the worst day in my OR this last year and it has to do with ignorance on my part as in the eye sees what the mind knows and my mind didn't know anything about what I was seeing although in retrospect it should have and I'm sure most of you in the audience are gonna be thinking I'm an idiot but that's why I'm showing this so it turns out if you don't know what you're getting into once you get into it you're really unhappy about what you've gotten into because you're not prepared to get into it so disclosures in the Academy so this was a case and yes it's 15 that's not incorrect your old male drunk driving in a motor vehicle accident he was driving he there was an air transfer to the University of Utah emergency room it was a trauma one and this was his initial presenting x-ray so this was the first close reduction attempt by our residents which was unsuccessful here's the second closed redempt attempt which was successful but there was a noted loose body that was incarcerated in the joint so I got a phone call the next morning that there was an issue that the obviously there was a appropriately reduced native hip but it was had an incarcerated loose body that needed to be fixed so here's the post reduction CT that I asked them to get showing the loose body clear as day you can see that nice curvilinear structure here's the CT not any great donor site that I could identify specifically at least in looking initially so my plan I'm gonna go in I'm gonna be a hero I'm gonna take out this this body it's gonna be great the hips gonna reduce perfectly we're gonna put on a scope table my trauma guys they're weak I'm strong they don't want to do it open and I'm gonna do with a scope it's gonna be magnificent okay so this is what it looks like when it comes in we came in and of course you might expect obviously there's a big hemarthrosis the capsule was obviously hemorrhagic that's all expected the problem is I had a really hard time getting in there was this tissue everywhere I couldn't see what I was looking at I couldn't figure out the labrum I found this giant you know what I thought was a loose body sitting in there but turns out it's a loose body with a really important structure attached to it called the entire labrum which was extended from posteriorly from the transverse appetite acetabular ligament all the way to 12 o'clock so that was the poster wall that that loose body yeah I should have known it since it was sort of curved and really looked like a poster rim fracture but I didn't really recognize that in advance so this was my hero maneuver at 5 p.m. at the main hospital trying to do a hip scope with no one that knows how to do a hip scope at the main hospital so that there's the labrum and now it looks like a hip that by the way took about an hour and a half to get to that spot and and then we got it back and at this point I said okay I don't really know what I'm doing I've never done this before but I used to shoulders so this looks like a bony bank card so that's what we're gonna do here so this is a posterior portal this was one that I had not done before for this purpose anyway so that was at this point hoping I wasn't near his sciatic nerve and then we're coming around the back this is looking at that donor position as well as the rim fracture at this point I wasn't exactly sure what to do because again I wasn't planning on this okay so I had not read on how to do this I've never done this before this was literally making up on the fly which is by the way not a good way to do surgery so we made the holes and then I tried to get things in this is it looks really good in the video by the way but this was attempt to maybe number 25 to get a stitch around this because every time I try to put a stitch around it the thing would go away from it and I couldn't get it because unlike a bony bank card this isn't attached it's literally flopping around so I tried to get traction stitches on it to hold it in place that didn't work I tried to use this thing which is and that didn't work finally I got that using that sort of suture passage device through it I was able to get control of it and it was at least able to stabilize that made life much easier and then I used both a combination of a knot knotless system and knotted systems one of these holes blew out I didn't show that for the video I probably should have and then because I went all the way out the back because I didn't know what the angle was labor reconstructions by the way helped me know how to do this fortunately I've done a number of those and this was helpful but interestingly this is a really hard place to work and when the tissue is mobile and you don't have control of it through a accessory portal and you don't have stitch controls of it in your anchors it's really really hard to make this go to where you want it to go so this was this was the intra floral and ultimately it took it turned out fine but we talked about traction time so they don't have a postless system of the main hospital because again we don't really do these there very often so I did this on a table I don't typically use because that you know it that was the main hospital and he was you know in the ICU and all that fun stuff so it worked out okay I took about three and a half hours he really really really big kid actually you can't see the soft tissue envelopes it's outside the zone of the floral so these are his pack you films at this point I was happy with how it worked out and he was all back back to all of his activities that I was you know are not really high-level athletics but nevertheless we're hoping he's not drunk driving and he's doing well but I will say I learned a number of things here the first is when you see if a kernel it's when you see a curvilinear structure after a hip reduction it's not just a loose body it came from some place and there are things attached to it that are soft tissue that you can't just cut out so I did get a somewhat of a unique rapid exposure to how to fix rim fractures intraoperatively there are a few things I learned that will make this much easier in the future the first is established a posterior portal right out of the gates the second is gaining control of a loose piece of tissue so you can manipulate it is much faster than trying to pass tissue stitches around a loose piece of tissue because it makes a loop that keeps falling off the loose tissue so after literally 20 to 25 percent 10 attempts of trying to do it just getting a stitch through it somewhere and then holding tension on it like we do everywhere else in the body what works really well you guys probably would have figured that out sooner and I did but that was that was quite helpful and then you just take the stitch out and that makes it much easier the last one is have lots of different anchors and many of them make them very small this is a really really small part of the rim actually and in some places holder you can make you know general to four holes but in some of these some of those anchor positions that was too big actually so make sure you have anchors available to you if you're gonna do this they're very small and very facile and make them so that they're sometimes not knotless because sometimes you can't find the hole so in this case a combination of knotless or not and have lots of things your disposal because it's a little bit of bobbing and weaving interestingly if I had recognized what this was in advance I would have read about it and sure enough this has been done a lot actually so a lot of these papers have demonstrated it's actually a systematic review so many of these papers have been out there that I didn't recognize so 13 out of 20 70s poster hip dislocations had non concentric reductions 5% incidence of poster hip dislocations I create this all these papers there are patients had no neurovascular injury or ipsilateral fracture the surgical time way faster than mine 90 90 to 140 minutes they used upholstery lateral portal in all cases actually an average of two to four anchors so these were the paper patients not surprising this literally looks exactly like my patient again knowing what you don't know so if you see that that's what this is these are their pictures from the paper looked similar probably better than mine did and turns out they do really well another series nine male patients these are more common in males six motor vehicle accidents three big Falls poster rim fracture all of them had labral tears they did they had five partial or complete ligament of Terry's tears I don't think that's really all that relevant you don't need to repair that by the way these stiffens stiffen stiffen so doing less ligament of Terry's reconstructions repairs like you see some of the talks on this this is not where you think about doing that to osteochondral fracture damn tad osteochondral damage capsular ruptures I do I would repair that again though these get stiff so if you're really angry it probably not as big a deal but you could try to repair it mine did not have that again postural lateral portals were reused sort of similar situation so this one was floating in the breeze on this person that's a little harder I think than what we had but again thoughts and food for thought here so in this case they had a balance 18 men 9 male this was sort of a systematic review again sort of the two before in addition to others interestingly there's United the most common reason for surgery non concentric reduction other reasons non unions of rim fractures and column fractures this is one I thought very important so dr. Philipp on just talked to you about concerns for fluid extravasation abdominal compartment syndrome is a risk here this is an acute fracture they can have little cracks through the acetabulum not just the rim but actually through the acetabular dome one of these patients got abdominal compartment syndrome so you're looking at that's effectively one out of 27 if I'm doing the math right so that's 5% that's really high for abdominal compartment syndrome so high risk here mark talked about keeping the fluid down I do that too mine I keep mine about 35 to 40 I will tell you it's really hard in these cases because there's blood everywhere here the bones bleeding the soft tissues are bleeding you have to I use lavage a lot to kind of get it up and then know what will come back down rather than just keeping the pressure high for this concern this person instantly or interestingly used 100 millimeters of mercury during the surgery for bleeding control so that's pretty high that being said I will say I will tell you I know why good because these are hard there is literally blood everywhere so it's really hard to control it it's not like a normal hip scope patients do really well though so that's the upside after you're you're done with the surgery they do very well 100% of these cases had Union so that was my worst case of the year mainly because I didn't know what I was getting into but in retrospect I think if I had it would have been a lot easier so hopefully you guys can learn from my mistakes that's a good one yeah well delivered too yeah do you would you would you do that open next time would you that I mean the trauma guys do that you still still do it through scope yeah I would do it with this with a scope but I would be a lot better prepared honestly that the things that the biggest issue is I literally didn't recognize what I was getting into and as a result I put my camera I was trying to get access to the joint I couldn't see anything there was tissue in front of my face that the nice triangle where you get your hand mid anterior portal that didn't exist because the labrum was inverted so it's getting getting access was difficult honestly so the mid anterior portal I basically made almost blindly in the sense that I put my scope from the anterolateral portal deeper into the socket and then found the spinal needle past the labrum and then crossed my fingers I tried to manipulate it like a switching stick to sneak around so I knew it wasn't through any tissue but I didn't know what it wasn't through and then put the mid anterior portal in carefully did not jam it all the way in like we normally do and it was just very careful to manipulate things around to figure out where I was so that took about honestly 30 to 45 minutes just to get into the joint because I couldn't see anything but I would do it again with scope no I think it's a great case and using like the point you made about using small anchors and then sometime using a ball spike pusher just to stabilize that that for me it makes my life easier but the point you made about smaller anchor like 1.7 or 2.3 because these are tough also it's very tough to drill a posterior like that so in extending your capsulotomy well the capsule is probably ripped like like you showed but that these are a difficult case but once you fix the fragment the labrum comes together well and but yeah these are tough case but the ball spike pusher to an accessory portal sometime is helpful fortunately these get filtered so when they call me they've decided they can't do it or don't want to do it open basically it's this these little tiny rims that they don't think our trauma guys are thankfully fairly aggressive in fixing these so I almost never get called about this although they fix rim fractures we're very very high level trauma center so they do these I'm literally weekly so I think they get filtered out to the point where these little small little and honestly that that bone is small it's just like when you see a bony Bankart it looks big on your CT and you get in there and for those of you who do shoulder that the bones never quite as substantial as you think it is so really you're using the labrum around the bone to control the piece it's not it's so small you're not really putting a screw through it I did I went around it which was why it was initially I went I went around let me rephrase I went around it twice and then use the labor I went around the labrum twice so the the first one I went around the bone that was hard actually so I put an anchor in and then basically passed the stitch right at the chondrolabral junction so technically it was in the bone and then went around like at the chondrolabral interface so it went around only the bone if that makes sense as opposed to around the labrum so anchor in first yep and then tied it yep correct correct correct and then I use the labrum as well because I wasn't convinced that the labral osteo osteochondral labral interface at that fragment was super robust so I wanted to use the labrum also to try to control the bone so similar as sort of a tibial spine repair if that makes sense use a soft tissue I put all the anchors through the dala portal and then took to Mark's point it gets really hard really far back there so that the final anchor I took a lot of time to take the and used a very small it was a one one three four anchor at the most inferior part it was all through the dala yep yep the anchor position was through the drill through the dala to control the fragment past the stitches yeah so I put the anchor through the dala and then passed the stitches through the poster portal yeah I'll put I'll drill through the poster a lot of portal them but yeah and sometimes even further around with a curved anchor a curved guide the poster I don't know no no basically the standard is a the rehab standard for a poster hip dislocation so they fortunately for him it was in the ICU because this was done he was intubated they completely out he had a bunch of cerebral trauma and a bunch of other stuff but assuming he was a not that and could get up and do things I treated in the same as opposed to hip dislocation so effectively toe touch weight-bearing for about three to four weeks and then weight-bearing is tolerated after that transitioning by six six weeks to do whatever they want no I I mean hindsight sure I do a lot of things in hindsight on this case frankly TX a interesting one it's I'm not sure it would make a big difference here to be totally honest with you it's not that we were worried about blood loss necessarily and maybe it would have helped in terms of the amount of bleeding we had but I kind of doubt it to be honest with you I don't have any data to support that though yeah that's good to know I've always thought that again I can't get my anesthesia do anything but I've wanted to do that that's good to know honestly like I mean maybe next time I will because I'll tell you anything to make this easier I'm all in on cool okay love it other questions here's here's question so these dislocations they're you know most all have pretty significant impingement right because it's a contra-coup mechanism and what's the role for treating his impingement whether it's on the femur or that's type of yeah really that Travis so I didn't touch that honestly by three hours in I was pretty pretty much done and not thinking about his FAI the I will tell you that's all that's a hard one right so that gets into a slippery slope where you start to think about the secondary potential risks of this and I have had that for what it's worth another guy dislocated his hip and you guys have seen that case before where he sheared off all of this cartilage and in his case I've repaired the labrum and kind of put the cartilage back and thought it'd be great and then four years later it wasn't and in retrospect I wish I'd done the FAI at the time so it's a hard balance of who needs to have FAI done when you're assuming that the risk is because of the contra-coup injury I still don't have a great answer for that yeah we know that's that's a good point because a case like this is trauma it's a little different but usually we would address it because of the if we have enough time just because of the secondary issue but this was a traumatic injury so the guy might not have been an active person so it might have made any difference for him to have a camera section I was guessing that his chances of getting an MVA were hopefully low in the future yeah yeah totally yeah yeah like in this situation traumatic injury like this it's different mechanism if it was a basketball player or a football player different and I would have addressed it for sure but in this situation probably I would have done the same thing absolutely so it's an interesting question good criteria yeah this has come up that question has come up in multiple talks and question that we've given in a variety of these settings and one of the questions that I'd be interested in all of your perspectives so one of my concerns in treating FAI in an acute hip dislocation scenario is the known risk of AVN for hip dislocations not for FAI treatment but for hip dislocation risk so these are patients that have not declared themselves on whether or not they're going to get AVN from the hip dislocation and then you scope them and you do an FAI chem resection do you worry at all about being blamed for a lack of a better term for the AVN yeah that's a good question so we when we have a situation when there's a dislocation history we we document if we do the camera section flow of the epiphyseal vessels to the head so I use a Doppler flow probe that we use for hand surgery and I document that really because for that purpose and I'll tell you a situation where I had a young guy college football player last game of the season dislocated on national TV he was a first-round draft pick for the NFL and I got a call the morning of the draft and I'll just say the purpose of checking your epiphyseal vessel the coach calls me says Philippon I want to pick that guy I love this kid he's from Alabama I love him but my ownership's telling me he's gonna have Bo Jackson's disease so well for what sources what I'm telling you fix his labrum fix his hip and then I documented when I did his surgery he had flow to the head and they sign him and the kid is so happy was in Cardinals in the hallway so so he and the reason why they drafted him at least when we took care of him yet flow he never went on to AVN but at least I felt comfortable telling him hey I don't think his hips gonna be an issue and he played five seven years NFL so if you decide to do that I agree with you you need to document the flow and make sure that you follow it closely that's that's a that's a great story that's that's a lot of a lot of impact there you had on his life in a lot of ways that kid yeah

surgeon

surgical procedure

hip dislocation

loose body

improvisation

complications