-year-old is seen in the ER with left hip pain, inability to move after a fall, tripping over a ball. X-rays show a hip dislocation. The factor most associated with increased morbidity is time to reduction. A pediatric avulsion fracture, when displaced, it migrates proximally. There's only one of them here, and that's the lesser trope. A 15-year-old male track athlete presents with two-week history of insidious onset of right hip pain. There's no history of trauma. The patient denies any fevers. Pain over the anterior iliac crest, especially with resisted abduction of the hip. The patient has no pain on extreme ranges of motion. What is the next appropriate step in the management of this patient? Is rest for three to four weeks, again, these are apophysial injuries. 14-year-old track athlete was coming out of the blocks and felt a pop in the anterior aspect of the right hip, was unable to continue to perform. An AP of the pelvis is shown. What's the treatment? Again, supportive management and gradual return over four to six weeks. 37-year-old female triathlete comes into her office with a two-month history of gradually progressive left groin pain. She's first noticed to have the pain in a week competing in the Olympic length event. Her range of motion is symmetric. Resistance testing is normal. A hip impingement test is not suspicious for anything. Plane radiographs are normal. What is the best step in the management of this athlete? Further imaging with an MRI to take a look to see if she has a stress fracture. Okay, nerve entrapment syndromes. Sciatic nerve entrapment, again, L4 to L3 nerve roots. It can cause some paralysis of the hamstrings, all the muscles below the knee. It's very rare that anything needs to be done than rest and stretching. Piriformis syndrome is a variation in normal anatomy. Again, the sciatic nerve is pinched at the sciatic notch by a split in the piriformis tendon usually. Multiple etiologies for this. The pain for piriformis is ridiculous. It doesn't have a muscular imbalance. It's a ridiculous type of pain. Treatment again is conservative, and if need be, surgical intervention would be to release the piriformis and to dissect out the sciatic nerve. Octorator nerve entrapment, again, L2, L4 nerve roots. The anterior division goes to most of the adductors and cutaneous distal thigh. The posterior division is the adductor brevis. Most of the questions go around the anterior division of the octorator nerve affecting the function of the adductors, adductor weakness. Pudendal nerve involvement, common as a complication of hip arthroscopy question, can come from prolonged bike riding or hip arthroscopy fracture table, and again, is numbness in the shaft of the penis or the perineum. Inguinal nerve entrapment is from hypertrophied abdominal muscles, body builders, and again, it's usually tenderness to palpation, pain radiating to the genitals. Femoral nerve involvement is from an anomalous slip of the iliacus. Patients will have a weakness in the quadriceps tendon and loss of sensation over the anterior medial thigh, medial thigh. Internal femoral cutaneous nerve entrapment or neuralgia parastetica is anterior lateral thigh numbness with no motor symptoms, and the treatment is to remove the offending agent, which are usually weightlifting belts or a question to that effect. Hamstring syndrome is sciatic nerve entrapment between the semitendinosus and the biceps, very common in track or running athletes. So what nerve is associated with hip pain referred to the knee? Again, the anterior branch of the obturator nerve, anterior medial thigh numbness. Twenty-seven-year-old power lifter complains of dysesthesia on the anterior lateral aspect of the left thigh. The remainder of the neurologic examination is unremarkable. Which is the most appropriate initial clinical step? Is the adjustment in the fit of the weight belt. A 19-year-old soccer player presents with a six-month history of groin pain. The symptoms had an insidious onset, and he describes a deep ache and numbness along the medial aspect of the right thigh, worse with jumping. Five minutes post-exercise, the patient has adductor weakness. An EMG study indicates adductor weakness. What is the most likely diagnosis? Obturator neuropathy. Okay, hip arthroscopy. Hip arthroscopy is really a growing field in the field of sports medicine, therefore the questions have increased in terms of talking about hip arthroscopy. Two different approaches that can be done are either supine or lateral, and either or are in whoever's hands operating them are totally acceptable. The key is the majority of problems that occur from complications from hip arthroscopy are related to either too little or too much distraction. The key, however, is the length of distraction time. You never want to go beyond two hours. Examiners are placed in an atraumatic fashion, and there are four portals. There's the anterior, anterior-lateral, posterior-lateral, and mid-anterior portal. These allow access to everywhere within the hip joint. And the key, just like knee and shoulder arthroscopy, these are easy questions for examiners to ask because there are complications, neurovascular, that are associated with each of the portals. So what's important is to understand a one-minute review on what are the complications from an anterior portal, anterior-lateral, posterior-lateral, and mid-anterior portal. Very easy. Okay? Here they are. Anterior-lateral portal, which is two centimeters anterior to the greater troch at the level of the tip, lies in a safe zone, and the risk is the superior gluteal nerve and a little bit of the lateral femoral cutaneous nerve. So anterior-lateral, superior gluteal, and lateral femoral cutaneous. Anterior portal, which is an intersection of the sagittal line from the AIS to the superior greater troch, the lateral femoral cutaneous nerve is at risk. The femoral neurovascular bundle is close by, but it's the lateral femoral cutaneous nerve. The posterior-lateral portal, again, this is posterior to the greater troch, generally lies in a safe zone, except in a leg which is positioned in external rotation. That puts the sciatic nerve at risk. So you want the leg in neutral rotation when making a posterior-lateral portal. The mid-anterior portal, which is probably the portal with which people are using most in their, or variation of that, for their labral repair and drilling of their holes for the anchors, have risks of the femoral neurovascular bundle and the lateral femoral cutaneous nerve. And you can see there's a triangle made between the anterior-lateral and mid-anterior-lateral portal. Peripheral compartment, as described by Deintz, is the area with which we're looking for camera section for femoral acetabular impingement. And again, to assess the periphery, you need the hip flexed 30 to 40 degrees and slight internal rotation. Capsular management, very commonly done and performed is an interportal capsulotomy. The key to that is to understand that a capsular injury of the iliofemoral ligament can lead to the foot going into more external rotation. In terms of whether or not you should repair these or not, it's total controversy. You don't have to worry about that. Peritrocanteric space portals, again, anterior and distal portals, and these are to get into the gluteal areas. Central compartment pathology, okay? Mechanical tears are the source of mechanical hip pain, and they are the most common lesion found at arthroscopy. Labral anatomy, again, we talked a little bit about it. It's a triangular fibrocartilage structure. It's function we already talked about, and again, they occur anterior-superior. Types of tears, multiple types of tears described, much like the knee meniscus, but there's been nothing out there to show whether or not a debridement or a repair makes a difference. Physical examination findings, you'll find them commonly associated with an impingement sign, which is the hip maximally flexed, adducted, and internally rotated, which is called a fader sign, FADDIR. Also there's a test called a McCarthy sign, which is flexion to extension with internal and external rotation. Plane films in imaging, by far the MRI best shows us what's going on with the labrum, as well as the articular cartilage on the inside of the hip joint. Labral debridement shows good results. Labral repair shows good results. The question is going to be on the test, either labral repair or repair, it's not going to ask you to choose which one is better. Again, I think as time goes on, we'll find out labral repairs are better, but there have been no good long-term studies to ask you those questions. Loose bodies, loose bodies in the hip joint are the clearest indication for hip arthroscopy, the clearest indication. Mechanical injuries, a spectrum of injuries, and of all the things that determine poor outcome data for hip arthroscopy, by far changes within the articular cartilage of either the acetabulum or femoral head lead to the worst operative results. Ruptured ligamentum teres we talked about can cause some mechanical hip pain. Synovial disease, synovial chondromatosis is the most common benign synovial disease within the hip joint, as well as pigmented villanodular synovitis, and again, treatment is to go in arthroscopically. Now that we can go centrally as well as peripherally, it's an excellent indication for arthroscopic intervention for this type of benign tumor. Femoral acetabular impingement, if you're going to concentrate on something on this talk, this is the key one. Arthritis is the end point of femoral acetabular impingement. We now are moving into this contemporary impingement, which is abnormal contact between the proximal femur and the acetabulum, and you think about these in terms of three thought processes. One is a femoral-based impingement, which is called a CAM impingement. That's in the peripheral compartment. An acetabular-based impingement, which is called a pincer impingement, which is a central compartment problem, and the most common type of impingement is a combination of both CAM and pincer. Femoral-based or CAM impingement has a three-to-one male-to-female ratio. This is caused from asperity of the head or insufficient offset at the head-neck junction. This type of impingement causes loading of the acetabular cartilage and leads to great stress and osteoarthritis within the hip joint. Pincer impingement. Pincer impingement is secondary to a femoral neck producing high stresses against the acetabular rim. Where CAM goes into the joint, pincer is about the neck hitting the acetabulum because either the socket is too deep or retroverted. So what's happening here is the neck is hitting the acetabulum as opposed to the bump hitting the articular cartilage in the central compartment. It causes indirect damage to adjacent cartilage, and it usually pushes against the labrum as opposed to tearing the labrum. Most commonly, again, you'll find CAM and pincer. This is the most common type of impingement. Physical presentation, groin ache, work with flexion activities. The key on the physical examination is that passive external rotation is markedly better than internal rotation, especially in comparison to the opposite hip. X-ray parameters. You can look at depth, coverage, sphericity. In the key here is the alpha angle. Cox and Profunder, again, looks at the depth of the socket as to whether or not this could be a pincer problem. Crossoversign is retroversion as the hip, the anterior and posterior labrum trade positions. Lateral center age angle is used to take a look at whether or not there's instability in the hip joint, and that magical number is around 18 to 20, where hip instability is very significant. Crosstable lateral is important, taking a look at the alpha angle, but by far the most commonly asked test is a 45 degree done view. The 45 degree done view, which is 45 degrees of flexion, neutral rotation and 20 degrees of abduction, allows you to see what's called the alpha angle. The alpha angle is the determining factor as to whether or not the person has a CAM deformity. And here it is. Normally the alpha angle is less than 50 to 55 degrees. And what we do is we look at the sphericity of the head. We draw a line from the center of the circle to the area where the CAM begins, and draw a line down the femoral neck, and that angle is your alpha angle. And we'll talk about that a little bit later on. False profile used, again, to take a look at instability, but also posterior osteoarthritis, and it's done in a standing position at a 65 degree angle between the pelvis and the film. Imaging CT scan is used, but very rarely now, as we do a good job with our MRI and our x-rays. MRI and MRI arthrography is used to take a look at both labral lesions, and it's the best way to evaluate cartilage degeneration of the hip joint. It is your go-to in terms of talking to patients about their osteoarthritis inside their hip joint. Femoral acetabulum impingement on the MRI is very easy. You want to do so on the oblique coronal images, and again, you want to draw a line down the shaft. You want to make a perfect circle, and then you want to come out with a line as to where the bump is on the bone, creating your alpha angle. Again, greater than 55 degrees is significant for a CAM-type impingement. Joint space width is important on the test questions, as we know, as we have longer-term outcomes from hip arthroscopy, that a loss of articular cartilage on standing x-rays increase the incidence of failed hip arthroscopy results. Again, this is the tonus classification, where you're looking at changes within the hip joint, sclerosis, narrowing, cyst formation. Anything more than a tonus 2 begins to increase your risk of osteoarthritis. FAI management, the labral tear is a sign of the underlying problem. It is not the problem. In general, you need to treat the bony disorder to take care of the patient with FAI. This can be done either open or arthroscopic, and the goal is to resect the impinging tissue and repair or debride the labrum. Failure to address bony impingement are the key factors in unsuccessful hip arthroscopy. Disordered management is done with a surgical dislocation and arthrotomy. Its advantages is it's easy access to all structures. Its disadvantage is highly invasive and the risk of AVN. Arthroscopic management is minimally invasive. Disadvantage is it's more technically difficult to perform, and you need to have a dynamic assessment while you're in the OR. Again, for CAM, what you do is a resection osteoplasty. For a pincer lesion, you want to do an acetabular trimming to get rid of the retroversion. Results of FAI vary depending upon the procedure. Pain relief is dependent on the preexisting damage in the joint. Survivorship, again, with osteoarthritis is significantly increased. So again, that's a tonus classification of two or more. Because as hip arthroscopists, we haven't found enough impingements to operate on, we came up with more impingements. This question can be asked, and this has to deal with ischiofemoral impingement, or impingement between the ischio area of the pelvis and the lesser troch. And normally the sciatic nerve is commonly effective. That's the distance between the lesser troch and the ischium, which is normally 20 millimeters. The key test question is, on an MRI, there is abnormal signal intensity in the quadratus femoris. AIS, or subspine impingement, is impingement between the AIS and the femoral neck. This is associated with young people having AIS, avulsion injuries. And the direct head of the rectus tendon has a broad insertion on this, and that area provides an area for surgical decompression. So the treatment here is to decompress the AIS. Complications of hip arthroscopy has a rate of 1.3, but 7.4. Iatric joint injuries are a result of your portal placement, which is a very commonly asked question. Traction is the most common injury to cause a nerve injury. Iatric joint damage, although not reported as being very high, as a guy who's been doing hip arthroscopy for 20 years, it is the thing which causes, is the most common complication. Reshaping, avascular necrosis, femoral neck. You do not want to resect more than 30% of the bone that has been caused to increase risk of fracture. And finally, hip instability postoperatively is a result of excessive iliofemoral leg cutting. So questions? What two structures are at risk for anterior portal? Anterior. This is the one that's off the AIIS, okay? Lateral femoral cutaneous nerve and femoral vessels. How about the anterior lateral portal? Anterior gluteal nerve and the lateral femoral cutaneous nerve. Forty-five-year-old executive concerned that he has scrotal numbness following hip arthroscopy for removal of loose bodies. What is the most likely cause of this complication? Most likely cause of all of these nerve complications after hip arthroscopy is pudendal nerve secondary to traction. Twenty-five-year-old triathlete has catching and popping in the left hip that is preventing him from running comfortably. Examination reveals a painful range of motion with mechanical symptoms of catching. Which of the following is the best indication for hip arthroscopy? The best indication for hip arthroscopy are loose bodies. Twenty-four-year-old professional squash player presents with persistent right inguinal pain and clicking after an episode of lunging for a backhand. The plain x-rays are unremarkable. The MRI reveals a labral tear. He has failed three months of conservative care. What is the most appropriate treatment plan? Again, debridement or repair is going to be on there. Hip arthroscopy with that. A forty-five-year-old male is considering hip arthroscopy for painful clicking which occurs while swimming and walking. Which of the following is a relative contraindication to hip arthroscopy in this patient? Relative contraindications. Osteonecrosis is a major complication. Positive impingement sign is not a complication. Previous overinduction into a fixation of femoral head fracture is not. Synovial chondromatosis is not. But a lack of being able to get into the hip joint is key. You need to have more than 90 degrees to get into that hip joint. The NFAI, what is the usual location of labral injury? Again, it's where it's widest and thickest and is most commonly coming in contact with a CAM lesion. It's anterior superior. During hip arthroscopy, the sciatic nerve is most at risk during which portal technique? Sciatic nerve is posterior. So now the question is whether or not it's in an internal, neutral, or an external rotated position. And it's done with limb and external rotation. Complications from hip arthrosomy are most commonly related to which of the following? The use of traction. Question 48. A 29-year-old male undergoes hip arthroscopy using three portals shown in figure A. Postoperatively develops numbness in the distribution in yellow. The complication most likely caused by which of the following? Okay, so I'm looking at this. Pudendal nerve. I don't think there's, you know, could be a cause of inflammation but not from a portal. Femoral nerve. No. Lateral femoral cutaneous nerve was huge in my discussion. Common peroneal nerve. Three branches of sciatic. Could be. Okay. Here's the area of description, which is the lateral femoral cutaneous nerve. Therefore, injury to the lateral femoral cutaneous nerve from portal A. The zona orbicularis is an arthroscopic landmark for access to which of the following structures? So the zona orbicularis is anteriorly, and we make an anterior incision to get to one structure to try to do releases, and that's the psoas tendon. So that incision is made between the anterior labrum and the capsule, which is the zona orbicularis. A 20-year-old collegiate ice hockey player complains of insidious onset of right groin pain and stiffness. He reports increasing pain with ice skating. Physical examination has a hip flexion of 100 degrees compared to the right, which is 115. His internal rotation is 5 compared to the other side, which is 20. He's got pain with flexion, adduction, and internal rotation. X-rays figures are in 1 and 2. What radiographic parameter is most commonly associated with cartilage delamination injury of the hip? Okay, so here's his hip. He has a bump here. Increased alpha angle, which is a peripheral compartment problem, which is a cam deformity causing cartilage delamination. So you want to look at alpha angle. Issue of femoral impingement causes injury to what muscle found in the hip? Quadratus femoris, which is the most commonly effective nerve in ischiofemoral impingement. So posteriorly, sciatic nerve. I know that I'm doing a pretty good job because I'm like reading everybody's mouth that said sciatic nerve. So you know now everything you need to know about ischiofemoral impingement. A 34-year-old weekend warrior presents to your office with a five-month history of worsening right groin pain. Pain is worse with sitting. He's been referred to you after seeing a non-operative sports medicine doc who obtained x-rays and an MRI orthogram. The previation has undergone physical therapy, has had an inter-articular injection with some relief, still continues to have mechanical symptoms. Physical examination shows reproducible pain with flexion, adduction, and internal rotation fader sign. What is the best preoperative predictor of early failure following the hip arthroscopy? Again, it's all about the tone of scores, the amount of osteoarthritis before going in. The incidence of CAM impingement in young male patients versus young female patients, three to one. The radiographic view obtained with a standing radiograph at an angle of 65 degrees between the pelvis and the film is a false profile. So you have more questions in your book. I thank you very, very much. Things about the test so that you know, and Chris is going to talk about these as well, make sure you do a good job of timing yourself. There's a little red thing that goes on the bottom that tells you how quickly you need to do. But the common thing is you get caught up with your questions and you don't pay attention to that. So pay attention to your timing. By far that was the only thing I had problems with. This course does a phenomenal job, Dr. Kading and Dr. Gill have done a great job of recruiting people to speak here. You know everything you need to know about that sports section. So good luck everybody. Any questions, please find me afterwards. Thank you.

hip arthroscopy

femoral acetabular impingement

FAI

labral tears

soft tissue injuries

nerve entrapment syndromes

piriformis syndrome

hip pathologies

imaging techniques