Thanks. I'd like to welcome Dr. Brian Biscone from UMass to the podium. Dr. Biscone is a veteran of this meeting and he always gives a very animated and energetic talk on hip, thigh, anything else? All right. And pelvis. All right. Good afternoon. Some disclosures. One, I do come from Boston, so we're missing some of the alphabets in the way we talk. So I apologize for that up front. Two, very easy to follow my talk. Everything that is in yellow is a testable portion to this. So as you're going through my talk, everything that's yellow, it should be easy to follow along with. There are 56 questions in your handout. I even think I threw in some more this year. More than enough questions for you to do later on tonight. We cut back our talk a little bit to hopefully have somebody else come on. So it's a little bit shorter than it normally is. And I'm happy to answer any questions in the back about the hip, pelvic, and thigh. So without ado, I have nothing to financially disclose. I have to thank Bruce and Chris very much. And it's just a pleasure to the staff at AOSSM. They're the ones that do the great job of putting this meeting together. If you have any problems, please contact me. And again, all this is in your handout. I'm going to give a general overview about hip, pelvic, and thigh injuries in the athlete, talk about the joint, soft tissue, bone, nerve, and arthroscopy-related pathology. As you know, the hip joint is made up of the acetabulum as well as the proximal femur. And really, the only questions that I have written and I have seen on the test have to do with the neck shaft angle of the femur affecting and how it can predispose to femoral neck stress fractures. So a decrease in your neck shaft angle or version can predispose to those types of fractures. When we're thinking about the hip joint now, we're thinking about compartmental anatomy. Obviously, I began my practice in the early 90s. And at that point in time, we talked about the hip joint. Well, now we talk about compartments. And when you're thinking about these hip questions, you need to ask yourself, are they talking about the central compartment, which is the articular surface that we think about with the hip joint with the labrum and pincer deformities, the peripheral compartment, which is where the capsule comes over, and that's where you're thinking about the femoral neck and CAM lesions, or are they talking about a peritrochanteric or a different soft tissue compartment, greater trochanteric spaces, snapping syndromes, gluteal tears? So when you're reading the questions in the hip, take a look and try to figure out what compartments. And I'll help guide you with some of the symptoms for those questions. So the hip joint, again, is a highly constrained joint. It's less mobile than the shoulder. As a result of this stiffness, it makes entrance into it more difficult. There's only one thing that you need to know about the capsule in the hip joint. It's made up of three structures, the iliofemoral ligament being the strongest one. And if cut, the hip will rest in increased external rotation. So there's a lot of literature out there about doing capsular, opening up the capsule to get into the hip joint, not closing it. What we're finding afterwards, these people were resting in a lot of external rotation. So very common hip questions you may get on your examinations. I know that question is in some of the examinations. The other important thing about the hip capsule is that it's taught with extension and external rotation, and it's lax with flexion and internal rotation. So that when we go into the peripheral compartment in a hip arthroscopy, we flex and internally rotate the hip, giving us room to go into that peripheral compartment. So those are the two important things that you have to worry about with the hip capsule. The labrum, we'll talk about that a little later on. Anterior, it's at its widest, and superior lateral, it's at its thickest. The function of the labrum is to help with joint congruity. It deepens the socket, increasing the articular surface area and acetabular volume. It enhances stability and resists motion and helps out with proprioception. So it functions in all of these things, and the treatment we'll talk about a little bit later on. Remember, neurovascular structures, Dr. Su just gave a great talk about that, that the hip joint is innervated by L3. So always remember the back when there's a hip question, just to pay attention to that. Anterior neurovascular structures, lateral femoral cutaneous nerve is a nerve which is frequently asked on in tests, and it exits under the inguinal ligament, and it becomes very important in terms of arthroscopic portals within the hip. So if you think, if there's a question about arthroscopic portals in the hip, remember, it's usually the lateral femoral cutaneous nerve that they want to talk about. Posterior neurovascular structures, we'll talk about in the nerve section. Femoral head blood supply in terms of test activities, the lateral ascending branch of the medial femoral circumflex artery is the majority of the blood supply to the femoral head, which is something that you have to know. Hip range of motion, flexion, extension, abduction, adduction in our practices, we see this oftentimes. But in terms of test questions, what they're going to ask you is about patients that have decreased flexion and especially a decrease in internal rotation. So patients have pathology in the central portion of their joint when they lose internal rotation. Soft tissue injuries around the hip joint, bursitis, snapping hips, core muscle injuries, and hernias we'll talk about. Remember, bursitis is a result of repetitive friction of nearby muscles and traumatic injury to the surrounding tissues. Greater trochanteric bursitis deals with the iliotibial band over the greater troch. The extrinsic and intrinsic factors that cause that include wide pelvis, leg length discrepancy, excessive foot pronation, and activity or banked on uneven surfaces. That's a very common test question to ask, what are the etiologies behind greater trochanteric bursitis? Treatment, again, for most of these things is conservative as a first line of treatment. Ischial bursitis is common with hockey players, figure skaters, distance runners, and these are pain in the ischial tuberosity in the posterior aspect. Now with newer endoscopic techniques that we can go in and take care of these lesions, the likelihood of you getting asked a question about that is extraordinarily small, so don't worry about it. What you need to worry about is whether or not they have pain over the ischial tuberosity and is there something going on with the hamstring tendon. Iliopsoas bursitis, we'll go into that a little bit later on, but remember, snapping iliopsoas tendon is something that you can hear. It's an auditory problem, so when the test questions, if it's the psoas tendon, they'll say an audible click. That should be your immediate response, should be the iliopsoas tendon and the hip joint. Snapping hip external is the most common, which is the iliotibial band, gluteus maximus over the greater troch, internal is iliopsoas, and intraarticular is very rarely discussed. So internal snapping hip exam is elicited by abducted, externally rotated, and flexed to an adducted, internally rotated, and extended position. The patients will talk about a large clunk and they can quote-unquote hear it dislocate. So that's for your iliopsoas tendon and you can see the patient in this bottom picture here is actually showing me where it's, where she feels her hip is dislocated. External snapping hip is again, the iliotibial band coming over the greater troch. It is the OBRA test. The affected leg is always up and you want to abduct, extend the hip, and flex the knee, and that the patient cannot AD-duct across midline. So you want to pay attention to the question that the patient can't adduct across midline, or the patient comes in and says they can visibly move their hip and dislocate their hip joint. So again, the external snapping hip examination is different because they can rotate their hip and that's what they feel is the dislocation in their hip joint. So visual is external, auditory is iliopsoas. Imaging again, you can see this, and ultrasound has really become a part of all of our practices. The new tests that are coming out actually will have and begin to have more and more video on them. So you just need to be understanding if this is a hip joint and you're looking at this, it's not a near-term child. It is actually the hip joint that they're showing you here. Conservative management is recommended for internal and external causes. And again, avoiding aggravating activities is used the best form of treatment and local corticosteroid, or PRP, or whatever biologics you may want to put into that area. Treatment, if you're going to take care of this arthroscopically, is the psoas release. And in general, the psoas release is done through the central compartment and it's a capsule artery between the anterior labrum and the femoral head. The structure that runs at that area is actually the beginning of the zona orbicularis, which is part of your anterior capsule. And when you think about this, it's a 50-50 rule. The reason why we release at that mid-portion is because 50% of the psoas tendon at that point in time is tenonous and 50% is muscular. So you're only releasing half of the psoas, whereas if you're near the top of the acetabulum, it's more, and near the lesser troch, it's all tenonous. Treatment for external snapping syndrome can be done open or through endoscopic releases. And again, it's very rare and they won't ask you that question whatsoever. Gluteal tears, the rotator cuff of the hip joint, the key one that you want to focus on is your gluteus medius. It can be combined with the gluteus minimus, but it's mainly a question about the gluteus medius at that point in time. It's usually going to be an athlete in the sixth or seventh decade, female greater than males, positive exam findings, weakness with hip abduction in a Trendelenburg gait, pain with resisted abduction and tenderness on the superior lateral or anterior facet of the greater trochanteric area. So remember, this is all about anatomy with the gluteus tendens, okay? Trendelenburg, again, remember the pelvis drops when the contralateral foot is lifted off the ground. So it's actually as a result of the, when you lift that foot up, the pelvis can't stabilize because the opposite leg is weak. And you basically just want to know this anatomy. This slide in my handout is excellent. It makes it really easy. The gluteus medius is the superior lateral facet. That's basically the only question you're probably going to be asked. Muscle testing, again, the gluteus medius exam is hip abduction, extension, and external rotation. The gluteus minimus is abduction, extension, and neutral. And the maximus is done usually, I do this as well, is in a prone position. Gluteus teres often respond to conservative management. That should be your first option of management, no matter what the tere looks like. Recalcitrant cases are candidates for surgical intervention. And there is no study out there saying open or endoscopic surgery is more superior than the other. So you can do either forms of treatment to take care of this, if indeed they go down the path of any type of surgical intervention. More than likely, they're going to comment about the Trundelen Brigade. Contusions are the most common athletic injury that we'll see as sports covering physicians. And the general treatment for these is to symptomatic treatment until the athletes can feel better. Hip pointer or hematoma over the iliac crest is the ones we see most commonly in sliding sports or football. And return to play is once full motion and strength has occurred. Quadriceps contusion is a commonly asked question on these exams. And again, the key to that is that you want to immobilize the patient after injury inflection to maintain their range of motion and to decrease bleeding. So again, if they ask the question, you're covering physician, the athlete's going home on a bus, what position do you want the leg in? It's in a flex position on the way home on the bus to help decrease bleeding and maintain their motion. Myositis ossificans, as you know, are areas of deep soft tissue injury and hematoma where calcification can occur. What's important is that we get these x-rays and we see the myositis in there. However, your treatment is not based upon your x-rays. Your treatment is based upon the clinical findings. So if the athlete feels good regardless of what the x-ray looks like, you let them return to play. Again, clinical findings is key. Muscle and ligament strains, when do they occur? They occur with a violent eccentric force. Again, the key to this whole thing is eccentric. Muscles that cross two joints are more susceptible than just a muscle that goes across a single joint. So when you're looking at a question and they say, what is the most muscle likely to tear in X athletic event? Well, first of all, it's eccentric. And secondly, it's one, it's a muscle with which crosses two joints. For example, adductor longus is the most common one that you can see in ice hockey soccer players. It also is associated with this term of athletic algeria, sports hernia, Gilmore's groin core muscle injury. Okay. So we'll talk about that a little later on, but the adductor longus is the most common adductor muscle to get injured. External oblique strains occur with forceful contractures when the trunk is forced to the contralateral side. Interesting enough, a recent question had to do with what Dr. Su just talked about with the fact that was the athlete having an external oblique strain or was he having a pars injury on the opposite side. So you just have to think about where the athlete's having pain and where they're pointing. Hamstring injuries, non-surgical management, are single tendon avulsions with retraction less than two sonometers. Okay. Surgical repair for single tendon with greater than two sonometer retraction or any three tendon avulsion, oftentimes with greater than five sonometers of retraction. They'll oftentimes show you an MRI and the test questions and basically if it looks really huge then you know it's something that you need to fix. But it's two sonometers is that cut off. Rectus femoris strain is the most commonly injured quadriceps muscle as the reflected head crosses two joints. Again, MRI findings will show this, but more and more we're using ultrasound as a diagnosis, not only on the field but also in the office. And again, you want to just watch out for that. Watch out for what type of tear they have and everything is based upon symptoms. What about these hernias that we hear and we talk about? Core muscle injury or inguinal disruption. These are injuries with which the athletes will complain about pain when doing exertion. So the athlete's going to come in, I have abdominal pain when I start up my running or when I'm playing. And the pain is in general, when you're reading the question, the pain is above the symphysis pubis. So when the pain is below the symphysis pubis, you've got to entertain. Is this a question about the hip joint, the adductor tendon? Where are they going with this? If the pain is at the symphysis pubis or above, they're leading you into an understanding of a core muscle injury. And these will be either tears of the adductor longus or the rectus abdominis. These injuries usually occur as a result of hyperextension and or abduction. And on physical examination, they'll talk about tendinous palpation in the peripubic area, the adductor area, pain with firing of the rectus tendon or resisted adduction. They'll say that they have difficulty doing sit-ups and that the neurologic and the hip examination are normal. That's key. Imaging, what you're taking a look for is to rule out most everything else. There are new protocols out there showing tears of the rectus tendon, both in sagittal and coronal planes, but that is not something that you're going to be asked on. Treatment algorithm, again, is conservative, conservative, conservative. If that does not work, the treatment is usually to repair that poster wall of the inguinal canal, either open or endoscopic. There's been no a study out there showing the effectiveness of one over the other. And in general, they're really not going to get into the surgical management. It's more about the diagnosis that this is a problem, secondary to having a core muscle injury, athletic rubalgia, or sports hernia. So questions, again, I'm not going to go through all the questions. You have plenty of them, but we'll go over some of them. High school running back takes a direct blow to his anterior thigh by another player's helmet. You evaluate him, soft tissue swelling over the anterior thigh. Due to a severe quadriceps condition, he is unable to continue to play. What should be included in his initial management? And I think Dr. Kading is going to give you the 15-minute review as to how to take these tests at some point in time during the course. We've all given that talk. It's sort of been like a torch that's been passed on to everybody. And again, what you want to do is take a look at the answers and come up with the one with which in the back of your mind is probably the best one. And again, you want to mobilize the knee in 120 degrees of flexion. Which of the following best describes athletic pubalgia or sports hernia? Again, you know that this is going to be something that's painful above the symphysis pubis. So as you're looking down, you can see that lower abdominal and adductor pain is probably the best answer. The injury mechanism postulated as a result of athletic pubalgia or sports muscle hernia is extension and abduction of the leg. What is the most common adductor groin strain? It's the one which is the largest across these two areas, the adductor longus. Most common quadriceps tendon, again, is a result of knowing your anatomy, rectus femoris. What type of muscle contraction force is leading cause of most muscle strains? This is another test question. And again, that was the answer we saw in our slide, eccentric. Initial treatment of myositis pacificum should be guided by which of the following primarily? Again, all of them are pretty entertaining, but the one that matters is clinical findings. 20-year-old college football running back sustains a hip hyperflexion injury during the game. You plan operative intervention. The MRI is shown in figure 14. Which of the following are you most likely to plan for surgery? So again, I usually go through these things quickly before I look at the picture. You know, he didn't talk about lesser troch. He didn't talk about rectus. You know, so now we've got semimembranosis, so we've got some hamstring stuff going on. There's the picture. And again, they're not going to make this subtle, right? It's going to be a large irregular looking tear in the back and the hamstring area. So you know that we want to have anything over two centimeters of retraction. The majority of the rectus femoris strain involved what portion of the tendon? Okay, and it's the reflected head as that's the one that's crossing the two joints. During hip arthroscopy a surgeon performs a capsulotomy that we talked about through the anterior and anterolateral portals. The foot rests in an externally rotated position while laying on the bed. What is the most common reason for this finding? The anterior, the largest anterior capsule was cut. A 58-year-old female presents the clinic with refractory left-sided hip pain. She's been treated with physical therapy. She has reproducible pain with flexion, abduction, and external rotation, a positive favor, and has a positive Trendelenburg sign. So again, the key phrase is has a positive Trendelenburg sign. Based on the physical examination findings, what's the most likely diagnosis? Gluteus medius tear. Bone injuries. Bone injuries require more force than similar fractures that occur in the algae, especially in our young patient population that's playing sports. I'm just going to go over a couple of the trauma things that you may see on your exam. Hip dislocations, the majority are posterior and the patients will come in or the patients on the sideline will have a flexed, adducted, and internally rotated hip in that posterior dislocation. These last three things are probably the most important things you need to remember. That the most common complication of a posterior dislocated hip is AVN. The least common complication is for it to occur again. And the morbidity, the increased morbidity occurs based upon how quickly you're able to get it reduced. So getting able to reduce as quick as possible is the best way to prevent complications. Again, post-reduction, you want to monitor them. Rehab, and again, surgery depends upon whether or not they have instability, loose bodies, or fractures. Stress fractures are very common on this exam. And again, these are people that have pain in and around bony areas. In the ram eye, they can be found. In the sacrum, they can find. In the sacrum, it's called an H sign. I don't think anybody really does bone scans much anymore. It's more on the MRI, but you can see that. Femoral neck stress fractures are the key fracture that they most commonly look at for exams. And again, your goal is to prevent displacement. And understanding anatomy is that on the medial side of the femoral neck, this is the compressive side, which is the more stable. And the tensile or lateral surface is the one that's more likely to displace. So remember, medial, we crutch weight there. Lateral, we need to fix. Again, conservative management for all of them except for the lateral or the tensile stress fractures. Operative management, again, you want to place cannulated screws. Avulsion injuries are very commonly seen in adolescents. And the good news is that for the majorities, you treat them in a conservative care fashion. Again, if you get x-rays, you just have to remember your anatomy, that the ASIS is secondary to the sartorius. The AIIS is secondary to the rectus tendon. The issue of tuberosity is a hamstring contraction. Greater trochanteric avulsion injuries are very rare. However, when they do occur, beware of AVN or the femoral head as that lateral ascending branch is very close to this entire area. Lesser troch avulsions is the only one with which moves proximal and as a result of the iliopsoas tendon. Treatment, again, is conservative, conservative, conservative. Apophysitis can occur anywhere along the hip girdle. We have multiple areas of fusions as the athletes get older and you treat by modifying the offending agents. Osteitis pubis is an imbalance of the abdominals and hip adductors. And in actuality, that diagnosis is slowly going away as a result of our understanding of what a core muscle injury is. And the treatment, again, is conservative. Degenerative joint disease becomes very important in terms of differentiating as to whether or not I should throw a scope into someone's hip joint. At what point in time are we actually causing more damage in these athletes? We know that impact activity increases the risk of DJD, especially time on the hip. We know that by looking at our NFL football players, other athletes who spend a lot of time in their hips, their ability to get osteoarthritis increases significantly. Tonus score is the way with which we evaluate that. And the key is to look for tonus two, with which you begin to get moderate, small cyst formation, narrowing of the joint space and moderate loss of head sphericity. That is an absolute indication to put an arthroscope into a hip joint. So tonus two, anything tonus two or above is an absolute indication for hip arthroscopy. Osteonecrosis can occur from multiple causes. Again, as you know, imaging of avascular necrosis is very important and there's the FECOD staging for this. And again, getting to these as soon as possible is very important. Remember that the hip and pelvis account for 10 to 15 percent of all primary musculoskeletal tumors and they need to be considered for unexplained pain. What is the most common direction of a traumatic hip dislocation? Good, everybody's murmuring the correct answers. I love that. Okay, posterior. 32-year-old marathon runner complains of five weeks of increasing pain in the left groin. Radiographs are negative and MRI shows a linear increased signal in the medial 50 percent of the left femoral neck. So you know, all you need to worry about is medial or lateral. So if it's medial, treatment is non-weight-bearing. Serious complication associated with avulsion of the greater troch. It's the only one you really have to worry about and that's osteonecrosis of the femoral head. 13-year-old male hurdler presents with acute pop in his right buttock. He's unable to finish the race. An MRI reveals an apothecial avulsion of the ischial tuberosity that is 1.5 by 2 sonometers with 1.3 sonometers of displacement. His mother wants to know the treatment options and the long-term prognosis. Again, the length of displacement is 1.3 sonometers. So therefore, non-operative treatment is likely to produce normal activity. Pelvic avulsion injuries, this is in your slides again. All you're doing is matching up the anatomy of where these tendons attach. 36-year-old female has been trained for the Boston Marathon. She's on her fifth week of training and has developed left hip inguinal pain. She's barely able to walk. So danger of something's going on inside the hip joint. Groin pain with hip flexion and rotation. Management includes an MRI. Here's your MRI. Great picture, right? So it's hard to do, but it looks like it's consistent with something that we should probably fix. I can tell you that this test question came... I helped develop this test question years ago and it was probably 15 years ago. The pictures on the test are much clearer than they were 15 years ago. So it's good news for you and for everybody. And not only that, they're on a computer now so you can blow them up so you can actually take a look at them. 22-year-old male is seen in the emergency room. Oh, how many people here have taken the test once? Raise your hand. How many people have taken it twice and how many people are on the third test? Sorry, Chris, it's just me, you, oh, look at that. There are four of us in the room. The test has gotten a lot easier now. The key is you just got to get used to the matrix. Chris is going to talk to you about how to prepare for that going to the computer. It's a lot more comfortable. The problem is you're liable to be with like 100 people that are trying to sweat for their paramedic test. So you just got to kind of quarantine yourself and pay attention to what you're doing. The good news, they moved all the typing exams. When we first took these things, you were in with people who were taking a typing thing for an admin exam. So they were busy their way cranking on your keyboard and you're wondering, Jesus, I'm just clicking every once in a while. Am I missing something? So the 22-year-old male is seen in the emergency room. Left hip pain, inability to move after a fall when he tripped over a ball. X-ray shows a hip dislocation. He's been diagnosed. The factor associated to increased morbidity is, right, time to reduction, time to reduction. 14-year-old triathlete is coming out of the blocks and felt a painful pop in the anterior aspect of the hip. Was unable to continue to perform. Physical examination reveals pain with active hip flexion, normal log rolling, neurovascular examination. Okay, an AP view is shown. Okay, treatment. Conservative, conservative, conservative. Nerve entrapments. Probably the most fun we have around the hip joint is trying to figure out these ridiculous pains around the buttock area. It's nothing like that 430 appointment that your admin put her niece in that has radiating pain into the posterior gluteal area. Something you're all pumped up to see, right? Anyways, you just got to know your anatomy and what's going on. Very rarely are they ever going to ask you any surgery questions. Piriformis syndrome, compression of the sciatic nerve by the piriformis at the sciatic notch. The key is variation in anatomy and believe it or not, we crazy arthroscopists now are in the posterior gluteal area releasing this. First couple times it was like diving in with great white sharks but afterwards it gets a little bit easier. Remember the pain in piriformis syndrome is ridiculous and they'll have tendinitis near the sciatic notch. Treatment again is non-operative, non-operative, non-operative. Now with ultrasound guidance we can actually do a good job of injecting steroids into that area. Surgery, release the piriformis but be aware of anatomic variants. Obturator nerve entrapment, remember you have an anterior and a posterior division. The anterior division is most of the adductors and it has, it is distal thigh, cutaneous distal thigh sensory nerve. The posterior is mainly the adductor brevis. So the one they're going to ask you about is the anterior division because they'll talk about adductor weakness. Pudendal nerve entrapment, you know, bike riders get it. The key to pudendal nerve though is they're going to ask you as a complication of hip arthroscopy. So if you see that a patient has had a hip scope and comes in with a nerve injury in and around, anywhere in and around where the hip operation was done, just put down pudendal nerve. Don't answer anything else in the question, okay? All right. Iliolingual nerve is relative hypertrophy of abdominal muscles and can give you tendinous depalpation. Symptoms are reproduced with hip extension. Femoral nerve entrapment will give you sensory loss over the anterior medial thigh. Different than the anterior lateral thigh, which is the lateral femoral cutaneous nerve, this is the anterior medial thigh. And again, the lateral femoral cutaneous nerve is the one with which is directly related to portals from hip arthroscopy. Hamstring syndrome, entrapment between the semitendinosus and biceps. Again, as we're using ultrasound, we're finding more and more of these diagnoses. So which nerve is associated with hip pain referred to the knee, okay? Distal, cutaneous, anterior branch of the obturator nerve. 27-year-old powerlifter complains of dysesthesia in the anterolateral aspect of his left thigh, okay? What is the most common nerve, anterolateral of the thigh? Lateral femoral cutaneous nerve. And this is one of those questions that you adjust his weight belt. 19-year-old college soccer player presents with six-month history of groin pain, insidious and onset. On exam, the pain is increased with resisted external rotation of the hip. Five minutes post-exercise reveals adductor weakness and muscle spasming. EMG indicates de-innervation of the adductor musculature. What is the most likely diagnosis? Obturator neuropathy. Hip arthroscopy. So two different approaches. The most common approach they're going to talk about in any type of exam and the most common approach done in the United States except in my OR is the supine approach. Traction is the number one offending mechanism to pudendal nerve injuries, okay? Traction of the hip joint greater than two hours. Cannula placement. We go into the hip joint, we get traction, we place cannulas in and we get distraction in the hip joints. There are four major portals. Just like they'll ask questions about the portals associated with shoulder arthroscopy, knee arthroscopy, elbow arthroscopy. This is a common area for tests because this answers the question of your knowledge of anatomy as well as what's going on with the hip arthroscopy. So four portals, anterior, anterior lateral, posterior lateral and then the two which are called mini anterior portal or distal anterior lateral accessory or dollar portal. Those two are considered the same type portal. So here they are here. Anterior lateral, this is all you need to know. Anterior lateral, very rarely injured. They're not going to ask a question about it. If they do ask you a question about it, the superior gluteal nerve is the closest structure. It lies in a safe zone. This is the one that's just over the tip of the greater troat. The anterior portal is aligned with the intersection of the sagittal line from the ASIS down the leg. That portal is the most common portal with which has a complication to the lateral femoral cutaneous nerve. So which portal in hip arthroscopy will give you anterior lateral thigh pain afterwards or they'll draw this yellow mark all over the thigh. What gave you this thing is from the anterior portal, okay? The femoral neurovascular bundle is also close. Posterior lateral, if they're going to ask about the posterior lateral portal which is not a very common portal anymore, the key to that is the sciatic nerve in that if you put the leg in external rotation, it brings the sciatic nerve closer to the portal. So if they have a posterior lateral portal and the patient has problems with the sciatic nerve afterwards, those are the two that are linked together. You don't want to actually rotate, you want to internally rotate. Finally, the mid-anterior portal, the dala portal, is very important for labral repair now. And you can have an injury to the lower femoral cutaneous nerve and the neurovascular bundle. Very, very rarely you're injured and they're not going to ask you about that. Peripheral compartment, the peripheral compartment has become important in hip arthrosphy because that is where the cam deformity occurs, which is what we'll talk about. Accessoring the periphery, remember, if you want to get into the hip peripheral compartment, you have to flex and internally rotate the hip as that loosens the capsule. Capsular management in hip arthrosphy, I already know the test question, the answer, that if you extend an interportal capsular incision, the leg is going to lie in external rotation. They're not going to talk about repair techniques because there's too much controversy involved with that. Peri-teric-enteric space portals, this is to help you get in to see the gluteus medius muscles to help repair the gluteus tendons. These are just accessory portals and there really is nothing neurovascular around any of those portals. Peri-trochanteric space is defined as that space between the greater troch and the heliotibial band. It's like the subacromial space. Central compartment, this is where the money is. Label tears, lots of diagnoses within this. Remember, label tears are a source of mechanical pain and it is the most common lesion found at arthroscopy. So if the question is asked, you're doing a hip scope, what's the most common lesion you're going to find in a hip arthroscopy? The most common one found is a label tear. It's a triangular fibrocartilage structure and its function, again, we've already talked about. These tears are usually found anterior superior. Types, they're not gonna ask you about the different types but there are multiple types, sort of along the nomenclature of meniscal tears in the knee joint. And again, physical examination findings will be pain, pain with the hip maximally flexed, adducted and internally rotated. It's called a FADER test, F-A-D-D-I-R. Flexion, adduction, internal rotation. That is also the leading exam for CAM pathology in the hip joint. McCarthy's sign is one with which is a dynamic examination but they're basically gonna say that the patient has pain with flexion, adduction and internal rotation. Imaging again, the MRI is the best way to take a look at these tears with or without dyes. That's a big state of controversy and they will not ask you that question. Interesting enough, if you actually look at the literature when you're trying to think about well, are they gonna ask me whether I should debride it or whether I should repair it? Debriding has good to excellent results in 85 to 90% of people and repairing has good to excellent results in 85 to 90% of people. So it's a point of controversy right now. What's important is that in an FAI question, they're gonna ask you, you need to treat the labrum whether it's debridement or repair and you're gonna need to treat the bony abnormality which is resection. So that's the answer to the questions. You need to treat the labrum and treat the bone. How you treat it, you're just looking at the question how would that both of them were answered. And again, labral repair versus debridement have the same type of sensitivity and specificity for outcomes. The clearest indication for arthroscopy are loose bodies. And chondral injuries have the poorest operative results. So as your osteoarthritis in your hip joint increases or if they go in and they find a lot of chondral damage, that has a severe impact on the outcome of the patient after hip arthroscopy. Ligamentum teres are talked about but they're still pretty rare to find. Synovial diseases, synovial chondromatosis can be a cause of hip pain and you'll see, you'll get these MRIs which show all these spots and again, the treatment is to go in arthroscopically and remove all of these pieces. Femoral acetabular impingement is something that you will be asked. It is at the end stage of femoral acetabular impingement is osteoarthritis. Two types of impingement talked about and the one that you worry about is the contemporary impingement. This is abnormal contact between the proximal femur and the acetabulum. It causes damage to the femoral neck, the acetabular rim, the labrum, and the articular cartilage. Four types that are discussed, CAM, pincer, and combination of CAM and pincer. And believe it or not, now we have more impingements and I'll talk a little bit about them because they are now on the tests. CAM impingement, key to this is understanding that as a result of the asphericity of the head or insufficient offset of the neck junction of the pathomechanics is that you overload where this bump is, you overload the labrum and the cartilage. So your highest damage of labrum and articular cartilage is with a CAM lesion. It's a three to one male to female ratio. Pincer deformities is as a result of, is an acetabular disease. So it is a disease with which you have a deep or retroverted socket and as a result of flexing the hip joint it comes up and it causes damage at the acetabulum and believe it or not, a lot of the cartilage in the labrum can be spared with just a pincer deformity. The most common type of impingement though is a combination of both CAM and pincer. Once again, the most common type of impingement is a combination of CAM and pincer. Presentation, these patients have groin pain, worse with flexion activities, their hips are stiff and tight. So if you see a question saying groin pain, stiffness and tightness and a loss of internal rotation, that is they're talking about femoral acetabular impingement until proven otherwise. Passive external rotation is much greater in these patients than internal rotation. X-ray parameters, Dr. Yu is gonna talk about that so I'm gonna briefly go over this. You know, you wanna look for coxa profunda where the floor of the fossa touches the iliacial line looking at a deep socket, looking for pincer deformity. Crossover looks at retroversion and here you can see the pelvis here. Notice that these two walls never cross over. Here the two walls cross over indicating that you've got acetabular retroversion. Okay, lateral center edge angle is the way with which the test questions will be talked about. Coverage, and again in general you wanna make sure that the coverage is above 20. Once the coverage on a test question gets below 20, they're looking at treatments involving moving, it becomes a pediatric question, right, that they want you to do some sort of an osteotomy to better cover the head. The type of X-rays that you wanna get, the 45 degree done view is the one with which is the most sensitive for detecting what's called an alpha angle which measures the cam deformity. And here you can see you draw a line down the shaft and you come out to where this bump is and you wanna measure this angle. In general, the normal alpha angle is 50 to 55. On the test questions, they're gonna say the patient has an alpha angle of 65. So as soon as you know that, as soon as it's above 55, you know that they're describing a cam deformity of the femoral neck, cam deformity. False profile view is an excellent view trying to take a look at and to assess the anterior coverage of the femoral head but is also very important in taking a look at a patient's osteoarthritis. CT scan, Dr. Yu may talk about this. I don't order a lot of CT scans. MRI is the backbone of what we do. And believe it or not, the importance of the MRI is to take actually look at conval where because if you have an x-ray of somebody that has a cam or pincer deformity that actually has FAI, the likelihood of them not having the label tear is very small. So much like slap tears were read oftentimes with an increasing frequency in shoulder examination, so are label tears in the hip joint as well. Again, that alpha angle is key and that key number again is 55 degrees. Joint space width is a very, very important tool to decide whether or not the patient has osteoarthritis and whether or not you should be doing a hip arthroscopy. Again, these tonus two classification is very important and you want to watch out for that. Label tear is a sign of an underlying problem. However, the bony pathology is what needs to be addressed. These can be done open or arthroscopically and again, failure to address the bony impingement in the hip are the key factors in unsuccessful outcomes in our patients. Open management is just as good as arthroscopic management. The problem is is that arthroscopic management is difficult to perform. It takes a while to get used to doing it but once you do them, the advantages and the fact that it's minimally invasive are very, very important. Again, this is just what it looks like in the OR. Here's what rim trimming looks like and again, the results of the treatment are dependent upon the chondral injury inside the hip joint. As you increase your chondral injury of the hip joint, you get more pain. Ischiofemoral impingement is the new kid on the block. It is the patient will complain of piriformis-like symptoms. Well, the pain in the sciatic nerve in the back of the leg, the pain on deep palpation. The sciatic nerve is most commonly affected and the MRI will show increased signal intensity in the quadratus femoris. So the only two things you need to know about this type of impingement is one, it's sciatic nerve-based and two, it has signal abnormalities in the quadratus femoris. There are some other things that need to be out there but for test purposes, those are the two things they're asking on the exams. A IIS or subspine impingement is the third impingement on the block with which is looking at A IIS abnormalities. And this oftentimes is associated with that pediatric patient who was playing soccer, had an injury to the AIS and then had overgrowth. This can lead to getting impingement. I have not seen a test question on this type of impingement. I have for iliotisial but not for this. Complications of hyparthroscopy. Direct nerve injuries. You just gotta remember your anterior portal is lateral femoral cutaneous nerve. Anterior lateral can be superior gluteal nerve and those are the two ones that they talk about. The most common iatrogenic, the most common complication is iatrogenic injury. However, that's not what we put on the test. It's actually been no paper out there showing that, although we all know it, there's no paper out there showing it. So again, traction injuries greater than two hours. Pudendal nerve, anterior portal injuries from hyparthroscopy, lateral femoral cutaneous nerve or the posterior lateral portal, not having the leg in excess of external rotation, sciatic nerve. Questions. What two structures are at risk with the anterior portal? Again, even if you didn't know this, the only one of them's gonna have the thing that you wanna worry about, the lateral femoral cutaneous nerve. What two structures are at risk with the anterior lateral portal? Again, it's a pretty safe portal. Kind of a sucky question if you ask me, right? Because not many people have complications from that but we know that the superior gluteal nerve runs right near that portal. I've never seen a superior gluteal nerve injury. 45-year-old executive concerned about scrotal numbness following hip arthroscopy. Pudendal nerve, what was the most likely cause of the complication? Okay. Pudendal nerve injury as a result of excessive traction. 55-year-old triathlete has catching and popping in his left hip. Examination reveals painful range of motion with mechanical sensations of catching. Which of the following is the best indication for hip arthroscopy? Loose bodies, right? Best indication. Most common finding is labral tears. 24-year-old professional squash player, persistent right inguinal pain, clicking. Plane radiograph on remarkable MRI shows a labral tear. Has failed to respond to three months course of rest stretching and nonsteroidals. What's the most appropriate treatment plan? This, by the way, meets none of Aetner's hip arthroscopy criteria. So, hip arthroscopy and debridement. 45-year-old male is considering hip arthroscopy for painful clicking, swimming and walking. Which of the following is a relative contraindication to hip arthroscopy in this patient? And they put relative. So, the relative one is the limitation of motion because it would be difficult for you to get your scope in there. FAI, what is the most usual location of the labral injury? Anterior superior. During hip arthroscopy, the sciatic nerve is most at risk in which of the following portal techniques? Posterior. You guys are all murmuring and correct. I'm very proud. Complications of hip arthroscopy are most commonly related to which of the following? Traction, traction, traction. 29-year-old male undergoes hip arthroscopy with three portals. Post-operatively develops numbness in the distribution. Which portal does that come from? Okay, remember, dolla, anterolateral, anterior. Lower femoral cutaneous nerve from portal A. The zona orbicularis is the arthroscopic landmark for access to which of the following structures? So we talked about this, right? Which structure might we wanna be able to do a release on? From the interarticular portion of the joint between the labrum and the capsule. Zona orbicularis is the iliopsoas tendon. 20-year-old collegiate ice hockey player complains of insidious onset of right groin pain. He reports increased pain with ice skating. Examines hip flexion of 100 degrees to 115 on the opposite side. His internal rotation is five compared to 20 degrees on the other side. Pain is reproducible with fader sign. X-rays are shown. Great X-rays, right? Awesome. Standard, I work at a state hospital, so this is my standard X-ray. You notice they kept the pants on while they took the X-rays? That rocks the world all the time. What parameter is commonly associated with cartilage delamination injury, right? We know that cam deformities are the ones with which called labral and cartilage tear, so you wanna look at the alpha angle. Issue of femoral impingement causes injury to what muscle around the hip? You guys all know that? Quadratus femoris, which is the most commonly effective nerve in issue of femoral impingement. Sciatic. 34-year-old weekend warrior presents your office with a five-month history of worsening right groin pain. He's been referred to you after non-operative medicine has not been helpful. He's had an MRI arthrogram. He's undergone physical therapy, physical examination is significant for reproducible pain with flexion, adduction, and internal rotation. What is the best preoperative predictor of early failure following hip arthroscopy? Only one thing, osteoarthritis, right? Greater than two tonus score. The incident for cam impingement in young male patients versus female patients? Three to one. The radiographic view obtained with standing radiograph with an angle of 65 between the pelvis and the film, what's that called? False profile view. All right, thank you. Any questions, please do. The test is extraordinarily fair. Sports portion, right? It is 70% sports and 30% general. It's a very fair test. So this is a great course, great review. So good luck with everything.

hip injuries

thigh injuries

pelvic injuries

bursitis

snapping hips

core muscle injuries

labrum

bone injuries

hip arthroscopy