Hi, welcome back to the third night of our AOSSM virtual fellows course. I'm here together with my co-chairs, Brian Forsythe from Rush and Lutul Faro from Cleveland Clinic. I'm also with Meredith Herzog from the AOSSM. So I just want to take this opportunity and thank all three of you for a wonderful collaboration on this. I personally had a lot of fun these last two nights. I hope all of you on the line had fun too. We already have more than a hundred people online, so welcome back. I especially have to admit I enjoyed late night surgery, I'm not used to that. So that was cool last night with the Latage that we did and the UCL, very, very cool stuff. So we have another super lineup for you today. I think it's going to be maybe the most exciting of all three days. And so we have Adam Antz today talk about biologics and we'll hear about hip orthopedic injuries from Mark Safran. We'll have some life surgery from Shane Ngo and then later talk about practice, interviewing and how to find a job. So you definitely want to tune in for that one at around 8.30 Eastern Standard Time. I'd also want to just quickly and honestly thank our sponsors. So Arthrex, Smith & Nephew and Striker helped us put this outstanding first ever virtual AOSSM course together. And please follow us on Twitter and all the other social media outlets. You can hashtag AOSSM fellows, put some fun slides up and get some action going. And of course, this is LinkedIn and Instagram and all the other sites. Please don't be shy and submit a question. It would be much more fun, of course, if you could do this all live, but unfortunately we can't. But we will answer all your questions if possible. So just bounce questions over. It's a lot of fun for us to see that people are engaged. So especially when it comes to the contracts, I think you'll have plenty of questions. Let me also just thank again, Mike Ciccotti, our president. And you've heard yesterday from past presidents, Dr. Inderlikado, Dr. Amendola. So this is a really high powered course and thank you for all your support. So without further ado, we'll now have Adam Antz from the Andrews Institute for Orthopedics in Gulf Breeze talk about biologics and emerging applications. This is really a highlight over the last four years we've run this course. And then after that, Mark Safran, who is professor and chief of sports medicine at Stanford. And he'll talk about management of common hip orthopedic injuries. So sit back, enjoy and send us questions. Any intros also from Brian and Lutul? It's good to see you all back tonight. I think it'll be a lot of fun. I just would encourage all of you to be engaged. The more questions we get, the more fun it is for everybody. So just bear that in mind. Thank you. Yeah, this has been fantastic. It's been great to be a part of this. Thanks, Meredith and the AV crew. And thanks for all of our presenters. This has been a world class conference and hopefully you all enjoyed it. OK, with that, thanks. And let's begin. All right, good afternoon. Today, we're going to discuss biologics and emerging applications in sports medicine. I always like to throw this in as where are we today? Because it seems like this space is constantly evolving. And at times, it seems that we're throwing spaghetti at a wall. And we try to learn, but it seems like we step on our own feet in the process. Because we're not asking perfect questions or we're not thinking about it clinically and applying it in a methodical fashion. To really make progress in this space, we got to think about this like building a pyramid. And what I mean by that is you have to understand that with development come steps. And those steps start with a benchtop and animal level asking questions and proving concepts. And then developing them through phased clinical application. First, proving safety in small cohorts, then proving efficacy with comparative studies, and then proving reproducibility with multi-center study. And with this process, you have some players in this space that have proven themselves, platelet-rich plasma being one of them. And some of these players that are trying to prove themselves but haven't quite turned the corner. And there's many products out there that we think have value. And they're in this process at some level. And then there is others that are appearing on the scene and you're getting buzz about, but are still way down at the base of the pyramid. So as you're approached with these products and approach with applications, think about where they are on this pyramid. Ask yourself, do they have clear value? And then consider how to apply them in your practice. I want to focus on platelet-rich plasma and bone marrow aspirate today because they have the most evidence that helps us understand how they can be applicable to our populations. We've been interested in a couple different subjects on here, hemipoietic cells, optimizing harvest, blood flow restriction therapy, and also applying these to the ACL. And I'll share with you some of our progress on these fronts, and then hopefully make some thoughts that stick for you. Now, I want to start with products for knee arthritis, because this space has the most evidence to really get some ideas and principles down. The first principle to understand is that when we think about these products, think about your immune system and how your immune system is constantly, basically watching you as an ecosystem, responding to insults, whether they be injury results or just stress of some sort, helping you adapt to that insult, and then helping you restore homeostasis as an ecosystem. And so your components of your peripheral blood and your bone marrow are part of this system. And they are parts that are activated in certain instances, and then turned down in other instances. And these are the elements, the blood and the bone marrow that we deal with as orthopedic surgeons every day. And then this tissue inflammation, proliferation, attempted repair, healing response, remodeling curve is sometimes what we are trying to initiate, and then other times trying to turn off. And so understanding those principles is the basis for thinking about these tissues. Now, I want to use osteoarthritis as an example, because it's something that as doctors and as sports medicine surgeons, we interact with, whether it be some patients that we're trying to help stay active in their later years, or whether it be dealing with post-traumatic knee array. And we know that there's the mechanical things that we see on our x-rays and also on our MRIs, but there's also the biochemistry of the equation too. And things that we can help such as alignment, and think about this as a joint, and also understanding that it's going through change. And sometimes if you help them through periods of change, the bones remodel, the tissues remodel, and the ecosystem adapts. So things that can help in your toolbox include changing alignment, or even just unloading the joint for a period of time. So for instance, if you have someone who's varus and they have an acute change like a meniscus injury, if you unload that joint for a period of time, and then also help it adapt with some of these technologies, then you can help them through this period. So don't always just think with your carpentry brain, also think with your gardening brain too, and your biochemical brain, knowing that it's an imbalance of these enzymes within the joint. And if we can restore homeostasis, then you can affect change. So with this, let's talk about platelet-rich plasma. And platelet-rich plasma is a point-of-care blood product, i.e. at the point-of-care, you are creating a blood product, and you're using two principles. One, if you centrifuge a liquid that has multiple components, it will layer out based upon the weight of what's in that fluid. And then second, if you select a certain element of what's layered out, you can create a product. So for instance, if you take this blood sample, and you wanted to create a leukocyte-rich, platelet-rich plasma, you could do a hard spin, a long spin, say in this device, and you would get it to layer out based upon what's in the actual blood. And then if you selected out the Buffy coat, you would get a solution that has a lot of platelets in it, and some white blood cells, and not a large volume. And that's the basis for Buffy coat-based systems that can create a leukocyte-rich PRP. Alternatively, say you wanted to create a leukocyte-poor PRP, you could do a shorter spin, and with that shorter spin, you would get what people call a soft stack. And the plasma and platelets are suspended within that top layer. And then at the bottom layer, you get the red blood cell stack. And by selecting that top layer, you get the basis for plasma-based PRPs. So understanding those two principles helps you understand all the different products out there, and potentially how they all work. And it's all kind of a different assortment of those principles, and then the techniques of each disposable. Now, there's plenty in vitro studies to support the use of these point-of-care blood products for knee arthritis. Studies have shown that you can proliferate cartilage cells in culture. You can turn down the production of MMPs or some of these inflammatory proteins that are caustic to the joint and cartilage. And you can have an anti-inflammatory effect upon gene expression in the cartilage cells and the lining cells. When we think about clinically, how is it performed, you have to break up these products into what they are. And when you first just look at, say, the leukocyte-rich Buffy Coat-based systems out there, there's variability in how they performed in the literature. These were the early studies, level one and two evidence that showed some variability, and these were predominantly the leukocyte-rich PRPs. Now, as you think about the plasma-based leukocyte-poor PRPs, they've consistently outperformed placebo and hyaluronic acid in head-to-head studies. And there's systematic reviews and meta-analysis, and even systematic reviews of meta-analysis to suggest that leukocyte-poor PRP has a role in this space. With that in mind, also, we need to think about one very common clinical question is, do we need one injection of PRP or do we need multiple injections of PRP? And we think about those eight studies that I just showed you around leukocyte-poor PRP, six of those eight were a series of three. So it seems that clinically, most times, people are applying a series of three because they want to compare to hyaluronic acid. Now, when we ask this clinical question, this is a study that's helped me give real meat to a recommendation. This was a study in guinea pigs, comparing one injection to three injections at three and six months. And what the authors did is they looked at the synovium and the cartilage, and with the synovial scores, they saw that there was a disease modification at just the three-month time point with the one injection. However, with the three-injection series, that improvement sustained out to six months, whereas it did not sustain in the one injection. And similarly, with cartilage scores, the disease modification was different at the three-month time point for the one injection. However, that did not sustain to six months, whereas with the three-injection series, it did. So it would appear that a three-injection series is more effective at disease modification than just a series of one. And that's something that helps you as you talk to patients. Another concept that's emerging is injecting bone with some of these biologics. This was a study published in 2018, comparing intraosseous plus intraarticular PRP compared to intraarticular PRP alone compared to hyaluronic acid. And the scores were best in the intraosseous combined with the intraarticular group. A second study looking at the same question in 60 patients randomized intraosseous and intraarticular compared to intraarticular, and the intraosseous and intraarticular outperformed the intraarticular alone. So remember that the joint is an organ as a whole, and in some instances, address the bone in addition to the joint. So let's think about bone marrow aspirate because bone marrow aspirate is something that everybody wants to use for NeoA because we know that there are cells with stem potential in bone marrow, meaning there is a population of cells in bone marrow that have the ability to self-renew and to differentiate. And then also more naturally, these cells monitor you, and then in settings of injury, such as in this wound in a zebrafish, become activated. They mobilize and have activation-release exosomes. And so we know that there are cells with stem potential around blood vessels and fat. We know that there are cells with stem potential within your bloodstream and within your bone marrow. And managing these cells and getting them into the game is the idea behind utilizing these technologies. So when we think about bone marrow aspirate, it's those same two principles. We take a bone marrow aspirate, we do a long spin on it, and then by taking the Buffy coat, we can get a bone marrow aspirate concentrate. And the cells with stem potential are likely at the top of that Buffy coat, the monocytes, as opposed to the neutrophils, which are more associated with the red blood cell layer. In terms of clinical application, bone marrow aspirate has a couple studies out there to review. This one from 2016 with Shapiro, 25 patients, bilateral NeoA. One knee gets 15 cc's of bone marrow aspirate concentrate. The other knee gets saline. And there was no difference in VAS, or this intermittent constant osteoarthritis pain questionnaire at three and six months. We performed a similar study, only we took 90 patients, and we divided them into patients who were going to get a monocyte-rich, platelet-rich plasma, seven ml volume product, versus bone marrow aspirate concentrate. And we used WOMAC and IKDC. And at six and 12 month data, we saw no difference between the two treatment arms. And we've walked this out to 24 months, and we're preparing a manuscript, we've seen no difference at 24 months either. And so perhaps we need to learn more about bone marrow aspirate concentrate, and perhaps how we harvest is the better question in terms of just throwing out bone marrow aspirate with the bath water. Now lipoaspirate is something that's of interest too, because we know there are cells with stem capability around adipose blood vessels. And the first studies that got us interested in this were from basically people doing liposuction, processing it with collagenase in a clean room, and then just injecting it after knee arthroscopy. Encouraging two-year data and co-study, and then this other case series in 10 patients, fat process with the collagenase with encouraging two-year data. Centeno published a cohort comparison of bone marrow concentrate versus bone marrow aspirate concentrate plus a minimally processed adipose graft with encouraging 10-month data, but no difference between the groups. And in addition to the lipoaspirate plus collagenase products out there, there's also micronized fat that's appearing on the scene too, where you can do a liposuction, then you can morselize it with ball bearings in a closed-loop system. However, there hasn't been any clear evidence around this product either. This was presented on podium at ICRS this past year, randomized controlled trial in 50 patients, and one injection of this product compared to the three-injection series of PRP with HA, showing no difference at six and 12 months. A similar study also at ICRS, randomized controlled trial in 118 patients, one injection of micronized fat compared to one injection of PRP with no difference between groups at six months. In addition, the Amnion products are out there. They have two studies from an animal model and some more around the animal model suggesting some mechanisms of action. This case series in six patients which showed a safety study, no significant difference in blood clouds, however, a small but statistically significant increase in IgG and IgE. This randomized controlled trial by Gamal and Pharr has shown that it is superior to HA and saline, and it'll be interesting to see where this goes in terms of repeat injections, considering that small but statistical IgG and IgE increase in the safety study. So in conclusion, for these products around osteoarthritis, we have to understand mechanisms better and consider what the immune system does naturally. PRP has a pyramid of evidence to support, and these other products need to develop themselves further and prove themselves. And think about this like a pyramid, and don't let the tail wag the dog in this space, and think about where all these products are before you let them kind of invade what you do, and then wait to see the evidence before you really move with them. So that was really about osteoarthritis and some of the products that we're always approached with. I wanna switch gears and tell you about optimizing harvest, because when we did this study, we were saying to ourself, well, maybe it's us. We're not really getting the best harvest, because it was a cohort that was average age 55, and we've really listened to all the different ways to optimize harvest, and we've been trying to crack this code, not throwing the baby out with the bathwater. When you look at the literature, it's true that you can get these cells from the proximal humerus. It's true that you can get them from the distal femur. The trauma literature suggests that the crest outperforms peripheral sites, and that the anterior, I'm sorry, the posterior crest outperforms the anterior crest. However, as we moved into the clinical practice, we also looked at Hernigo and saying that you should use smaller syringes. You need a pretty good vacuum. You need to do several small portions and small aspirate volumes, and don't draw more than five NLs in any one space, and that a divergent vector aspiration is just as good as parallel aspiration. So we've been looking at this, and when we moved into our ORs, because we wanted to augment our surgical procedures, we kind of went around the block, and we really landed back on posterior iliac crest, and the reason being is that you would think that it's gonna be quicker to get it from the ASIS or from the distal femur. However, this is very reproducible to just turn them in the lateral cubist position, to palpate out the PSIS, and really when you get that perfect vector, you get a nice downhill flow, and remember fluid dynamics. This is a viscous fluid, and if you're trying to horse it up a column of air through a narrow syringe, it's a lot like trying to drink a milkshake with a narrow straw up a column of air. If you fight the column of air, it makes your life harder, whereas if you use it to your advantage, it makes it easier. So we looked at some of our data, and what we found is that with distal femur harvest, we just weren't getting consistent growth, and even with anterior crest, we were getting better growth, but we weren't getting consistent growth, and then when we moved to posterior superior iliac spine, we started to get the most consistent growth, and so that has really changed clinically how we do this, and I really advocate for just turn them in the lateral cubist position, and you're gonna spend less time with your harvest because you can do it quicker versus trying to do it from the anterior crest or one of these peripheral sites. With that in mind, we've also thought about other ways to optimize harvest, supercharging PRP, if you will. We did this study with our colleagues in Naples, a human exercise model, 20 subjects, 20 minutes of vigorous exercise, looking at the blood and blood products. We saw that we could consistently manipulate these products with exercise, meaning both products, the Puffy Coat-based and the Plasma-Bose had higher platelets with exercise, and also the Buffy Coat-based had a higher volume and a higher concentration of cells with what are labeled as hemopoietic stem cells, so that's something we published recently in arthroscopy. We also wanted to think not only about exercise-mobilized PRP, which had a nice ring to it, what about neupogen-mobilized PRP? Neupogen is a synthetic form of a naturally occurring hormone that causes your bone marrow to make more of these cells and to release them to the peripheral circulation, so we thought, what if we gave them neupogen and then just took their blood and processed it at the point of care? We did this study with our colleagues, helped with the ones from Naples as well as with our colleagues at Auburn University, 10 subjects, on day one, we did a bone marrow aspirate, on day 30, we gave them neupogen for four days, then we processed it with an angel, and what we found was a pretty cellular product, a product after neupogen, just as cellular as the bone marrow aspirate concentrate. We found hemipoietic progenitor cells that were more proliferant in our neupogen product. Now, when we went to grow them, they didn't quite grow the colonies with the neupogen, meaning, of course, when you try and grow colonies with PRP, you don't get much of anything. When you use bone marrow aspirate, you get some good growth and they tend to start looking like fibroblasts, but with the neupogen product, we didn't get what you would typically get from bone marrow. We got things that were more consistent with white blood cell colonies, cells that looked like they were more like monocytes, cells dividing, of course, but then markers that were more consistent with white blood cells and cells that are typically known as monocytes. And that really got us thinking about monocytes, too, because we've also been thinking about monocytes in terms of giving people neupogen and collecting with apheresis for a long time as a possible cell source, too, because you can give people neupogen, you can collect, through apheresis, a whole lot of monocytes. And so we've been looking at using these to augment cartilage repair through a clinical trial since 2017. And that trial is maturing and showing some pretty cool results in terms of the ability to regrow cartilage that's more natural. But we've also started to ask how much gains do these cells have? And this is something we've been doing down at our site. We've been looking at proliferative potential of these cells and we've also been looking at the ability to differentiate these cells. And we can take monocytes and get them to reproduce in culture. We also get them to differentiate to cells of all three cell lines, chondrocytes, adipocytes, and osteocytes. But we also can get these cells to also differentiate into cells of the endoderm and the ectoderm layer as well, which means that monocytes, in certain settings, are more pluripotent than multipotent. And it's a good cell source that needs further development and that's an exciting thing. So when you think about all these products and you think about the white blood cells, remember, not all white blood cells are the same and some have more stem potential than others. We've also been looking at blood flow restriction therapy. I'll go quickly through this. We know that it's shown up in our training rooms. It's in our PT clinics. There's many systems out there, but the bottom line is it's always been advocated as a growth hormone spiking process through the release of lactic acid. But we wanted to ask the question, is it also causing a systemic release of cells? So we took 10 subjects, used this Delphi system, did a control session with no BFR and an intervention session with BFR. And what we found was a lactic acid spike that you would expect, but then also a spike of white blood cells. And these had cells that were markers for CD34 or these hemipoietic stem cells, a lot of monocytes. So that's kind of interesting too, because you may be able to use BFR not only to help your patients recover, but then also to think about some of these point-of-care blood products too. So we always have to understand these mechanisms better, consider what the immune system does naturally, exercise and stress can be used to change your PRP. So can filberstum. At this point, BFR causes a systemic response. I don't have enough time to go into what we're doing with augmenting the ACL reconstruction. So if you wanna know more about this, just reach out to me or my partner, Steve Jordan, as we're doing this study that's been pretty exciting too. And I'll end right there. And thank you for your opportunity to speak to you today. Hi, my name is Mark Safran. I'm the Chief of Sports Medicine at Stanford University. And I'll be talking about the evaluation and management of common hip injuries. I wanna thank Latul, Volker, and Brian for inviting me to give this talk. These are my potential conflicts of interest that really don't have anything to do with this talk. Now, hip injuries are being increasingly diagnosed. And the question is, are they occurring more frequently? Are we just more aware of them? Certainly learning about new problems such as femorisci tabular impingement and hip micro instability, as well as things like MRI and hip arthroscopy have increased our interest in this area. My plan today will be to give you an overview of the most common diagnoses that you'll see as a team physician, particularly intraarticular problems like FAI and micro instability. We'll talk about the core muscle injury or sports hernia and osteitis pubis, adductor injuries, hip dislocations, and stress fractures. There's a lot more to cover, but I won't be going over avulsion fractures, hip pointers, gluten meat tears, hamstring injuries, or iliopsoas problems to suggest not enough time to go over all of these things. So why is this important? Well, the hip is very important for performance. Here's Willie Mays Hayes from the movie, Major Leagues. And you can see he's loosening up his hips before he bats. And athletes will tell you, it's important to have loose hips and strong hips for performance as it's important in the kinetic chain. An example of this, as you can see this former professional basketball player trying to play golf, not using his hips appropriately and not using the kinetic chain appropriately to hit the ball. Whereas if you look at this professional golfer, you can see the hips are really where all the lightning comes from, all the energy to be able to hit the ball well. So the hips are important in sports. You require an increased range of motion and take the hips through the extremes of motion in sporting events. And in doing so, it puts the labor at risk, particularly if you have the anatomy of FAI or if you have hip dysplasia. So when we talk about FAI, FAI is impingement of the femoral head neck junction against the acetabulum. Generally classically described as an internal rotation, but the more you flex the hip, the less internal rotation necessary. And when you adduct the hip, less internal rotation is necessary to cause the impingement. But based on where you have the femoral head neck offset loss or the acetabular overcoverage, you can also impinge in other positions such as extension or abduction. So this is from Gans originally. And when you look at the anatomy of the hip, pincer impingement is really acetabular overcoverage relative to the normal acetabulum. CAM impingement is loss of femoral head neck offset compared to the normal offset, which can be up to about one centimeter. But the majority of patients have some combination of the two. When we talk about CAM impingement, you'll see that with the loss of femoral head neck offset, it does not go underneath the acetabulum. So you start to abut against the edge of the acetabulum, causing a labral chondral separation and articular cartilage softening delamination and injury, usually in the anterior superior aspect of the acetabulum. Pincer, on the other hand, where the acetabulum is overcovering, you get crushing of the labrum and some articular cartilage damage, but not as much. You can see some notching in the femoral head neck junction, as you see here as a clue. The labrum itself gets crushed, you get some articular cartilage damage. But as you continue to lever on the acetabulum, you can get this so-called contracoup injury. So you have a more diffuse articular cartilage and a labral injury on the acetabulum if you look at it as a clock face. So a patient with FAI will generally complain of pain in this area. We've talked about his groin pain, but it's really in the inguinal region. They oftentimes will complain of difficulty putting on their socks and shoes. They say it's worse with activities, as well as with prolonged sitting, as we see with our computer programmers in this area. They have pain squatting, cutting, pivoting, and sudden stops and starts, pain going upstairs, or they may just say they have limited range of motion and pain in their hip. We talked about the impingement test. You flex the hip to 90 degrees, you adduct and you internally rotate, and that can cause pain in the hip. But it is not pathognomonic for impingement. Other intraarticular sources of pain can cause pain with the impingement test. The labral stress test, we flex the hip, we go into abduction, external rotation, and we internally rotate and extend. And you can also further externally rotate, abduct, and extend. And that is more like a McMurray's test for the meniscus, trying to catch the labrum as you try to do this labral stress test, or also known as scour maneuver. Good radiographs are important in the evaluation of patients with FAI and hip pain. You want to make sure that the coccyx is centered one to three centimeters over the pubic symphysis, and the obturator or foramen are symmetric. In doing so, you can look at the anterior and posterior walls of the acetabulum and looking for the so-called crossing sign. You can see how out of round the femoral head is looking for a CAM lesion. You can see os acetabuli, or rim stress fractures. You can look at the caudaloid fossa floor, relative to the ilio-istral line to look for coccyx profunda or protrusio. You want to get a good lateral radiograph. I like to do cross-table laterals because they're easier. Here you can see the CAM lesion, but it also shows you the posterior aspect of the acetabulum. Frog laterals and dumb laterals are not true laterals of the acetabulum, so you can't get a full view of what's going on. You can get a false profile view, and that can be helpful as well. MRI can be helpful in making the diagnosis here. You can see a CAM lesion. You can see the labrum is not a triangular shape. It's more round, suggestive of an injury. But here you also see a labral chondral separation. You can see some articular cartilage damage. And here you even see that notch in the head-neck junction consistent with the pincer impingement. So this patient has combined FAI. MRIs also can show you the so-called PITS pit, which is a herniation pit. You see it in about a third of patients with FAI. When I do an MR, I like to do an MR arthrogram as that improves the sensitivity of labral tears. Here you see a labral chondral separation. I like to add anesthetic with the contrast that they give to see if it relieves their pain. And that's, as we'll discuss, 70 to 80% of adults have labral tears, even in spite of being asymptomatic. MRIs have poor sensitivity for detecting chondral injuries, so you need to be aware of that as well. And when reviewing the MRI in patients, again, as opposed to the shoulder where the capsule attaches to the labrum, the capsule does not attach to the labrum. It attaches directly to the acetabulum. So there's a cleft between the labrum and the capsule. That is normal. What you look for are things like this, a labral chondral separation here on the sagittal and on the saxial views. You can also see intrasubstance labral damage. But again, remember, 70 to 80% of asymptomatic adults may have a labral tear on MRI, so don't just operate based on an MRI. When we look at CAM lesions, we try to quantify in the so-called alpha angles aligned from the center of the head to where the head comes outside of the sphere and join that to align from the center of the head to the center of the neck. That's the so-called alpha angle. Less than 50 or 55 is normal, so greater alpha angles are consistent with CAM impingement. There's a high inter-observer reliability on this. So 3D CT scans I find to be very helpful because not all CAM lesions are the same, but it shows the anatomy better, particularly in post-surgical patients, I find this to be helpful. Also be aware, there's a thing called subspinous impingement where the AIIS might be elongated either from injury or just from repetitive uses in youth. This was a soccer player, he's 17 years old, complaining of hip pain, had a small CAM lesion. His main issue was that the AIIS on his dominant leg stuck out further, and I think that was causing the impingement. So when you have a patient with impingement, you want to treat not just the bony issues, but also the soft tissue issue. So the labrum, you can do a partial labrectomy or a labral repair. The CAM lesion, you can do the CAM resection or restore the femoral head-neck offset. You can do a pincer resection or acetabuloplasty. And then for articular cartilage damage, you can do just a breed mod and or a microfracture. So this is a patient intraoperative fluoro with a CAM lesion. You can see pre and post-op on the AP view. And then the same thing on the lateral view, a large CAM lesion that we resected. Now the core muscle injury or sports hernia tends to occur in males, but you can get it in females much less frequently. You generally see it in elite athletes, but football players, hockey players, soccer, and tennis. They get pain with exertion and with adduction type of maneuvers. They may complain of lower abdominal pain. They may complain of adductor pain. They may have pain with valsalva, but usually not. And the pain may radiate to the testicle, inner thigh, or lower abdomen. And I think this is associated with FAI, which is why I put it here. Generally, when you run, you flex, you adduct, you internally rotate. That's part of normal running mechanics. if you have a normal offset of the femoral head-neck junction and normal offset of the acetabulum, you can maintain a good stride and good clearance. But if you have loss of that offset of the femoral head-neck junction or overcoverage of the acetabulum, you either have to shorten your stride or you try to make that motion up somewhere else. And that can lead to motion at the pubic symphysis, that can lead to osteitis pubis, or I think the muscles that are crossing that area might be trying to stabilize it and can get injured. And that's where I think your sports hernia or muscle injury may occur. Alternatively, you can get pain at the SI joint. So low back pain at the SI joint is also common in patients with FAI. And then lastly, the most mobile joint upstream from the hip is the low back. And you can see a lot of individuals with low back pain as a result of facet irritation or even herniated discs. And seeing young athletes with herniated discs and FAI is not uncommon. Patrick Birmingham did a study looking at FAI and seeing the motion at the pubic symphysis and at the SI joint. And you can see that there is motion at those with CAM impingement. So when I assess people with FAI, we check for adductor pain and strength, both in extension as well as inflection. Obviously, I do this also for adductor strains. And so that's the way I like to test the strength. But then I like to do the so-called Hesselbach's maneuver. So I feel the lateral edge of the rectus as it inserts into the pubis. And then I have the patient do a sit-up with my hand there, and that oftentimes will reproduce the pain. So again, along the lateral edge of the rectus, and they do the sit-up. Alternatively, a resistant sit-up test can also elicit the pain of a so-called sports hernia. MRIs can be helpful, but they have to be specific to look for sports hernia protocol. And you can oftentimes see these pubic cleft injuries where the muscles of the lower abdomen and or adductors attach at the pubic plate. The treatment for sports hernia, generally, we start with core rehab exercises. It's less than 50% successful, but obviously, they can get back most quickly. I think adjuncts with injection can be helpful. We like to use cortisone. Some people have tried PRP, but there's reports out there of possible heterotopic ossification of the tissues associated with the PRP injection. So that's really in doubt at this point. You can do, if this doesn't work, then surgery can help with these. Unfortunately, there's a lot of different surgical approaches that have been tried. They all seem to be relatively beneficial, except probably mesh does not seem to be as beneficial. Again, you see combined cases of osteitis pubis or a core muscle injury with FAI. This is a so-called crossing sign on this young athlete. Osteitis pubis is inflammation of the pubic symphysis. It's usually related to mechanical strain. Something as trauma or abnormal motion or sheer stresses that can cause this. You may see pubic instability with this. But again, I think the motion from FAI is why this may be associated. And again, commonly seen in sports like soccer, football, and ice hockey in males, same group that you're going to see your core muscle injury in. Again, they're 0.10 to right over the pubic symphysis. You may have pain with doing resistive straight leg raise or adduction maneuvers, and also with compression of the pelvis, as you see here, doing a sideline compression test. Bone scans have pretty much gone away from in use. We generally get MRIs that show edema in this area, both in the bone and the pubic symphysis. But it also shows you other structures, again, like the core muscle injury. The natural history is that this is relatively self-limited. The treatment is rest and core strengthening. You can try an injection of steroids in the pubic symphysis. I find this to be very beneficial in getting athletes back in the season. As far as surgery is concerned, I'd be a little bit careful with that. You can do a resection of the pubic symphysis that can be done open or through the scope, as seen here. This is a Dean Matsuda picture doing an endoscopic pubic symphysectomy fusion I would be very concerned about. Some people do try this, but it does put more load on the SI joint and might cause some issues there. Moving on to adductor strains. Again, this is in that spectrum. It's one of the most common hip injuries, certainly one of the most common injuries in the hip in soccer and hockey, but we also see it a lot in tennis. It can be partial or complete injuries. And the treatment in all is based on the level of the athlete, the type of sport, and how they use their leg. We realize the adductor is the only muscle that's completely active via EMG throughout the running phases or walking phases, and that's why this is such a critical injury. Moving on to the treatment of partial adductor strains, as I showed you how I test for strength, the treatment is conservative management starting with rest, non-steroidals, and physical therapy. I think ultrasound-guided injections into the insertion site, particularly with some cortisone, can be very beneficial. Again, the role of PRP is in question because of the risk of potential HO. In high-level athletes, Ernest Shilders in London showed that if there's no MRI evidence of enthesopathy, partial adductor strain patients do well with this treatment. For recreational athletes, you can do the injection, and it'll do well whether or not you have enthesopathy or not. If they fail rehab and get a chronic adductor enthesopathy, then the treatment is an adductor tenonomy or partial lengthening, as you would cut just the tendon but leave the muscle still attached. It's about two to three centimeters distal to its insertion into the pelvis. Shilders showed that 42 of 43 athletes were able to return to their pre-injury level of participation by nine weeks, and that they had exo-pain relief and returned to pre-injury level even in their pro-athletes. If they have a complete adductor tear, there's still a little bit of controversy here. It depends on a lot of factors. One nice study by Ted Schlegel looked at 19 NFL athletes with complete adductor ruptures. 14 were treated non-operatively, five were repaired with suture anchors. They found that all the athletes returned to play in the NFL with or without surgery, and that the people treated non-operatively returned twice as fast as those that had surgery, six weeks versus 12. However, there seems to be a recent enthusiasm for repairing the adductors at this point. Moving on to traumatic instability, here you see this Philadelphia Eagles player being landed on by over 1,000 pounds of athletes. If they land onto the flexed knee, you can dislocate the hip posteriorly, so falling on flexed knee or flexed hip or being piled upon, such as you see in football or rugby, can be the source of a traumatic hip instability. It does seem that there's an increased prevalence of FAI in athletes that have hip dislocations in athletics. And so what you'll see is pathology, you'll see oftentimes chondral damage to the central femoral head, a posterior labral injury or a bony Bankart equivalent, the ligament of teres will be torn, and the iliofemoral ligament will be torn. Oftentimes there's also chondral loss that can result in a loose body, it could be chondral or osteochondral, and that can affect reduction of the hip. So this is an NFL defensive back I took care of that had a reduction of the hip, and you can see that it's not concentrically reduced. You also see this small fleck of bone off the posterior wall. It seems that these posterior flecks, which we're seeing more frequently, do not seem to affect the stability of the hip. If you test the stability of the hip and they're stable, nothing needs to be done about this small posterior fleck. If it's obviously a bigger piece of the posterior wall, or they're unstable, then I think you need to fix it. So here you see this athlete, he also has an iliofemoral ligament injury, but because he was not concentrically reduced, we scoped his hip, you can see large shared off pieces of particular cartilage that come off of the central femoral head. The key to a hip dislocation, you want to reduce these as soon as possible. You want to get a CT scan to rule out loose bodies and confirm concentric reduction of the hip. They're usually on crutches for two to six weeks post reduction. If they're stable, you want to watch for avascular carcosis or chondrolysis, so we'll get an MRI initially as well to see the status of the articular cartilage and bony bruising in the head. And then we'll get another one in about three months. And you can even consider it six months because late ABN has been reported. Again, if they have loose bodies, then we will consider arthroscopy. There's some controversies to whether or not you should try to repair the labor at that time, because the traction does affect blood flow to the hip, and you already have jeopardized blood flow due to the dislocation. This question is whether or not you want to be in there that long to do a repair. Moving on to sports that require laxity or increased range of motion, things like figure skating, gymnastics, dance, and synchronized swimming. These individuals oftentimes have dysplasia or just congenital laxity or hypermobility. It can lead to micro instability about the hip that can lead to labral tears. And so the way I like to assess abduct, extend, externally rotate the hip, and then apply an anteriorly directed force on the greater trochanter. If that causes pain anteriorly, that might be suggestion of anterior micro instability. We found that to be the most accurate test in making this diagnosis with a high sensitivity and specificity. Another test, Bendome described with the patient prone external rotation and an anteriorly directed force on the greater trochanter. If that causes pain anteriorly, it has a low sensitivity, but a very high specificity for the diagnosis of hip instability. And our third best test is using the hyperextension external rotation test with the patient at the end of the table and their hip is extended, you externally rotate it. And if it causes pain anteriorly, there may be instability. As you can see, 70% sensitivity, 85% specificity. If they have two of these tests positive, they have a greater than 95% chance of having a hip instability diagnosed intraoperatively. Don't forget your posterior apprehension test, flexion, adduction, internal rotation. That's also the impingement test, though, but with posteriorly directed force if they hurt posteriorly, you need to worry about posterior apprehension or posterior instability. If they hurt anteriorly, it may just be impingement. You want to assess to make sure they don't have dysplasia looking at their center edge angle, looking at the femoral head neck junction, looking at the femoral head shape and looking to see if there's a so-called crease in the femoral head. And here again, I think a false profile view can help be sure that they don't have anterior undercoverage. We described a so-called cliff sign where if you look at the femoral head, it comes out around and drops off like a so-called cliff. We've seen this both on AP and lateral radiographs on individuals, and it has a high association with hip instability, particularly in women. John Sakia and a group at Michigan looked at the area just lateral to the zone of obicularis on an axial oblique for both the size of this recess, as well as the capsule in this area, and they suggested a recess of greater than five millimeters and a capsule thickness of less than three millimeters associated with instability. We looked at this in our group and didn't find that the joint recess size was associated with instability, but certainly a capsular thickness of less than three millimeters was associated with women with hip instability. Intraoperatively, we also confirm instability by the ease of distractibility, how easy it is to distract the hip, and then after we remove the negative pressure, do they completely reduce or not? So here on the left, you can just see with body weight traction, the femoral head is already displaced from the acetabulum. Then once we applied the traction, we took out the negative intra-articular pressure and then took all the traction off the device, and hip was still somewhat subluxated. Both the first and last pictures are consistent with instability in our practice. Other things that you can find arthroscopically, there's a labral chondral junction tear at straight anteriorly at the three o'clock position or straight laterally at the 12 o'clock position, and then there may be some chondral wear just at the rim of the acetabulum from the femoral head riding, and it's just a small area, either straight anterior or straight laterally. On the femoral head, you'll see chondral damage centrally or a ligamentum teres tear, as you can see in this bottom right. You can also see on the MRI a ligamentum teres tear as a suggestion of instability. Our treatment of instability patients starts with rehab, particularly strengthening of the core and the hip, the iliopsoas and the glutes particularly, and found it 70% successful in patients that have not had surgery that had instability. Alternatively, you can do, if this fails, you can do surgery. For this, Mark Philippon described thermocapsulography, Ben Dome described his so-called inferior capsular shift in patients with borderline dysplasia, and Chris Larson looked at patients with Ehlers-Danlos syndrome where he closed the capsule, and all of these showed greater than 80% good excellent results. I described a procedure called the, what I call the RITCH procedure, the rotator interval closure of the hip. It's taking out a piece of the capsule between the iliofemoral ligament above and blue and the ischiofemoral ligament in the green on the bottom, and then we put some sutures there, and then this allows us to tighten both the iliofemoral ligament and ischiofemoral ligament, like the rotator interval, not closing any one specific ligament. Then finally, talking about endurance athletes, you can get stress fractures, obviously, and then classic histories would be a change in training routine and intensity, duration, equipment, or surface. Generally, again, in runners with repetitive loading, or that you've got to be aware of the energy balance issues or what used to be the female triad, and so they oftentimes have pain in the hip, groin, or thigh. It's worse with exercise and pain with range of motion and with axial loading. I've seen people sent to me for FAI when they actually had a stress fracture, and we did find an increased prevalence of pincer FAI in patients that had stress fractures. The key is to see if it's on the compression side or if it's on the tension side, as that will dictate how you treat these. This may be negative. Again, you'll oftentimes see FAI with this. You can get a bone scan, again. That's generally been replaced, though, by the MRI, and you can see very clearly stress fractures on the MRI. In the treatment on the tension side, we put screws in to fix it, and if it's on the compression side, we generally will put them on crutches if they're stable. The hip is being recognized as a significant source of pain and reduced performance. The diagnosis can be made with history and physical examination and radiographs. The MRI generally should be just for confirming the diagnosis, not to make the diagnosis for you. I covered a lot of stuff in a short amount of time, and this is just an overview. I hope you have luck during your fellowship, and hopefully you'll get a lot of exposure to hip problems. Thank you very much from Stanford University. Thank you very much from Stanford University. Great. Thanks so much, Adam and Mark. Those were excellent presentations. I especially like all the videos of clinical examination, which we really couldn't do better live. I think this is a great junction now to go live into our Surgical Theater at the OLC in Chicago, where we'll have Shane Ngo. I see you already scrubbed in over there, who is Associate Professor at Rush and, of course, Associate Fellowship Director as well. Shane, what do you have for us? Thanks for doing this. First of all, I just want to thank you guys for having me. I just want to thank Volker, Brian, and Latul for moderating and hosting tonight. I also want to acknowledge Stryker Sports Medicine for sponsoring this demo today. I hope that everybody that's tuning in, hopefully we'll try to convince you to be a hip arthroscopist at the end of this, and maybe even Volker, Brian, and Latul as well. Without further ado, I'll just go to the presentation here. This is a cadaver, a 93-year-old cadaver that was graciously donated. We did get a hip map. The hip map is actually a CT scan that was obtained of the cadaver before we actually brought the cadaver to the lab today. This is a CT scan that was performed with a low-dose protocol that is available for clinical use. This is actually the cadaver's CT. Sorry to interrupt. We can't see the slides. You cannot see the slides. Okay. Do you guys need to turn on to the— Now we can see them perfectly. Everything's good. Go ahead. Okay, terrific. This is the map. It's a PDF report. Once you get a CT scan, they'll go ahead and process the images. They'll send this back to you in a few days. I think that this is really helpful just to help to objectify and quantify your hip pathology. I think a lot of times we'll use x-rays, but getting a three-dimensional map, I find it to be very helpful. Again, this is a map of this specific cadaver. When you look at this map, it gives you a nice layout as far as what the morphology is on the acetabular side and the femoral side. It gives you easy-to-read lateral center edge angle. This one's 29 degrees. Versional angle, tonus angle, acetabular coverage, and alpha angle. You can see on the femoral side, you can see the appearance of this loss of head neck offset, this large alpha angle that you can see between 12 o'clock over here and about 5 o'clock down here as well. You can get more detailed measurements. Again, LCA, tonus angle, acetabular coverage, and version. Then you can also use this particular PDF. It actually allows you to be able to manipulate it. You can actually rotate this around so you can really visualize it 360 degrees around. It's a nice layout. We actually will see this being used in our tablet that we'll use for arthroscopy. We're going to go ahead and make our way over to the cadaver, and then we'll go ahead and continue over there. We'll meet you guys on that side. Awesome. While we go over, can I ask you, Shane, on your procedures, this is something you routinely use? Yes. I would say that I get it for cases that I am not certain about. If I'm concerned about dysplasia, dysplasia variance, versional issues, I find them to be very helpful in that case. There's a lot of in-between cases that we're not so certain about. I think that sometimes it's almost like getting a consult. You can just reconfirm what you think based on what you're seeing on the map. Here we are inside the hip. I agree with you. Perfect. Are we on the arthroscopic view? Okay, here we go. Yes, we see both. We have a camera through the anterolateral portal, which is over here. We have the shavers through the anterior portal or modified anterior portal, and now we're looking inside the joint. As we place our portals, we'll go ahead and look at the femoral head to the right and the S-tabulum to the left. In this particular case- Give us the landmarks for your portals, Shane. Yes, sorry. Here's the ASIS up here. The greater trochanter is down here. I'll make my anterolateral portal about a centimeter proximal and medial to the tip of the anterolateral aspect of the greater trochanter, and I'll make my anterior portal. We'll draw a vertical line down the ASIS and a horizontal across the tip of the greater trochanter, and I want to be about a centimeter distal and a centimeter more lateral, and that makes up my modified anterior portal. I like to use three portals. I'll place a third dollop portal over here, and we'll do that percutaneously. Now we're inside the joint, and you can see that we got the head cartilage. It looks pretty good. Unfortunately, the labrum is very frayed, and it's going to make our visualization a little bit challenging, but I think we'll be able to get through it. As far as your diagnostic examination, we'll go ahead and look at the cotyloid fossa. You can see the ligamentum teres over here. This is more anterior. Then I'll just use my light cord and shimmy my way around so I can get a really good look at the entire acetabular cartilage surface, and then at the same time, I'll back up my camera just so I can see the entire periphery. Here's the anterior aspect of the acetabulum, and I'll work my way towards the lateral and posterior aspect, and so now we're very peripheral. If we take an X-ray, you can see where our camera is located, and so that kind of gives us some landmarks, and then we really want to look at that anterolateral triangle, and so this anterior triangle is the landmark for our next portal, and so we really want to be in this zone, and this will make up our... Can I interrupt for one second? Yes, go ahead. The image that we can see is quite bright. I don't know if the technicians in the room can tone that down just a little bit. Is that better? Awesome. I think this is better. Okay. All right. Then do you always do a generous capsulotomy? I do, yes, so we've already taken the liberty of creating the capsulotomy already between the anterior and the anterolateral portals, and we've already kind of continued that, so here we've kind of made that capsulotomy, so you can see we're continuous from one portal to the other, and this kind of gives us a nice of an expansive view of the entire central compartment. You can see, unfortunately, the labrum back here is not looking so great, but I think we found a decent interval in which we can go ahead and do a repair, but the other key is that we went ahead and put a traction stitch to retract the capsule. Why don't we do one just for demonstration purposes, just so we can kind of show what that looks like. Once we've been able to isolate the labrum from the capsule, we'll go ahead and try to violate that interval so that we can get right down to the acetabulum, which I think we're right here. Sometimes the capsular tissue may overhang the acetabulum, and so one way to help to see is to just place a traction stitch, so we've placed in one already. We'll go ahead and do another one. We'll go through that anterior portal. We'll go ahead and put this stitch up here, and what it does, it'll just basically kind of pull everything out of your view, and then this way, it'll just kind of help with retraction. Let me get that shaver back, so we'll go ahead and continue with our debridement, so if you were going to debride the labrum, you can go ahead and just continue that over here. I think there's enough tissue, although it's not great. We'll go ahead and put in a couple anchors just to repair it. You know, one of the things that's really important with hip arthroscopy is that you need to work through both your anterior and your anterolateral portal, so before we do that, why don't we switch to the, with the camera in the anterior portal, and then we'll look back, and just so we get a different idea as far as what that perspective looks like, so we'll go ahead and use that. So, I mean, there are some, you know, it's a good question about capsulotomies. I think the unusual thing about hips is that, unlike the knee and the shoulder, you do have to use a capsulotomy. Well, I don't say you have to, but I would say most surgeons do use a capsulotomy, but I think it helps to manipulate your instruments. It helps to kind of get your bearings, so I'll take the shaver. Yeah, it looks like you have great exposure there, so I think, obviously, that helps, and you will close that in every case, or just in some cases? Yes, in every case, and so I think, you know, in the world of hip arthroscopy, capsular management is kind of an important topic, because I think what we're finding is that, you know, while we do need to see and perform what we need to do as far as labral repair work and osteochondroplasty, we also don't want to destabilize the hip, and I think in some cases that might have happened in the past, but I think now that we're more keen on restoring the biomechanical characteristics, I think that that happens less so. So here we are looking upside down, if you will. Mark Safran mentioned at the end of his talk about hip instability. In a patient that is already hyperlaxed and has hip instability, will you also do a big capsule release like you did in this case? You know, we try to minimize and tailor to, like, the patient's individual pathology and their needs, but I think what I'll try to do is I'll make it smaller. Let's switch back, and then I'll tighten it on the way out. So we'll do a plication just to kind of over-sew it just to make it, I think, a little tighter. So now we're going to go ahead, and now that we've kind of prepared our capsulotomy and made our portals, we're going to go ahead and take our burr, and then we'll do our rim trimming, which will be up here. And then thereafter, we'll go ahead and repair the labrum. So here, unfortunately, you know, given the amount of kind of fraying gray tissue and not great quality tissue, like, it's just a little bit hard to see, but the acetabulum is right here. You know, we'll use this burr just to kind of trim down the rim. You know, depending on this precise pathology, you know, we'll have to either remove some or a lot. You know, if you look back at the hip map, you'll see that she actually, this particular specimen doesn't have a huge rim. And so I'll just kind of clean up as best I can. Maybe a shaver will help here because we just got a lot of soft tissue just all over the place. So in this case, do the rim trimming mean that the labrum has a surface to heal back on? Yeah, in this case, I would say that that is the goal. So basically, we want to decorticate the acetabular rim. Here's a better view up here. And so now that we see the rim, in some cases, we, you know, we will have a very specific goal in terms of reducing the size of the acetabular rim, like in labral ossification, or if there's an os acetabuli. I think now that we see the rim very well, we'll go ahead and kind of prepare ourselves to go ahead and repair it. So that's a nice view. So again, we're looking back, we'll go ahead and use our, put in our cannula up here. And then we'll place our distal accessory antilateral portal down below with a spinal needle. So this, this is what we'll use for suture management. And this portal, you can see out here, we're about three centimeters distal and relatively in line, maybe a little bit more medial. And then this will be a percutaneous portal in which we want to place our anchors. And so if you look at the, if you look on the screen, you can see us coming, coming in right about, right up top over here. And so this, this portal is helpful for that, you know, kind of the 12 o'clock to three o'clock position. And I think it's, it's a nice portal because it really kind of makes your trajectory kind of point away from the, the rim. Okay, there we go. All right. Just, just hold this spinal needle. Okay. And then, you know, once we've created this portal, we'll go ahead and, there you go. We'll go ahead and put our guide wire, the guide wire, followed by the drill guide, the drill guide kind of fits nicely over the guide wire. Make that a little bigger here. So, we'll get our drill. So again, here's our rim. This is our drill guide. And then we'll go ahead and pass our anchor, you know, and so there's a lot of obviously fraying, we're just going to look at the joint surface, make sure that we're not penetrating. Stephanie will go ahead and do our, pass our drill, followed by our anchor. Kind of watch it as it goes, goes in up here. It's a nice angle. What, what angle would you say about with respect to the acetabular rim, this is? As far as the, the drill guide? I mean, the drill guide and the anchor? Yeah. You know, it's a nice, you know, I like this trajectory because I think it's kind of in line. So rather than going down on the, let me get a switching stick just to kind of advance this. Rather than going down on it, you're kind of going in the same plane. So I think it prevents you from entering the joint and causing any trauma. So go ahead and grab the nano pass, loop retriever next, not pusher, not cutter. So this is a little device that's both a tissue penetrator as well as a grasper. And this is kind of designed for the labrum. So I'll kind of look on the opposite side here. And we lost our stitch. Let's see if we can grab it again here. Okay. Well, I'm really missing you guys in the lab here. I wish you guys were able to come join us here. Yeah, it's been 10 years that I've done hypotheroscopy. These instruments look great. Maybe I get back into it. I'm probably referring more to the fellows than you Volker. I want to be right there with you. I'd love to have you too. So maybe next year as we come back online, God willing, that we'll go ahead and do that. So now we'll go ahead and tie. So we're kind of tying on the outside and, you know, whatever arthroscopic knot tying technique you like to use. I'll do two half hitches and in one direction, then I'll start to alternate my direction of throw. And then we'll go ahead and alternate our post as well. Our label tissue is not looking great. I'm thinking, you know, maybe we'll try to put in one more if the tissue will allow us to. You know, if this was a patient or if we had more time, you know, maybe we might consider a label reconstruction. But I think, you know, for the purpose of this demonstration, I think it kind of gets across the point here. But we'll take a look and see what it looks like after this. This has been cut. When did you make your decision to do a labrum reconstruction? Do you do that beforehand in preoperative planning or do you you may do that in job based on what you see like a labrum like this? I mean, I, you know, I tried, you know, I would say that in a primary situation, it's probably pretty uncommon. We could try to do one more, I suppose. Go ahead, Stephanie. I wouldn't say that it's, you know, I would say that in a primary setting, I'll probably plan for that pre. Usually in cases of like labral ossification, maybe in some situations of oss acetabuli. For the most part, I would say that we're doing it in revision cases and revisions, you know, really depends on the appearance of the labrum and the quality of the tissue. You know, I probably do it maybe about 20 or 30 percent of revision cases. So it, you know, I think for young, young, healthy patients, it's always better to, you know, preserve your own tissue if you can. You know, so I think if it's good tissue, we'll do it. These days, actually, labral augmentations become much more popular. So in which case, you know, we'll be able to preserve the chondralabral junction and then supplement the deficient labral tissue with graft tissue over the top. I think we lost our suture there. We can try one more time. Okay. A lot of, a lot of pixie dust over here. Oh, there we go. Let me get a loop retriever. Yeah, I don't know. But I think, you know, I think for advanced courses, you know, obviously the fellows who are interested in HIP and everybody else, I encourage you guys to take advantage of labs at the OLC once hopefully we're back to normal. Okay. But yeah, I think, you know, doing some of these more advanced techniques might be, you know, might be fun to do in the lab. Do you guys have another, like a, yeah, what is that, a grasper? Inkfisher? Yeah. Still not coming up. Well, we could, we could try another anchor, I suppose. Oh, here we go. I don't know what's getting caught up on here, but how was the view, Volker? You guys able to see everything all right? Yeah. Yes, we can, we can see well now. Okay, good. At least I can. Loopy. Okay, so we got this finicky suture. Okay, so again, we'll go ahead and tie. And I think, you know, given the quality of tissue, I think what we'll do is we'll probably just, you know, go ahead and work in the peripheral compartment. I'm hoping that the tissue appearance will be a little bit, a little bit better. We'll get our camera to co-op. I think we're up here, Stephanie. I mean, obviously in this cadaver specimen, the labrum quality isn't all that great. When I did my fellowship in 08, we did mostly labrum debridement, but these days you would say your goal would be a repair or in a young patient, if you can't, like you said, 30%, you would reconstruct. Is there ever a time you just debrided? Yeah, there are times. I mean, I think if the labral, the quality of labral tissue looks pretty good, I think, you know, debridement still has a role. It's interesting, like sometimes when we have these debates, like people talk about repair, reconstruction, debridement, you know, Mark Philippon has a 10-year data that suggests that his actually debridement patients had a better survivorship than his repair. Right, right. You know, there's probably something to it. You know, let's see if we can kind of get a decent view of the labrum here. Take that out. I'll take the shaver. And I think once we do that, we'll probably get the traction down. So I don't know if Sean needs to get ready to start to do that. But, you know, this, here's kind of the labral tissue. It's not looking so great, guys. I apologize. But I think, you know, we got the point here in terms of how to access it and how to perform it. But I think it's not bad. I think it'll keep it stable. But what I like to do when I go into the peripheral compartment is I'll go ahead and put my camera up in the entry portal. So I'll ask my assistant to pass me the switching stick and then the cannula. And then we'll go ahead and take our traction off in a moment. My assistant will then take off our traction stitches. Go ahead and take the traction stitches. And then we'll work on the peripheral compartment. So let's get the shaver back. And so I'll put my shaver back in the interlateral portal. You know, I always want to just get my bearings just so I know where I am. And then, you know, kind of watch the hip as it goes into off traction. And then we'll start to think about our capsulotomy and so forth. But here's our, now we're back here in our interlateral. I'll have Sean go ahead and take the traction down. And so as we go in the peripheral compartment, you know, I think it's important to, and then the x-ray, you know, actually we didn't talk about this in x-ray, but what we'll have to have you do is see it back about 15 degrees and then bring it towards the foot about 15 degrees. The traction off. And then go ahead and- Shane, can you talk just about techniques? I see you're crossing your hands. Yes. So to me, this sounds really complicated. Tell us what's, how you manage your 70 degree lens and your shaver. How do you, what are some tricks here? Because you make it look so easy. Yeah, you know, I'll be honest with you. I think with hips, we have it off. You guys want to flex it up? Mikey or Stephanie? You know, getting the positioning is tricky. So I'm glad that you kind of made that point and was able to recognize that. But, you know, the interesting thing, I think handedness and right and left side and hips, I found to be very noticeable right away. Meaning, you know, when I was working on a right hip, it felt very different than working on a left hip. Early in my career, now it's pretty easy to separate. I think one of the interesting thing is that you're doing a lot of work as far as like shaving and burring and things like that for extended period of time. You know, like if you're doing a chromioplasty, you know, you might be burring for like, I don't know, 10, 15 minutes or so. But when you're doing a femoral osteoplasty, I mean, sometimes initially, like that could take like 45 minutes. And so, you know, I think that what I try to do is I try to bias my dominant hand to work with the shaver burr because I think that, you know, I just get a little bit more precision, better control and then able to perform what I need to do. So what I'm doing here, which seems like, you know, what's this guy doing, wasting all this time here, but I'm really debriding the anterior capsular fat pad. And I hope this shows up, but what we're trying to do is we're trying to show the collagen tissue up here in the anterior capsule. Do we have an x-ray of the lateral view? Okay. Should we get the hip check going? Probably do that. Okay, let me do the capsulotomy first and then we'll get the hip check going. So this will help just repair at the end. You just want nice capsular edges. Okay, so we'll go ahead and switch over to the burr. I get this, I get the cannula and then the samurai. Then I'll need a couple of free sutures, yep. Okay, so this is a T-cut. And so, you know, I like to do this just to help expose the peripheral compartment. So what I want to do is I want to find kind of the 50 yard line here and then we'll go ahead and perform our T-cut and I really want to be perpendicular down the neck so we can really expose the proximal femur as best as possible. So I think that this is helpful, especially with large cam deformities. And I don't know if you remember that CT report that I showed you guys before, but, you know, this cadaver actually had, or this cadaver actually had a pretty large cam deformity. So here we're exposing the head-neck junction. Can you guys see that? Yeah, that's beautiful. What do you think, Wilker, is that inspiring you to be a hip arthroscopist or? Yeah, my God, I'm going to start booking tomorrow, Shane. I mean, it's like. That looks great. Huh, what do you think? That's very good, it's nice exposure. Nice exposure. Yeah. You know, you can see everything real well. You know, you can, you know what? I'm going to redo that one just to kind of get a little bit, there's a lip of tissue. Go ahead, Mikey. Take that out. Okay, so let me see if I can just get a little bit better bite. But the other thing I find that, you know, your preparation, your prep work is like really important. You know, if you take the time to like, you know, to kind of give yourself a fighting chance here, it helps a lot. Otherwise, if you kind of rush through it, it ends up, you end up, you know, skipping steps and it ends up actually costing you more time in the end. Just trying to get this last layer here, if I can. It's not quite cooperating, but it's not bad. Okay, let's get the injector for the other side here. Is the burr ready? Okay. Okay, so in this one, you know, one will go through that dollop portal, the other one through that anterolateral portal. I've got my camera through the anterior portal, and then I'll go ahead and pass this stitch through that, through that anterolateral portal. And then you'll see when I pull traction on that, how much better of a view you get. And I think that, you know, here you can see the entire cam deformity. I want to show this technology here, if you guys don't mind. So here's what we call the hip check. It's an interoperative way of measuring alpha angles. Or if we can, you want to tilt it up, Mikey, a little bit. And so what it does is it, yeah, we don't have to get all the exact measurements guys, just cause I think we just want to get the point across here. Okay, flex it up guys a little bit. Okay, stop. Okay, and then take a picture. So what it does while they're doing that, it'll actually calculate the alpha angle kind of automatically. Mikey, can we get this off? I think, yeah, like, no, no, the- Whole screen. Yeah, there we go. Okay, and then, there we go. Okay, do you see how, Volker, do you see how we're measuring the alpha angle? Maybe you can't see with the- No, no, we can, it's actually pretty good. Yeah, so, and then if you take another picture, go ahead, one more picture. And so what this does, that basically it measures your alpha angle kind of automatically. And so you can kind of track your pre-op alpha angle and then compare it to your post-op alpha angle. And there's six recommended positions so that you can get all the way around the anterior aspect of the femur. So here now, if you look back at the screen, we've got a lot of screens going on here. X-ray, got our fluoro, we got our hip check, we got all sorts of technology. So for all you tech people out there, you're gonna love this. X-ray. So we'll go ahead and, you know, I like to take an X-ray here just to begin our head and neck resection here. And I apologize for all the bubbles on the screen here, but, you know, once we're able to measure everything- And maybe show us the scope screen again. I'm sorry, Volker, can you say that again? Yeah, no, we were just missing the scope screen, but it's back on. Now we can see it. That's perfect. Okay. So this, so now we're just gonna go ahead and do our osteochondroplasty. And so the osteochondroplasty, you know, is essentially like, you know, now we're, you know, we're just kind of like doing some wood carving here. You know, we basically just wanna make this, you know, make the offset more normal. Some of the things that I try to look for is I wanna match the head and neck offset on the anterior side to the posterior side. I wanna start, you know, where I see the offset beginning. Maybe I can show you guys on the hip map or the hip check over here, but basically I shoot for here, which is on the opposite side of where the offset is over here. And so, you guys see that? Yeah. So that's where I wanna start. And I wanna, you know, basically I'm drawing a line going all the way across. You know, let's maybe shoot one more X-ray. One more X-ray. And so I wanna start up here, you know, just like what this measurement is doing. And I really wanna just start to just make it more, more of an offset. And that'll match, you know, the angle on the inferior side, also known as the beta angle. And, you know, that's kind of our goal. And so we wanna go really from 12 o'clock to six o'clock. You know, now that we have our traction stitches, I think our view is actually pretty good. How much flexion do we have? And the other thing, Volker, that we have to do is that we have to determine how much flexion, rotation that we're gonna do on the leg to be able to deliver the areas of the cam deformity that might not be in our sights right now. So for example, if we really wanna get to that 12 o'clock position, you know, I'll ask my assistant to place the hip in extension, and enter rotation. And you can see, oh, maybe a little bit less internal. A little less, okay. And then you can see how we've kind of brought this head and neck offset into view over here. Perfect, and what o'clock position would you say you are now? So we are at roughly, probably 12 o'clock up here. Yep. We can take a picture. It'll be 7.30. Volker, what do we have until 7.30? We have 11. Yeah, we have another 10 minutes, so you're doing well. Okay, all right. Okay, let's get a little bit more flexion. Hold on, let me shoot an x-ray here, if you guys don't mind. X-ray. X-ray. Okay, so we still have a little bit of work to do over here, guys. You know? That's the x-ray up here. Okay. Dr. No, are you always using a T-capsulotomy? Yeah, it's a good question. So Stephanie, our fellow soon-to-be attending in about a week and working with me behind the scenes here, but yeah, so it's a good question. So I would say that the T-capsulotomy for me is my workhorse. I do that probably about 80% of the time. There are some times when I just do an interportal capsulotomy. It depends on how flexible the tissue is or how loose the tissue is. You know, in general, like I want to make my capsulotomy somewhere between two to four centimeters by interportal. And if I get to the peripheral compartment, it looks like everything kind of retracts very nicely. I won't do a T. But if it looks pretty stiff like it does in this case, then I'll go ahead and do a T-capsulotomy. Sorry, guys. X-ray here. Let's see, x-ray again. Okay, so you can see how we've kind of changed the offset on that view. You know, if I wanted to be really critical, I'd say that we probably should go a little bit more proximal. I think in the interest of time, what we'll do is we'll go ahead and put the, we'll go ahead and flex it up a little bit. Stop. And then the other thing is when you flex it, it'll allow you to access more medial and more anterior. And so, you know, what we're trying to do when we extend and internally rotate, we want to get to that 1145 position. And then when we, as we get more flexion, then we'll slowly work our way around from like 11 to 12 to one to two to three, and then eventually to six. I got a lot of smoke over here. Wow, look at that. I think our thing is like melting. Do you see that? You see that Volker? We've melted our burr. Look at that, it's too hot. It's melted. Hey Shane. I just realized there are a few questions that were posed, so I apologize guys. I'm just now getting to those, so. Can you briefly comment on where you put your portals? Are you changing portals based on how big the cam is? No, my portals stay about the same. I would say the capsulotomy may vary somewhat. So I might go a little bit more lateral if I've got like kind of a more of a pistol grip deformity. I might go more medial if necessary. You know, I might extend the length of my T-cut or make it not as big depending on what I can see. So my portals are usually, you know, three portals. Again, the interlateral we talked about, modified anterior and dispal accessory interlateral portal. And then, you know, how extensive my capsulotomy will be dependent on the pathomorphology as well as the quality or the pliability of the tissue. And then with the capsulotomy, obviously you made this nice T-cut which is slick and made a really beautiful exposure. Are you very aware of course where your circumflex is and anything you need to look out for if you're a rookie? Yeah, we'll see if we can try to expose it here. But yeah, we do want to be aware of that, you know, and we'll go ahead and debride some of this periosteum over here. Let's see. So here we're in the inferior neck over here. And do you see the synovial folds over there, Volker? Yep, very well. Say hi. Hi, how are you? Just want to know where they are. And then, you know, similarly on the lateral side, you want to see those as well. So typically my landmarks, that one go from like 12 o'clock to six o'clock, go all the way down the neck. I think in the interest of time, what we should do is we should probably do some closure. Cause I think maybe we have five minutes. Yeah, we have five minutes to close it. X-ray? Yeah, you can see that we've restored the offset. You guys want to look at that fluoro shot. Maybe Stephanie can point that out. Obviously at this juncture, the typical question, of course, the jinx question is femoral neck fracture. I mean, I'm sure you've seen it. Like are there, what are your limits? Of course, these chemplasties always look quite large. Yes, yeah. Yeah, it's a good question. So I would say that I've seen it once in my own practice. It's thought to be a problem when you're the breeding more than 30% of the width of the femoral neck. Right. Okay. And so that, I think that's, you know, that study was done by Rodrigo Mordonez. And, you know, really when we're doing our, when we're doing our neck debridements, we really want to stay on the kind of metaphyseal area of the bone to rather than on the diaphysis. And I think we try not to go deeper than the neck itself. Yeah. Go ahead and pull back on the cannula a little bit. Good. No, that's great. Yeah, show us how you do the capsule closure. Yeah, this is, I'm going to restart this one because it's just not looking so good. Okay, so this is the capsule closure device. It's kind of like, you know, like in the shoulder you use like an espresso or like a scorpion. It's similar to that. It's just kind of designed more for the hip. It's kind of more up and down. Let's see. What are we running into here? Okay. It looks like we're clear. Okay. Hold the camera. And then we'll go ahead and place this on the opposite side. We will position our device so we can grab the lateral aspect. Man. Nice. I think we actually, I don't think we got it because I'm going to pass it again, Volker. Where is it? Maybe right here. Okay. And then should, I guess we could consider the slingshot. Well, let's keep using this, I guess, if it's working. So Dr. Noe, you're starting at the bottom of your T-cut then here? Yeah, so go at the kind of at the apex distal most aspect. We'll go ahead and pass our first stitch. We'll start closing it up. And, you know, if you'll notice, you know I've kept those traction stitches up. I think it does help to give you a little bit of tension on your capsular leaflets. So I'll probably keep them up until my last T-cut stitch, last vertical stitch, and then that point I'll release it. So it'll give me a little bit better ability to kind of tighten my edges up against each other. So we'll go ahead and cut this. And so at this juncture, if you have somebody to get back to the instability that has a more loose capsule you just grab more tissue and placate it, or? Exactly, yeah, that's exactly what we do. Yeah, so if it is loose, then we'll go ahead and make wider bites when we do our capsule repair. Okay, I think that didn't go on this one. Let's see, so here is our... Okay, I think that seemed to have grabbed. And then we'll go on the other side here. And so one of the things to keep in mind is that we need to take all that excessive suture out of the cannula. And otherwise then we get kind of a little bit too much tissue. Shane, here's another question that just came from the fellows. How do you determine the loose capsule? You know, it's like kind of the... Loco, is it the preoperative imaging? You know, one of the things that we'll do is we'll measure the kind of the baiting criteria for patients that we think are suspicious. It's probably the same patient profile as the patient that we see with like recurrent shoulder instability. And if we're concerned about their tissue laxity, then we'll go ahead and tighten them up a little bit. Hold on, the cannula's a little narrower than... Okay, there we go. Yeah, I could try the slingshot, I suppose. Here's a second stitch here. Okay, so we're kind of marching our way up. Okay, so we're kind of marching our way up. Okay, Stephanie can show her. Not going down here. We get the idea. You would probably place two or three stitches and depending on laxity, more. Yeah, I mean, we'll probably place similar amounts of stitches. We just will make our bites wider. Yeah, and then can you just briefly tell us just your post-op regimen, brace, yes, no, weight bearing, crutches, how long and range of motion? Sure, so I'll use a brace for about two to four weeks, 20 pounds foot flat with crutches. We'll progress the full weight bearings from like two to four weeks. We'll start physical therapy within the first few days after surgery. And then typically it's about therapy twice a week for about three months and usually about once a week between three months and six months. I tell most of our athletes, like we'll clear them somewhere around, well, they'll go back to sport about four and a half months and then we'll usually kind of clear them for sport around six months or so. So it's pretty similar to like an ACL in terms of length of time to get back. Well, great Shane, this was a great presentation. It's very slick. You know, obviously you've done this many years. You know, the technology that you introduced here was really nice too. And I'm sure over the years, we'll get even better. So this is great. So hopefully the fellows can enjoy a live demo and a live lab later in the year, as you mentioned. Do you have any final words you wanna say about the case of hip arthroscopy? No, I think, you know, for all the fellows that are out there, I mean, you know, this is, you know, it's a great field. This is definitely the time to learn hip arthroscopy during this year. You know, seek out as many labs, you know, come to the OSC as often as you can. You know, this is kind of the steep part of your learning curve, but I think that you'll find that this is a fun field to be in. I think the colleagues in this field are terrific. There's a lot of questions that we still need to answer. And so we're really interested in recruiting a lot of young people to kind of help enter the next frontier in hip arthroscopy. Great, Shane, thanks so much. Awesome job. Thanks all the support around you too. And we'll march on in the program. Great, thanks guys. Thank you, have a good one. All right, super. So that was great. And I see Kevin on the line here. Kevin, how are you? Long time no see. Thanks so much for joining us. That's fantastic. Hi, Mark. Great. So the next hour or so, we'll talk about contract negotiation. Obviously switching topics here, but from the life courses we did over the last couple of years, we all know that this is something very important for you. And if you don't mind, just take a second, look at this quick poll question. We will ask you this now, and then talk about what it means throughout this little session. I can tell you and urge you, pay good attention to this. Ideally in your fellowship, just so that you will be able to focus fully on all the learning opportunities, surgery, clinic, team physician, et cetera, you should be done with all your contract stuff in October, November. That is my personal opinion. We can see what Kevin and Brian have to say to that, but I would get started as early as possible. Without further ado, so Brian, my co-director here in the course, let's start out with the first presentation. Brian, all yours. Thank you, Volker. Let me see if I can share my screen now. Okay. It's coming up. All right. I think you can see me now. Yeah, very well. Okay, perfect. So I'm going to talk about contract negotiation, choosing a job, and some do's and don'ts. I've got a ton of slides, and there is a little bit of overlap with Dr. Plancher's presentation, so I'm going to gloss over the slides that pertain to practice types, ranging from single specialty to multi-specialty, academic, private, et cetera. So I want to talk about some principles. As you all know, learning involves repetition. You've got to hear something six times or do it that many times before it becomes ingrained and rote. I want this talk to be kind of conversational, so I really need you to send in some questions so that we can address them and stimulate conversation afterwards. You're looking to get a job, but really what you want to do is build a career. You've worked very hard to complete your residency and garner an outstanding fellowship. Just remember the first two years in practice are going to involve a lot of hard work, and in some respects, it's harder than what your residency entailed because there's nobody looking over your shoulder. And to build a reputation in busy practice is quite pressure-filled and burdensome. It takes five years in a saturated market to build a high volume practice. If you're a less competitive environment, you can get there within one to two years, so you should take that into consideration while choosing a geographical location. If you haven't made a splash in five years, you might think about moving on. All of you have to define your career goals. What is your ideal scope of practice? We're going to cover some of these issues, how you network, how you make initial contact, how do you negotiate contracts, and just keep in mind that you want to start this process early because it may take up to four or six months to get credentialed in hospitals, and you want to start in August or September. You don't want to wait until November or December, so get on the ball early. There's a saying you can either work where you live or live where you work, and this is very much dependent on the geographical location you land in. There are cultural and compensation issues in practice types you need to be aware of. You guys are all workhorses. You put 14 years into defining your career. You jump through hoops. You follow rules. You work hard. You all have these characteristics in common. You've got a superiority complex, and not to say that we're narcissistic, but we have a deep belief in our own abilities. You're a little bit insecure, which drives you to do more, and you're really good at impulse control. You guys passed the marshmallow test, and all of you have delayed gratification for quite some time. So we all know that surgery is a contact sport, and when you're looking for a job, some of these principles apply. You've been through rigorous training. You can handle joint replacement, polytrauma, and by the end of the year you'll be facile with scopes. But ultimately what you need to do is prioritize what kind of work-life balance you want to have. How much money is enough? Just remember in 30 years for every $2.5 million you save for retirement, it's going to generate about $100,000. It may seem ridiculous to think about retirement, but if you approach this strategically, you can be in a place when you're 50 or 60 years old and work because you want to, not because you have to. Be thankful. You're living in the richest country in the history of the world. Even making $34,000, you're in the top 1 percentile. We know that happiness starts to plateau at $80,000 to $105,000. That sounds ridiculous, but on an individual basis, it's more or less true. As an attending, you're going to make a lot more than that. You'll make $400,000, but you're going to pay a lot of taxes. If you buy a $1.5 million house, it goes pretty quickly. You might only end up saving $5,000 per month, so it's important how you budget. Happiness obviously is correlated with income to an extent, but plateaus very readily. It costs more to be happy on the coast because cost of living is higher, so that speaks to purchasing power. These are some of the favorite pearls that was conveyed over the course of my training. The most important thing you need to think of is where are the patients coming from, the fact that the inside of an operating room looks pretty much the same wherever you are, and as long as you're within a 30-minute drive from the airport, you're going to be okay. Ultimately, as you pursue this job process engagement course, you're going to want to get married, but the reality is you're dating. Fifty percent of us will change jobs after two years and 70 percent in five years, and that's really frustrating for many of us because we feel like after 14 years, we're entitled to a little bit more return on our efforts. Don't stress about it too much. Beyond six months, most practices don't really know what's going on in their markets. There are hospital mergers and acquisitions, offices open and close, partners come and go. So every six to 12 months, your practice ultimately will sort of shift directions. It's more like a speedboat than an aircraft carrier. The essential clinical dilemma that you guys have, having been well trained and specialized, is whether or not you really want to just do sports. If you take an academic job and things are funneled to you, it's a lot easier to specialize. In private practice, everybody does sports, so you really have to be able to put the work in to develop that network, or you're going to join a group that already has a feeder system. Your fundamental priorities will range from being slick in the LR, to writing prolifically, to teaching, putting yourself in learning environments. You may want to be an industry consultant, and you may just want to get rich quick and retire early, or at least work because you want to. So this is kind of the spiritual dilemma. Is it about money, power, fame, or balance and spirituality? And most people are somewhere in the middle. Volume counts. And the reason I say this is one of the best pieces of advice that I received as a medical student from North Vic attending was that volume drives everything. It makes you a better surgeon. A young surgeon has got to get in the LR, so you don't want to join a practice that doesn't have any cases for you. You've got to pass your boards. You've got to get competent. And you really have a couple of years to consolidate the skill set that you guys have spent six years developing. If you've learned how to do laterges and hip scopes, you don't do any for two years, you get pretty rusty. Gladwell might have overstated the importance of practice. It's probably between 20% and 30% of your ability in the end, but the concept I believe in. You've got to know about the three A's. If you're going to build a practice, you must be available, affable, and able. And it probably goes in that order. If you're not around, if you're not saying yes to every case that somebody sends you, they're not going to send the next one. People have got to like you. If you're pissing people off around the office or in the operating room, that feeder system of referrals from partners and nurses will soon evaporate. And, yeah, you've got to be good. As I said earlier, if you want to be a specialist and you go into sports, it's kind of difficult. If you're an oncologist or an oncologic orthopedic surgeon, spine surgeon, P, foot and ankle, or hand, it's really easy to specialize. But everybody does sports. Sports is a sexy specialty, and a lot of generalists will dabble in it. So you've really got to put yourself in a situation where you can generate referrals quickly. Now, these next 10 or 12 slides speak to different practice types and environments, and Dr. Plancher is going to cover these in quite a bit of depth, so I'm not going to spend too much time here. But you're all aware of private, academic, hospital, and at Rush, Roth and Vale, maybe HSS, we're sort of best of both worlds, I believe. We're academic, but we also run our own business. The single specialty group, I think, is a great place to be with like-minded surgeons, all specializing in musculoskeletal medicine. The multi-specialty group has the advantage of a sort of built-in primary care referral network. There are some local examples. They cover everything except for surely tertiary, quaternary-level referrals. Hospital employment is on the rise. It's a lot less headaches in some respects because you don't have to worry as much about where patients are coming from, but you have a lot less autonomy. Most of these jobs entail RVU-type compensation, so you do more cases. You probably get a bonus after you meet your threshold of covering overhead. The problem with a hospital employment system is that every three years or two years or so, you're up for renegotiations. You don't have a lot of leverage. If things don't work out, you really don't take any equity with you, and you have to essentially reboot. Multi-specialty groups are a little bit larger, potentially more stable. You might have a little bit more skin in the game as multi-specialty groups are typically physician-owned, and at least you have some say in how things are done. I think that single-specialty groups probably offer the most potential if you're not going to academics, into building a specialty practice. They also offer the advantage of ancillary income revenue streams. In this era of declining professional reimbursements, we're becoming more and more dependent on ancillary ownership of surgery centers, DME or durable medical equipment, radiology, MRI, income streams, not to mention physical therapy and occupational therapy. If you're going to go into private practice, you really need to take a careful look under the hood to see what that practice has in its armamentarium. Far and away, the biggest opportunity is from a surgery center. With the migration of outpatient total joints and spine, there's an opportunity to collaborate with all of your partners and for it to be a win-win situation. It's usually eat what you kill, and if you're a capitalist at heart, you're probably going to feel more comfortable with it. Academic careers are fabulous. I think a lot of us do this because we want to make a difference. You want to teach. You want to learn. In some respects, it can be challenging in that you may have less control over your over your volume or referral base. You usually don't have as many ancillary income streams, but you're going into academics because that's what you got to do. And I think that it's wonderful. And we should all be thankful that there are many people who are going to make the sacrifices that it entails. And it's really at the end of the day, 20, 30 years from your start in practice. I think you'll look back and the things you'll remember most are relationships. And in academics or private demics, you get the opportunity to interact with residents and fellows. And it's really rewarding. You'll look back and you'll you'll probably cherish that as much as anything. It's also the fastest way to specialize because academic centers and institutions have robust affiliations with high schools, colleges, professional teams, and they can steer patients your way when they have 500 or a thousand primary care docs. You've got to network. You've got to explore every opportunity to get your name out there. Look at job postings and AOS or GBJS. If you know you want to be in a particular suburb outside of a metropolitan city, just do an Internet search. There's no there's nothing wrong with cold calling a group. Call the group CEO. Talk to your mentors and residency and fellowship and see if they know somebody in there. It's a really small family. Most of us are within one degree of separation. And you'd be surprised at how robust all of our networks already are. Some practices are just looking for an employee. If they're telling you that calls Q3 for two or three years and it's a great way to build your practice. You've got to be a little bit wary of that opportunity. Ask to ask which offices you're going to be situated in, because if they're using you as a buffer with another competitive group that doesn't have an established patient flow, that can be problematic. If they're not offering equity and they want you on an employee track, you may want to think twice about it. They may believe it or not, your partners or your potential partners may have your best interest at heart. You want to develop a specialty practice. You want to be a sports med doc. They may not be particularly incentivized to share those plum cases with you. The ACLs, the shoulder instabilities that are difficult to get when you start out may be funneled to another one of the partners who is not particularly egalitarian. So you want to have a balanced life and a fulfilling career. You've got to think about all these things. One good way to figure out how a practice is run and recruit is to ask him how unassigned referrals are handled. So if you call the hospital, ask them if patients call the office. Are they are they dispersed in an equitable manner from one surgeon to the next in order? Or is everything being piled into the senior surgeon schedule? Also, take a look at the pair mix. We're all charitable at heart. But if you're being inundated with under or uninsured patients, it's really hard to meet your partnership metrics. Ask your ask your perspective partners how busy they are. Many aren't willing to admit how many cases they do. You can always call the hospital system where they're working at and say, what's a typical week? Typical week. You can kind of pin people down on how busy they are. And if your perspective partners aren't busy, that's something to consider because they may not have enough patients for you. Taking your call is a good way to build confidence until it gets no primary care docs. It's not a sustainable practice model. Better referral sources for all of you is the number of high schools, colleges and pro teams that your practice might be affiliated with. Ultimately, your bread and butter is going to be high school athletes. You know, if you take care of a college or professional team, it's going to generate a handful of cases per per year. But the vast majority of numbers lie in the younger and the younger population. So you want to build a practice that networks you into the soccer mom point of contact for every good interaction you have here. He or she will tell 10 people for every bad 100. So you've got to be wary about your reputation. Ultimately, the best referral source is your own set of patients. If you take care of your patients, they will take care of you. They will send their family and friends. And when you're five, seven years in practice, you're almost self-sustaining if you're in a reasonable market. So if you want to know how busy your perspective partners are, ask them how far they're booking out for surgery. You can call the practice and say, when can I see a specialist that will give you an inkling? And this is a question for all of you that I want you to ponder in this moment. So what do you think the number one reason for a surgeon leaving a group is? Is it geography, culture, money, academic versus private interest or family reasons? To my surprise, when I heard the answer, it's actually culture. Are your partners practicing in an evidence based manner? Are people practicing state of the art techniques? Although although you may find it hard to believe how your partners are taking care of patients reflects on you and actually will make an impact on how you feel about being part of that team. So ask around and see what kind of reputation the group carries, because it will ultimately influence how you feel about it. If practices are not transparent, if they don't show you the books on your second or third visit, that's a red flag. Because if they have liabilities, when you sign on to a group, you're certainly entitled to assets, but you might get tagged with liabilities. If they haven't been paying taxes or if there are issues, their accounting, you're buying into that. So you need to be aware. You need to know if it's a pyramid scheme, if there are fat cats who are essentially treating younger partners like indentured servants. That's not the type of group you want to be a part of. There should be democratic principles employed. I think if you're going to private practices, ancillaries are key. Ancillary income in some practices constitutes between 40 and 60 percent of your take home pay. So check out their ancillaries and get equity. There's an evolving landscape with respect to orthopedic groups. And the trend is bigger is better. And that's because that's because it confers more leverage and negotiating contracts with insurance companies and purchasing alliances. So if you join a group, it might get snapped up. Private equity and M&A is actually an active phenomenon right now in our country. If you're looking for an academic job, the buzz is, is that all the best jobs word of mouth. In some respects, I've found this to be true. You should talk to your fellowship director. that you work with from residency as well and get you in, get your name out there. Just keep in mind that this network that you develop in residency and fellowship will serve you well beyond your first job. When you're looking for your second job, you're going to still need them to vouch for you. And the first people that your next employer are going to talk to are typically where you've trained. So start with geography. Keep in mind that the more desirable location, it's probably the less you're going to get paid. Send letters, cold call, talk to recruiters, start thinking in terms of this balance between clinical practice and the business of medicine. We're in a period of change. It's not necessarily a tsunami, but just keep in mind that there's always downward pressure on payments and ancillaries are becoming more and more important and consumers are becoming more responsible for their costs. So this has implications for hospital employment, which I've alluded to earlier. Outpatient surgery is sort of the next big trend. You will see a further proliferation of outpatient joints and spine, and that's an opportunity for all of you to collaborate with your future partners. Service line agreements and co-management agreements are opportunities to work with hospitals. You guys are all going to do well. You're going to be able to pay your bills. That's not going to be an issue as an orthopedic surgeon. We're well compensated. You've got to work hard, though. You've got to generate 10,000 RVUs to make this kind of money. And where you live has some impact on how much starting salaries are. The more coastal, the lesser you get paid and the higher cost of living. It's usually an inverse relationship. You need to think about what your immediate financial goals are. I wouldn't recommend buying a house right away. If you do and you're looking for another job in two years, you may take a substantial hit on transactional costs. So have a have a plan that's reasonable. Think how much money you get when you retire. You're going to make about an 8 percent return year on year and you're out. Don't trade. It's time in the markets, not timing the markets. The reality is if you're in a saturated locale like San Fran, where you've got four or five times as many orthopedic surgeons as you need, you're going to have a wonderful city, but you're going to pay more to live and you're going to take a lot longer to ramp up. If you're in Texas, your dollar goes a lot farther. You're probably going to build a practice a lot faster. So ask yourself what's important. There are substantial differences in purchasing power, secondary to cost of living and state and local taxes. And this is the map which summarizes what I've said earlier about coastal coastal cities being compensated less. The problem that I see with lots of young attendings is lifestyle creep. You guys have suppressed your your whims and your desires to live a comfortable lifestyle for a long time. Delay gratification. And when you hit it with your first job, there's a tendency to try to buy a house, a boat, live large. But if you do that, you're setting yourself up for some serious headaches. It's called lifestyle creep and you really need to avoid it. You don't want to keep up with the Joneses. Just live within your means for five or 10 years. You're going to do great. Start thinking about investing. Einstein is purported to have said that compound interest is the most powerful force in the universe. I'm not sure that it was him, actually. But your portfolio, your portfolio value increases exponentially over time. If you say five thousand a month, it compounds at eight percent over 32 years. You're going to make a substantial sum of money. Let's say you've got shares in a surgery center and you can save twenty thousand dollars a month. You save everything. You're kind of miserly. You're going to be really rich. If you hit it lucky with the stock market and buy index funds and a 10 percent return may sound ridiculous, but the S&P returns 12 percent over over decades. You're doing really well. It really entails a lot of discipline. So I'm going to move along a little bit to save time. But if you're looking for an easier life, think South, Southwest, not the Northeast and West Coast. You guys all have grit. You've got to put this to use and you've got to persevere. Don't give up because your long term goals are going to be best achieved with the gritty approach. So when you first make contact with a group, be positive, be interested, have a plan and explain your vision. Don't just show up and ask them where my patients coming from. No one wants somebody who seems laissez faire and entitled. Don't burn any bridges. Every group you talk to is a potential future employer. Talk to your family about what their expectations are. Talk about the macro environment with your with your colleagues, your mentors and see if that's a market which is desirable. The second time you visit, it better be to get an offer. You can't you can't visit a place two or three times just to socialize. If you're not getting down to the brass tacks on your second visit, think otherwise. Remember, your first job won't be your last one. It's really important to realize that over the first two to five years, your marketability as a surgeon increases. It's really nice hiring an orthopedic surgeon with two to three years experience. She's fellowship trained because they've already consolidated their skill set and have learned on somebody else's dime. After five to seven years in private practice, if you want to go back into academics, it becomes difficult. Much of where we land up has to do with serendipity or luck. So although you may think that life and your career will be a linear path, it actually tacks back and forth much more than you might expect. It's really important to get an offer. Once you get an offer, you've got leverage. You can leverage one offer versus another. And if you have an offer in a particular geography. If you have an offer and a picture geography, you can leverage an offer from another group because other groups become fearful of a young, well-trained surgeon entering the market. We have a reputation as physicians to be bad businessmen and women. We're risk averse. We think we're entrepreneurial, but we've been removed from workforce for 14 years. So don't and also people exploit our obligation to treat and that we shouldn't just do things for money. But when you're applying for a job, money is ultimately at stake. Once you have an offer, you absolutely need a contract attorney. Do not sign one until it's reviewed. Don't push too hard for a higher base salary. You're better off negotiating for a higher percentage of collections. Once you've reached your break-even threshold, make sure that your overhead is delineated. You know, you need to know what your direct and indirect costs are, plus your salary and benefits. You should negotiate for earlier partnership. Don't ask for more money. Groups don't like entitled applicants who want to take cash from their practice from the offset. This is a slide showing how professional revenues have decreased and ancillary incomes have increased over time at MOR over a five-year period. And this trend has continued. Get everything in writing. If it's not in writing, it's not real. All of these issues must be addressed. Get a contract attorney. And if I'm going to give you the best advice, I think it's good to consider geography, but you should ultimately live where you want to live and do what you want to do. You're going to work hard and strive for balance, but recognize that perfect balance is impossible. In parenting and relationships, good advice that I've received is that you should always do your best. You should never give up. When your kid's got a bloody nose, say hello. Dealing with OR issues in the moment is oftentimes hugely frustrating. Don't yell. Don't throw instruments. It's not worth your stress. Thank you for listening. And I'll leave it to Dr. Fletcher next. Great, Brian. That was a great presentation. On cue, a little son walked up. That's cute. He's got a bloody nose. Lots of great points. So before we go into questions, we're going to hear from Dr. Plancher. Of course, Dr. Plancher is the orthopedic sports medicine and clinical professor at Albert Einstein. We're friends to the ACL study group, and I'm excited that you're here tonight. And I've heard your talk before, and it's really good. So everybody enjoy. It's an honor. I want to thank Dr. Farrell. We all have to, Dr. Forsyth and Dr. Muschel. They put together an incredible program of winding down. You've heard great academics and a little different now. We also have to thank Jeff Dugas for inventing this section of the talk and behind the screens. Meredith, thank you. And to the executive directors, you'll hear from Carolyn coming up, Greg Drummer. It's a great organization. So let me dig in as I can. When I went to Asia the first time, I learned that when it's sunny, you put out an umbrella. I always thought you put an umbrella out when it's raining. My point is I want you to sit back. This is where you feel a little uncomfortable. And the next 19 minutes and 30 seconds, I'm going to make you as good as any administrator, because guess what? It's not that hard. And between Brian and I, we really can help you. And it's important. So why are we here? Brian said it. The likelihood of one of seven out of nine of you will leave a job within the first two years. Fifty one percent of you will leave the job at the completion of the fifth year. And I want to take a little different position than Brian did. I don't want you to leave a job. I want you to stay in there for life. And the reasons for leaving are financial, family, practice wasn't as advertised as he well covered, but most often than not, inadequate preparation on the business side of orthopedics. You were afraid and you lacked the skill set. So let's get some skill set. You need to know who's speaking to you all the time. This is as good as my golf shed golf shot gets. It sucks. So like you went to medical school, residency, did two fellowships and then went full time faculty in Bronx, Montefiore Medical Center, didn't find the satisfaction was wrong. How I selected. I didn't ask the right questions and opened up for private academics. As you heard with sports medicine fellows, cadaver lab, bio skills, great. And help develop an orthopedic course. So you need to ask the right question. Let me tell you that your knowledge is good. Your experience is a little limited. Your judgment, it's still young, but it's exciting. Every time you go to the operating room, you're excited because it's the first time you're doing it and you're the boss. So you need a program that whether you're in the hospital has a great chairman that will mentor you, or if in private practice, a great senior partner that will mentor you. The con in the hospital, you have to know, is they're going to ask you to make quotas all the time. Your salary will be set more often than not by RVUs. The con in private practice is there's a pressure to compete and most importantly, to be accepted in your community. But no matter what job, you still have to be a team player. You heard him. Brian said it. It's so true. Availability, affability and ability. Let me tell you a story. I was six years into practice in my day. You couldn't see the X-ray. We didn't have cell phones. We didn't have any smartphone. So the ER doc calls and says, I want you to come in. It's three in the morning. I have a non-displaced radial head fracture. I said, I'm not on call tonight. And in a community, you don't want to upset people that are on call. He said, no problem. I called them. They don't want to come in. I said, you want me to come in for a non-displaced radial head fracture? Yeah. So three in the morning, I came in, smiled. It was a non-displaced radial head fracture. I just adjusted the sling. And you say, why did I do that? It turns out that gentleman helped me for the next 20 years as he became the CEO of Merrill Lynch and furthermore became the chairman of the Securities Exchange Commission. Grandma's pubic ramus is tomorrow's ACL. You need to say yes. It's hard to be nice these days. Everyone tells you what to do. Colleagues, nurse managers, administrators. Learn how to play in the sandbox. Your ability is amazing. It's only going to get better after this great year. And you may know better, but I want you to hold your tongue sometimes because it could be a problem. I didn't do that well when I was young. Who are we? Orthopedists? We're older. We're 57 years age on average. The 2020 data is not out yet. Mostly male, but thankfully many more females are joining our divisions. Mostly white. Mostly we're getting more diversity and we're going to work on it. Mostly in sports medicine, almost 18 percent. And if you want to know where more orthopedic sports medicine doctors are, the highest are listed there and the lowest are below. And so you can pick your job accordingly if you'd like. But we know private practice is down. And even though in the American Academy of Orthopedic Surgeons, over 60 percent of them are private practitioners. So academics and hospital employees are going up. So let's talk about it. Where do you start? It's about the patient in a hospital based environment. Whether you like it or not, it's a minimal relationship because the expectation by the patient is. And it's OK that the physician assistant or the resident may show up in the middle of the night for someone in house. In private practice, the patient expects a strong relationship. And the con is it's a high expectation. Time for another story. I was not on call. I wasn't doing surgery the next day. I went to dinner with my wife. A glass of white wine was at the table. A lady swoops up the white wine and yells at me and says in the community, what are you doing? My son could get hurt tonight. You can't drink. Be aware. In a small community, you're always under the microscope. And so you have to be careful. You are your own boss, though. In private practice, you spent all those years, as Brian told you, becoming an MD, being told what to do. In a hospital based environment, sometimes your autonomy is lost. In private practice, you can hire and fire whomever you want without asking. You can come and go as you like. You have to be productive. You have a personal responsibility and you must have some backup. That's probably why some people are leaving private practice. The decrease in reimbursements, the difficulty in practice management, the difficulty in marketing to compete with hospitals. The unwillingness to provide uncompensated care, some call indentured slavery, and something that I do terribly. I don't do well work home life balance. I fortunately have the most understanding partner. And you need to have one if you are in a private demics or private practice versus hospital base. So the advantage of hospital employment, you most often don't have to worry about business issues. You won't have to worry about the overhead expenses. You'll have a wonderful steady paycheck and you'll have an automatic referral pattern. But I said before, watch out for your pay or mix. You're going to have a large patient base. It's not yours, though. It's hospital owned. And it's OK when you're in a subspecialty orthopedic department to know that your clinical productivity is 20 percent less than in private practice. But realize it's 20 percent more dedicated to research, teaching, administration and health policy. We know that salaried physicians see 1.7 fewer patients per day, up to 450 patients less per year. I'm sorry that the volume doesn't work. I'm sorry that we're not going to get together in the cadaver lab. And I look forward to that for meeting all of you. But this video, which it can play, but you'll see, I want to just let you know, is a CEO that's talking or being talked to by two consultants from McKinsey advising him what to do. And it's a very complex plan. And the CEO surprisingly says, OK, do it. And the consultants say, you misunderstand us. We just advise you what to do. We don't actually do it. I want you in your whole entire career to do things. If you need a thyroid scan, organize it. Don't dump it on the internist because it won't be done. You have to care for your patient every day, please. So what's great about hospital employment? Also, 401k, pensions, holidays, time off. The contract with payers are probably higher and you don't have to worry about it. And the malpractice isn't really affecting your pocketbook directly. Hospital employment, the benefits, the employee benefits realize yours. You don't have say they can change it at any time. They have to watch your payer mix. And that's a way they can get rid of you with a limited salary potential. You don't have an ability to share most of the hospitals and ancillary revenues. And you have to watch out in your contract about a non-compete that's enforceable with a 50 mile radius. And lastly, the woman or man in front that greets your patients may be having a bad day and you don't have control of the employees. And it is your reputation. So you should be aware. What is the advantage of the hospital to you for employment? You are a goldmine. Please realize that there is no downside for hospital administration. You generate four to six times your salary. You have a tremendous negotiating ability. You can choose if you want productivity bonuses. You want to add ancillary staff. Perhaps you want vacation time. Perhaps you want a salary adjustment where you're going to discuss your productivity based on RBU. And you're going to negotiate the value of your RBU and never lower than 75 to 80 dollars a unit, please. So I want you to be flexible, whether it's private practice or hospital employment. Often we as physicians think we have a problem with our job. This gentleman who came into my office thinks he has a problem. He's warming it up for me. You know, he's going to be a voluntary dislocator, but he's not ready yet to show me what he has. I want you to think twice. Does he really have a problem? The answer is no. I'm going to kick him out of my office pretty fast. Do you have a problem in your job? I want you to think about it and ask the right questions as you go out. And I'll show you because they limit our time to talk. But it's great to see if you ever knew the wild world of sports. This is the wild world of dislocating and relocating. This gentleman is going to step in and out, dislocate, relocate, no pain. And he thinks he has a problem. Ironically, among those currently employed, 58 percent said they would consider making the move to private practice. Yet 58 percent in private practice say they would consider moving to be employed full time. We are schizophrenic. We are orthopedic surgeons. And with the increase of stress, which happens whether employed or private practice, I want you to take the step back to know it may not be greener on the other side. How about malpractice? Hospital based. You don't have to worry about it. It's paid for. But please be careful. If you leave, you need a tail if you want, and it can cost sometimes up to $80,000. There are two types of malpractice occurrence versus claims made. Occurrence means anything that happened in the time that you were employed somewhere with a private practice or hospital base. And 30 years later, something happens. You're covered. Claims made, on the other hand, only covers you for the time that you're working at that job. And when you leave, if you don't get a tail, you're not covered. In private practice, you can select the type you want. Usually in a hospital base, you can't. In a hospital base, if a lawyer makes a decision to settle, you don't have a role in private practice. You can state on the policy whether you want final say so to settle or not. Unfortunately, seventh highest number of claims is in orthopedic surgery. I'd like to give you some guidance. If you're a general orthopedist, which you're not because you're going to do an exciting year in sports medicine. You have a lower risk for medical liability lawsuits as a specialist. If you try to belong to more than one professional society, you have a lower risk of liability lawsuits. If you're a surgeon in an academic faculty appointment, you have a lower risk. Only 19 percent of multiple claims. Unfortunately, 80 percent of orthopedic surgeons face at least one claim by age 45. And most of you are less than 45 years of age. And that means 50 percent of all the claims will come into your lap. Realize, and it's a separate talk. It's a movie theater. It's a theater. And you take it personally and rightfully so. But for the lawyers, as they always say, they never lie, but they withhold the truth. Watch out for your contract in hospital traps. Try to demand a greater than a long term contract rather than two years. Try to remove from your contract termination without cause, because if you're making too much money, you should be also be paid on productivity basis. Learn how to say no politely to nurses and lawyers and administrators and patients. As Brian said, it takes a while to earn respect of your community wherever you are. You've sacrificed all those years. Be patient. You're starting your job in the mid 30s. Your Wall Street friends started their job at age 23. Stop worrying. You're going to make money, save it, and like this orthopod, get a disability policy early. Beware of the non-competes. You have to ask for carve-outs. If they say there's a non-compete, say, can I live in this school center and still operate at this other hospital? And if they say yes in your contract, then if you leave, you're still not leaving the whole community. Avoid contracts that have clawbacks. Hospitals now have lots of money. If you don't make that money or that 10,000 RVUs, they can come to you and say, you now owe us money back. So get a healthcare attorney because the language is too complicated with these production formulas. Make sure if you do activities outside of the normal business hours to exclude it so you can take that money home with you for independent medical exams, depositions, medical record reviews, any paid agreements with implant companies, clinical advisor fees, consultant fees, speaking fees, royalties, intellectual properties. You deserve it. You earned it. You worked at night. You worked outside on the weekends. That should be excluded from your contract. In private practice, same thing. Termination without cause, please. As you get older, you're not well liked. The group wants to get rid of you. And notice the length of partnership, limit it. Try to get something that's easy in, easy out for ancillary services so that you don't owe your older partner on his or her retirement. And work for productivity in private practice. Don't work for equal splits because that favors the lower producer. Coding, if you didn't do it in residency, demand of your fellowship director and faculty to learn how to do it. It's a game. It's business. There's no emotion. Do it ethically. Consider pro bono work maybe 10% of the time as I do. Realize in a hospital-based practice, they're gonna keep track of your billings. You need to. Don't lose control of your appeals. Usually what happens when something's put in for billing, there's a mistake made. It could be a simple thing like a comma. And so it's not paid. You need to know that they appeal it so you get your money. Because if you don't get your money, that's ways to get rid of a doctor with lower earnings when you were working so hard. So encourage monthly reports. Go to national courses. Learn how to code. It's the Bible. In fact, your documentation has a direct impact on collections. Being ethical is essential, but accurate reimbursement occurs if you code it. Don't let hospitals code for you. In fact, reimbursement increases by up to $2,000 more per case, up to $600,000 per year for physicians performing at least 300 surgical cases per year. I talk about the other side of the classroom. You need to tread lightly. There are people that are going to help you. They are the operating room environmental services. They are the receptionist. And let me tell you, if they have had a bad day, take a deep breath because they're so important. You were given by God two ears, one mouth. Even when you're right, consider biting your lip at times. I did that really in a bad way when I was younger. It takes a long time and you can get frustrated. Don't. Be that team player. Take a stand when you feel you need to. Be ready for a no. Then you must be ready to stand strong and walk out like the Wall Street people do. If you're working with athletic trainers, be aware they run the show appropriately. They're there every day. Surround yourself with quality people, whether it's billing for ethical accountants and bankers and IT people. Spend a little more of your money to get quality help. Know the laws, work as a team, never break the laws. When should you never tread lightly? When you're protecting your patient. It's you against the world. It will secure your practice for life. Please sit down in an exam room. I will tell you, I learned in my residency something that a lot of people don't do. I dictate in the room, never in the hallway. The first thing you hear in a courtroom when you're helping is the lawyer says, where did you dictate the notes so the patient knows? And if you're one of those that gets a pile of charts at the end of the day and doesn't go home to the family, I hope that you change and dictate in the room with the patient. Positions are fickle. You can send referral letters. Hospital-based employees are forced to refer to you. Private practice refer to the good guys, not necessarily the best trained. So focus on your patients and it will work out wonderfully in your career. When do you never apologize? For me, against an insurance company. They are the enemy. They want profit. Their stock must go up. Did you realize in a hospital, you're reimbursed almost double for the same procedure as a surgery center? Does that make sense? Get mad, make a difference, do it well. And a survey that was done to the public on educated college graduates in the New York Times, they said doctors are fools. They are underpaid. Believe it. They know it. So work to help and get better reimbursement. The classic business model says, spend and invest in your future wisely. You must earn before you spend. Please don't be greedy. Don't get that Lamborghini right away. Stop worrying. Focus on your patients. This was one of my patients as a younger man. Enjoy the best profession. You're in it now. You're in our club, orthopedic sports medicine, and we welcome you. So the keys to success, try to be humble, put away your pride. Don't be afraid to work. Pound the pavement for senior citizens groups. Get known with athletic trainers, physical therapy groups, hospital grand rounds and private practice. Still publish. Talk about your experience. Always say yes. Please don't say send it tomorrow. Send it on Monday. Try to be that person in reverse and see what it feels like. We are known as orthopedic surgeons to not have good empathy. Work on it. Most doctors as well are cheap. Please don't be cheap as well. And at home when you go to dinner or you're out with a couple or with anyone, a wife, a husband, a partner, talk about anything else but medicine because we're known as being boring. Lastly, don't screw up your personal life. It's really gonna cost you. Look at that license plate. And so as we finish up, it is COVID-19. It's a new reality. You're gonna be better at telemedicine and I'm happy to learn from all of you. You're going to learn how to work in ambulatory surgery centers because there's a higher demand for patients for outpatient surgeries as hospitals must house COVID-19 positive patients. You need screening protocols, strict preoperative interviews, meticulous patient selection. It's gonna bog you down. I want you to assess and anticipate. This little girl assessed that it's raining. She's too excited because it's her first rainstorm but she might've anticipated to put up that umbrella. Do that before it rains. Ensure success for your patients. Be adaptable. Do it yourself. Don't assign the task to others. As Dr. Zeus said, why fit in when you were born to stand out? Be confident to stand up for what is right even when you're the only one doing it. Don't lower your standards to fit in with the crowd. Instead, let your example be what lifts others around you to raise their standards to yours and ours. I leave you with this that Volker and others know. This is my daughter when she was five years old. She's now married and 26. But who knows what was in her mush brain at that time to hug this other person on the beach that she didn't know. Perhaps today she'd have a little mask, unfortunately. But nonetheless, she was kind to that other person. My generation is not kind to each other. We're learning to do it better. Teach us how to do it better, to hug each other. Because together, if we help each other, we will win. I hope you have a wonderful career, an amazing fellowship year. And if there's anything you need, please call us all. And I wish you the best of luck. And thank you. Great. Excellent presentation, Kevin and Brian, both of you. This is very inspiring. And I hope that you all feel that you're somewhat at least better prepared. Take a second and give us another round at this quick poll. What is most important to you in finding a job? Is it the location? Is it the opportunity to specialize? Or is it the pursuit of an academic career? Now that you've heard these two fantastic talks. And then as you are putting these X's on, Brian, let me start with you real quick. It's a fellowship interview, but a job interview. So how do you sense from the person sitting across from you that they're serious about it? They actually wanna be there. What is it? Is it in the body language? Is it the first questions they ask? What makes you think this is the right person for you? You're on mute. I think you're on mute, Brian. No. No, still on mute. There we go. I was locked. Sorry about that. Yes, perfect. Now you are. Wonderful. I think the most commonly appreciated characteristic is passion. I think if you're not passionate about the work that you're gonna do, the practice that you're gonna join, that it's really transparent. So you gotta have a plan. You have to sell yourself. You gotta project confidence. And you gotta seem like somebody who's easy to work with, because this is all about relationships. And believe it or not, your partners and your staff that you're gonna be with are sort of like your work family. And if it's not somebody you wanna spend time with, if that's the image you say about your personality, you're not gonna be a highly sought after. So you just gotta be yourself, have a plan, be passionate, and be someone who's affable. I agree with you. Absolutely. Kevin, you mentioned that a few years into your job, you went into private practice. Can you tell us, and I was done as solo practice at the time? Yeah. I wanna just answer one thing. I think you also wanted to hear the person interviewing you, how might you tell they're serious about you? Was that also what you wanted to know, Volker, in that question, right? So I think this is gonna sound very trite. If they ask to meet your partner, your wife, or your husband, whatever it is, I think then they're very serious. That's the turnover. Because if they've accepted your credentials, they wanna know we're a family. And when you're in the group, they wanna know who they're being with. So that to me is a light bulb that goes on. I absolutely agree. When I came to interview for the research fellowship position in Pittsburgh, I stayed a whole week because I wanted to see the place and see if I can hang there. Obviously I did. I'm still here 20 years later. So Kevin, when you started your solo practice, what are some of the risks that you had to mitigate? So the first thing you have to mitigate is that you think you're not a failure. And I take that seriously. When you change a job, you think, what was wrong with me? But I moved from a very business, Bronx, New York practice that I became successful. And the survey says, so I don't wanna blind it for the jury. But at that time, I didn't feel that working seven days a week and things that I was being rewarded, there was a philosophy that as a young man, you pay for the older senior staff. I don't think that's as pervasive anymore these days, fortunately, in most hospital-based things. So I got together with five other surgeons and we did something they say you can't do, probably not today. We opened in two years, five offices, nine doctors and 150 employees. Now I wouldn't recommend that. That's something that's very difficult to do. But I had a good relationship with the chair. And so we actually opened across the street from the hospital. And so it ended up that we had a good relationship. It was more about wanting ancillary staff to help us. At those days, you did it alone. And so it was a necessity. Right. Meredith, if you can prepare this as a slide, the poll questions, you can throw them up anytime if that's possible. If not, that's okay. I wanted to give you a quick shout out from Pete Indelicato, who is still on the line following the course, our past president. I'm excited that you're still on here, Pete. So Pete made a great point and said, if you're interviewing for an academic position at a university, you should definitely meet the dean of the medical school and of course the chairman of the department. So that's what Brian mentioned earlier. And of course, Kevin too, there are multiple layers to interview. So if you're serious, you're probably going for a second one and you do want to meet some of the key people. Thanks Pete for bringing up this point. So this is the quick poll. I think Meredith, this is the one we had before we gave the talks, right? So 60% of you said most important is the location. 30% said opportunity to specialize and 15% pursuit of an academic career. So that's interesting and very similar to what we found last year when we did this poll. Brian, what do you think about this? Is this what you expect? Do you have advice? Yeah, I think that it's expected. My advice would be that you should explore opportunities outside of your comfort zone. One thing I tell people to do is to read obituaries and you'll read about some, because most people think that a person's life and career is linear, but it ends up tic-tacking all over the place. And although you may imagine yourself training in a certain location, living in a certain location for much of your life and career, the reality is that really successful and interesting lives involve diversity of experiences. And I'm from the East Coast. I did all of my training in the East Coast, Boston, Philadelphia, Pittsburgh, and Pittsburgh was sort of my gateway to the Midwest. And I've landed in a fantastic situation, but it involved a little bit of cards and risk to try a new geography. When you're young, I think you've gotta be, you've gotta have that spirit of adventure and at least take interviews in other locales. You might get blown away by a community, a culture, which you weren't even aware of. And I think it's important that we train in different places and interact with different cultures because I think life is more rewarding that way. Kevin, obviously it'd be interesting to hear your perspective in the era of COVID, of course. So if our current fellows, 150 of them are still online tonight, going out for interviews, most likely you're looking at a video interview. And so what, give us some, and the old culture of upfront money and all this. So what are your suggestions here? Do you go early, you go late, do you wait it out? Give us some of your thoughts and then Brian too, maybe. Yeah, so this is uncharted territory, as you said, it's very sad. I think, as we know at meetings in person, I'm very partial, you really learn about someone in person. So if they're doing the virtual, which I think they're gonna have to do, one, like Brian's doing a better job than me, it's a nice background. It shows seriousness of purpose. And I think it's important. I think I will say, I think you still need to dress up. I'm sorry, I'm a stodgy old guy with a tie and a jacket. You don't know the people, don't take those casual approach to it for your first interview. I think you should be energetic as always, as Brian said, and excited. You're doing it. And then I think it's gonna fall this year upon fellowship directors, mentors in residency that are going to have to vouch their reputation for the individual, which has always been a small part, but I think it's gonna end up being a bigger part if we can't see each other. And so I'm hoping that things will change and vaccines and bubbles will occur that will let us the rest of the population won't be so stupid and wear some masks. And if that happens, that you can have that one in-person visit because for the fellow as well, you just don't know what it looks like in that office space. I think they should take a virtual tour like a real estate office and literally make them walk the office to show where you're going to work after the first interview. So I think you should dig very deep to the nooks and crannies and then keep fingers crossed and I'm hoping it's gonna work out. Great, great points. Brian, do you have any additional thoughts to the virtual interview process that's gonna face all of us? Smile. I think you need to smile. It projects some confidence and the fact that you're comfortable. You might wanna role play. Try doing it with one of your mentors or one of your attendees you're rotating with and let them interview you because if you're gonna do a cold, it's probably not gonna come off as well. If we're all getting better at zooming and trying to project emotion, but I think that it's harder to do when you're not in person and you don't have body language to help. So practice with a mentor, smile. I think that- Great points. I think what Kevin said is spot on that your job interview process is gonna be very dependent on your mentors, your fellowship attendees and directors. We all know everybody in the country within one degree of separation. So they're gonna call us and they're gonna depend on our opinions of your character because they're not gonna be able to assess it on their own. And if there's one thing that will irk an attending or a fellowship director is somebody who's not a team player. So if you're the person who's in the case, does the cases engaged and as soon as the attending leaves, turns off, all the nurses know it, all the residents know it, the PAs know it and the first person to hear about it is the attending and you'll never know it. So if there's one thing you've gotta do this year is you gotta be a team player because we're in the midst of a global pandemic and if you're not a team player and if you're not doing the dirty work, we're gonna hear about it. And unfortunately, we may not admit it to somebody who is asking about you but we're not gonna come across with a certain passion. Great points. We're running a little bit over but there are a few more questions and I'm happy to see those questions or I wanna field them all. When you negotiate or when you talk about your new job, who particularly is the one you wanna talk to about a contract? Is it the administrator, the chairman? Who is it, Kevin? It's the last person that was hired. You wanna know that the last person hired, what did they not see coming? And there'll be something, that's okay, but to know, so when you're ready and you've read the contract and you've thought, and I'm gonna quote Chuck Bush Joseph, he's a great guy. You need to be able to ask if there's something you want as absurd, I want a motorcycle, whatever it is, you have to ask because they're never going to offer. They can say no, that's okay. But in medicine, we're not used to that. In the business world, they are. And you're the fool, you know. But I would ask the youngest member how they're doing, how long did it take to get busy and are they having a good time? Yeah, no, I absolutely agree. And of course, if you go into an academic job, you will be told that this is a standard contract. There's no such thing as a standard contract, obviously, but in most big academic centers, you'll probably get the same contract that the last person Kevin just mentioned got. And of course, if you're so inclined, you can take a lawyer to take a look over it. Another question is, in the era of COVID, of course, how do we negotiate all the networking? So usually, we would all go meet in Chicago right now and then we meet, and hopefully, we all meet in AOS in San Diego. That would be hopefully a big spot for all of you. But if that's not going to happen for some reason, how do you suppose we do the networking? Brian, what do you think? Again, fellowship directors, attendings, residency mentors are crucial. And 60% of people said that geography was the number one factor in considering their first job. So it's not difficult in this day and age to figure out which the dominant and successful practices are. You just do an internet search. There's gonna be a local academic center. There are going to be large private practices in every city, even a small city will have a big orthopedic practice. So figure out if you know someone, just look at the bios online, figure out where people trained, just put two and two together and create a web and matrix and see who you know that has a contact at that locale. Perfect, Kevin. One other thing, if your fellowship isn't far from where you may want to practice, even if it's a car ride, you will be able to then get in the car and perhaps drive socially distance if you make that arrangement with that fellowship, that job or that thing. That shows a lot of initiative. It's not great, it's not easy. You may end up driving 10 hours where if unfortunately you're in the West Coast and you're looking because you wanted something different to come back to the East Coast, that's a harder thing, but don't put that out of realm. And Megan, I might add to this. One thing that we've done here through the pandemic called creative, when we do a journal club, which we do almost every week, we just called up Brian and said, Brian, can you do the journal club with us because we're looking at your paper and then you can present and then Brian or Kevin or Lutul can hear you present. So, and it's an easy thing. It takes 20 minutes. I bet you, if you call up Lutul or anyone, they hop on a quick journal club. So those little things, you can be creative, I think. And then I have one more question here. So if you end up locking a job down early by fall, the question here is, you may not have rotated with the fellowship director. So how can they vouch for you? What do you think, Brian, what would be your answer there? So you found a job that you've set your sights on and you're happy with it and you need someone to call on your behalf. I mean, I think the attending that you're currently working with would do, hopefully would do an admirable job. If the practice requires the fellowship director to vouch for you, I think that most fellowship directors would be understanding and you should just have a conversation. I think that's ultimately what you need to do in this era is you need to communicate. So you need to talk to the people that you know with the program, explain this is where I wanna be, what I wanna do. How can we get there? Even the fellows at Rush, they get fantastic offers, but it amazes me that every year they don't realize that we are here to advocate for them. Some of our, many of our fellows take jobs because they tell us they wanna be somewhere and we call our friends and figure out who's looking on their behalf. And that can be your approach as a fellow as soon as you get there. Figure out where you wanna be and ask every attending, hey, do you know anyone in this area? We're more than happy to work on your behalf. And probably the strongest referral base will be where you're training or where you've trained. So you gotta leverage that. You can't be shy. And if you're gonna work hard for us, we're gonna work for you. I agree with you. And I think we're, like you mentioned before, it travels fast. So even though you may not have rotated with everyone, everybody kind of knows who you are by two, three weeks and people know. And it's teamwork. It's a big family. The nice thing about AARC is it really is a small family. It's a close community. People know each other. There's so few degrees to all of us. So I wanna thank Kevin and Brian for this outstanding set of presentations and little panel discussion. It was really cool. So we have one last presentation for all of you. If you can bring up Carolyn Hedrich. Carolyn will talk to you about the AARC's Emerging Leaders and Candidate Membership, which is another way how to get into this family. And so Carolyn, of course, is the new Chief of Shoulder at the Brigham. And Carolyn, the microphone is yours. Thanks for being here. Thanks, Volker. So 10 years ago, I was just about to start my fellowship and time goes really fast. So I'm gonna talk to you guys about the Emerging Leaders Program. And this is something that's available for members. And so I'm just gonna go ahead and put this slide up there. Membership for you guys this next year is free. So after August 1st, you guys can sign up for membership. You'll get AJSM and Sports Health and reduced price on meetings. And another one of the benefits is that you can take part in this Emerging Leaders Program. The Emerging Leaders Program is something that's, it's really fantastic that ALSSM has developed to help with networking and leadership. It was really the brainchild of Mike Ciccotti in the board. And they put together this task force in 2018 to try to figure out how to engage younger people, how to develop the next leaders for ALSSM. And that morphed into kind of a committee and advisory board that we have now. Our mission statement is to, purpose of the program is to nurture, mentor, and guide the future of the society, promote leadership. We want to nurture the highest sports physicians for the first society, maximize outgoing benefits to the society for athletes through research and education, and ensure long-term sustainability and relevance of the society through seamless progression of leadership. So who can join Emerging Leaders? This is something that, again, is available to any ALSSM member who's under 45 years old, or who's within 10 years of starting practice. And for some reason, somebody has started practice later. The way to do this is you sign up through the ALSSM webpage at sportsmed.org. You'll go to the webpage, it's under Memberships. You'll click on Membership. You'll see a little red Emerging Leaders down here. And once you get to the Emerging Leaders page, right here in the center, you'll see Get Involved and Apply. And there's some boxes for you to fill in your application. One thing to note, there isn't a Submit button. So as soon as your information is entered, it automatically kind of sends your application or your form to ALSSM staff. So why should I sign up? There's gonna be some great benefits to this program. Everything from fun things like a cocktail hour, the annual meeting where we're working on getting together some great speakers. It'll be your chance to do some networking, have a good time. You'd be eligible for the Emerging Leaders Retreat. We're gonna put together a half-day leadership retreat in which there'll also be additional opportunities to network with ALSSM leadership. We're gonna put together some webinars on topics of interest. And we've just started doing these series at night called Night Caps. And what Night Caps are is there's these informal conversations via GoToMeeting. And the whole purpose is that younger members can then sit around and ask questions from senior experts or younger members that have experience in these areas. The sessions are capped at 25 people. We ask that people share their cameras. And it is really kind of a small group. They're not recorded. You could ask anything that you want. It really is a great opportunity to meet experts in the field. Sessions that generate a lot of interest may be repeated or turned into webinars. We did one last week and it was Kurt Spindler. And he gave a nice kind of question and answer session on how to get started collecting outcomes and doing clinical research with kind of some background in participating in multi-center trials. And it was a really great session. We're talking right now about doing kind of topics in several areas, you know, for sports coverage, like how to start covering high school or college sports teams, how to get involved in Olympic sports coverage. You know, a lot of us go to these fellowships and these things are in place, but how did they, you know, how did they get into place? Like what was the process for finding those? Because you might go out into a job where you don't already have high school teams or if you want to do Olympic sports, it's actually not that difficult. And so kind of getting some insight from some people who've been very successful at this, you know, practice management, how do you best utilize your PAs in clinic? Research, you know, how do you do clinical research? How can you get started in basic science? If you want to do research as a private practitioner, a lot of, there's a lot of experts within AOSSM and industry, you know, how do, if you want to get involved with industry as a consultant or if you research, what's the process? Do you just go and ask? Who do you have to know? You know, questions like that from some people who've been very successful. And also just in general, opportunities to get involved in AOSSM from some of our AOSSM leadership. We have a website that's up. We've just kind of started it. It's going to be continually evolving. On the website, there's other, going to be the upcoming events will be announced and that'll be including, like I said, the cocktail hour when we have the application up for the leadership retreat. All of those things will be announced on the website. We're going to post and save all of our sports medicine articles, update articles. The first one coming out is we have kind of an overview of the, excuse me, of the committee and what we're doing. And these are going to be the topics as we go throughout the year. There's a whole section on how to get involved and AOSSM has been really fantastic. It's a great way to network with your peers. It's fun, it's stimulating. You learn a lot. I've gotten a ton out of being a member of AOSSM. And one of the ways to really get involved, which is really rewarding and interesting, is to get involved in committees. And they're actually not hard. There's a call for committees that comes out in the fall to kind of further showcase the commitment that AOSSM has. They've actually added some additional spots for residents and fellows onto the committees. And there already was spots on the committees that were for members under 45. Those existed previously. So they're really trying to get the young people involved. You can volunteer to be on the Council of Delegates. The Council of Delegates, there's members from every single state and you can kind of volunteer to be the representative of your state. AOSSM has an awesome traveling fellowship. If you want to get started in research, they have young investigator research grants. You can get involved by being a journal reviewer. And the board has two members under age 45 as well. So that's another great opportunity to get involved. We will, again, on there have some webinars, topics pertinent to starting practice. Our first one is gonna be a webinar that again addresses some of the issues on how to get involved in covering sports. And the difference in the webinar and the nightcap is the nightcap is there's not gonna be a planned presentation per se. It's more just we give the expert a chance to just say something for a couple of minutes and then people get to ask questions. Where the webinar will have more of a set schedule and more speakers will be recorded. It'll be a little bit more formalized. And so even though they're gonna cover some of the same topics, they do think they each have their own purpose. There's also some resources on the website now and there's some recommended books on leadership. There's some great books on negotiation. One of them is called Never Split the Difference, some other leadership books. There's some TED Talks and also some websites which can be helpful for certain people. So we really do encourage you guys to check out the website. We just brought it up and so in the coming weeks and months we'll continue to add to it and make it better and better. If anyone has any questions, I'd be happy to answer those. I have my email addresses both on the screen. The easier one to remember is just my first name dot my last name at Gmail. And I'd be happy if anyone had any questions about the committee or getting involved to answer those now or to via email later. Thank you. Great, thanks so much, Carolyn. This was a great overview and Carolyn, of course, is the chair of the Emerging Leaders Program and there's a new program which I think is super exciting and you should all try to get involved in that and many of the other programs. So with that, be a little bit over time but I think it was well worth it because it was a great program today and of course the last two days. I would like to thank Meredith Herzog. You know, we can't say it enough because you run this show so tight and so awesome. It's easy for Brian Lutul and I to just jump in and look like we're organizing this. We're not, you are. So thanks so much. And all of you on the phone, thanks for staying with us so late night, have a great year, just enjoy it. I said it on the first night and I say it again, lots of changes, lots of things will be thrown at you. Just be flexible. It will be fine because we're all in the same boat and this is one big family. Welcome to it. And I let Lutul and Brian wrap it up and have a great rest of your week and see you soon. Yeah, absolutely. Thanks Volker. Well run, thanks tonight. To all the fellows, it's exciting time coming up and this is the most amazing year for you no matter what it looks like with COVID. You spent the last five years doing some things that you may have loved and some things that you may not have loved so much, but this is a year where you learn nothing but sports medicine and take it all in. It's a great time because this is what you'll be doing for the rest of your life. And unfortunately, this is the group of people that you're gonna be associated with for the rest of your life. But it's a small world when you see any of us out and about. I know a lot of you from interviews, but for the people I don't know, if you see us out and about, please say hello. Just introduce yourselves and if that's what kind of organization this is. I've had a lot of people who have helped me along the way and it's been my honor to give this conference and hopefully we'll be back in person next year to do this. But I think this was great because I think we got the message out to a lot more fellows in this virtual format. So thanks for being involved. Cool, Brian. Well said Latul and Volker already. Just to echo some of the sentiments. Thank you so much, Meredith. You are the glue that holds us all together. You guys are gonna have a spectacular year. I think Mark Miller, a former Pittsburgh fellow, said it best about that year he spent, which was the longest decade of his life. I think what he meant was that the experiences that he had were so memorable that they could have filled a decade. And to this day, I can still remember Freddy barking in on one side and 30 people watching me screw up an operation on the other. And it's a special time. You guys are gonna love it and just cherish it and hone your skills because it won't be too long before you get the chance to do it on your own. Great. All right, everyone, have a great night. Good night all. Thanks, guys. Thanks, Meredith. Thanks to the AV team. Thank you.

AOSSM virtual fellows course

collaboration

third night lineup

biologics

hip orthopedic injuries

live surgery demonstration

sponsors

social media

principles

considerations

choosing a job

building a career

work-life balance

networking

healthcare landscape