Mike, Guillaume. Got the next slides pulled up too. We did get a question from the audience about how best to measure acetabular retroversion on the CT scan. I think three-dimensional CT scans can be really helpful because you can have undercovers in the back and overcovers in the front and you can get a really good gestalt by doing a 3D rendering. So any other comments about how to measure a 3D, or how to measure acetabular version on your CAT scans? Okay. Gonna do some good cases here. So this is the 16-year-old football player, high school kid with a right anterior hip pain for about six months. He's now unable to pitch. He's a elite pitcher. He also plays football and basketball. He has a neutral foot and knee progression angle. He flexes on his right hip only to 80 degrees, internal rotation zero, external rotation 45 with a positive impingement test. We're kind of looking at this weird lateral rim here and we have, these are lateral center edge angle and we measure maybe 50 degrees to the edge of that rim and 24 degrees to the origin of the rim fracture, I guess you'd say. Some more imaging here. A dunn lateral, frog lateral and a false profile show a large subspine on the right and a moderate to large cam deformity that wraps around the front, as you can see with the frog lateral. So 3D CT scans, I get these in all my operative patients that are undergoing surgery for FAI. MRI showed a labral tear. You can see this large rim fracture here that looks like it's maybe partially fused in the back and kind of fragmented up by where it blends in with the subspine region. So, who's using, anybody using fear index now to make decisions about borderline hips or hip stability? This guy does not have an unstable hip but his fear index is converging laterally so a little worry there. Femoral version's 11 degrees. So Stephanie, how are you gonna manage this kid's rim? He's failed a conservative treatment. He's got a painful hip. He actually broke his humerus when he, like the week before I saw him so he had like 12 weeks totally off to do hip surgery. So, hip surgery with a broken humerus. Yeah, I think these are hard to sometimes decide what to do. I think with this one being partially fused, I think you can make the case for sure for sort of doing an acetabuloplasty and I've been actually pretty happy with more of actually a suture anchor based repair of these versus screws more recently. But I think assessing interoperatively if it's loose, obviously that's gonna make a big difference in how you might incorporate it. But I think I would probably do some rim trimming to sort of decrease the volume of the fragment, get your sort of lateral center edge angle in all locations back to what you were wanting. And then if it was still a relatively small piece, I think doing sort of a suture bridge technique really and incorporating interior laboral repair has been a helpful technique. But otherwise I think this screw fixation can also be utilized. I would hesitate to take it back all the way, especially if it was a really large portion of the weight bearing zone for sure in that lateral aspect. I mean, you are taking it back to about 24 degrees of lateral center edge and some anterior coverage too, but the kit is a pretty stiff hip. So, Bamfy or Guillaume, do you guys use that femoral version or fear index to kind of convince yourself that you're not gonna make this kit unstable? Well, I think that you... You hear me? Yeah, I think that using the fear index could help you, but I wouldn't be so concerned about it. And I wouldn't necessarily even use the fear index, just looking at these x-rays and looking at his history. He's got a stiff hip. I'm not so concerned about 24 degrees with regard to a male athlete bringing him down to that. So, I think that if it's unstable, I certainly would probably just resect it. And I've found that if you start doing a rim trim and try to put the screws in, then you don't have a lot of bone to have that purchase and then you can crack it and then it turns into a big disaster. By the way, is he right-handed? He broke his left... I think he's right-handed, yeah. And did this hurt him while he was pitching? So, it was a dry blade? He missed about half of last summer pitching because of his hip. That's the other thing that we talked about it yesterday in our fellowship symposium. And I typically will see that, that's the symptomatic leg, but it doesn't make sense to me. I don't know if any of the panel agrees with this, because they should be opening up instead of impinging on themselves. I mean, the data would suggest that it's the plant leg, but I actually more frequently see it the same side as their dominant arm. So, switch their side, it hurts. Okay, well, we actually proceeded with a complete rimmer section here. I convinced myself he was stable with his stable femoral version, the sphere index. We did AP camera section, as you can see here. Two o'clock camera section, as you can see here. Label repair, refixation, corrected his offset. So, it was pre and post rimmer sections here. So, I mean, basically creating maybe borderline dysplasia, but in an otherwise very stable appearing hip. So, he returned to basketball at five months post-op. He'll have his year follow up this fall, but at his return to sport testing at five months, his hip outcome score is 100 for sports specific subscale. So, good early, but long-term is probably unknown. This is a little bit more of a controversial case. We'll start before Dr. Banfi. This is a very large rim fracture, probably involving more of the weight bearing surface here. Doing some simple measurements here, maybe 10 degrees or eight degrees if you resect the whole thing, and a pretty substantial piece if you leave it alone too. This is Larson's case. Mia, any thoughts here? Yeah, so unlike the last case, this one I would be concerned about instability just looking at that AP radiograph. If you were to remove a significant portion of that, and it looks like it might be mobile, although obviously checking in the OR is your best test. So, I would be prepared to fix this one, although that can be very technically challenging. Gail? Yeah, I agree. This is one where I'm definitely a little bit more concerned. I wouldn't take the whole piece out. If you're someone who's gonna put screws into these, this is one where it might need it. It almost looks like he's starting to get a little bit of degenerative changes more laterally under that piece as well. Still decent joint space though, but I think addressing the cam here is really, really important because it's probably what's continuing to press upon that piece. I think it's really important. Lars, any tips for us trying to do, these are your long, these are your 4-0 canulated screws? Yeah, I mean, I think the key thing here is you wanna have a long guide wire. It's hard because if you just have the guide wire over that screw, it's so far in, you have a hard time controlling it. So, I like to use a long depth gauge to kind of put in there with it to kind of keep good control while you're drilling the guide pin in. But other than that, I mean, I think Stephanie's right. I mean, you could argue that if you just take some of this down and leave it, will it heal if you get rid of the impingement? I could argue that I could leave more there for sure, but I think the bottom line is you kind of see where the cartilage looks normal as you're coming down and you're just kind of visualizing it. And then ultimately, you think you've left enough and then you start securing it with the screws and everything compresses down a little bit. So, maybe one thing is leave a little bit more than you think, but the problem is you only kind of get one good shot to put screws in there. You can't like redo it. So, I think you're left with what you have, but I was happy with how it turned out. He's several years out. He's doing great. He was a division one basketball player and he's finished up college and done well. But I think the key with these is the impingement, the femoral side impingement is hard and you need to get around the vessels. And if you correct the femoral side and impingement, I think that's the key because it won't stress that fragment and that's why you could probably take or leave fixing that fragment. I just have a hard time leaving it. Chris, do you have any pearls for the audience with regard to how to get that long guide wire? Because most of the time you get this foot and ankle set that has these tiny little guide wires. Do you mix and match or is there a particular company you go with? Yeah, so I can't, Nick's in the back there. He's the rep who works with me, but we have a company who comes in with the screw and then they just bring in that same side guide wire that's this long. I never know where anything's coming from. I just know what I want and now that they know it, I don't even know what it is. I look at it and I'm like, this is the right one. So I can't help you there, sorry. You can get burned. You have to plan for this. Yeah, for sure, yeah. I think Dr. Mayer might have said this earlier, but I've really turned to using suture anchors on these as well because I think as well when you decompress the can, it helps offload that. And I think the fixation with the long suture anchor works pretty well too. Have you guys noticed any lysis in the rim fractures, fixing those with suture anchor or suture bridge fixations or? With screws, I mean, I've really got x-rays on most of these after they've healed and they heal up well and I've never had a hardware problem with them. So I think it's really a matter of how much bone do you have left? And if you have good bone to purchase, then maybe you put the screws in there. And if you're starting to worry about the size or the thickness of that bone, I think it's totally fine just to, even your suture anchors, right, for the labrum are gonna secure that and pull everything back down. And I kind of move it. If it's not moving a whole lot, I don't think you have to put screws in there either, but. This probably isn't the first hip I would schedule two weeks out of fellowship. Yeah, we actually did a systematic review on these rim fractures a year ago and there's actually more technique articles there are than published cases in the present literature. And Robbie was right on this one. This is actually, this one had a huge subspine component you can see on that AP. So like every part of this case was like highest level of difficulty for me. So you just gotta be patient and you definitely need to put traction on when you're doing that femoral resection at the end too. Yeah. Good tip. We're a little bit, wanna do one more or? Wanna do one more case? All right, we'll do one more. All right, Mike, you wanna do your. So we're sticking with the 21-year-old male Division I basketball player theme. This is a revision of mine, right? So I have no disclosures with regard to this and my thought process behind this was to kind of ask the question of why do these kids decompensate? Because we know that there's a huge amount of cam morphology in these athletes that are completely asymptomatic. We see it all the time in the combine. And is it a rim fracture that just occurred or it became unstable or is it something else? So this is a 21-year-old male, D1 collegiate basketball player. Always said he had these tight hips, little bit of limited range of motion, but it never really bothered him just like most of our athletes. But then something happened. So he came down from a rebound, had this twisting injury and then it became intractable where it wasn't just unable to be playing basketball but he was limping at this point and he couldn't walk comfortably. So he was working with his trainers. They did a variety of different soft tissue treatments and whatnot. He didn't have any injections when I first saw him. And on his exam, he's this pretty tall guy, 6'7, 205. That's not him on the right-hand side. That's my old PA. But he had a pretty reasonable exam, classic of what you'd see with FAI. It wasn't really anything out of the ordinary with regard to his pain that was elicited with the impingement test. But he certainly did have a positive impingement test and no signs of a fracture or anything like that. And so these are his radiographs. It's the right side that is symptomatic. And I would say on that done, it seems that he does have an asymmetrical CAM lesion which I don't think is the most common thing in the world. But really nothing else aside from some rim sclerosis bilaterally, but maybe more on the right than on the left-hand side. And this is his MRI. The thing that I thought was interesting, on the right-hand side in that sagittal view, you can see the labrum tear obviously, but the edema, that's what I thought was really surprising. And I've seen this since then and it's made me a bit more aggressive. You know, you can't really tell if there's any sort of cartilage issue just aside from that labrum tear there. So, you know, as far as the panel goes, what would you guys want to do next? Would you want to get further imaging, CT scans, some sort of esoteric MRI protocol, something like that? Gil? Yeah, I think since this is second time around for him, I think CT with 3D reconstruction certainly makes sense. You want to look for the common things, so residual FAI morphology. He does look like he's got some. This is a primary case, he never had surgery. Okay, well I'd still do that. Looks like he's got some FAI morphology, so look for the common things. That subconjunctal edema though, that hip's starting to get in trouble and sometimes that's trouble that we can't always make as well as we want to, that horse is a little bit out of the barn. But I don't think that other than the CT scan, any other additional imaging. Robbie, would you do any kind of injection first, a diagnostic or therapeutic? In these no-doubter hips, as we called them this morning, the only reason to do a diagnostic injection in the hip would be to rule out a component of sports hernia, athletic pubalgia, trying to get a sense of how much his hip versus core muscle. Didn't sound like he had much of that in his presentation. Other things, if it's like mid-season, you want to get him through the season, an injection of your choice might be an option, but it sounds like he's pretty miserable now, and I think if it's no-doubter like you're showing, I'd probably just go forward with the scope. Also, Mia did publish a paper last year showing that the edema and acetabulum is like the most sensitive thing to predict a chondral injury in acetabulum, so that's an arthroscopy journal, I think. I usually agree with that, but I would inject this guy because this seems weird to me. I think you may end up operating on him, but usually you're seeing somebody with kind of this recurrent issue, they're still able to play their sport, but this guy was just tight, had an episode, then all of a sudden he can't walk. So this is kind of weird, so I'd love to see that an anesthetic-only injection, is he walking normal? Is this one of these cases where if he's still struggling after an anesthetic, even though you think it's kind of a straightforward slam-dunk radiograph, you might want to give this time to calm down and see how it plays out before you actually jump into surgery, because this is not your typical presentation, so I've got sort of question marks going on with this presentation, and I would start with an injection, and I wouldn't be too aggressive jumping into surgery right away. Anyone else? I would tend to agree with that a little bit as well. I'm not, I think with an acute injury, with that bone edema, you could also question whether he just is having kind of bone bruise symptoms, which may be what you're alluding to, and it could certainly be from cartilage, which I think is maybe what we're getting at, but I might consider letting it calm down a little bit for a little while before jumping straight into surgery. So it had been two months, so he did have some time with that, and I did actually do a local anesthetic-only injection, and it did cure his symptoms temporarily. But this, you know, we're doing a talk here, so this would not be fun without surgery, so clearly, we did some surgery. And these are his findings, so pretty significant chondral delamination there on the S-type of the rim. We went ahead and debrided that, and I was, you know, tempted to leave that alone, but it's one of those cases where it just started peeling back, like the orange peel, and I repaired his labrum, got a good suction seal, dealt with his CAM lesion. I did take some cartilage from this prior to potentially use for implantation on the acetabular side, so once I've done with the labrum and the debridement of the cartilage, then I dealt with the femur, then I actually put traction back up, and then I did microfracture it, and in my hands, when it is a large area of microfracture, then I will use some sort of adjunct, and in this case, I utilized his autocartilage as well as a mixture with some allergenic cartilage as well. There's your final pictures there, and you know, just like all of the cartilage literature in the hip, we really don't have a lot of data on this. You know, it's just mini case reports. Travis Mack did show that the cartilage cells in the femoral head and neck junction are very viable, so you can utilize them, and he has published some techniques on this, but fortunately, he did well. The interesting thing is his edema in his femoral head, this is a six-month-out MRI, or excuse me, the edema in the acetabulum completely resolved, but then he started getting some edema in his femoral head, which was completely asymptomatic, but he actually played two seasons without any issues with his hip. He did have patellar tendonitis and an ankle issue, which may have helped his hip, but that's it. Yeah, Lars, are you gonna manage that differently than that, or you know? I mean, I think that's great, but I will just say that, like, over the last 10 years, whenever I see those flaps that keep going and going, I don't ever remove that articular cartilage, I just haven't, and I was worried, like, is this gonna work, and I would just curette behind it, microfracture behind it, and if you do a great CAM resection, I think the femoral head pushes that back to the acetabulum, it's not gonna cause the shearing stress, and I've never had to come back in and readdress anybody after doing that, so I would've left that articular cartilage rather than take down the unstable part, unless it's, like, a big parrot beak hanging on by, like, a small piece of cartilage. So, it wasn't hanging on by a small piece, but there was significantly a large area of damage, and then when I started debriding that, then it went a little bit more, so I curetted that to have stable borders, but the edge of that area that I put the cartilage in fiber and glued, it still would be unstable. I could've gone even further. Yeah, yeah, yeah, so that's the only thing I'd say, is that your tendency, I always used to remove the unstable fragment, and so my tendency has been to be very conservative and just try to leave that cartilage, let the femoral head push it back, sometimes put traction on, look at it, but I would just say that's maybe the one place in the entire body where that cartilage might actually seal back down, so take less than more is all I'd say, but I think it looks great. One question, just to, that's obviously a very big lesion. Probably more commonly, what you'll see is obviously a smaller area along the periphery where the labral tear is, and I think earlier on, I was doing more microfractures on some of those. I'd be curious to see what everyone else is doing. I've started doing more chondroplasty, just sort of benign neglect, leaving it alone if it's a smaller periphery. What's the rest of the panel doing? Yes, likewise, I've really turned away from microfracture recently based on more recent data, I think, showing the outcomes there, so I'm much more conservative now. I would agree with that as well. I think the hard part is, like Chris was saying, you start debriding it to do a microfracture, and it starts as five millimeters deep into the acetabulum, and all of a sudden, the whole thing could come off if you wanted it to, and so I think if you're going to try to sort of do less is more, and just do it along the rim, but I agree, I've kind of tried to just leave the flaps there, and as you do the camera section, hope that it just will kind of peel back in. If it's big enough to measure, like you can put a probe on it and measure it, and then I'd do a microfracture. Yeah, and I think that also we've gotten so much more conservative at, you know, recognize these early degenerative hips that if you find yourself microfracturing a lot, you're definitely operating on the wrong patient population, so that's totally different. That was probably some sort of injury, but I don't find that I'm microfracturing hardly ever in my practice. I agree, it's very rare in my hands too, but I think that the ultimate, or the best case scenario for me on those ones you're talking about, Guillaume, is where you debride it a little bit, and it's not full thickness, and it does seem like it stabilized itself, and then you're happy. And good FAI correction, because if you don't do that, then none of the rest seems to matter. The last thing I wanted to say, we were talking about before, you were talking about the pitcher. All of these young male athletes have limited internal rotation, and internal rotation is not what ends up being predictive. Decreased internal rotation doesn't really end up being predictive of the developing symptoms. If you look at these athletic sports-related studies, it's decreased external rotation, and I think that's still related to the CAM, and I think what happens is, because you're limited in internal rotation anyway, if you start to lose external rotation, you lose your window to play. And so I think these athletes that start losing external rotation have nowhere to go anymore, and I think that's the most predictive thing, is over time, as they hurt, they'll start to actually restrict more, and they'll actually have decreased external rotation, which may be why that same-sided hip, as he's going back, if you're limited, look for that in your practice. If you see a loss of external rotation, that tends to be the person who gets into trouble. It's kinda interesting. Awesome. Yeah, that's great insight. I'd like to thank our experts for contributing to the panel here, and I'd like to thank everybody for showing up for the four o'clock session. Again, we had a really well-attended hip session two years in a row at AOSSM, so thank you to all of our panelists. Thank you.

hip injuries

panel of experts

3D CT scan

surgery

chondral delamination

treatment options