All right, we'll get started. So first of all, I want to thank our great panelists for submitting their lectures and joining us for this talk. And we want to also thank Alexandra and Caroline of AOSSM and ISHA for helping organize all of our busy schedules together without them, this is definitely not possible. So that being said, we'll start with our panel discussion. First, we'll start with Dr. Byrd. You know, I think with your talk, it's very, I think on point when we all compare the abductor tear, abductor pathology with the rotator cuff and shoulder pathology. And in that, in that same thought process, I was curious what your decision making regarding fat atrophy of the abductors and tear size, how does that fit with your algorithm when deciding whether or not a rotator, I'm sorry, an abductor tear should be treated surgically? Well, I think a big part of that sort of falls between whether to try to do it endoscopically versus open. And I don't know that we have hard data on it, but sort of like we learned in the shoulder, sometimes fatty infiltration is a little overrated that to me, that's some fatty infiltration isn't a contraindication to an endoscopic approach. To me, what I really look for is, is there a lot of retraction of the tendon? Is it something I feel that we can mobilize and repair endoscopically? Most of them we can. If they're not repairable endoscopically, if they have extensive fatty infiltration, that's where with the open techniques, you've got so much more versatility where you can take the posterior border of the tensor fasciae latae and the anterior border of the gluteus maximus, bring it together. And one way or another, you can recreate and restore the abductor mechanism. Yeah, that's very interesting. You know, also as a follow-up question, and we're starting to have some research come out as well, evaluating lumbar spine pathology and how common it is in the setting of abductor pathology, especially abductor tears in this age population that we're discussing. Does that kind of affect your treatment algorithm as well? And how do you think that correlates with the overall clinical picture of these patients? Well, it's certainly important to evaluate, and oftentimes just like hip problems coexist with abductor problems, lumbar spine disorders coexist with abductor problems. They tend to be an older population, as you know, in their 50s and 60s and not infrequently in their 70s. Those are all things that you have to assess and kind of take into account because to me, as I tell people, it ain't the surgery, it's the rehab. Because I tell patients they're likely to be on crutches or a walker for about eight weeks, but it takes about four months for the repair site to be healed. My nurse says don't ever mention the word four months to anybody. Tell them it's going to be at least six months before they think it's worthwhile going through it. And the rehab process is onerous, and you want to make sure they don't have enough other things working against them that are going to really compromise their ability to do the rehab. And kind of hand-in-hand with that as you're talking to the patients, getting a sense of what they're looking for. If they just kind of have pain, surgery is not a great way of correcting their pain, but if they've got specific goals and things they want to do that are reasonable goals, then that's where surgery is oftentimes going to be successful. And the lumbar spine disorders don't contraindicate the role of an abductor repair, but you just want to make sure you're operating on what's really creating their greatest dysfunction. That's where the injections can be so helpful to try to help differentiate the pain generator. Dr. Bird, a quick question for you about endoscopic versus open. What's your percentage you think of doing endoscopic tear repairs versus open, and how are you assessing when you're looking at your MRI, how are you assessing which direction you go? Well, my percentage of endoscopic versus open is 100% endoscopic, because if they need an open one, there's a gal here who's very accomplished with that, and I'll send them to her for the open ones. I just enjoy doing the endoscopic ones. Now, in the past, because there was a great guy named Joe Davies up in Milwaukee who was doing open abductor repairs. Very few people have heard of him. He only had a couple of papers he wrote. He recently retired, but I met him through the Great Lakes Athletic Trainers Association meeting where I heard him speak. Magnificent speaker, fantastic techniques. He could kind of with open techniques, he could always figure out a way to put things back together. But in the past, basically for people around here, either I would try to offer an endoscopic approach or send them to Milwaukee to Joe Davies. And with people that didn't necessarily have the resources to travel, I was probably more aggressive about trying to do something endoscopically. But now that we've got somebody here in town who's very accomplished with open techniques, I tend to be a little more selective. But even when we're trying to tackle some of these that are more extensive endoscopically, our results were still quite good as long as you get a secure fixation. The key is being able to mobilize the tendon. And most times, it's not just the MRI, but really that we look at these under ultrasound. And I'm really looking at both of those before making a decision about whether this is one that I can tackle endoscopically. I don't know if I ever answered your question there. No, 100% is a good number. And that's where, because I'm punting on the ones I think should be done open, and I'm definitely a much lower threshold for encouraging them to go do an open approach now that we've got somebody in town who does them. And to be honest with you, Brian Kelly is the one who taught us about the paratrochanteric space. Brian does not do these endoscopically anymore. He does them all open because there's much more of a fetal factor with the endoscopic approach. And if somebody prefers to do them open, that's a very appropriate way to address this. So Tom, what is your definition of an irreparable abductor tear? And what is the role of a glute max transfer superior gluteal reconstruction in the setting of these tear pathologies? And I think that the main things I look for, do they have substance of tendon that remains? And I don't have a specific number on how many centimeters of retraction, but mostly looking, do they have decent quality tendon that you can get back to the greater trochanter? If they've got retraction, if they don't have much tendon substance, then you combine in a lot of fatty infiltration. Those are the ones I would definitely defer to the open surgeons. And with the open techniques, you've got all your choices right there. If you think you can repair it versus if you think you need to do some sort of a transfer. Great. Thanks, Tom. We'll go next to Per, who's the champion of this panel for being up at midnight in Denmark. So the core injuries are kind of a black box for a lot of us, especially in North America, regarding evaluating these injuries. I was just curious why you think in my experience, they're definitely more common in the male athlete compared to female athletes. Why do you think this occurs in this athletic patient population, especially kind of the middle-aged weekend warrior male that we see very often with these kinds of core injuries? Well, listening to my talk, you probably heard that I do not know what a core injury is. I do not believe in the whole idea of this strange concept. I think that what we're talking about is the doctor injuries, or we're talking about inguinal related problems related to the inguinal canal and the fascia transversalis. Not a hernia, but a weakness of the fascia transversalis. The fascia transversalis is actually not a fascia, but it's a tendon. It's what's also called the falx inguinalis, which is the conjoined tendon of the transverse abdominis and the external oblique going down into the pubic tubule. They are constituting the posterior wall of the inguinal canal. This is actually a muscle tendon injury that are weakened. It can be from a trauma or it can be from overuse. These patients, they do have a weakness there. They get softness, they get stretching, they start to get pain, and sometimes they even compress the genital femoral nerve in front of it. This constitutes the pain that you see in the, you could say, upper part of the groin, or you could say the lower corner of the abdomen. They are a little bit similar to hernias, but they're definitely not hernias and should not be treated as such because a hernia you cannot treat by exercise treatment, but you can treat a lot of these patients with exercises. If not, then you can treat them actually not with a big, strange call surgery that I never really understood. That's, as far as I can see, mainly done in the US. But this is simple hernia-like surgery where you actually do either, some do it as a laparoscopic surgery, some do it as open, some put in a net, or some do a placation kind of tightening. Then you have the other part of it, which is the adductors. As I showed in my first few slides, there's a lot of misconceptions of the anatomy out there, where these muscles are going directly into each other, pulling on each other, and there's a pubic plate in front and strange stuff that doesn't exist really. But if you look to the anatomy, if you do your dissections, and we as surgeons are the ones who actually should do the dissections, then you can see that the adductor is inserting into the pubic bone and the abdominal muscles are inserting into the pubic bone on top, and they're separate. They're separate muscles. So they are not in conjunction with each other and not working as such. They're working together as all muscles are doing in synergies, but that's something quite different. So core muscle injury to most Europeans, and I think to a lot of other people around the world, is a strange diagnosis that we really do not understand. Yeah, I definitely think nomenclature throughout kind of the hip preservation world is definitely something that we need to discuss and think about and work on, especially in this field. You know, in my experience, I see a lot of male athletes with very aggressive hip impingement morphology that had these adductor injuries and have, you know, pubic symphysis pain. What's the role of us treating central compartment pathology in relationship to these painful conditions that you discussed about in your talk? Well, I think it's really true that sometimes, when especially if you have a hip problem with decreased range of motion, if you have a huge cam, you have some pincer that is giving rise to decreased range of motion, then you get problems with your range of motion doing various sporting movements, like playing football, basketball, coming up and down, inflection, rotation, and so on. And in that sense, you're using your muscles differently. And of course, they are the adductors and the abdominal muscles, especially the oblique muscles, are very important. But I think a lot of the pain that you find in the groin, you find in front. And if it's not only solved by the hip joint, then in many cases, you should also be aware of the psoas. I think the psoas is, as Dr. Okius is telling us, that it's a snapping psoas. There's definitely also a lot of patients who are having psoas problems as a pain problem, both in the muscle and in the tendon. And I see lots of patients where I'm scoring all the cheap points by being the last doctor looking at these patients and diagnosing the psoas. And it's not difficult, as I show in my talk, it's not difficult to diagnose it. And this pain is a very, very common pain in a lot of our patients, both us as hip surgeons, but also in the general population of groin patients, at least in general. As we deal with people with symptomatic FAI in the hip, we worry about letting that go indefinitely because of consequences, and we'll tend to lean towards maybe being more proactive in addressing it. Historically, with these inguinal-adductor problems, we kind of look at it more symptomatic treatment, meaning if you can play with it, knock yourself out, try what you can from a conservative standpoint. If that doesn't work, surgery is a fallback option. Is that a proper strategy, or do you think that there's any harm being done by just treating them symptomatically? Well, far the most of the adductor and also the inguinal problems are overuse problems, and that's how we know overuse problems usually are. You can actually play, as you say. You can go out there, you get a good warm-up, and then you can actually play for, well, most of the match, okay? Then you start to have pain, and then you have the revenge in a couple of days. And this is the normal pattern of these injuries. And it's also the danger of these injuries. This is why some of them become really long-standing and sometimes even chronic. So what we're doing and what we have shown in most of our studies is that if you are doing exercise therapy at an early point, taking them out for a while, and then strengthening these specific few muscles, actually, that are causing this, then it's a good strategy. And you can, with exercise, do it in most cases. What we are doing most surgery with is actually the inguinal patients. I would say it's 50-50. If you have a patient with inguinal-related problems, some call that sports hernia or whatever, but it's not a hernia, as I say. But half of them, we actually do surgery with. But I can't remember when I last did an adductor tenotomy. And believe me, I see a lot of adductor patients. I'm a nerd with that, so I get patients from all over. And we can treat far the most of them with exercise treatment. And adductor tenotomy is not, in my opinion, it's very rarely necessary. It's very interesting. Also said in his talk that we are very careful. We're being more and more careful now doing the psoas tenotomy. And it should be exactly the same with the adductor tenotomy. Don't do them, do the exercise therapy. There's plenty of good research showing us how to do that. Yeah, it's very interesting because down here in Australia and New Zealand, it's very common to perform adductor tenotomies in our patient population. And it's just very interesting how this kind of field has regionally very different philosophies. and just like you said, even David nomenclature that kind of drives us in a certain way, it's something that we definitely as a society need to think more about kind of everyone getting on the same thought process, going moving forward, it talking about so as pathology, that's a good segue to Steve's talk, Steve, maybe you can talk a bit about your transition in your career, maybe being a bit more aggressive with so as tenotomies and now I think, you know, there is a bit more of a trend of, of trying to rehab, snapping so as and, and painful so as pathology, how has your journey been regarding treating your so as patients? Sure. So, you know, when I started doing hips and FAI, there was this concept of the triple impingement where you have, you know, the soas impingement that's causing part of the problem. And, and maybe that's still possibly part of the issue. Although I you know, you when I first started out, I was if someone came in and they had FAI symptoms, and they also had popping and that was reproducible with with internal snapping hip maneuver, I was kind of lean more towards just doing a release of the mechanical popping so I wouldn't have to go back and potentially deal with it at some point. And so there's a point in my career where I was pretty aggressive about just releasing anything that was mechanical at the time when I was doing an FAI surgery and, and, you know, for the most part, I didn't seem to be an issue, I accept you'd have those individuals that came back every once in a while. And when someone really struggled with weakness and difficulty from a release, made you rethink what you're doing. And, and that issue on top of, you know, the, the soas potentially being a dynamic stabilizer anteriorly, I may be a little bit hypersensitive about hip stability and the issues related to capsular management and, and stability of the hip. And with with the soas being that dynamic stabilizer up front, you know, potentially doing a release in the front probably adds to that whole process where those individuals were really uncomfortable where they, they were incompetent in their capsule and then they've had a previous soas release. And so it really made me gun shy with a lot of the soas pathology or soas issues. And, and so I backed off quite a bit from, from doing that. We did, we looked back at, at some of our patients, the impetus of a study that we did where we looked at that, that time period when I was looking at those, or when I was doing a little bit more of an aggressive release at the time of FAI surgery, we went back and looked at those patients and we did strength testing and, and MRIs. And, you know, there's atrophy from, from doing a release and there's, there's issues with weakness in the sitting position. And so it's not without its potential issues. And so it really made me kind of back away from doing that. And I, I'd have to say maybe I'm missing some of these, these issues of, of pain from soas, but I, I've kind of went to a point of saying, you know, I deal with the FAI, if they have issues of pain that they relate to the popping after the fact, then I can always go back in. I'd rather go back in a second time than to regret doing a release and not having an option of kind of putting things back together. And since doing that, you know, I have not gone back in on someone as a revision to do purely a soas release. And now again, that's maybe there's, there's some issues of me not recognizing that there's some discomfort from a soas related issue, but I really feel like a lot of the popping that occurs at the time with FAI surgery, that it's popping, and maybe someone relates that to, they think that that's painful because that's what they relate. They, they can reproduce that popping and they, they kind of equate that to being a reason as to why they hurt. So my practice now, I is, I can't remember the last time I did a soas release in, in kind of the primary setting. I really, the main reason for me for a soas release is, is in the total hip patient population. Yeah, I, I agree as well, especially in, in an athlete, I would be very cautious about doing a soa, so as release, I deal a lot with surfing population covering the USL and those guys have to go into deep hip flexion and releasing a so as on them would probably be a career ending injury for, for the most part. You know, we're, regarding the physical therapy aspect of treating so as pathology, as you said in your talk, there's not really a great idea of what is actually snapping with the so as. So when we, so when we talk about rehabbing these patients, what are we really trying to focus on with the rehabilitation to kind of treat this snapping so as, because I think that this is kind of a concept that we don't fully understand very well when we tell them just to go and rehab and we don't know exactly what we're doing regarding the rehab. Sure. You know, it's interesting. It's you know, from the standpoint of popping, it's, it's really, there's been descriptions of the location of the popping being anywhere from way up high to above the brim to anywhere along the course down to the lesser trochanter. And so, you know, I think one of the things that's been really helpful is that there's more individuals who are savvy with, with doing a dynamic ultrasound examination. And so we're starting to get more individuals that are going and trying to find and identify that popping. And you know, one of my partners who's really savvy with, with dynamic ultrasound examinations, there's, she, when she ever, whenever she does a exam for evaluating internal snapping hip, you know, sometimes she's not able to localize it, but most of the time she says that it's the tendon sitting inside the muscle belly. And on the talk, there's an example of, of the snapping that occurs where you've got the muscle belly, you've got the bone of the brim, the muscle belly, and the tendon sitting inside the muscle. And as, as you roll, the tendon flips over the muscle belly and comes underneath the, the muscle. And so that's, what's popping or snapping. And so I guess, regardless of where along that line of where is it snapping, I think the concept when we're, when we're looking at non-surgical therapy treatments, it's trying to elongate that, that muscular tenderness complex, right? We're trying to, it's almost like a guitar string. You're trying to take that, that twang out of the guitar string and make it so it's loose. So it's not so violently popping over the edge. It's fascinating looking at having an ultrasound to, to find those areas of, of where things actually pop. Yeah, Tom, you're obviously, your clinic's obviously been really moving forward with ultrasound use in clinic. Maybe you have some thoughts regarding the use of ultrasound and the snapping psoas. And I think that if somebody is truly painful from a snapping iliopsoas and an exhausted treatment, a fractional lengthening of the iliopsoas can be a highly successful operation. Outside of that, the iliopsoas, in my experience, doesn't like to be messed with. And people who've had a fractional lengthening for poorly defined reasons oftentimes really struggle getting over the operation. And I see a lot of people come to see me who aren't doing well from a previous operation. And about a third of the time that involved getting their iliopsoas released. And most times I don't need more surgery. They just hadn't gotten over the first operation and need a more sort of refocusing and just takes longer, but they can get better. And as Steve noted, I think a lot of times the snapping isn't going across the brim of the pelvis or the femoral head. And sometimes it's a bifid or even a trifid tendon flipping back and forth on itself. And under ultrasound, you can see that quite well. And again, my indications for fractional lengthening haven't changed if the snapping is so painful. But my doing it is very infrequent compared to what it used to. I think most times I just try to talk the patient down that as long as I understand the difference between the pain coming from their joint, which is commonly FAI, and the snapping aren't tied together and let them know they'll still have the snapping. It's if you don't tell them they have the snapping, go doc, my hip's still snapping. The other important point that Steve was drifting towards is if they have any sense of instability, dysplasia, increased femoral antiversion, that iliopsoas is working overtime. So sometimes it's kind of symptomatic, but the last thing you want to do is release it. Now I remember a plaintiff's attorney I operated on one time. This is back before we did timeouts. She had a snapping iliopsoas that I was going to release in addition to addressing her joint. Well, I just forgot. I addressed her joint and forgot to do the iliopsoas. And I just told her afterwards, you know, it just got biased. Now the neat thing is on her operative permit, it didn't say iliopsoas release. So technically from a legal standpoint, I guess I was covered. But I just told her, listen, I talked about doing it. I forgot to do it. And if we have to go back and do it, you know, I'll do it for nothing. But let's see how she did fine. She was happy to be rid of the hip pain and the snapping didn't bother her, fortunately. Great. So Chad, you know, you've obviously have a lot of experience with endoscopic repairs of proximal hamstring tears. I was just wondering, you know, for the novice that wants to go down this pathway of scoping the, you know, posterior aspect of the hip and repairing proximal hamstring tears, what should be their evolution of training to make them more comfortable performing this procedure? Yeah, that's a great question because I think in those of us who have gone through that learning curve, it has been a great addition, a technical addition to our practice. So, but getting there can be certainly be challenging. I remember the first one I did was a patient who was desperate. I mean, she had pain for 10 years and she, you know, she said, you got to do something. And I said, well, you know, and I had done an open one not that long before that, that just was very dissatisfying. And well, I don't, you know, it seems pretty reasonable that I could do this endoscopically. And I remember actually getting in there and getting right to the hamstring and thinking, well, it can't be that easy. That can't be, that can't be the hamstring. It can't be that easy. And it, you know, it is for the most part, I think, I think you've got to, you know, really be very careful about where you are initially, you know, in the hip, intra-articular hip arthroscopy where we, we never have a level horizon, right? It's like, we're spinning through space, you know, anti-gravity to be able to see it all around the hip. But in, in the, in, in that initial space there near the hamstring, you, you really have to keep a very flat horizon so that you always know where the sciatic nerve is relative to you as you get started. You always start, you know, right off the ischium and, and generally that allows you to open up the space pretty well. Um, the other thing I'd say is I, I think, you know, uh, recently we've done several really nice cadaveric, um, uh, procedures and, you know, and, and, and, uh, in training sessions. And so, uh, I originally kind of anticipated that because a lot of this hemipelvi are there, they're not, um, you know, they don't have attention on the muscles that it wouldn't work very well for cadaver, but I was quite wrong about that and they actually can work really well. So I would encourage, uh, definitely encourage anyone who goes to a course, um, take a little extra time, flip that hemipelvis over. Um, you know, hopefully, you know, one of us or somebody there's got some experience with it and I think you can get a lot of comfort that way. So most of the people that I know that have started doing it have found the same thing that it's generally, um, you know, it's a little bit scary, but it technically isn't, um, isn't as hard as it is intimidating. Chad, when you are, uh, chasing proximal hamstring pathology, how often are you going over and skeletonizing sciatic nerve? I, I never do. I don't, I don't identify it, but I always identify it. Definitely. I always identify it there. There is a fascial band at the proximal portion of the, of the, uh, in the proximal anterior portion of the, of the hamstring insertion. Um, and I always do release that because otherwise you can't really get to the semimembranosus. I think the first handful of these I did, I probably didn't repair the semimembranosus at all. Uh, because, you know, cause yeah, really, you really have to mobilize the nerve to get, you know, to the full footprint. Um, but, um, but yeah, I don't, I try to leave it alone. I, I think there's a handful of these where, um, you know, there's, they're, they're a bit like a cubital tunnel, I think. And they get, you know, there's maybe some, you know, some kinking of the nerve through there. And, and, um, just by mobilizing it, you've kind of done it effectively a transposition, if you will. So if, so if the patient is having sciatic symptoms, are you more likely to mobilize the sciatic nerve or try, uh, try to release it? And do you feel comfortable doing that endoscopically? Or do you feel like that's a patient that needs to be done open if they're having a sciatic symptoms? I don't, I don't do any endoscopics like, you know, targeted to the sciatic nerve neurolysis. I don't feel I'm qualified for that surgery. Um, I didn't, I didn't do neuro neurolysis surgery and training. And, and, um, you know, I, I think that's where I, that's where I kind of had to kind of stop. I drew a limit there for myself there. And if we're going to do that, I'll, I will have peripheral nerve surgeon do that. I don't find too many that I think that's, that's really the problem. Um, some of the more impressive ones have been just issue of femoral impingement again, looking again, having an entrapped nerve and they do find by having that nerve basically transposed, but not skeletonized or, you know, or aggressively mobilized along its length. And, uh, what's your opinion about, uh, bracing, whether it be at the hip or the knee in your current practice regarding, uh, post-op recovery for your hamstring, uh, repairs, or is there any role for bracing at all in the year 2022, or is it just for, um, very, um, retracted, uh, uh, proximal hamstring tears that, uh, were successfully repaired? Yeah. Well, I, I don't think it is very well tolerated to lock somebody in a knee flexion very much. Um, I don't like to have them weight bear at all that way. So I think they naturally will be centrically resist, um, uh, the extension, their gravity to extend the foot. So I think, um, I don't trust that. So I, I never, um, brace, I never brace them when they're, uh, or at least, uh, yeah, never really braced them when they're ambulating at night. I will, you know, we'll kind of lock them into about 50 to 60 degrees, whatever they can tolerate to protect it. So they don't end up rolling into some stretched out position, but I would lie. That's evolved for me over the years. And I did again, went away from using any race at, uh, during that phase of ambulation, just for having them focus on the weight bearing portion of that is an area of, you know, one of the areas of research I'd like to pursue with some, we have some surface EMG shorts. We actually got out of a pair's, uh, neck of the woods that, and that's one of the studies we want to do is kind of assess what, you know, what, uh, protective position and bracing activates hamstring at least. Great. Well, it looks like we're getting to, um, our, uh, 30 minute, uh, deadline. So I want to thank you all again for, uh, spending your time, uh, to join us today and, um, hope you all have a good morning, good afternoon and good night, and we'll see you all soon. Thank you. Thanks for sparing. Thank you. Thank you. Thanks guys. Thank you.

orthopedic surgery

panel discussion

rotator cuff

surgical treatment

treatment algorithms

endoscopic techniques

current practices