About day three, we got a call from my administrative assistant who said, we got a big problem. I said, what's going on? He said, well, I just talked to the father of your case from three days ago. He happened to know her and actually was an electrician doing some work in our clinic. He said, he's distraught. I said, what's going on? He said, well, he thinks that his daughter was raped in the OR. I was like, I'm not much of a catastrophizer, but I was definitely catastrophizing. You can imagine where this is going to go. I know what's probably happened. It's a post-related complication, but I'm thinking, this is really off the rails. Going back to the start, it was a really uncomplicated case. Back when I used to use a hand, it was probably my second or third year of practice. It was an uncomplicated case, and they grant maybe 60 minutes or so traction time. Everything seemed to go fine. Post-op day one, I guess she had had a little bit of numbness, and it turns out maybe had gone to the bathroom and wiped it more aggressively because of the numbness. It was irritated, so she went to her nurse practitioner, PCP. She told me, in retrospect, just to get some symptomatic cream or something for it. The PCP thinks she's been raped and sends her to the ER to have a rape kit done. No one calls me in any of this. When this is happening, I'm thinking to myself, I'm never going to tell anybody about this ever. Then a few weeks later, I'm like, I got to tell my boys about this. I called Slot, and I said, Slot, I can't believe they even called me about this. He said, well, they never called a rapist. I'm like, geez, man, that is not helping me right now. So that's post-op day three. This family's now like, they don't know what to think. They don't know what's happened. Obviously, things are completely off the rails at this point. So we get them into the office, and I sit down and explain everything. They said, we didn't think that you had anything to do with it, thought maybe when you're out of the room, somebody came in there. But they thought that's exactly what had happened. Even though we had talked in pre-op about the posts and things, they don't remember a lot of those things. It turns out it wasn't even that bad of a complication, it was just some numbness. I thought it must be some soft tissue injury or something. Nothing. They said, it's actually not that bad. So all that, and then by the end of the week, pretty much completely resolved, all the issues gone away, fortunately. I mean, a lot of trauma for the family, trauma for us, and really, for some, it wasn't even that bad of a post-related complication. So I think, for me, the lesson there was sometimes we think of things as temporary, and maybe not that bad. But this is one where that really got off the rails in a hurry. So just a quick overview, I think everybody's familiar with the type of injuries. You get the neuropraxies, but also the soft tissue injury. It happens more than you think. And I think this is a case where one of these relatively minor ones became major. You do enough, it's going to happen, and some of the rare ones can be some of the soft tissue injuries. The post, though, isn't good for you either, and those of us that have gone away from it I think realize that. You do it for patient safety initially, but then you realize there's a lot of benefit for you as well, especially in the teaching environment. So when a post-free option came available a few years later, I was all over it, and I was like, yeah, I'm definitely using that. And so I've used it since 2017 pretty much continuously. You know, the learning curve used to be, you know, this video just kind of shows how you adapt to the Trendelenburg, because the main issue is that your anterior portal goes up, and the first few I was up here like this wondering why it was so hard. But now with some modifications of the foam and things, we don't really even use Trendelenburg anymore, so that's been a nice advantage. You know, some of the other advantages for me have been a greater working space. So I think especially in the training environment, I'm comfortable just getting a little bit more distraction so that when they access it, there's less risk of atriogenic injury to the head. It's not going over that, and I have really definitely seen that go far down. I think I'm going to be able to access the medial space a lot more, so I'm getting down to those, like, you know, there's almost those labral root-type tears where they go down to the transverse tibular ligament. I was never repairing those before, and so now I'm getting far down there. I think a peripheral compartment without the compression there allows you to have a little more space and is an extra capsular as well, I think. And then the posterolateral cavity, you know, you can get both distraction and like your extension internal rotation. So kind of bring those guys out to you. It makes those easier to get. But I think the thing I like about it maybe the most is it's enabled more complex hip arthroscopy, so you're kind of double-double, you know, reconstruction, you know, here's a labral capsule reconstruction that's, you know, a lot of time in there and a lot of complexity. And being able to take the post-concern out of it is just, you know, just decreases the stress. You know, doing osteochondroallografts, that's what the top right there is, so that's something I probably never would have attempted with a post. A lot of those folks, as you know, are stiff to begin with and requiring a little bit more force, so never would have tried that before. Bilateral hip arthroscopy, we do, you know, probably done 50 of those, you know, simultaneous with a good fellow. And again, never would have done those before, too. We've had good results with those. And then my partners, you know, they use the approach to do a combined PAO hip arthroscopy. So I think this is probably my favorite part of getting rid of the post is being able to do some of these things. So yeah, for me, you know, the worst day in the OR was made it so that I was definitely going to convert to a post-free system when it came available. But again, I think the message, too, is that it's not only better for the patient, which is obvious, it's better for you, too. So I'll stop there and some faculty comments on their experience with that and whether you've been subpoenaed or anything. You can all see why I asked him to present another case, too, right? So a quick question just for the audience, quick poll. Who here does posted hip arthroscopy still? And post-less? About 50-50. Okay. Interesting. That has changed dramatically over the last two years. I think even last year, Chad presented this last year, similar at the same ICL, and I think there were maybe two or three people doing post-less. So that's been a huge change. I don't do any Trendelenburg, and there are lots of ways of doing it. You can use this table. There are other ways of doing it without the table. It really doesn't matter, honestly. But I think it's a great way to do it. That said, Mark does obviously a phenomenal job with a post. It doesn't really matter, honestly. I think you just pay attention and try to avoid that complication. But I think it's great. So thanks so much on that, Chad. And any questions in the audience on post-less, posted? I don't know about other questions specific to this, but... Yeah. Do you think that the lack of a post means that we don't have to worry about how long they're on traction anymore? I mean, the anatomic studies seem to say it's the blood flow from the post, it's the compression from the post. Can we stop tracking traction time? Does it even matter anymore? I really don't worry that much about it. At this point, though, it's never that long, but I can tell you it's not something I'm worrying about. I'm really big on removing factors out of my brain so I can focus on the things that matter. I don't think it matters that much, yeah. So I would say I wouldn't completely forget about it. We just submitted a paper looking at post-less versus posted and tracking traction and the actual distraction amount and all of that. And I can tell you the one thing that still happens, and maybe it's just my patients and I'm not doing something correct, but you can still get a superficial perineal nerve palsy on the top of the foot. Yeah, that's true. So the patients hate that. They absolutely hate it because they can't feel their shoe and it bothers them. So that's the traction from the boot. Yeah, I haven't had any of those. I don't know if it's this boot system or what, but I used to get those before. It may be something to do with the compression of the boot or something, it's a little even. You know, that's a good question because the way I evolve doing these things now is I set up my patient, Sly Trunenberg, with a post. I've been using a post for a long time. I just apply a little traction, not much. I use a spinal epidural. I wait maybe 15, 20 minutes actually, mild, mild traction. The muscles are super relaxed when I start. Then when I start, I apply traction. And having that technique, I actually almost do not tape my feet like I used to. I used to tape them very, very tight, not anymore. And with that technique, for me, we solve a lot of our issues we used to have with the perineum. So we just kind of take our time. I mean, it depends where you are. If you're in a surgery center with high volume and stuff, it might be difficult. But I just wait a little bit, then I apply traction so it allows us to have good relaxation before. I think it's more not the time, how long you're on traction, but how you apply your traction. Even the post less, actually, I think. That's good. Great points, great points. Other questions before Chad? Oh, yeah. Hi, Chad. I have a question. Is there any role for lateral hip arthroscopy in the year 2022, in your opinion? Oh, certainly. I wouldn't tell anybody to change just doing it that way. I definitely think it's advantageous if you're doing peritropes things or other non-articular things. So I wouldn't, I mean, I don't have any problem with that. I'm not going to go learn it, but I think it's got a, yeah, it's got a good role. Yeah, I'll do the next one. This one isn't too long. So this was another bad day and not the worst day, but this is a representative x-ray. This was so, as an aside, you get these hard drives and nobody ever tells you they go bad. So I had these old cases and I couldn't get them on the hard drive because the hard drive went bad. But this is a relatively representative case, but kind of a Petruzio-esque type of case. You know, one of those where it looks like the acetabulum is trying to eat the head or something, swallow the head. This is a 22-year-old aspiring professional golfer, so about a 55, 50, 80 degree center edge angle. And this is my first year of practice, so probably didn't know enough to know better at that point. So we start the case and I can't get traction. So we get to do an outside-in approach and then I start the rim resection. So I do a rim resection, you know, so maybe take off, you know, I think get down to about 40, 38 or something off of traction. So that was hard enough as it was. Then I tried to get some traction to get in there, which I sort of got. So now we get it out here, but I still can't get in the joint, but then I get a new problem though. I can't get it back in. So the head is basically perched outside of this acetabulum, just stuck there. And this is on a Friday. See, I didn't have time to put my gifs in, but I was definitely melting down at this point. Yeah, a lot of, you know, swear words and I didn't know what I was going to do. We got to open this up, move it to ASC, I don't even know what we have. I mean, I don't know how we're going to get this back in here. Fortunately, I had a, you know, in your first year of practice, all the residents you work with, they're your friends. And you know, I had, you know, as Mark will appreciate, I had Mark Hamming with me. And Mark is, as Mark knows, Mark is a very calm guy, you know, and he said, it's going to be okay. Let's calm down. Like, how's it going to be okay? So fortunately he was with me, kind of, we kind of said, well, how are we going to get this back in? So we ended up deciding to take a switching stick and kind of sneak it into the edge, like just sneak it into the edge a little bit, you know, and I mean, it's sort of some focal iatrogenic injury, but not as bad as you'd think, too, because it was, you know, it was kind of open there a little bit. We snuck that in, kind of wedged him open and Mark pushed his leg back in and got it all back in. So then we proceeded to do labor repair off track, not on traction, with a spectrum. So that was, that took a while, too, and put all the anchors in without X-ray, you know, without being able to see, so I'd get X-rayed at each of the points. So it ended okay, except that it ended at 7 p.m. on Friday, six hours after starting it, so that was not so good. But definitely learned some things from that case. So you know, despite all that, this guy did like ridiculously well. Like I didn't have any pain afterwards, loved his hip, wanted the other side done, did like just ridiculously well. You know, that true petrusia is probably rare and maybe best treated open. I don't know if I, you know, I might attempt that today, but I don't know that I, I don't know that I would. It's nice to have a really thoughtful and good assistant if you're doing a really tough case. You know, I'll do that now. I mean, I'll make sure I've got like a best fellow or, you know, someone there. And that really, I think that does matter a lot. And probably cases like this are not best for your first year of practice, too. So any thoughts from the faculty on the super deep hip or something, you know, something like that? Yeah. I think the only thing I'll say is I'd echo the last line and probably the second line. These are very hard and you, your patient did well. I will tell you that's in my practice, rare. I probably got lucky. True petrusio with general global overcoverage, holy smokes. They are very hard to treat. They are very hard to get better, to make them get better. So I'd lay a lot of crepe and in advance telling them, I actually think they can be done arthroscopically and I do them arthroscopically. I do not like to do them arthroscopically or do them period. But I do tell the patients, this is not a standard hip scope. You're not expecting 90, 95% good to excellent. You're sitting around the 75, 80 maybe. Well, you know, the other thing is, I mean, I could have done maybe three other cases in that period of time, at least two. And are we better off spending our limited time, which we, you know, we are, we have limited time. We're better off treating things other than that and doing that open. I don't know. What do you think? Yeah. So one thing while I haven't over, I would definitely also get a second opinion from an open guy, just to have the discussion so they understand what's going on. Somebody else telling them their perspective on it, their technique, so they can really think about it. I'll tell you how that goes. I trust a few people. You get a second opinion from your open guy, the open guy goes, oh yeah, let the scope guy do it. Who gets it first, right? It's whoever gets it first. Yeah. That's true. You know, I was thinking about your probe and Mark, you're lucky to have Mark on that case. Such a great guy. I've had a situation, it was not exactly like that. I was, I want to have more traction. So I use a Foley catheter, I inserted it and I inflated it. And that gave me the exit. That's good. So that's, and as a matter of fact, we, it's available by one of the company, but they're not selling it, but that's something maybe for the future for the young guys to look into, to develop an accessory balloon that you can put in there for these tough cases. That's good. That's cool. Yeah. Yeah. Good. Other questions? Yep. Perfect. I was just wondering what the goals are for a case like this where you have global overcoverage. What are the clock positions that you're really focusing on trying to reduce that overcoverage? I mean, at this point in my practice, it was really probably more, you know, 11 to three, four or something. Now I probably, I'd do all the way around. Yeah. But back then I wouldn't, couldn't do that. What angle are you shooting for? That's a good question. And we talked about that. I think, I don't, I don't really know. I mean, I do a lot of dynamic exam, you know, with patient, with cases like this. I think that's, I don't do that all the time, but I, but for something like this, I definitely would. I think you go from, you've got a 55, 58. I mean, probably, you know, high 30s, 40s is plenty, but I don't know. What do you think, Mark? I mean, yeah. I think, that's a good question. I think obviously there's overcoverage on the acetabular side, but I think you got, I like what you just said about a dynamic exam. It's really when you move the joint, you'll see the impingement. And I think to me, it's the key to a dynamic exam and take your acetabulum and head into consideration. And it's hard, it's, this is a difficult case. I mean, you don't want to over resect either. I know it's stupid to say you don't want to over resect, but in a situation like this, you can be in the wrong place and over resect. And the other thing I'll do in something like this, I'll cut the cartilage off and put the labrum back too. Yeah. If I'm doing what I would say is a real rim resection for global impingement, not just taking off the reactive bone, like the vast majority of pincers are. I would remove the cartilage, put the labrum back. It's a lot better function and seal and everything. All right. Great. Thanks, Chad. Yeah, thank you.

hip arthroscopy

challenging cases

numbness and discomfort

severe hip deformity

post-less hip arthroscopy techniques