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IC 104-2022: Hip Arthroscopy - My Worst Day in the ...
Hip Arthroscopy - My Worst Day in the Operating Ro ...
Hip Arthroscopy - My Worst Day in the Operating Room in 2021: What Happened and How it Changed My Practice (2/5)
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It's early, so this is not a complication. I guess maybe long-term I'll find out, but for now, no. So it's just one of the, I had to think long and hard which case to pick, but it was probably the worst day in the OR. Turned out to be the longest case I did last year. So a 20-year-old male lacrosse player, D1, two-year history of worsening focal groin pain stiffness. He had an injection before, three weeks of complete relief, intra-articular cortisone, and local anesthetic. Failed four months of PT, focused on the hip with the physical therapist he got outside of school and the ATCs, and I got him sent to me by another surgeon who asked me to take care of this for him. On physical exam, range of motion, flexion 105, intervention severely limited, anterior pain on fader and faber testing, no tenosympathetic around the joint, no lower back pain, no SI joint tenderness, none of that. Nervously, grossly intact. Here are the images. So pelvis AP, and then frog lateral, that's what I got from the outside. So I typically get different views. I get a pelvis AP, down 45, frog lateral, and then also a false profile view. So here, see, you know, overcoverage, see, it's about the left hip here, by the way, so, and I could argue maybe both hips are not really doing great, but basically concerned about that piece of bone there. Some people might call it an os acetabuli, or rim fracture, we'll get to that. Few different views than we got, and you see large cam deformity as well, and you see the overcoverage and the false profile view as well, with that piece. So MRI shows somewhat vertical orientation of the line of that rim piece. You see some bone meridema as well, and on the coronal views and axial views, you also see a label tear. So I thought, okay, well, this is great. I think I probably need a little bit more information, so I got a CT scan, 3D reconstructions. Want to really understand that piece there. So unfortunately, I don't have a video of this, but, you know, took a few pictures here, screenshots, basically delineating that deformity, and, you know, the CT was not only helpful for that rim piece, but also for looking at the cam deformity, which was very sizable. So here, views, then I started measuring stuff. So you see on the left side, it's about 52 degrees of the lateral center edge angle, so nicely overcovered, and then I remeasured that without the piece. So there's 30 degrees. So it's not dysplastic on that view. So then false profile view, overcovered as well with the piece, and without, it was not dysplastic. So, okay, here we are. This guy, athlete, failed non-op treatment, did everything, obviously, always a timeline with these athletes, right? So everything else was done, so it was pretty much surgery left. So here's this large acetabular rim fracture, acetabular, overcovered for that. It's a large cam deformity, labeled here. So here, what am I thinking when I'm looking at this, right? So I was like, okay, how do I get in? So this is overcovered, so this might be hard. So I typically use a post-less system. So will I get in? Not sure, so I'm ready to think about doing a Dean's portal, right? So outside in, just to have the option and mark that out as well when I start the case. I'm also thinking, hey, what's the labrum gonna look like? Can I repair this? Do I have to detach it? What's going on? Do I need to do a reconstruction? Make sure I have a graft ready. And then, management of the capsule. Well, these pieces can be scarred nicely into this capsule, so how do I get it out without messing up the capsule? So I'm also ready in my mind. I typically always repair the capsule, but I'm also ready to do a reconstruction if needed. So management of the cam. Well, it's a big old cam there, right? So how do I get to all this? Do I typically don't use a T-capsulotomy? So I use suspension stitches. So in my mind, though, this would be one of the cases I'm thinking, I'm probably gonna do a T. So how do I manage the fragment? In general, if you have these, you think about, well, do I excise it? Do I refixate it? What happens if I take a piece like that out? Am I going to make it dysplastic? So iatrogenic dysplasia. What's the cartilage gonna look like? Pretty banged up, I would guess, with this large cam deformity. So I'm ready for cartilage treatment. Microfactor, without augmentation, chondroplasty. So just ready for that. Make sure everything is lined up as well. Depending on where you operate, they may not have it available, so make sure it's there. So went to surgery. I ended up doing three portals. Didn't need the Dean's portal. So antilateral, mid-anterior portal, and then the dollar portal. The excision of the fragment. So instead of using my typical capsulotomy blade, only for the caps, I also used a curved one. Gave me a chance to kind of peel it out a little bit. Curved shaver. Also had a curved burr ready, just in case I need it. But didn't need it in the end. So that's where those three portals can help. So then did the rim trim, smoothened transition. There was a subspine decompression as well. Ended up doing a labor repair. Did a chondroplasty. And then for the cam osteoplasty, ended up just doing an interportal capsulotomy. Didn't need a T. Had suspension sutures. And for the capsule, was enough tissue. It was good tissue. It took a long time, this case, but I paid a lot of attention not to mess up the capsule, because I was worried there's nothing left at the end. So here are the images. So again, I was worried about how do I get in. Post list, do I need a post? Post was ready. If I needed it, didn't need it. So I put the distraction up. See on the left picture, it's like, oh man, this is tight. Put the needle in, gotten the arthrogram, opened up nicely. When I put the needle in, I also realized that piece is pretty mobile. So that helped me in this case. So when I put the cannulas in, I could diligently, slowly move that away, had enough space to get in. And on the right, you see some pictures while I'm doing the osteoplasty. Interop imaging. So here, just trying to peel out that piece from the capsule. You know, I ended up using a burr. I used a ronger as well, so piecemealed it. Obviously this piece was too big to get out in one piece. So it took quite a while. Then did the repairs. You see one suture. There were two or three more I put in. Here, the interop imaging of the camera section. So I did, took a long time as well, but did a cam osteoplasty through an interportal capsulotomy. And that's where those suspension sutures really help. Post-operative imaging. So if you look at the Lausanne edge angle, 25, 26, anterior side edge angle is about 22, 23. Believe me, I remeasured it many times and had other people measure it as well because I was worried about having some ivergenic dysplasia. But that's where the pre-op imaging helped as well, where I outlined everything, made sure that if I take that piece away, what are the angles, it was fine. So I was asked to do a little literature review quickly. So osteoacetabula, so the unfused secondary ossification center. So these here, what I'm showing here, I think that's more accurately described as an acetabular rim fracture. So it's not a secondary ossification center. I think it is, if you look at the picture that's taken from Professor Ganz, one of his papers, it is a fatigue fracture over time. So a vertical line that's more consistent with a rim fracture as opposed to osteoacetabula, which is typically a little more horizontal. So thought to be a result from repetitive impingement, irregular shaped femoral neck, so impingement, large impingement like this here, and a stress fracture as a result of that. So epidemiology here, so a paper from 2020 in arthroscopy. So it's about 3.46 in the general population they found in the epidemic neurologic study. The thing here is though, I mean, this is not the big thing I just showed you. These are any kind of ossicles or calcifications. So there's a huge variety of what they put into this study. There's a bunch of different techniques to refixate them if that's what you need to do. So recently, in the last four years or five years, a bunch of them came out. So whenever you have multiple techniques, there's no right or wrong, so pick what you want. I typically use Dr. Sosheno's technique with the cannulated screw and using that as a suture anchor as well, so then you don't have to double up on some of the suture anchors. So Soshi, he published a nice paper in 2018 with a nice algorithm, when to excise it, when to fix it, when to fix it, or, you know, considering also PAO. I'll count this guy, so he's about four and a half months out. So if you do the math, this case is actually 2022, not 2021. And much improved range of motion. He has no pain with a fader favor exam. Vector running, currently plyometrics, started non-contact drills, so far progressing well, and is really amazed about his lack of pain and excellent range of motion. So considerations in general. So you want to make sure you look for the risk of iatrogenic dysplasia, get adequate imaging. So I had to get a little bit more views and, you know, get the CT scan. I think it was very important. You also want to look at version, acetabular version, femoral version. Yeah, be ready for labor repair, capsular repair, reconstruction on both as well, if needed, cartilage procedures. And talk to the patient about the risk here involved with iatrogenic dysplasia. Talk to them about a potential need down the road for a PAO, potentially even, just to educate them about what you're really concerned about and then what I learned. So book enough OR time, right? So this was about four hours in total in the end. And so, you know, this was, I think it was the first case or another few more afterwards. So people are getting antsy. So that's just give them an advance notice and plan accordingly. So, and then I think in my mind, I'm thinking right now as well, I mean, he's doing well, but should I get a CT scan as well? Just a post-op, which I typically don't, just to, you know, yes, on imaging, on the plane radiographs looks good, but 3D reconstruction might be helpful at this point as well. So this is what's going on through my mind right now. But general, I think that was a difficult case, a lot going on here. It's not a complication. I guess we'll find out in the longterm, but he seems to be doing well right now. Thank you. Great, thanks, Thomas. Any questions in the audience first before we get started? Great. So quick question on my end. These, I've had a few of these in my practice and it's always a hard decision about whether to excise it, to do a sort of partial debridement, partial excision versus an actual fixation. Chad and I were just chatting here. I've fixed these in the past and I've actually gone to not fixing them recently. And I think that's also been Chad's experience as well because they tend to heal if you fix the impaction problem just by frankly fixing the underlying issue rather than putting screws across. But I put screws across before. My question for you is how do you, so in this case, you took it out. It sounds like you're still thinking back, wondering if that was correct or not. How do you, what's the threshold? So I mean, you just take the cutoff. I think in my mind, you know, it's in the literatures, just the lateral side edge angle 25 without the fragment, that should be adequate, right? But we all know, I mean, if you have five people measuring 20, you know, that lateral side edge angle, some people might come back with 24, 23, and 26, 27. So just a hard stop at that number. And that's exactly where I landed with this case, right? It was right there. Pre-op, I had measured it and it was a little bit more. So that's where, you know, I don't think there's a right answer. So now if he would have been a she and a ballet dancer and hypermobile, that would have been a different story. I think I would have probably actually had a pre-op second opinion for a PO with a combined scope PO. So I don't do the PO part, but I would do the scope part. But that's just to be ready, because I'm worried that, you know, if I take the number of hard cutoff of 25, that's not, I mean, there's a spectrum of this. This guy was a young, muscular, stiff, you know, tight guy. So I don't know, there's no right answer, I think. No, I've had a good, recently had an interesting experience with these. It goes back to when I started practice, I had one of these and back then I would have been afraid to do much with it. So I think by default, I didn't do anything. That kid was 16 year old and his healed at six weeks. Then recently I had like one more like this and fixed the first side with a screw. That wasn't my worst day, but it wasn't the best day. I let my fellow that taught me into using some stupid headless compression screw. Don't ever do that. Yeah, it seems like a good idea, but it's not nearly strong enough for that bone. So the screw broke, of course, the head broke off. We had to get out the, you know, drill over it. Fortunately, it was perfect hole for, you know, like a lag type fixation for the proper four millimeter screw. It's funny that, you know, that you guys remember Tommy Boy, of course you remember that scene where he's like, it doesn't hurt here or here, but right here. The patient was like, I'm feeling great, doc, except like my glute, a little sore. I'm like, yeah, yeah, yeah, well, get better, you know? Because we were putting all that through. But anyway, short of it is that healed. So his other side comes up and he's got the same thing. And I was thinking back to that 16 year old. And so we got in there and it was, it was a little bit of a move, but not bad. And I just did like what I would normally do for a rim resection, not take it out and left it. Six week x-ray, completely healed. So going from that experience going forward, I'll probably won't. I'll be unlikely to fix another one of these ever again. Great presentation, Tom. Along the same line as Chad just said, we had a patient, a basketball player actually, NBA potential, very good player. He came in with a fractured rim like this on the left side. I fixed it with a screw like you. And it's tough because the fragment is really small and I had only room for one. So anyway, we did it. He healed. It was very difficult because it was around the rectus and we didn't want to cause too much soft tissue damage. It healed, did really well. We did the other side and I didn't fix it. I took it out like you did. And actually he feels the same on both side. So I'm more inclined now if the center edge angle is around 25 or 23 even in males, I am more inclined now to avoid that excessive stress because I had to get my nitrile pills out. That's right. One thought I had also was before, it's like why don't I just take away that big cam and his range of motion is much improved, particularly also since it was mobile then. So maybe just leave it at that. And I thought, okay, what if I partially resect it, but then once I would have done that, there's not much left. So it's like a thin waver or something and then put a screw through that, it's gonna go right through that and break it apart. So I just go for it and just talk about it. I mean, they're stress fractures. Yeah, they are. You can take away the stress or maybe. Yep. Excellent, thank you. Thanks.
Video Summary
In this video, the speaker discusses a case of a 20-year-old male lacrosse player who presented with worsening focal groin pain and stiffness. The patient had a previous injection that provided temporary relief and underwent four months of physical therapy, but failed to see improvement. The speaker describes the physical examination findings, which included limited range of motion and anterior pain on certain tests. Imaging, including pelvis AP, frog lateral, and false profile views, revealed overcoverage and a large cam deformity. MRI showed a rim fracture, and CT scans were obtained for further evaluation. The speaker discusses the surgical approach, which involved three portals and excision of the rim fragment, as well as other procedures such as labral repair, subspine decompression, and chondroplasty. Post-operative imaging showed improved angles, and the patient had good range of motion and reduced pain. The speaker also discusses the literature on acetabular rim fractures and considerations for treatment. The overall outcome of the case was positive, but the speaker notes the potential need for a post-operative CT scan to further assess the results.
Asset Caption
Thomas H. Wuerz, MD, MSc
Keywords
lacrosse player
groin pain
stiffness
cam deformity
surgical approach
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