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Hip Pain in the Young Athlete in 2024: Decision Ma ...
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Good evening and welcome to this AOSSM webinar titled Hip Pain in the Young Athlete in 2024, Decision Making and Surgical Techniques for Consistent Success. Thank you for joining us. Here are the disclosures of the faculty and organizers for tonight's webinar and the learning objectives. CME credit is available for this activity. You'll receive further details at the end of the program. I am now pleased to introduce tonight's moderator and presenter, Dr. Sanjeev Bhatia. Dr. Bhatia is the director of the Hip and Knee Joint Preservation Center at Northwestern Medicine, West Region. He has treated thousands of individuals with hip pain and has authored numerous peer-reviewed articles and book chapters on hip arthroscopy and hip preservation. I'll now turn the program over to Dr. Bhatia. Thank you so much, Ashley. It's a huge honor to be here tonight with AOSSM and a very esteemed group of individuals from around the country. You know, very grateful to have several people here tonight, including Dr. Ryan Roach, who's an assistant professor in the Department of Orthopedics at University of Florida. My mentor and very good friend, Shane Nho, also here in Chicago from Rush University. And then my other good friend, Dr. Michael Ellman, who's a director of hip arthroscopy at the International Center of Hip Preservation out in Denver. So tonight, we're really hoping to kind of share some pearls of wisdom, just things that we've learned along the way, things that we've seen go well, things that we've seen not go well as we take care of athletes with hip conditions. And to kick it off tonight, we're going to have Dr. Roach tell us a little bit about the clinical workup and surgical decision making. He's going to give us his pearls of wisdom and how he manages athletes at the University of Florida. Thanks, Ryan. All right. Thanks, everyone. And thanks, AOSSM, for having us tonight. So, you know, we have our disclosures. I have to give you a disclaimer. So I practice in Florida. And so, you know, my patients are very special and you have to take everything I say with a grain of salt. So why do we care about hip pain? It's, you know, it's common and it's becoming increasingly more common, especially in our athletic population. I think historically, we chalked up all hip pain to either early arthritis, a pulled groin or hip flexor strain. And we just know that's not true. So unfortunately, patients with hip pain are often misdiagnosed. They see about an average of four providers before an appropriate diagnosis. They have three treatments on average, three diagnostic tests. And this equals a pretty significant amount of money. More importantly is the delay in diagnosis. And this is almost as average as over two years. We know that unrecognized pathology can lead to long term issues. I think worst case scenario would be arthritis. But for our athletes, obviously, unrecognized injuries lead to a loss of play and that leads to an unhappy athlete. So hip pain, I think the reason that there is such a problem is because there's so much that goes into the hip and there's so much overlap with other parts of the body. And this can cause confusion. And I think it makes a lot of providers head spin. Certainly sometimes in clinic, my head feels like this. So, you know, when I, these are two pearls that I think of every time when I go to clinic, you know, the eyes are not responsible when the mind does the seeing. And Dr. Andrews used to say, you didn't see it, but it saw you. And I think the point here really is that knowledge is power. And so you can't really make a diagnosis if you don't know what you're looking for. And I think that's incredibly important when you approach patients, especially with hip pain. So how do I approach them? Really, I have to be systematic. I try to break things up and compartmentalize them as best I can. I have to know my anatomy because if you don't know your anatomy, you're not, you're not going to get the diagnosis correct. Personally, I differentiate, I try to differentiate things into compartments. Like I said, anterior, lateral, and posterior, but understanding that hip pain can be atypical and it doesn't always follow these rules. Differentiating inter, inter-articular versus extra-articular age can obviously help clue me in, in terms of what's going on and make sure I try to make sure I rule out everything else. In terms of, you know, the idea of compartmentalization, I think Dr. Kelly put this forth and I think it's a great paper to look at in terms of the layer concept and approaching a hip systematically and making sure you rule out everything. So obviously history, this is, this is basic, you know, thorough history is critical. Just listen to the patient and what they're telling you. Usually they're, they're telling you what's wrong. For an athlete, mechanism of injury is huge. Understanding how it affects them in their sport. Is this acute or chronic? Previous history, any surgeries, any other weird stuff going on, and especially in the hip, weird stuff can, can clue you into other stuff going on. So locking, snapping, ridiculous symptoms, et cetera. And the physical exam is equally important. I think, again, this is how we approach most patients. Inspection, palpation, range of motion, strength, sensation, and provocative tests. But in the hip, there's a few things that we want to highlight. So just, this is kind of my hip template. This is how I evaluate patients in my, in my clinic. So you can see it's got, it's pretty thorough. Provocative testing is where, where I'm going to kind of hone in and try to figure out what's going on. I think you can't stress the importance of bite and score enough, especially as we continue to kind of figure out hip micro instability and instability. Hypermobile patients present a unique challenge, and I think you should evaluate that and document that. So rotational profile is, is huge. You can tell a lot about what's going on with an athlete just from how their hip moves. So internal and external rotation, either in the prone or supine position is very critical to the diagnosis. And in terms of provocative testing, again, this kind of depends on, on what the athlete is presenting with and what you think is going on. For FAI and labral tear, I think this is a good paper kind of looking at the specificity and sensitivity of, of all the testing. And really the anterior impingement test is the workhorse. That's the flexion, adduction, internal rotation. And for me that, that is, that is, if that's positive, I am, I am thinking that at least FAI or labral tear is a patho, is a, is a, is a likely diagnosis. Instability testing is critical. Obviously, if there is micro instability or any form of instability, that is a different patient and may need to be treated differently. And then I see a lot of core muscle injuries, so they have their own specific tests that can help me figure out. And the Doha consensus has helped us kind of put, put to words what we agree on in terms of a core muscle injury. So equally important as the physical exam is kind of the diagnostic imaging. And I think it's, it's critical for a complete diagnosis. Certainly the physical exam can clue you in, in terms of a labral tear and impingement, but you're not going to understand what type of impingement you're having until you have a diagnostic image. So multiple studies are usually needed. I would stress the importance of a radiograph. There is a lot you can glean from radiographs as we'll go through. MR is important, plus or minus arthrograms. I put this here because there is a trend towards standard MR and avoiding the arthrogram in certain patients. And we'll kind of go over that, but it is important in terms of diagnosing the soft tissue injuries and the cartilage status. CT can be useful in certain situations, especially really unique bony deformities or if you have version or rotational issues. And bones can certainly in some situations. So I put this picture up just because I love it. And I tell my residents and you really, you know, you can't stress the importance of getting two views. So for the hip, this is my workhorse, basically AP in some form of a lateral. I usually use a 45 degree done, but in certain circumstances we'll get other imaging. And these two images just show the difference. This is the same patient with a frog and a done, and it just shows you how how you can get different views of the proximal femur depending on the imaging that you select. The Cohissy paper, again, this is a very important paper for my practice. We make the residents read this, and I think it's an incredibly important paper in terms of understanding how to approach radiographs in a young athletic population. The most important first step is just to make sure you have a good image and a good quality image because all your measurements are based on this. Measurements are probably a whole talk in and of themselves, but that paper really helps show you how to measure things appropriately. And if you measure things appropriately, you'll probably diagnose people appropriately. So there's a lot that goes into it. Again, the quality of your x-ray is important. So you have anterior wall, posterior wall, you have your ischial spine, lateral center edge angle, and your tonus angle or alpha angle, and then alpha angle there, sorry. So lateral center edge angle. So, you know, this is critical for diagnosing coverage, right? And really we're talking about anterior and lateral coverage. Obviously, overcoverage and undercoverage represent different pathologies, and it's simple and reproducible, but, you know, I caution you, it doesn't always tell the whole story. So it's a great screening tool. It can clue you into what's going on, but sometimes it needs to be investigated further. The best example of how important lateral center edge angle, I think, is the dysplastic hip. And just simply measuring the lateral center edge angle, you can clue into just how different these patients are. And if you approach both of these hips the same way, you're going to get one of the diagnoses wrong and you're going to treat one of the patients correctly and one of the patients incorrectly. So again, incredibly important, simple radiographic measure that can help you get the diagnosis correct. This is, again, an example of the tonus angle. And then the fear index is a newer measure put forth that has also shown validity in diagnosing hip dysplasia. Alpha angle is obviously the workhorse for the diagnosis of KM impingement. I think if you read the literature, there's some variation in terms of what angle actually is consistent with impingement, but for all intents and purposes, it'd be something above these two numbers. And it's important to measure it on two views. Again, remember, get AP and laterals and measure them both so you don't miss anything. And again, I put this picture here just to show you how important a radiograph is. If I skip forward to the MRI and you just got an MRI and you quickly looked at this, you're busy in clinic, you may miss it. But here, you can't miss that this person has heterotopic ossification within the rectus and obviously has a form of impingement here. So MR, I think, is important still. There are studies looking at the utility of MR and whether or not you can skip it completely, but I think right now it's critical for soft tissue diagnoses. I still would say that the arthrography is the gold standard, although there are certain times where I would say a non-arthrogram is okay. There are different types of contrast agents you can put at. Dr. Safran has a good study looking at non-gatalidium and its effects on lidocaine. I think a good MRI, a non-arthrogram MRI, is okay in some patients. And these are kind of the classic patients with no risk of anything weird, instability or capsular thinning, etc. But you have to understand what your institutional limits are. Not all MRI machines are the same and not all radiologists are the same. And so your arthrogram probably will help your radiologist figure things out if they're not used to looking at hip arthrograms. And this is just an MRI. The one on the left is a non-arthrogram. One on the right is an arthrogram, just showing that you still can diagnose the labral tear. So CT scans, again, I don't get these in all my patients, but I think there's an argument to be made to get them in some patients. Certainly, if there's complex bony deformity, if you need a 3D model or you're using navigation, and the patient on the right has a prominent AAIS. This is a person with osteogenesis imperfecta. And so we got a 3D recon to just see what we're dealing with in terms of the morphology of the AAIS. And you can see on both sides that there's a prominent subspine and causing her that impingement. Now, in terms of indications, you know, indications depend on the diagnosis, right? And there's certainly multifactorial. So in terms of the two specific things, obviously the disease is most importantly. So what are you treating? Is it traditional impingement? Can pincer combine? Is there micro instability? And then there's all the other things that affect athletic hips, hamstring, core muscle injuries, et cetera, et cetera. And those indications are going to be specific. But when you talk to an athlete, the way that they differ is their timeline. And so you have to appreciate the athletic timeline, understand what their goals are, where are they, how much eligibility do they have left, and what their time for recovery is. Now, I think for most patients, I would still say start with non-operative treatment. I put an asterisk there because there are some studies, and I think in some patients, it's completely reasonable to think about jumping to surgery. But for most patients, I would say starting with non-operative treatment is safe, plus or minus injections. Now, in terms of injections, obviously we have a lot. I think the CSI is the workforce. So this has therapeutic and diagnostic benefits. It's certainly a good thing for an in-season athlete that needs symptom relief. But more importantly for us, it helps distinguish where the source of the pain is coming from. Unfortunately, the response to a steroid injection, especially an intra-articular steroid injection, doesn't always correlate with outcomes. So just take the results with a grain of salt. So in terms of my approach, obviously I try to be systematic. It starts with anatomy. If you don't know it, you can't diagnose it. Be comprehensive. So do a good, thorough history, physical exam, and get good imaging. If you get an accurate diagnosis, you'll probably get good treatment and you'll have a happy athlete. And again, when you deal with athletes, talk to them and understand what their specific goals are. Thank you. Thank you so much, Ryan. That was a phenomenal overview of how to approach patients with hip pain and FAI and other types of issues. A couple of quick questions. You have a lot of experience with athletes down in Florida, especially you mentioned core muscle injuries are something you see a lot. In your practice, how do you kind of differentiate intra-articular versus extra-articular? Do you use injections much? And what's your approach with that? Well, so yeah, I think that the, again, it's just starting from the basics. It's, you know, what they're telling me. So classic, both of those are a little different. So classic groin pain, more medial, non-articular radiates down the middle of the thigh and into the rectus. I'm thinking more core muscle injury, more kind of C-sign lateral groin pain. I'm thinking more FAI. Obviously patients are super complex and there's a lot of overlap. So if I'm at all concerned, imaging, I think then helps me tease that out. So I think physical exams key probably gives me 99% of the certainty of the diagnosis. Then the imaging is next. And if I need one, I will do an injection to kind of further elucidate that. The problem is, is that sometimes core muscle injuries and FAI go hand in hand and you have patients with both of them. And I think that's where it gets a little tricky. So. Very good. Very good. No, thank you very much. So to move things along, I'm going to take our next topic, which is once you've identified a patient or an athlete with FAI, you know, we're now starting to talk about how to best surgically manage them. You've indicated them for surgery. Now we're going to talk a little bit about osseous management, which in my opinion is one of the most important aspects of hip arthroscopy. Here are my disclosures. Nothing is relevant to tonight's talk. One thing that we've learned over the last several years, and this is some great work that came out of Shane Nho's group at Rush, is that revision hip arthroscopy, one of the, one of the main reasons why, why patients fail these surgeries is that the bone resection wasn't proper. And one of the, you know, it's easier to, you know, sometimes, you know, point blame or, you know, look at an x-ray, you know, as a Monday morning quarterback. But we have to remember that, you know, to resect bone properly is often very, very challenging. It can be very difficult. And this is probably one of the key things with hip arthroscopy that leads to the high learning curve. So tonight I'm going to try to give you some pearls that I've learned over the years and we've learned, you know, from each other and many, many, I've learned a lot from the people on this panel and a few dictums on osseous management, which I think are really key. Number one, like any surgical procedure, a good exposure is paramount. That's probably the number one aspect for being able to properly treat the bone pathology. Number two, as Shane Noah has taught us, we have to respect the capsule at all times so you can close or placate it at the end of the case. Improper capsular management is another chief cause of persistent pain after hip arthroscopy and that's definitely something we want to avoid. Number three, we really only want to remove the bone that is causing the pathology. We don't want to create iatrogenic dysplasia or any other or lead to any kind of sharp edges. And speaking of sharp edges, Mark Philippon used to say, as true to veil vernacular, we want to create blue slopes and not black slopes. So in other words, as we're resecting bone, we don't really want to leave any sharp jagged corners because this can irritate the patient. So to start with, on the pincer side, this is when you have bone spurring on the acetabular rim. Essentially, the treatment process is we want to first expose the acetabular rim. It's very important to protect the capsule during this process. Number two, we want to address the bone pathology. Sometimes there may be an os, there's going to be pincer lesions, sometimes you will decompress the subspine. And then at that stage is when we focus on the labrum and that's where we usually will repair the labrum or treat it in different manners, as Dr. Ellman will tell us in the next talk. So one of the key things for exposure, which I think is very, very important, is that we really want to separate that capsular leaflet from the anterior superior labral tissue. And really one of the key aspects of doing this is to be able to visualize the pincer by essentially rotating the camera body and the lens simultaneously. This is what Ben Dome refers to as the upper deck view. And it allows you to really see the pincer morphology in a manner that, you know, allows you to reach it. And so if you can see it, you typically can reach it. And that's how you can you can get to the get to those pincer lesions. So to show you what this looks like, essentially, what we're doing is we're, our camera is in the AM portal, typically, we're protecting the capsule, and then, and then we're basically rotating the camera body and the scope simultaneously in order to see the pincer lesions as they're creeping up against the superior aspect of the labrum. And this also allows you to prepare the bony surface of the labrum to improve healing potential. Next, you know, I want to talk a little bit about subspine. So subspine is an area where oftentimes this can cause pain and deep flexion. So here's an example of what it looks like. You can see that with deep flexion, you often can have a difficult time. You know, with deflection, you can often have persistent pain or a difficult time achieving full flexion if you have a very large subspine lesion. So indications for taking down subspine impingement is typically your type two and your type three, basically any area of subspine that's protruding. I'm pretty aggressive on the subspine decompression. I think it helps most patients and also it improves the biology at the labor repair site. Next, we'll talk a little bit about our cam lesion. And this is a very, very important area where, you know, the cam has kind of been described as a silent killer of the hip. You know, there's it's definitely an art to try to improve the, you know, the alpha angle and to do it in a very symmetrical and contoured and contoured way. But there's really different ways that we can do it. The key aspect on this is to understand what kind of exposure we're going to get. There's essentially an East Coast versus West Coast, you know, you know, distinct battle, so to speak between interporeal versus T capsulotomy. Shane and many of the Rush fellows will tell you that T capsulotomy is the is the way to go. Many others will will talk about the interporeal side. And that's often, you know, it really doesn't matter which one you do as long as you properly close and take care of the capsule afterwards. The advantage with the interporeal is that it does not violate the zone or brachialaris, which is an important stabilizer of the capsule. There's less morbidity if it doesn't heal. And then it's typically faster since less sutures are needed for closure. Disadvantages, it definitely requires more camera manipulation. It's harder to visualize. And in some cases, it's a little harder to reach posterior than the T capsulotomy. The T is easier to visualize. It's much it's also easier to it can be done technically without violating the zona. And then the disadvantages is it just requires more more stitches when you're placating at the very end of the case. Just to show you kind of what the zona looks like or what the zona the importance of the zona. This isn't this is a very cool video from Britain where they're essentially showing us what the what the zona looks like by placing a camera through the acetabular fossa. So essentially with the hip when the hip is in full extension, the zona orbicularis essentially tightens with a screw home mechanism that provides stability to the hip. This is very similar to what what the capsule and what our glenohumeral ligaments do in the shoulder. And then as the hip flexes, that capsule and that zone orbicularis relax, which allow more stability. So this is this is an important stabilizer the hip that we're trying to protect as we're doing our camera section. Femoral osteoplasty steps, expose the cam lesion address the bone, and then assess the adequacy of your your resection. So just to kind of show you what this looks like on a video. So step one, expose the cam lesion, I like to use an RF starting distally. That's usually where we like to start our camera section. And, and then step two is we're going to try to address the cam systematically, almost like a cutting block similar to what we would do for a subacromial decompression. So first, it's typically easiest to start your camera section distally on the femoral neck, that's usually the area where you have the most cam impingement anyways. And, and you want to protect your vessels, it's, you want to move the leg and extension and flexion, internal and external rotation to achieve all areas. And typically, it's easiest to start that resection distally and posteriorly. Once that's done, then you can set your cartilage bone resection line, which is another area where you kind of want to go slow with the burr to avoid any kind of, you know, to avoid the burr from jumping and causing inadvertent damage to the cartilage. We're trying to create a very smooth line that eventually will make it easier for the for the hip to flex in and out. And then once you do that, you can typically go very fast in between to blend it to blend the to blend the bump. And so when you're all said and done, your your goal is to be able to do a dynamic exam and make sure that there's no areas of impingement, you want to see that the labrum is nice and free and not not being pinched or impinged in any capacity. The goal with cam resection is to create a spherical femoral head with no sharp corners. And, and it's definitely something that is probably the hardest part of hip arthroscopy in our learning curve. This is a video of what a T capsulotomy looks like courtesy of Shane. You know, it's also a very, very good reproach. It's very, very efficient to do. And it's a the key to this is just making sure that you close and placate the capsule appropriately at the end of the procedure. Mark Philippon talked a little bit about a dynamic exam, the concept of a dynamic exam to gauge your camera section. And the main goal of this is because it's often very difficult to translate 2d perspective seen on intraoperative films to the 3d assessment of hip motion. And the key to this is just knowing that excessive bone resection can compromise your suction seal or structural integrity. So you want to remove bone, you don't want to remove excessive bone, and you don't want to leave any sharp edges. So in summary, optimal osseous management is the key to durable long term outcomes and survivorship. It's really the main factor in our hip arthroscopy learning curve. And it also is one of the main factors that allows us to impart a significant risk reduction, the development of arthritis for many of our patients and athletes. We want to avoid sharp corners in any bone resection, take your time being artists, this is a right brain, right brain procedure. And, and in my in my experience, I think it's easier to go distal and posterior, and then work your way more proximally. And then smooth things off in between. So take your time, and, and, and it'll, it'll be much easier. So next up, very grateful to have my my good friend, Mike Ellman from Denver, who will be talking to us about the importance of labral preservation, and his methods for labral treatment and the algorithm that he uses when he's assessing these patients. Thanks, Mike. Yeah, thank you, Jeeves. Great talk. Hey, quick question for you, just before I get started. I think one of the hardest things in my learning curve was avoiding over resection, because Shane's paper, while it was a great paper to show that residual FAI is the number one cause of revision hip arthroscopy, it also kind of scared me when I started in that I got to make sure I take it all. And then I think, you know, personally, like, it's certainly possible I over resected some, and that's a really difficult problem to treat. So any kind of, you know, thoughts or comments to the younger guys to avoid that? Yeah, yeah, very, very good question. And it's, that's something I think all of us struggle with, you know, at all times is trying to figure out how do we, you know, how do we find that perfect balance? You know, I think the one thing which I've heard others say, and, and, you know, Ben Dome had a, you know, this is one of the things that he was very good at explaining, was that it's always easier to take more bone than it is to take, than it is to, you know, over resect. So, you know, for for the newer people starting out, you know, it just know it's always it's, it's, you're better off under resecting than over resecting. And if in doubt, always better to leave it. That being said, you know, I think it's, you know, I think the key thing to this is, you know, looking at x-rays, if you're seeing, if you're burring somewhere on the femoral neck, and you don't see anything change on the x-ray, it's a good idea to stop because it's likely that your burr is in a, you know, in a different part of the plane. The other thing which I think you do this as well, Mike, is, you know, often using the burr in a, in reverse. That's a very useful way to kind of help slowly polish the femoral neck and avoid inadvertent, you know, you know, sudden, you know, sudden jumps to the burr, which can take away soft bone very quickly. Yeah, no, that's great. All right. Well, thank you. And thanks for the kind intro. I'm going to be talking about treatment of acetabular labral tears. So, you know, from a disclosure standpoint, they're updated on the Academy website. You know, I do want to issue a disclaimer before we get going here. When discussing the labrum, I think it's very important to avoid labral myopia, kind of a term we just made up. But what I mean by that is we all like to focus on the labrum, the labrum, the labrum, and in truth, in hip preservation, the labrum is usually the effect, not the cause. So I think it's really important if you're going to do hip preservation, to focus on the cause itself, whether that's a bony issue, such as dysplasia, soft tissue issues, such as micro instability or impingement FAI, like Sanjeev and Ryan already talked about. I think it's really important to keep this in the back of your head. If for some of you guys who just want to tune out for the next 10 minutes, I think that's totally reasonable. No, I'm just kidding. But I think it's really important to keep that in the back of your mind. That is not all about the labrum. The bone is king in a lot of these cases. So this is a slide looking at the evolution of treatment of the labrum that ends in about 2010. And it started in about the early 2000s. And you know, back then, the hip preservation was just beginning in terms of hip arthroscopy. And so safe access was just a big deal. It was a big deal to get into the joint. Then we started thinking, oh, the labrum is a pain generator. Why don't we cut it out? Right, just similar to what we do sometimes with the meniscus and the knee and, and these patients actually got better in the short term. And then we realized, well, you know, the labrum is actually could be very important from a functional standpoint. So we should probably preserve it and repair it. That was about 2010. And really, over the last 15 years, we've grown a lot from a hip preservation standpoint, we're going to talk about some of the advancements we made. And so for me, really, the, you know, the principles of labral treatment should be based on the principles of labral function, we really want to be focused on restoring anatomy, biomechanics and function of the native tissue. What do we know about the labrum? It's chondroprotective, forms a hydrostatic fluid layer, it allows for proprioception, and it provides for stability to joint distraction. Sanjeev, this is a great video that I think is monumental in the hip preservation world that you and Jorge Echala put together about 10 years ago, looking at the power of distractive stability, this is an intact labrum, you see distractive stability, the hip there, this is a labral debridement, complete loss of distractive stability. And this is a segmental labral reconstruction, where you're able to restore that distractive stability. So I think this is a really important video for us all to see to visualize the power of stability provided by the labrum. So what are our treatment options, right? Well, we can debride it or cut it out, we can repair it or fix whatever's torn, we can augment it or bulk up an abnormally thin labrum, or we can reconstruct it, where it's really poor quality, and we're going to take it out and replace with cadaver tissue or autograft. So what does the literature tell us? Well, we know when we compare labral repair versus debridement, both subgroups honestly do great, like consistently good clinical outcomes with both debridement and repair, likely because we're addressing the bony abnormality, that's the true cause. But biomechanical and recent level one studies have certainly favored repair from a long term standpoint. So patients get initially better with a debridement, but then they peter out, whereas repairs continue to get better. What about outcomes of a labral repair? Several papers now, short term, mid term, now even long term studies are starting to trickle out on labor repair, most of them with really good to excellent results over 90%. Recent studies have shown over 95% short term with which with durable results in two and five years, it's a great option for a lot of our patients, especially athletes, we have about a 92% return to play rate in athletes, which is better than the 73% return to play rate for ACL. So, you know, it's a really good surgery from that standpoint. So this is kind of the algorithm that goes through my brain, every case I'm in, I'm going to evaluate the labrum, if it is fixable, good quality tissue, I can get a seal, I'm going to fix it. Okay, labor repair, pretty straightforward, pretty easy. From a technique standpoint, anchor placement, I think it's really important to get as close to the rim as possible without penetrating the joint. So I used a curved guide, typically from the DALA portal, an accessory distal portal, gives me a better trajectory to hit the to basically avoid the joint cartilage, but get as close to the rim as possible. It allows us to avoid what we call eversion of the labrum allows us to maintain that seal. Knotted versus knotless, kind of transition here, I started knotted, then I went knotless for a couple years. And for the last six or seven years, I've been all knotted again. So I tie knots. To me, it's surgeon preference. I think as long as you do a good job keeping that anchor close to the rim, whatever works best in your hands is going to be acceptable. Labral base versus circumferential. This was a paper of Bendome looking at the different suture configurations of the labrum. And the mattress is what I've gone to as kind of my workhorse for most labor repairs. I like how the labrum you kind of, it's mostly torn at the chondrolabral junction. So once you get that labrum fixed to bone, the majority of that labrum is still triangular shaped and is still able to maintain conformity to the femoral head. And then there's newer labral advancement techniques, such as inside-out anchor placement, where we can place the anchor via an intra-articular view underneath the labrum and actually kind of advance or invert the labrum down to the femoral head to restore our seal. I think in general, the key is restoration of the suction seal. So you just don't want to invert that labrum. You want to make sure it lies perfectly on the femoral head and you have good conformity of that over the head with a good seal. All right, what about the right side of this equation? If the labrum is irreparable, if it's poor quality tissue, our options are to debride, meaning cut it out, to reconstruct, replace it, or to augment it, bulk it up. What does the literature tell us? Debridement versus reconstruction. We know once the labrum is excised, it doesn't grow back. We know that segmental resection or debridement decreases contact area and increases contact pressures. And a recon can actually reverse this, improve it. And we also know that stability of the hip is better restored with a reconstruction than a debridement. So the literature, at least biomechanically, suggests that reconstructions do better than debridements for irreparable labral tears. What about repair versus reconstruction? From the same biomechanical study out of Vail a couple years ago, which was a great paper looking at the biomechanical effects of hip stability, a repair did better than a reconstruction, which did better than a partial debridement and a complete debridement for the restoration of hip stability. And that's corroborated in the literature as well. Now several studies looking at both primary and revision hip arthroscopy, including one by the MASH group with Shane, looking at outcomes after repair versus reconstruction. And in general, existing studies demonstrate no significant difference in PROs between repair, segmental and circumferential labral reconstruction as short term follow up. Key here, it's short term, not mid or long. Also key is that the recon subgroups had more severe pathology with equivalent PROs. So those actually did really well. So in the cases of advanced pathology and more severe pathology, I think a recon is totally acceptable in that setting. Josh Harris in his editorial in 2022, a year and a half ago, wrote reasonable indications for primary labor reconstruction include a calcified or ossified labrum, irreparable tissue and hypoplasia of the labrum with a proven deficient suction seal without resistance to axial distraction. And the way I run my practice is very similar to this. If it's good tissue, it's pretty simple. Good tissue, good seal, I'm fixing it, repair. If it's poor tissue, poor seal, I'm gonna recon or augment that hip. So what are my indications for reconstruction? In a primary setting, patients with an ossified labrum, poor quality native labral tissue and a poor seal. In a revision setting, previous labral debrimas or failed repairs or recons with persistent pain. From a technique standpoint, I prefer the kite technique. Sanjeev, Jorge, Chase and I published this back, all the way back in 2016, which seems like forever ago. And we've been using it really, at least I have in my practice ever since. It's been a great advent for us in terms of how we do this. It is a segmental reconstruction. We try to preserve as much native healthy labrum as possible. I typically use Tibant Allograft, about six millimeters for a recon, four millimeters for an augment. And my typical length is about 50 to 60 millimeters from a length standpoint. We've published several techniques now on our kite technique for both recons and augments, enough so that my team now makes fun of me pretty routinely for being the kite guy. And I'm frankly pretty proud of it because flying a kite is fun. So if you have an issue with that, you know, that's probably a problem more with you than with me. So from a recon standpoint, the key is the restoration of the seal, okay? So you get your recon done, you wanna make sure that you have adequately restored that suction seal. So the labrum has come back onto the ball. We usually take it through a dynamic exam and we make sure basically that we have restored that suction seal in that hip. And when I do this in every case, I think this is one of the most important parts because you wanna restore dynamic stability of that hip. What are outcomes from a recon standpoint? Several papers out there, most of them short-term, but some midterm outcomes are trickling out as well. Show about a 75 to 90% success rate. So pretty darn good. That also means 10 to 25% failure rate. So, you know, it is something to keep in the back of your head. I think that the failure rates are a little bit higher than a standard repair at this point. We have about 85% return to play at athletes, but that is limited in terms of who we're doing our data in. And importantly, in one of Dr. Brian White's papers, he showed a 10% conversion rate to total hip arthroplasty, which again, that's a pretty high number for a primary procedure. So you gotta make sure it's indicated and you're not doing this if it's not indicated. What are my outcomes? 327 segmental recons since 2018. I have about a 12% revision conversion rate. So it's real, it's higher than my repair outcomes, but I have a ton of patients doing very, very well after these surgeries as well. So what about labral augmentation? Okay, this is what I call the new frontier. This was really popularized by Mark Philippon back in about 2019, where he just, you know, the patient with the everted really thin labrum, it's really doing nothing from a stability standpoint for that patient is plastered up against the wall. He introduced the labral augmentation where essentially you put cadaver tissue behind the native labrum and push the labrum down onto the head, kind of a form of a labral advancement or inversion, and it recreates stability in that way. And it's a huge, it's been a huge benefit in my practice in terms of we're maintaining chondrolabral junction, we're maintaining proprioception. Our patients are actually recovering quicker and easier than a reconstruction. Our outcomes are better than our recons. So to me, it is, it certainly has a potential to increase in popularity over the next couple of years. But our indications still evolving, but again, increasing at least in my practice, hypoplastic or thin labrum, less than two to three millimeters width with a poor native seal, intact chondrolabral junction, young active patient. And to me, it is safe to augment in general in a primary or revision setting. We've had good outcomes in both. And so I think it's just kind of dealer's choice. How do we do it? Very similar technique for labral reconstruction. We're basically just putting graft in. It's easier than a recon because we're keeping the patient's native labrum in, and we're basically just bulking it up, putting it behind the labrum and tacking it back down. So you can see here a nice solid labrum after our augment. And you could see that we've restored the seal in this patient as well. So what are our outcomes from a recon and augment standpoint, mid and long-term? Frankly, we have no idea. So this is certainly something we will be studying moving forward. This is kind of a summary of my treatment approach. This was back in 2021, guys. This is not that long ago. This was three years ago. At that point, I was repairing about 86% of my patients, reconing 12% and augmenting 2%. And in the last three years alone, these have kind of flipped. And so if you look at my numbers from 2023, moving into 2024, about 80% of my patients are getting a repair, 12% augments and 8% reconstruction. So I'm augmenting more, I'm reconing less. And I will say some of those really borderline hypoplastic super thin labrums, those are the ones, at least in my practice, that I saw fail more than the normal size labrums. So we have kind of trended more towards augmentation in that patient cohort as well. Ultimate goal, no matter what you do, again, restore that seal, restore proprioception of the labrum against the ball. And then in all of these cases, whether you're doing a repair, a recon or an augment, just make sure you're doing the best job you can to restore that seal. So back to my initial slide, right? In 2010, we were pretty happy with repairs. And frankly, we still are, still the workhorse of what we're doing from a labral treatment standpoint. But in the last 14, 15 years, we've now added recons and augments to our armamentarium. So we have a lot more options from that standpoint. It's really interesting and fun to see what's gonna happen in the next 15 years. So it's still a rapidly growing field. It's really fun to be a part of. Thank you. Wow, that was an incredible talk, Mike. You put together a lot of really, really good information. And I thought it was really fascinating how you shared the evolution of how this field has changed just in the last 10 to 15 years. I think that's one of the cool things that makes hip arthrosophy and hip preservation so exciting. Somebody who has really, really good perspective on how this has all changed is our good friend, Shane Nho, who's been around from the beginning. The OG, the OG. Shane, we'll let you take it away and then we'll talk soon again. Thanks, Sanjeev. Real honor to be here. Rehab, I think, after hip arthroscopy is really critical. And I think that when I first observed working with a lot of the real OG hip surgeons, Mark Philippon and Tom Byrd and Brian Kelly and others, I think that I realized that they really relied on their physical therapist quite a bit. And in watching and observing their practices, I thought, hey, why do they have like a go-to physical therapist? And when I started my own practice, and I'm sure the others who are on the webinar would agree, that having a really good therapist is important. And so if you don't remember anything about this talk, I would say, if you don't have a really good therapist that you can depend on and rely on, like forget about all the slides, find that person. It'll make your life 100 times better. I can guarantee that. So my name is Shane Nho. I'm at Rush University Medical Center in Chicago. Again, a real pleasure to be here. Thank you guys for taking the time out of your evening to spend with us. Hopefully you guys find it to be worthwhile. So I'll be talking about rehab. And this is an article that came out in the BMJ Open Access Journal, just talking about physiotherapy or physical therapy after hip arthroscopy for the treatment of femoral acetabular impingement. And what they concluded was that if you incorporate physical therapy, you're gonna have a better and faster recovery. And if you emphasize early range of motion, you're gonna minimize the risk of adhesions. And lastly, physical therapy after hip arthroscopy certainly promotes high levels of function and return to sport. And so I think that, obviously for most of us who are doing hip arthroscopy, I think we all believe that physical therapy is an important part of it. And in fact, I tell my patients that the surgery is probably only about 50%, and physical therapy is probably about 50%. And I'm sure we can all talk about and remember patients of our own that the surgery went perfectly and they're just struggling in physical therapy and just kind of wondering like what the heck is going on. But I think it just kind of goes to show how important the rehab side of it is. In this study, they also compared post-operative supervised physical therapy versus a home exercise program. And what they found was that patients who had undergone supervised physical therapy had a faster recovery at 14 weeks. Both groups actually did better, but certainly a supervised physical therapy group did better and much more quickly. Most physical therapy regimens are phase-based and the principles that are guiding the phases are firstly healing time or biology. Secondly, functional performance. And lastly, patient report outcomes. There's a variety of different PT protocols after hip arthroscopy that you can find in the literature. These are just a few of them on the right. Most of the protocols usually are about six months in duration. The phase timing is poorly reported, but I would tell you that it is emphasized throughout many articles that progressions are both patient and surgical procedure dependent. For example, if the patients have microfracture, they will be on a protected weight bearing for a longer period of time than your standard hip arthroscopy. And most physical therapy protocols are based on four phases. And we'll talk about those four phases. And those include phase number one is the joint protection phase, and that is your immediate post-operative phase. Phase number two is restoration of joint mobility and stability. Phase three is restoring functional performance. And phase four is return to sports or appropriate functional demands. So phase one of my patients and all of our patients, again, emphasizing joint protection. This is for the first three to six weeks, depending on what needs to be done and what was done at the time of surgery. I think it's important to start your physical therapy with a quiet hip that is not in pain with minimal amounts of inflammation. And that can happen with anti-inflammatories, obviously keeping control of the pain with pain medications. Cryotherapy I think is really important as well as pneumatic compression. Typically I place the patients on 20 pounds foot flat. I keep them on crutches as well as a hip brace. We do have some range of motion limitations for the first like two weeks or so. I want to restrict flexion to 90 degrees, extension to zero degrees. I will limit excessive amounts of extortation, but that being said, we do emphasize early circumduction as well as we also want to have the patients lie on their belly to extend their hip as much as possible. And one of the guidelines that one of my physical therapists said that every step you take is actually physical therapy for the hip at this point in the protocol. So just kind of keep that in mind. In addition, you want to promote early pain-free passive range of motion. Again, circumduction, the patient's caregivers oftentimes can actually do circumduction if educated properly by their physical therapist. Quadruped rocking or flexion and stationary bike without resistance. And I tell patients that, you know, you want to use your opposite side to motor the operative side. And it's really kind of like a poor man's CPM. If you can get CPM, it's great. I actually really think CPM is very helpful for post-op patients. And so I do encourage it, but unfortunately I think in most cases, insurances don't actually approve it. And so at least the DME providers in my area will either try to bill their insurance, but if it doesn't go through, then they'll offer patients an out-of-pocket option as well. Manual therapy, soft tissue mobilization, I think are really important for hips. And, you know, I tell patients that their therapist should be providing a decent amount of hands-on work for them, at least for the first several weeks or so. I think that it's really helpful. I think it provides help in terms of pain control. I think it restricts the amount of adhesions and stiffness that might happen. And, you know, I really think of, you know, your post-op hip is similar to any post-operative joint, whether it's post ACL reconstruction or shoulder stabilization. You know, you want to maintain that fluid motion and progressive range of motion initially, because if you kind of get behind the eight ball as far as the range of motion is concerned, the patients can have a really stiff hip and a really stiff hip can affect their trajectory of the rehab pretty dramatically. It's like if you had an ACL patient who has a flexion contracture, I mean, once you get past a few weeks, like it's really hard to get that back. And so I think they have to know early and often that they have to get that motion back. And it'll show because if they don't progress and have a normal hip extension, their gait obviously is affected pretty dramatically. And we'll talk about that in a moment. The cardiovascular portion of this phase is limited. If the incisions are healed, I do think that water therapy can be helpful. It also helps with like gait training as well. Again, stationary bikes should be an important part of their physical therapy regimen. And they'll transition from going from mostly a passive motion standpoint to active assisted and then eventually active motion with minimal resistance. Some physical therapists like to use an anti-gravity treadmill as an adjunct to help with gait training. So I think that that's fine. Obviously I wouldn't use it for running at this point. Criteria to progress to phase two is minimal to no pain at rest. Their pain should be less than three with any types of activities of daily living. Their pain should be limited to 70% of the opposite side. They should be able to achieve a single leg stance for about 30 seconds without balance loss. And they should be able to complete pain-free 30 degrees flexion double leg squat as well. Phase two can begin somewhere about four weeks to about 12 weeks. And the goal of this phase is again, restoring joint stability and mobility. And you wanna restore a symmetric range of motion. You wanna improve function in terms of muscular function for weight-bearing tasks. And then you wanna focus on restoration of normal gait. And I think this is critical. Again, if you don't have normal motion, especially terminal extension, the patients can't have a normal gait. If they can't have a normal gait, it's gonna affect their ADLs. It's gonna affect everything that they do. If the patients are walking in at like eight weeks or 12 weeks and they're still limping, like that is a real problem. And so first of all, the therapists have to recognize that that's a problem. But if they lose extension, then they'll usually have a trunk shift. They'll circumduct their gait. They'll have all sorts of compensation patterns that are kind of one leads to the other, and it just kind of leads to like a poor recovery. And so if you recognize that, you gotta get on that as quick as possible. And that might entail educating and speaking to their physical therapist. In some cases, I'll use either a MedDRAL dose pack just to help just bring down the inflammation, but most importantly, educating patients to understand that they really need to focus on motion and gait training before they can work on like any strengthening or strength progressions or activities because if they don't have that back, everything else is gonna be an uphill battle. As far as cardiovascular considerations at phase two, you can start to add resistance on the stationary bike. I tell patients that at this point, you wanna increase the volume of your activity, not necessarily any speed or power, but if they're using the stationary bike, let's say low resistance, they can increase from like 20 minutes, twice a week, 20 minutes, three times a week. Maybe they could go 25 minutes, three times a week, 30 minutes, and it should be a fairly gradual progression as far as like how much volume they're adding into their activities. And in addition to that, they also have to keep in mind how much activity they're doing outside of physical therapy. So if they're doing a lot of walking on the weekends, if they've got a lot of errands that they're running, if they're walking a lot at work, all these things are additive. And one of the things that we've asked patients to also look at is their step count too. So I think if they've got a heavy day at work and they're doing a ton of walking, to do physical therapy after all that tends to be really difficult. They may get tired and fatigued and have pain again. And so whenever the patients are saying like, I've got more pain, you always have to interrogate like what's been going on. What's happened in the past like few days? Has anything changed as part of the routine? And their joint may flare up if they've got a lot of activity that they're doing as far as like walking and standing and ADLs, but usually shouldn't be a problem. It should get better after a day. NSAIDs can help, icing can help a lot too. Again, water workouts can be really helpful if they have access. Some patients will recommend doing deep water jogging and running if they're interested in running as well. In order to progress to phase 3, the criteria is minimal or no pain during or after activity, normal symptom-free gait with community ambulation, symmetrical hip is active, I'm sorry, symmetrical hip active and passive range of motion, they should have normal motion, they should be able to complete maximal double leg squat, 75% of their symmetry and hip muscle strength and 70% symmetric with single leg functioning performance tests. As far as restoring functional performance, the advancement should be guided by functional goals, their overall joint and soft tissue health, patient motivation as well as engagement and you know at this point I think you can really focus on advancing strength, speed and power as well but I think you know I think going back to that volume adage usually at about three or four months you know especially for our athletes we'll ask them to increase the amount of strength that they're doing, increasing repetition, adding more weight to what they're doing but everything should be fairly progressive. If they're doing squats for example you know obviously start with body weight, you can add dumbbells, 10 pounds, 15 pounds, 20 pounds but they want to go gradually rather than going like very quickly and they should focus on mechanics, symmetry and form and so they shouldn't be doing a lot of strengthening just for the sake of doing it but they should be doing it with the proper techniques. Here a couple examples of good exercise that patients can be doing, these are called lawnmower pulls which is good for resisted hip extension as well as elastic band splits for abduction exercise as well. As far as cardiovascular type activities again cycling is really helpful, elliptical is helpful either indoor or outdoor and then if the patients are runners I typically will get them on a running progression program and that would entail a run walk so usually I say run for a minute, walk for four, take a day break, run for two, walk for three, take a day break, run for three, walk for two, take a day break, run for four, walk for one until they're doing like a light 10-minute jog and then just kind of work their way up and again jogging first, adding volume before they add any speed, speed work or anything like that. And then criteria to progress to phase four, I think the focus should be on single leg balance and strength. One of the things that I'll do in my office that's pretty quick is to do double leg squat in front of me as well as single leg squat and if they've got any like gait disturbances or asymmetry with single leg squat compared to their non-affected side to me it's they don't they're probably not ready to progress to phase four. Really easy to do in the office and something that we've done some biomechanical studies on as well and they should have 90% symmetry between their medial and lateral hop test and you know once they get to transitioning from phase three to four some of our physical therapists will use like a functional sports assessment in order to see their readiness to go back to sports and so forth. This is a study that we did in our lab looking at single leg squat at six months and one year post-hyperthroscopy and what we found was that patients had restored their range of motion and biomechanics of their single leg squat and I really do think that the single leg squat is a good way to kind of follow them. It's a good biomarker as they're going through their rehab and it will show you their readiness to go back to more sports specific activities. Phase four return to sport will be 24 months and above and again the goal is to optimize physical performance for activity or sport, return to pain-free competition, maintain load management and chances of overuse or overloading and obviously there should be communication between the entire sports healthcare team that includes the MD, the ATC, physical therapists, strength and conditioning and coaches and at this point I do think if you incorporate some of that functional sports assessment that this is something that can be done weekly so that the patients and athletes can understand kind of where they're at or where their deficits are. If you do have the luxury of having some motion analysis testing we have like sports performance athletic trainers that will do a series of tests and compare them to the opposite and affected side and I'll give them a numerical score that will show them when they're ready to return to sport and so I think these these types of adjuncts are really helpful. Obviously college athletes will have more resources but I think our high school athletes are the ones that you know sometimes it can be a little bit tricky as far as like when they're actually ready to return to sport just because it's hard to gauge based on an office visit and at this point now is the point where you can really start add speed and power and you can add skill coordination and rotational movements and so forth you know plyometrics sports specific activities you know if they're throwing or pitching or kicking or what have you I think all these things you know at this point you know I tell the physical therapists weren't used to seeing hips like it's really pretty much the same as an ACL so whatever criteria you might be comfortable using to assess hip patients post-op is very similar to you know ACL patients post-op and so if you follow those guidelines and those metrics you know whether you do like a you know like a veil sports test or veil hip test or a functional sports assessment test ACL assessment they're all pretty much the same like you know are they going to be able to withstand sports type movements and activities and do it safely without either causing harm or injury to the affected joint or to any joints for that matter if they're going back to sport so just a couple take-home points in terms of post-op rehabilitation after hip arthroscopy you really want a team approach and again if you don't remember anything from this talk what I would say is you know find a therapist that you can rely on that go-to therapist can help your patients tremendously you know I've got a handful of them in the city and if I have patients that are just kind of struggling and just not making progress and I just can't explain why there's nothing objective on x-ray their MRIs are fine you know they might have some obvious things on physical exam particularly like stiffness and adhesions could be one of them you know I think they really need to see a therapist that is used to seeing these types of patients they understand like sometimes the comorbid conditions including the contribution from the lumbar spine pelvis a side joint as well as you know sometimes the length of time due to like significant amount of muscular atrophy and disuse that has been incurred over years of like pain and compensation you know I think that that's probably the most important thing that I've kind of realized dealing and treating with hip patients understand that healing time criteria patients return to activities does vary quite a bit and the rehab is certainly not linear I mean sometimes they can feel great then get worse then get great again then get worse and then as long as they're going to an upward trajectory I think that that's fine but you know sometimes it can take a while and there are some patients that just seem to fly through and other ones that kind of struggle for a while and other ones that get better and get worse again and I think it's similar to like other other you know conditions that we treat as well so it's not entirely unique to the hip but I do think that regular performance measures and assessments can be helpful whether it's subject to PROs but I think physical therapists that they're doing like functional sports assessments can be really handy and then testing them and retesting them even on a weekly basis I think could be helpful just so that we understand like when these patients are ready to go back to sport without incurring any risk of further injury thank you very much thank you Shane that was an incredible group you know talk group of really good pearls that you sent and yeah I really like what you mentioned about the single leg squat I think that's a really really good simple thing that a lot of us can use in practice to you know help gauge readiness quick question you know you mentioned how you know if you lose your hip extension early on that can be a really detrimental thing for rehab are you doing anything early on to help promote that in terms of you know teaching patients any kind of home stretches that they can do or you know tummy time so to speak to try to help promote hip flexion or hip extension early on yeah so we do restrict hip extension for the first like two weeks and that is to protect the labrum and the capsule following repair but beyond two weeks you know all of our patients are instructed on and even actually within the first two weeks tummy time we do emphasize that but beyond that once they come in for their two-week post-operative visit we'll have the patients will demonstrate like you know Cobra poses as well as like you know hanging their leg off their bed hip flexor stretching techniques like just a variety of different things that so that they understand what they should be doing and and I think it's similar to like ACL patients that we you know we really want to re-establish that like terminal extension within the first couple weeks so that the patients don't develop a flexion contracture because if they do that it's just really hard to get back and and I think that you just want to stay ahead of that if you can makes total makes total sense so we have about seven minutes left would love to invite everybody else to kind of join join back on and we'll kind of make these last few minutes an opportunity to kind of just go through a simple case or a straightforward case and then also hopefully kind of answers you know answer some questions that have come up while also you know you know going through some other concepts so here's a here's a case which we can kind of go over the last few minutes and and then go over some questions there was a question that came up about about camera section a couple questions came about that which we can talk about so this is a patient that you know many of us have seen very athletic 19 year old male division two college football player O lineman you know long-standing sharp left hip pain you know as one can imagine you know he's a very stout very thick-thighed individual 6'1 300 pounds and then he's got a his fall season is starting in about five or six months and you know it hasn't improved with you know the non-operative measures that Ryan talked about real quick for the panel you know how do you counsel some of these athletes in terms of timing on hip arthroscopy you know they've they failed non-surgical treatment they have the condition they're now trying to figure out timing and some people some of these folks are year-round athletes how do you guys briefly how do you guys you know do that yeah I mean I mean for our our patients it's generally about a four to five months for for like pretty successful safe return to play and so we start our return to sport protocol around three three and a half months and then usually for these young kids they do really really well pretty quickly so by four or five months we're getting them back so like this would be an optimal time for this guy to get fixed if he needs to get fixed assuming he's failed everything got it thanks thanks Mike his exam is pretty standard for an FAI patient you know pain with flexion adduction internal rotation that key tests that Ryan mentioned he's got good strength you know we did a pre-op hip score assessment you know his his PROs were low indicating that he was dysfunctional and having pain from his hip here's his imaging you know he in the key takeaway here is he's got you know a significant cam lesion on the left side he's got good joint space he's not dysplastic and he essentially has cam dominant FAI on an MRI or MR arthrogram has a detached you know anterior superior labral tear and and I'll just kind of jump in to kind of what we wound up doing so we wound up doing a hip arthroscopy he had a pretty detached labral labral tear actually wound up having to use five anchors to you know get it back in place Shane how many anchors do you typically use for labral repair and you know what's your approach usually on these very detached ones you know to answer the first question I typically put I would say about three anchors I would say that's average but yeah I mean the completely detached one it's you know it's obviously sometimes you got to add more anchors depending on how extensive it is if it's far anterior or far lateral you know wherever the pathology is I think that's where you have to start to add your anchors okay great thanks very much we also did a camera section in this individual you know he had a very he had a very distal you know cam and and which which came back fairly easily one quick question on the cam side there was a question that came up about a couple questions that came up on this number one there was a question about many times the cam is very sclerotic and Shane your group has published on you know the bone density I think of cam lesions in different settings do you have any pearls in terms of how to manage the question was in regards to you know this how to manage the sclerotic bone that's there and you know do you have any pearls on how to manage the sclerotic bone and balancing that with the with the rest of the bone to achieve a normal contour I mean the sclerotic bone is typically where sort of the the bulk of the cam deformity lies and so I think most of the time I end up having to you know resect the sclerotic bone and some people say that they you know some surgeons say that they want to remove as much sclerotic sclerotic bone so that the you know the I guess the bone marrow or the cancellous bone looks fairly I guess consistent so that there isn't like that that area of like pink or like thick bone like you almost have to kind of get through it that's kind of the way I've approached it thanks very much and then another question that came up was in regards to the intraoperative software that's you know that can be used to help you assess your intraoperative alpha angle Mike or Ryan any experience with that and have you used that at all yeah so I think I know striker has a hip check software system that basically allows you to optimize your bony correction and I think one of the keys to that system too is it actually it draws a perfect circle for you and it allows you to avoid ovary section so I think early in your learning curve that's actually a really nice software to avoid ovary section but really focus on the areas that need it I don't routinely use it personally but I do routinely use it personally but I know several docs who do and I I think it's it's it's a way to objectify the most subjective part of the case so I think in your your early in your learning curve I think it's a really nice tool to have great right you do you use that software at all so no things at the University of Florida are incredibly hard to get approved so I'm still in the fluoroscopic age but I will tell you just as I started doing it hip arthroscopy and I transitioned from fellowship into being in attending I was worried about not having it and I will tell you as I got as I become more comfortable with it and I know the fluoroscopic views that I need I actually don't see a role for in routine patients I think in the complex osteoplasty maybe but for most patients I think just getting routine views and being comfortable with those views I can do a good resection. I think that's a good point I think that you know Chris Larson published a paper on just doing it systematically so you know however you're getting your information whether it's through the software program or just using fluoro I think you just want to have a consistent way of doing it that allows you to comprehensively observe see the entire cam deformity and you want to repeat that so it becomes repetitive every time like you know Chris has published that there are six different positions that you want to incorporate and those should get you like from 11 30 to I think 1 30 or 2 o'clock and I think as long as you're doing that systematically like that's you know a good way of going about it. Great great great points I'm reminded that you know unfortunately we're we're bumping up against our 8 15 end time you know to close out this case you know this this procedure this case actually was just a couple days ago earlier this week you know we're he's in the rehab phase our hope is to try to get him back by September for the season to start and you know really want to as we finish out this this evening you know really want to thank AOSSM and Ashley Meyer who helped put this together it's really a incredible opportunity to you know have webinars where we can have you know academy level and you know type talks you know just in the comfort of our own home. I also really want to thank Ryan Roach, Mike Ellman, Shane Nho for volunteering their time they had incredible you know pearls of wisdom that that I learned a lot from and and hopefully everyone got a lot out of this too. So thank you again a huge honor to have this opportunity to speak and be sure to submit your CME.
Video Summary
The video transcript features a discussion by experts on the importance of proper hip pain management in young athletes, particularly focusing on hip arthroscopy and treating conditions like FAI and labral tears. The panel stressed the significance of a thorough clinical workup, including history, physical examination, and imaging, to make informed surgical decisions. The importance of addressing bony abnormalities and soft tissue issues alongside labral treatment was highlighted for comprehensive hip preservation. Techniques like labral repair and reconstruction, bone resection, and utilizing intraoperative software for bony correction were discussed to achieve optimal outcomes. The panel emphasized the need for a systematic approach in diagnosing and treating hip conditions in athletes, with a focus on restoring native anatomy and function for long-term success. The experts also discussed rehabilitation protocols, timing for return to sports after surgery, and shared a case study of a college football player undergoing hip arthroscopy, illustrating the multidisciplinary care required for successful recovery and return to play.
Keywords
hip pain management
young athletes
hip arthroscopy
FAI
labral tears
clinical workup
bony abnormalities
soft tissue issues
labral treatment
rehabilitation protocols
return to sports
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