up early this morning and joining us for the ICL 201, Hip Pain in the Athlete, cases from the court, field, and ice. So, my name is Mark Safran. I'm the moderator. I'm a professor of orthopedic surgery and chief of sports medicine and team physician at Stanford University. Also happen to be a past president of ISHA and on the editorial board of the Journal of Hip Preservation Surgery. We're very fortunate to have an esteemed group of faculty here for this interactive instructional course. We have Steve Aoki from the University of Utah, Brian Busconi from UMass, Dr. Thomas Bird from the Nashville Hip Institute associated with the Tennessee Orthopedic Associates, John Christopher Reddy from Texas Health Orthopedics and Sports Medicine. Unfortunately, Josh Harris was unable to make it today. T. Sean Lynch from Henry Ford Health System in Detroit, Chad Mather from Duke University, Jim Rosnick from the Cleveland Clinic, and Andrea Spiker from the University of Wisconsin. All very established, experienced hip arthroscopists and team physicians that will be able to add a lot of insight for each of these cases. You can look to the academy website for our disclosures. The format for this ICL is that I'll present a case and what I would like is that everybody come to these tables because each table is going to have a faculty member associated with it. This is really meant to be an interactive instructional course so you can have a good discussion with one of these experienced hip arthroscopists and with the faculty discuss some of the nuance and management of this ICL. It's a bit, a little bit on the looser side as far as where you want to go with the discussion with the faculty member and what things you want to learn. And then we'll have a discussion, you'll have your discussion as a group and then we'll have a discussion amongst us as the entire group and then I'll go over what was done. And there's not always just one way to treat, to treat things and probably some of the stuff I've done people will sit there and go, why'd you do that? But we'll discuss that and again this is meant to be interactive and really kind of tailored to kind of some of your interests. So I'll start off with the first case. I'm sorry, Steve. Hold on one sec. What's that? Actually, you know what, like, John, why don't you go to a different table than Andrea. So I have every faculty member have, one faculty member at each table. And, so yeah, we try to have a faculty at every table and just have everybody come up at a particular table that would be helpful. Thomas, I'm sorry, you had to ask something? Okie doke. Great. So, again, I thank the faculty for being here and I thank all of you for, attendees for being here and again hopefully you'll really enjoy this because there's really some, a lot of experience around here. So, our first case is a 28-year-old left-hand dominant NHL player. He complained of deep, when you describe more posterior lateral, right hip pain for at least a week. It was acute onset when he was hitting a slap shot in the first period of a game. He did end up finishing out that game, playing through it. The next morning, however, he woke up and he had significant pain in his hip. He complained of pain while crouching, getting in a car, pivoting, hip flexion and particularly what was bothersome was walking upstairs. He was treated by a physical therapist and the athletic trainer with the team, with non-steroidals and some rehab, all without benefit. He had no prior history of hip pain or hip surgery. He did have an ipsilateral ACL, so ACL in that extremity six years prior. He's presenting a third of the way into the season to just kind of give context of where we are. And on examination, he's 6'4", 210. His Trendelenburg on the affected side was positive compared to the contralateral leg. Had some decreased strength in his iliopsoas, both on the right and more so even actually on the left, which was the asymptomatic side. Hip flexion was symmetric at only 100 degrees and it caused pain on the right, but not on the left. His external rotation was 40 on the right, 60 on the left. His internal rotation was symmetric at 30 degrees, but he had pain on the right. His impingement tests and labral stress tests were both markedly positive on the right, not on the left. He had no tenderness around the trochanter. He had a negative OBRA test, so no IT band tightness. His piriformis was non-tender. He had a negative bicycle test, trying to see if he had any snapping of his IT band over his greater trochanter. These are his radiographs, and you can see he actually has a center edge angle of 25 degrees, a lateral center edge angle of 25 degrees. His alpha angle was 65 degrees. You can see he has a CAM lesion. He's got a crossing sign, and he's got what looks like what may be a low AIIS on that side. In summary, you've got a 28-year-old NHL player who has pain in his non-dominant leg, relatively acute, and he clearly has the anatomy of FAI, and he's in the early part of the season. How would you manage that? We'll give you guys about seven minutes to discuss amongst yourselves, and if you have any questions, ask away if you need anything more to complete. Yeah, Winston. There you go. All righty. So why don't we wrap up here and talk about this case. So we'll start with, actually, Brian Visconi. What did you guys... Okay, Brian is actually passing up an opportunity to talk, which is impressive, actually. I can't hear you now. Jim, is yours not working either? Steve, I know yours was hot. Can you give yours... I don't know where our IT guys are, but we'll get it worked out. Go ahead. Hey, I'm Frank Nugent from Columbia, South Carolina, and I've got a distinguished table, including Drs. Visconi and guys from Birmingham and New York. So our first impression was that we need to look at the muscle, the rule out sports hernia, groin strains more. This has only been a week. He had no history of pre-existing hip pain. He obviously has FAI deformity, but the pelvic view is not great, as you showed there. And Dr. Visconi was pointing out that a large majority of his sports hernia repairs have FAI concomitantly on x-ray and or maybe not exam. And so we talked about should we do an MRI or not, had a little bit of disagreement, but probably not an MRI initially, because he's going to have a label tear, and then we'll probably go down the path of, oh, this needs surgery. The athlete may start thinking they need a surgery, and we're thinking more of a sports hernia type evaluation and workup. Okay, so I can tell you that, just out of space I didn't put there, so he had a negative, what we call a Hesselbach's test, where I palpate along the lateral border of the rectus as it inserts into the pubis and have him do a sit-up, and that did not bother him. He had no pain with adduction, and he had a negative resisted sit-up test. So clinically, it wasn't pointing towards a sports hernia. Plus his pain wasn't actually over there in the groin, it was actually what he would, originally he was complaining of was more pain posterolateral or deep into the hip. So with that information, which again, limited time, limited space, so I apologize on that, it did seem that his exam was pointing potentially intra-articularly. So anybody else have any thoughts when they were discussing? Yeah, so the pain with straight flexion and the limited flexion at that would suggest that the sub-spine probably also was contributing to this. So you're concerned with subluxation. One of the things about this view, it is a very bizarre view, but if you actually look, his coccyx is within that one to three centimeters from the pubic symphysis. So though it may look very much like an inlet view, based on, we want an AP pelvis that's one to three centimeters between the coccyx and the pubic symphysis. So it looks like it's more of an inlet view, but that's kind of where it should be from that orientation. But I would agree with you, so that might overestimate the crossover sign. So the potential subluxation, we didn't test for subluxation, he was a bit on the stiffer side as well. Again, it was more that he was weight-bearing on that leg when he was taking a slap shot, so he didn't describe any hyper-flexion mechanism or anything to that effect. So he had come to my office, but we weren't able to get him into an MRI scanner to do an MR arthrogram on him. I always do an MR arthrogram that includes anesthetic. And with him, we needed to confirm whether or not it's intra-articular or extra-articular, as you were commenting, is this a potential for sports hernia or not. So we did give him an intra-articular injection, because I was able to get that done. This study was done several years ago, and we weren't doing as many ultrasound-guided injections. So we couldn't get that MRI or MRA fast enough for the player. So we did do an injection, and the plan was to get an MRA later. He ended up getting 100% pain relief with that intra-articular injection. We did include corticosteroid with it, because if it was intra-articular, and trying to get him through the season, I don't have much of a problem having a player get cortisone to get them through the season, as it were. Interestingly, he made it entirely through the season. He never had pain the rest of that season. In fact, declined getting an MRA after the season, because he felt pretty much normal. He played six more years in the NHL without any more hip problems. Never had a hip scope. And so, this is a guy that had FAI that was symptomatic temporarily, but was able to get through okay. And one of the things that's interesting, when I looked at our Stanford athletes, we did a four-year study on Stanford athletes, and we treated them all to start off conservatively, and I would have thought, when I went back and looked at it, that I must have operated on 80 or 90%, because this is a bony problem. But in all reality, we operated on just over half of the athletes, and the rest of the athletes were able to make it through their college careers without having any surgery. So, not everybody that has the anatomy of FAI, or even becomes symptomatic, needs surgery. But a lot of them do end up coming back and having issues. So, any comments on that? Yeah, and actually, when you look at some work, some nice work that was done by Steve Aoki's group at Utah, and also when you look at Stephen Rucks, it seems to be interesting that people that have 80 or 90% of their body weight, they're able to get through their college careers without having any surgery. And so, I think that's a good thing. I think that's a good thing. Yeah, and actually, when you look at some work, some nice work that was done by Steve Aoki's group at Utah, and also when you look at Stephen Rucks, it seems to be interesting that people that have asymptomatic FAI will have some limited range of motion, probably in the 20 to 30 degree range. The symptomatic people, it tends to be even more than, like, 0 to 10 degrees of internal rotation. And whether or not they have limited rotation, and that's why they're symptomatic, or more limited, or maybe it's because they're flared up, they limit their rotation. That I couldn't tell you. John? So, one common thing to raise at this table is the acuity of the trauma related to the symptom. So, we have a link of contact related onset of being in pain in a professional athlete. Many times, we may not have access to that right now, and we may be looking for MRI for just a simple, did you have a called stress injury? Did you have an injury in the joint before you were checked with a professional athlete? And it has some type of documentation prior to performing an intra-articular injection. And there can be sometimes some value when we're not talking about insidious onset impingement symptoms, but rather post-traumatic, you know, one week later, the trainer can't get them to feel good, and they've had a trauma. There can be some value to non-contrast MRI scanning to sort of search for the edema, or search for the area where there was an acute change in the symptom. And it can be sometimes, at times, a little bit putting yourself out there as a team physician to intra-articulately check, you know, and then maybe at the next time, well, that was a stress injury, or that was an acute fracture, or something that you've missed. So, just some comments that came up back here about the acuity of the onset of the symptom versus evaluating a chronically impinged type patient in this setting. Yeah, that's a great point. If you do want to make a, that's a huge risk. So, you know, if you're going to do something that needs to slow down further, you can't do things at risk because of the FAI. But if you're not controlling it, like I did, but it totally wasn't symptomatic at all, they're having to go to an FAI to give them that PDMS. So, you can see, you can hear your doctor. One comment I just wanted to bring up about his past medical history. So, he'd had an ACL reconstruction ipsilaterally. It's a pretty unusual injury in a hockey athlete. So, what do you guys think about the correlation of lack of internal rotation and injury on that ipsilateral leg? We know that there's a correlation that's been shown in the NFL athletes, where if they have limited internal rotation, they're more likely to sustain an ACL rupture. But thoughts on performing surgery, decompressing the cam, increasing internal rotation, preventing further kinetic chain injuries below and above the hip. So, it's certainly the ACL-FAI relationship is there. Several people have noted an association. We actually presented at the Academy, I think a year or two ago, where we looked at a big database of, a huge database where they had 25,000 people that had surgery for FAI. And there is clearly an association between FAI and ACL. Interestingly, the ACL surgery preceded the FAI, as far as the breakdown. So, I'm not entirely sure if that's not complete restoration of the kinetic chain, that may lead to the FAI becoming symptomatic. But yeah, there's people worried about limited hip rotation leading to the ACL injury. The problem I have, you know, you also see a lot of people with back pain. And the limited hip rotation, you think that if you correct the back pain, I've had a lot of patients that said, you correct the FAI and their back pain goes away. But I've had people that come to me with just back pain and limited motion and no pain in the hip wanting FAI surgery. And, you know, I worry about that. So, I'm not a believer in that. And until we have a stronger correlation again, prophylactic surgery to me is a slippery slope. So, Thomas? Yeah, no. So, absolutely. So, first of all, related to the ulnar collateral ligament, kinetic chain, hip FAI, I mean, Tishon wrote a nice paper on that, showing that correlation. And if you are at higher risk also, you know, if you're at higher risk, you're going to have a higher risk, you're going to have a higher risk of having a hip injury. So, you know, if you're at higher risk, you're going to have a higher risk of having a hip injury. And if you're at higher risk, you're going to have a higher risk of having a hip injury. And if you're at higher risk, you're going to have a higher risk of having a hip injury. And Tishon wrote a nice paper on that, showing that correlation. And if you are at higher risk also of disrupting your kinetic chain and having ulnar collateral ligament injury from that. As far as the other thing, it's interesting. I have trouble getting this published. We looked at a series of patients. I think we had nearly 100 patients that had MR arthrography using gadolinium and anesthetic, because that's our test, is whether or not it relieves at least 50% of the pain before I would operate on them. And we had about 100 patients that actually didn't get pain relief that I was expecting from the intra-articular injection. And so at our institution, first of all, I can't rely on the effect of the intra-articular anesthetic injection in the months of July and August, because our radiology fellows are not very good at those early on in their training, but they get better as the time goes on. So I sent them for an ultrasound and got injections. So the gadolinium can block. So we looked at the series of hundreds or so patients that had gadolinium arthrography with the anesthetic, and then we had them get re-injected, because if they didn't get the pain relief, I sent them for an injection under ultrasound guidance or without the gadolinium, and they got a significant pain relief. And we operated on them and saw that there is a thing called gadolinium sensitivity. And so I don't use gadolinium at all anymore. Actually, I use the anesthetic as my contrast. They used to use saline as contrast, so why not use the rapivacaine as a contrast? And some places don't like doing that. At Stanford, they do that for me as our routine. And so that way, we don't end up getting the gadolinium blocking pain relief. But that's the other thing to consider. If you have an extra-articular component to this, such as the subspine impingement, you may not get the pain relief that you're looking for. So yeah, that's a great point, Thomas. Jim? Yeah, just one comment, a case that I had in support of what John said about imaging this demographic. We had a guy, one of the baseball players, Indians, now the Guardians, who presented with trope pain, was treated initially with an injection, no imaging. Some relief came back. We got imaging on him, he had a femoral neck stress reaction. You know, unusual patient population, outdoor athlete, but he was always wearing sleeves, low vitamin D. And you know, that was something that ended up needing screws eventually. So you know, I think that's the, not trying to scare everybody, but that's the, that's my kind of story for, you know, we should have imaged this guy first before we treated him. Yeah, no, and there's no question. And again, I really wanted this guy to get the MRI scan. He was like, you know, at a point where he wanted to still be able to play. I don't like, I don't let players play after an intra-articular injection for at least three days, because you lose negative intra-articular pressure in the joint when you have the, plus you want the cortisone to take effect. So but I really wanted him to get an MRI to make sure I wasn't missing anything. But he was, when he had 100% pain relief, and he just kept saying, no, let's do it at the end of the season. But yeah, so I mean, I may have dodged a bullet on that low likelihood thing, so I'm not advocating for not getting an MRI. That was just his choice. Yes, Thomas. Yes, Thomas. Just from a practical standpoint, I think that was the greatest sort of circumstance when you get an MRI. Unless you're a little bit, it tells you everything inside the pit. A lot of things going on around you, like stress traction, TB and everything else. It's really impossible without anything to think of. But sometimes, practical circumstances, you're treating somebody, and you say, well, you know, there could be these other ugly things happening. It's unlikely, but there may be circumstances where we can't afford them anymore. You remember this bit about it? And you say, well, you know, we've got to keep these things in mind, but I'm OK saying we're going to initiate the treatment without a hemorrhoid. So that's a good point. You see people at the ventilator or something, they can't get a hemorrhoid. So it's not like, oh, we can't have a decision when we get a hemorrhoid. But I think as long as you're keeping those other things in mind, those weird things can happen. They happen often enough, and I would rather have a hemorrhoid. But at the same time, I'm not saddened that I can't make a record date and go see a hemorrhoid surgeon. No, absolutely. And in fact, if he didn't have 100% pain relief, I would have told him, no, you can't play until we figure out where this is coming from. But the fact that he got 100% pain relief with the intra-articular injection made me feel more confident that we could go this route again. I wanted to get it at the MRI before the season was over, but he didn't want to do it. And then when the season was over, he's like, I'm normal. I don't need anything, so. I didn't get to play as well here. Yeah, probably. Probably. All right. So here's the next case. 20-year-old male water polo player had acute onset of sharp left hip pain with deep flexion as well as egg beater kicking, which is like treading water, if you will, what the water polo players do. And he has a prior history of right hip pain, but it's the left hip that has got his attention. On his examination, he had no prior history of left hip pain. On examination, his Trunellenberg was negative. His iliopsoas strength was a little bit weak on the right side, not the one that he's presenting to me that day. Hip flexion was 110 on the right, 120 on the left. External rotation, 30 on the right, 45 on the left. Internal rotation, 15 on the right, 10 on the left. His Faber, so the distance between his lateral joint line of his knee in a figure 4 position to the table was symmetric. Had a positive impingement and positive labral stress test. These are his x-rays. And just to make it easier for you, you can see he's got bilateral CAM lesions, both on the AP and cross-table lateral radiographs. He's got a crossing sign more so on the right than on the left. But he definitely has also a posterior wall sign. So the posterior wall sign is the center of the femoral head should go through the posterior wall of the acetabulum. If the center of the femoral head is lateral, then you worry about posterior wall insufficiency. Center jangle was 24 on the right, 21 on the left. His MRI showed that he has anterior labral tear. He's got an alpha angle of 72, femoral version of 9 degrees. So large CAM anatomy and labral tear with borderline dysplasia, acetabular retroversion, and a 23-year-old male, 20-year-old, sorry, male water polo athlete. So why don't you guys all discuss that, and I'll figure out what we can do about our microphones. Sorry. Huh? No, this is his presentation to you. Yeah. Yep. Sorry. Let's see what people would do here. Dr. Spiker, what would your group do? We had a little bit of discourse and disagreement at our table on how to treat this. Full disclosure, I am an open and arthroscopic surgeon. So I have your. That's why I wanted you to discuss this one. So I think the reasons that I think he's dysplastic, there's not only the lateral center edge angle demonstrating on the left what we would consider borderline dysplasia, but he's got an elevated tonus angle on that x-ray, very shallow acetabulum. You can see there's no posterior wall at all. It's basically just touching the femoral head. We like to see that posterior wall at least going to the center of the femoral head. And so we're going to have to do a lot of work on that posterior wall at least going to the center of the femoral head. He's in a sport that is not necessarily high impact. So it makes me think that he's symptomatic of more micromotion or even macromotion in that hip. So in my hands, this would be a scope PAO. Now, I understand the hesitation in doing a periastatic osteotomy in an elite athlete. There's, I think, a stigma that those athletes don't get back to full level of competition. But I think in my practice, I see that they do get back to sport very frequently. The downside, of course, is the very long recovery process. So I'm going to pass it off to another open scope person who had a different opinion on this here. Yeah, I mean, I'm certainly worried about it. Could you speak up a bit? Yeah, sorry. I'm also worried about potential instability. But I think, to me, more the limited motion, the large cam drive me more to attempt if we can't get him through the season non-operatively. I think my first choice is non-operative. I would do an injection on him. And then probably would talk to him about a scope and the understanding that if that did not work, or if symptoms persisted, then would move to a PAO. Chad, you guys, anything different? Yeah, we did. We had a PAO, but we had a nice discussion about the practicality of that. And a couple of my table members provided six hours to the closest PAO surgeon for him. And then the question, send him across the state, or it's difficult to get him in there. And so I think that often gets missed in these type of forums, where I think it's pretty clear that that's the best treatment for this kid is a combined procedure. But in the real world, it's not that easy. And so I don't know that I have a solution for that. But I think that could be, I mean, I'd love to hear from anybody that, you know, while you get around that, or your thoughts, Mark, on what we do about this, you know, access to these complex procedures. Yeah. One of the things that, and I think that these comments are right around what we were discussing. And one of the things about the periodicity of osteotomy, of course, is that it's designed to preserve the joint during ambulation, or preserve the joint during the force of ambulation. This player, this athlete, is going to have different vectors while their egg beater kick pushes against the water and tries to raise the hip up. So inferiorly, there's a lot of need for stability inside these athletes, because they're literally trying to push themselves up out of the water all the time, which is really not the plane of instability that a periodicity of osteotomy is designed to augment. You know, so this is a different type of implication in a swimming athlete versus a land sports athlete. And I'm not so sure that we have a great amount of understanding about vertical egg beater kick and what the Bernice osteotomy does to improve stability in that dimension. And the second comment was about hyper-elasticity that we were talking about. No comment about Baten's here, and what the concomitant soft tissue laxity was in the patient may maybe affect some of the treatment decisions. So those are great points. And I'll tell you, actually, when we measured Tony's angle on the left actually was less than 10. So his roof angle was, I would probably not even consider the scope in him if his tonus angle was certainly greater than 13 or 14, which is, my usual threshold's about 16. And, you know, as I look at this case, and I went back and looked at this case, and again, I tried to pick some controversial real-life cases, you know, this one, I went back and forth and had a long discussion with him. I'm more in favor of a PAO in a water-based athlete like this than I would be in a land-based athlete that has to do a lot of running. And so I think they can get away with it. But in actuality, we had him get through the season with some cortisone and intra-articular anesthetic. He ended up, this was at the time before we stopped all gadolinium at Stanford for my patients. We rehabbed him for three months, but he continued to have symptoms with water polo and even with weightlifting. So we did discuss, though, the surgical options. And we opted to try arthroscopy first. Brian? Yeah, you know, anything that's just an online and trying to get a CT scan? I'm sorry, a CT? A CT scan, is that what you're talking about? Yeah, I was gonna ask, how's the ephemeral version of the MRI? So part of my routine for MRIs at Stanford are we get just cuts through the knee as well and measure the ephemeral version. I will tell you, though in all honesty and disclosure, those numbers oftentimes can differ from the CT scan because I think the CT scan acquisition is faster and I think the results are a little bit more precise potentially. But I mean, I have a big problem in general. I wanna make sure they're just in the ballpark. I had a pro tennis player that had CT and MRI at a couple of prominent places around this country. And the same patient, without having ephemeral osteotomy, their ephemeral version was measured from minus one to 27. I kid you not, from those four studies done outside of Stanford. So I was kind of like, okay, this isn't really helpful. The two CT numbers were closer than the MR numbers as far as the spread. But it went from having retroversion to excessive anaversion. So I still have problems with the assessment, particularly by MRI. I think the CT scan's probably a bit better. So, I'm sorry, Brian, what was the other? No, I just said the CT scan. Yeah, CT? People have been talking about PAOs, like back reduction, doing PAOs without CTs. Are you doing PAOs without CTs? No. So I don't get CTs as a routine. I do when I'm concerned, and you'll see another case that we got, a couple more cases from here that included CTs. I don't get routines as a routine. I don't get CTs as a routine, because when I came to Stanford, one of the fellows in all honesty said to me, you know, what's the deal with the radiation dose on that if you get that as a routine? And so we sat down with one of our radiologists at Stanford and calculated out, for every 1,500 patients, and again, understand my age group of my patients, average age is 27, for every 1,500 CT scans we get, I'll be causing one case of sarcoma. And to me, that's just not acceptable. So I'll get CTs when I'm specifically worried about it, about the anatomy, revision cases, and that sort of thing. But, you know, if you see over 1,000 cases, you know, 1,000 new patients a year, and you get CTs on all of them, that's a problem. So from my standpoint, even the low-dose CTs, that what people are saying is that what you're getting with the low-dose CTs are not as low-dose as maybe advertised. Our only barcode that is called a trauma surgeon and I get CT scans, that was all of mine, and I have not yet had a sarcoma case. And I'm well over 1,000. Yeah, so it's not, I mean, the sarcomas, the risk, sarcoma risk is over their life, right? And the younger they are, the higher the risk is the longer they live, right? So it may not be something you see in 10, 15 years. But you're, you know, so it's hard to know. And especially, are you following your patients for 25 years and seeing if they developed a sarcoma later? You're a trauma surgeon, baby, you follow us for 25 years. All right, so here's the arthroscopic picture, a view of what you can see. Is that a sound? Oh, it's not, it's not playing. It was playing in the back. So basically, you can see anterior and anterolateral, this, I'm looking for post-lateral portal, but you can see anterolateral chondral delamination of the articular cartilage on the acetabulum. The femoral cartilage looked fine. The ligamentaries was fine, had some synovitis. And you can see after we did the chondroplasty, that the labrum actually was well affixed. So we did the chondroplasty first so we could get a good look and feel of the labrum. And so here I am probing it. But the labrum was well affixed, even though the MRI was read as an anterior labral tear. So with that, we just did the chondroplasty, did not do anything with the labrum. Here you can see the CAM lesion in the peripheral compartment. We did our CAM resection. And then I closed the capsule. I think you need to close the capsule, even though the way I do my arthroscopy is, I do a capsulotomy pretty much straight laterally in the area between the ilio and ischiofemoral ligament. So I'm not cutting the iliofemoral ligament. I think if you have somebody who's dysplastic and you do a two-portal arthroscopy and cut the iliofemoral ligament, I think you have to repair it. I think your risk of making them unstable is too high. But what I do is, in this case, I'm trying to tighten them up a little bit as well. And so I made that capsulotomy to do my CAM resection, and then we closed that up. His follow-up, he returned to water polo, and Stanford won the national championship with him starting a year and a half later. Next case, I'm sorry, question or comment? Thomas? No, it's all right. Go ahead. 19-year-old female track and field athlete was concentrating on the jumps, high jump and long jump, and then she recently added triple jump to her repertoire, and she started to develop some left hip pain. And she started to do the training for the triple jump, and then she went from training one day a week to training four days a week in the triple jump and doing a lot of plyometric exercises. She had no history of trauma when it started up, but she did give a history that the pain was progressive when she started to ramp things up. But then, in questioning her, she said, well, she sprained her left hip landing wrong with her hip extended about three years prior, and basically just treated with rest, never saw a physician about it, and kind of just wrote it off and really didn't have much problems with it again until she started doing more with the plyometrics and the triple jump. She saw me, we centered on physical therapy for three months, but still was having pain with hiking, activities of daily living, butterfly stretch, and certainly having trouble doing her jumps. On her exam, her left hip had a positive, it was positive Trenelenburg. Her iliopsoas strength was five out of five. She had a symmetric hip flexion. Her external rotation was actually increased on the left compared to the right, so 70 versus 55. Her internal rotation was slightly reduced on the left compared to the right by about five degrees. Her Faber was significantly, the lateral knee was closer to the table on the left as compared to the right. She had a positive impingement test, had a positive labral stress test, had internal snapping of her hip on that side, but the right hip was completely normal. Her hyperextension external rotation tests and her posterior apprehension tests were both positive. She was five foot 11, weighed 170 pounds, and her Batons, she had seven out of nine Batons that were positive, so ligamentously lax individual. These are her radiographs. She had a posterior wall sign as well. She had a center edge angle on the right of 23 and on the left of 22, so borderline dysplasia. Her tonus angle was 16, so that's on the upper limits, being obviously less than 10, but in my book, the limits that I worry about. She had an MRA that got rid of 50% of her pain, and she had labral tear cut anteriorly as well as laterally. Here's your CT scan, Brian, and you can see that she has a moderately deficient anterior wall. She has no significant CAM lesion and a relatively low AIIS. So micro-instability with a history of remote trauma and a setting of borderline dysplasia and retroversion with a labral tear and a low AIIS in a 19-year-old female track and field athlete slash jumper. So what would you guys do? What was her femoral version? Her femoral version was within normal. I don't remember the exact number. I probably should put it in here. I'm sorry? Why don't you guys talk amongst yourselves what you do. X-rays. Sorry. Looking at it, it does not look that high-profile, yeah. And the right size... The C-angle looks less than 22. I think basically they're painting a soft tissue instability picture, sort of compounded by the low volume that they're having. I'm a little surprised on the CT that she's got fairly good prominence of the anterior rim. Yeah. But this is one that kind of makes me nervous. That's right. She only had 50% relief with injection, too, so there's probably quite a large component of extra-articular involvement. Potentially, it was gadolinium. There's something else going on. Something, something. I want to examine her. Yeah, the hypermobility, the presence of probable subluxation during sport. Mark, any comments about her partial relief from the intra-articular injections? I mean, I look for at least 50% relief because, you know, and I always ask if they've, you know, was it a traumatic injection? Did they have multiple sticks before they got it in or something like that? But I look for a minimum of 50% relief. Less than that, I'd get concerned. But it's not there. But, Thomas, I think, as we were talking about, I think that may be related to the AIS component, which was that may be related to that. Ashley, you must see this a lot in terms of patients, you know, with instability. They have this pain, and they're challenging to rehab, aren't they? Quite. Any pearls? Well, first of all, we usually see greater than 50% being a qualifier for good relief, right? So anytime I see 50% or less for sure, I'm looking at what from a rehab perspective do we need to do. Sure. But I think a lot of— I think the point she's making is you want to make sure you know who's doing the injections. I mean, is that because they had a tough time with the injections? Good point. And what's better? Like, is it just that rest is better? Or, like, did they have her jump? Did they have her, you know, do the things that recreate the pain to see if what she's going to ultimately want to get back to is any better with anesthetic internet? And then that helps me figure out what are we going to focus on in rehab. With a lot of these, we see that they have horrible pelvic control. So they're in a lot of anterior tilt. They aren't really using their abdominal wall to assist. They get really over-dominant with iliopsoas, which can cause them the snapping and the pain associated with that. So we work a lot on pelvic control. And then a lot of deep rotator inhibition. So they're really—they actually become very glute-dominant. Then the glutes feel weak, so everyone focuses on strengthening the glutes. But really the glutes are just doing so much work that they can't keep up. So we find that if we—we still do glute strengthening, but sometimes we focus a lot more on that local rotational stability to try and create dynamic stability around the hip, and then start adding the layers on top of that. So the two big things we focus on from a rehab standpoint is the pelvic control and the deep rotator activation, kind of sequencing going from unloaded to loaded position. So rotation, internal and external? Yeah, mostly controlling the external rotators of the hip. All the deep rotators, we start focusing there and then working on can they create that stability in a weight-bearing position and move around it using prime movers. So it's a tough process. You have to have a very compliant patient. Y'all are asking the right person the right questions, because with this problem, what she has to say is much more important than what the surgery team has to say. Oh, yeah, there's no questions. This is a tough case. Right, these are tough patients. What we have to do a lot of times that helps him is quickly in the clinic be able to show, hey, when we try this, you feel better, and this is a muscular activation or sequencing thing. So I'll do a lot of, okay, it hurts with a straight leg. Like with our dancers, they can't lift their leg high enough. They're like, I'm tight. They're putting their leg almost to their nose, right? So I'll go in and I'll help manually stabilize their pelvis, what they can't do on their own with their muscles yet, and have them do it, and it's totally pain-free. I'm like, okay, so if we can get you to be able to do that on your own, then in theory you might not have to go through a surgery. We've actually, with a lot of our dancers, treated them pretty conservatively because, honestly, post-op. Most of the dancers don't let you operate on them anyway, no matter what. Yeah, well, they're here six-plus months. It might take a year. Well, it wouldn't. Yeah. Talking about kind of the anterior pelvic tilt, we saw that one kind of inlet radiograph. Frequently, I always get standing radiographs because I think that gives you a sense of where they live. Sometimes they've got a suit kind of built, and it looks like an inlet. But if you stand them up, it looks more normal. But if the patient is standing, you get this major, it looks like an inlet, accentuates the posterior sort of the ischial spine sign, gives you a false sense of retroversion. Does that give you the sense that, hey, they have some anterior pelvic tilt related to floor controls or anything? They just don't always know what to make of it. It's like they're just standing. Why am I seeing an inlet, an inlet view? One of the differences with TAF is that if you see a big difference in standing X-ray, that tells you they've got a lot of mobility. If you don't see much difference, there's nothing. That's a good point. Yeah. Yeah, I mean, some of these, you know, if you're a more hypermobile athlete, I mean, it's a big range. So what do you look for on your eval that tells you that they've got, you know, major anterior pelvic tilt? I mean, a lot of it is just like, how are they standing? How do they walk in? How do they lay? Why don't we discuss this case? Steve, did I give you an opportunity to start off? Why don't we get a microphone to Steve Aoki? Somebody have a working microphone? All right, Steve. Okay. You know, this is obviously an instability hip, under-covered, soft tissue laxity. You know, this is an acute injury. You know, it doesn't sound like there was a whole lot of issues before. You know, this is an individual that I'd be looking at trying to get through non-surgically initially and doing what we can with medicines and working with the trainers and plus or minus an injection and see whether we can get them comfortable enough to compete. If they can't, I'd still be kind of dragging my feet and not be jumping into anything surgical right off the bat. These are, you know, when someone comes in, these are challenging because, you know, it's very difficult to predict how long someone's going to hurt. And, you know, sometimes it can be, you know, shorter periods and other times it can be, you know, you've got coaches and trainers and athletes kind of asking you for a timeline. So that can be tough. But, like, non-surgical treatment for something like this can take a while. And I'd be interested to hear from, like, the PAO group how long you actually wait with someone with acute pain like this. Andrea, I think he was aiming that question towards you. I think this was the same argument that I had for the last patient. And I would argue that, you know, unlike a hip arthroscopy where we assume we're changing the natural history of the patient's hip, we know that we're changing the natural history with a PAO. I don't wait as long, I think, with a PAO patient as I do with an impingement patient. The edge loading that's happening in this hip, especially in somebody who's hypermobile, very athletic, is probably causing irreversible cartilage damage. So the sooner you get in there, the better. And I've definitely seen 18-year-old patients with half of their acetabular cartilage completely gone because they have severe dysplasia. And if you can get to it before that happens, then you're doing the patient a service. But, I mean, there's a lot of things going on here, right? She's got some dysplasia. In my view, on the upper limits, on the tonus angle that concern me, where I think it's just too biomechanically bad situation to be cured with a soft tissue issue. But can you get somebody who's both a speed and jumping athlete back to that level with a PAO? And how long would it take to get them back if they could get back to that level? So I always have some hesitation about that. Again, she's got 7 out of 9 beating signs. But I've found that, actually, even in patients with Daley's Danlos, I think they actually do better with the instability treated with capsular placation than they would maybe in a shoulder type of setting. Right? There's a lot of talk about the potential of using ultrasound to do an injection in the anterior capsule in the AIS, and to see what she felt like 10 minutes afterwards in terms of reproducing her... So a diagnostic ultrasound-guided anesthetic injection? To see whether or not this is coming from her AIS. That's a good diagnostic option, absolutely. So that we can get through more, what we did was we tried to rehab her some more. I don't know if I'd call this necessarily entirely acute, Steve, only because she had that episode three years prior in that hip. I look at this as kind of an acute on chronic, so that this might be a second type of bout, if you will. And so we tried to rehab her. What we found is that when I looked at my individuals that come in with micro-instability for the first time, that 35 percent, and this is an average five-year follow-up, so 35 percent were basically cured with rehab. Another 19 percent were better with rehab and didn't want surgery. 19 percent were not better with rehab, but didn't want surgery. And 30 percent actually came to surgery. The athletes was a little bit more like closer to 50 percent ended up coming to surgery. So just when we looked at that, and we just published that. John? One of the things that is easy to lose, I think, is the patient's goals in these cases because the preservation of a patient's goals. I'm sorry? The patient's goal may be to return to sport this season. The patient's goal may be to do something different than to theoretically preserve their joint and move their hip replacement 10 years. And I think that that's where the natural history of PAO is unquestionable in the definitional aspect of delaying arthroplasty. But the question about restoring the patient's goals in the moment is something that I think is significantly easy to overlook when you start to feel the pressure of preserving the hip for the long run. And I think that's a healthy debate, and I'm glad we're having the debate. And I think at the same time, you know, the patient has to have a massive vote. And you see these largely dysfunctional patients with this type of story, and potentially they're an absolute slam-dunk periosteoporosciotomy. Your life is, you know, we're surrounding this. But potentially, when we have an athlete like this, you know, this may be a separate conversation once the athletic career is done until we get some better data to allow us to better understand this because I think that it's compelling in both ends. Yeah, no, and I agree. I mean, I think the way we define PAO at this point is very immature. I mean, I think we need to really get into more detail about trying to understand more about acetabular volume and things like this. So we have a lateral center of jangle is not the way to define necessarily. It's more to dysplasia than a posterior wall sign or a lateral center of jangle or anterior center of jangle. I think there's a lot more to it. And I think PAO is great for reducing the risk of arthritis, but not all dysplastic patients act the same because we don't, I think, really define dysplasia well enough to really look at subgroups and who need it and who don't need PAOs. And, you know, the reason I started doing capsular placations arthroscopically was because I sent a couple patients to one of my partners to do a PAO because their center of jangle was 23 or 22 because that was what the literature said, you know, that hip arthroscopy does poorly in borderline dysplasia or any dysplasia. And he'd say, no, this is not bad enough to require a PAO. You know, try to do something with scope. That's kind of what he ended up doing. And we started to see some good results, obviously, with the borderline dysplasia. It's a tremendous point. And one of the things is while these newer, like Andrea is going to lead us, because in this case, newer, more courageous PAO surgeon population needs to be more courageous and then continue to press and look at these for us, not that the others weren't pioneering, but it was just simply not what Jeff Mast was doing for certain. And looking at these questions are very important in counseling the patient about what your next step is going to be. Like, do we really know? And I'm looking forward to seeing it. You know, we see so many of these questions that we just don't know. So if I can comment on the... Yes. Question for the panel. Can you get a microphone to him? And can you get a microphone also back? Oh, you got one already. Okay, thank you. I got it. Question for the panel on your capsule applications and closures. I've been using suture tapes, simple sutures, and closing it that way, maybe to breathe a little bit of capsule to sort of shorten it. With all the new sutures that we have, you know, the luggage tag techniques and other closure techniques, are any of you experimenting with other different ways to close it or placate it with the newer sutures? Or any other tips on preserving your capsule repair? So I'm a big capsule preserving guy because we had published the studies that showed where the ligaments are relative to your capsulotomies and where they are on the clock face. And when you do the two-portal arthroscopy and join those two portals, the anterior and anterolateral portal, you basically cut the iliofemoral ligament. And so I think that's a big problem. And I know people say, now repair the ligament. And I'm not so sure, you know, that the ligament is going to function normally in that case, and sometimes those stitches rip out. I always say, you know, my pushback that I give is that, you know, if you do knee surgery, right, it's much easier to do a PCL reconstruction when the ACL is not in the way, right? So why don't people cut the ACL, do the PCL reconstruction and repair the ACL? Because we know that doesn't work, right? So I'm not entirely convinced that just repairing the iliofemoral ligament is going to give you normal kinematics to the hip. But I think there's a greater tendency to try to preserve the capsule now. And what I see in general trends is that people tend to use absorbable stitches when they do that anterior capsulotomy because the permanent stitches can cause irritation to the iliopsoas. And so they go with the absorbable stitches. Because I make my capsulotomy only laterally, only when I'm doing camera sections or to do a placation, I use permanent stitches because I know that's not going to be rubbing against the iliopsoas. Yes. Just a comment. So John, totally correct on the return to sport. But I think Dr. Bird can give some insight. We have an NFL player that got back after a scope PAO. We have now multiple college athletes of different sports that are getting back. So we're trying to get that data out. But the more that we've done in that population, the more impressed we are with their ability to return. So I think if they're an athletic population with the goals of returning, I've seen it just as consistent with hip arthroscopy. So it tends to be the intra-articular abnormalities that drive it. So if they have grade 4 chondral defect, if they have a bad joint, then that tends to limit them versus the PAO. Because they really converge at about 4 1⁄2 months. So our younger patients are running and doing agility stuff at about 5, 5 1⁄2 months after a scope PAO. And so we need to put that data out there like you're saying. But I wouldn't be afraid of telling this patient they have a very high chance of returning after a scope PAO. So let me quickly get us going so we can get to other cases. But here's a straight anterior labral tear at the labral chondral junction. Viewing from the posterolateral portal. So we completed that takedown. Trimmed up some of the articular cartilage here. We were able to get to the low AIIS through this approach as well. And so then we repaired the labrum back down. And here's with the repaired labrum with the base fixation. And then I did a capsular flication on her. Basically she returned to collegiate track and field. She completed the last three years of her eligibility. And since she graduated Stanford, I don't know what she's done since. This one's going to be a pretty quick one. But this is one that's going to make that back table really happy back there. She's a 23-year-old female gymnast, so a senior Stanford gymnast, four-year history of right hip pain. She had a hip scope three years prior to seeing me, getting relief for two of those years and then kind of struggling through her senior season. Her symptoms are recurrent, now she knows she can't really compete, she can't run, she has pain walking, has a positive impingement and a labral stress test. Her internal rotation was 40 degrees on the right and 60 degrees on the left. Her external rotation though was 80 degrees bilaterally. These are her radiographs, you can see clearly she has a center jingle of 16, she's got a tonus angle of 14, she's got mild to moderate arthritic changes of her hip and clearly dysplasia. You can even see her less than 10 degrees probably anterior center jingle with some joint space narrowing. So she got an MRA, 90% pain relief with the intervertebral injection, she had a labral tear, chondral wear and post-surgical change. So you got a 23-year-old dysplastic, former gymnast, essentially four-year status post hip arthroscopy. So the question is what would you do? I think Andrea will just kind of slam-dunk this one. Andrea, what would you do? PAO? You'd scope it? Scope PAO? Okay, good, okay. I gotta get the scope in there too. But she ended up just getting a PAO and actually she graduated Stanford, had the PAO, five-year follow-up, she's doing recreational activities, hasn't symptomatically progressed, but again limiting what her activities are with the PAO. Hey Mark, just a quick comment. I have someone, I take care of gymnastics at Utah and a few years back we had someone sort of similar to this that was mild, had a little bit better coverage, mildly dysplastic, had a hip scope done before she came to the University, got better, able to, but it was like a mild, like a hip scope kind of clean up, not much was done, got her relief. She had hip pain on the other side and I didn't want to touch her, so she went back and got her hip scoped and got another kind of washout and was able to kind of finish the year. And I don't know, I don't know how to interpret that. It confuses me, but I just, just to throw that out there. Yeah, no, I mean, you always come up with that question, do you try to do a short-term fix and will it affect their ability to do a long-term fix or not, and you know trying to get them through the career, I think there's a lot of discussion about it, but Thomas had his hand up there for a second. So yes sir, Thomas. Unfortunately these last three cases bring so many things to mind, and I sort of fall back when we look at kids getting into trouble with FAI and stuff. We point out that the problem they're up against has nothing to do with their sport. The sport just brought it to a head at a younger age. The issue is their underlying architecture. We talked about FAI a lot, but dysplasia falls into that as well, and the treatment's not just about when can they get back to the sport. The treatment is about a young person with a lot of years ahead of them trying to give them the best hip you can for a long time to come. Now most of the things they're doing, going back to the sport, is not good for their joint, but the question is whether they can do it, and we don't tell them they can't, but at the same time trying to prioritize how important is the sport, and if it's your way of making a living or your passion, again, we'll try to help them with that, but the treatment ultimately is what's best for them in the long run. And these dysplasia cases, I point out to people, I'm not a hip preservation surgeon. I'm a sports guy that scopes a lot of hips. I don't do PAO, so it's not proper for me to pass judgment. You don't need a PAO, just let's try scoping your hip, and to me these three cases are completely different. The one you just showed really, in my opinion, had the wrong operation the first time around. They needed the PAO. The case before that makes me nervous looking at it, that with what role dysplasia or needing a PAO plays, and that's one I would want to have a PAO surgeon weigh in, and I think for anybody's dealing with hip problems, if you don't do PAOs, you need to have somebody who you have confidence in that you're teaming up with, and being a good PAO surgeon isn't just technically knowing when and how to do the operation, but a lot of times knowing when maybe it's okay to not use a PAO as a first line. So for so many years I used Mike Millis, who was very helpful. He goes, Thomas, this one makes me kind of nervous, but I'm okay if you want to try to scope them first, and we'll just watch them, but I think everybody in this room knows that a PAO following previous arthroscopic procedure, the results are nowhere near as good as getting it right the first time. Now the first case you showed, you know, that to me, that's one that I would get a CT scan because if they were terribly undercovered anteriorly, that might get me to have a PAO person weigh in, but that's the kind of case that I would at least mention the reduced volume acetabulum, but that one was screaming so much impingement to me, that's one that I might have been more inclined to say, well I'll go ahead and tackle this one and address the impingement stuff. So each of those cases are distinctly different, which I suspect is why you presented them. Yeah, no, I wanted controversial cases. I mean I think borderline dysplasia, you know, again just saying 25 degrees, under 25 degrees of dysplasia and they should get a PAO, I mean I think, I think the more you look at this, you're like, well maybe that's not all, you know, that you shouldn't look just at one measure, if you will, and I think that as time goes on, as smart people, smarter than I, try to figure out when PAO is necessary and when it's not. I know Martin Beck didn't necessarily believe much, you know, he thought dysplasia was instability, but you see a lot of dysplastic patients with with CAM lesions, right, and so you realize some of these people present more with CAM related symptoms and some with more instability and it's trying to figure out which are the ones and, you know, is which and, you know, that's where the fear index ended up coming from. So I think the more we start to look at this, I think we'll be less dogmatic, I think we'll realize there's, there are some people with borderline dysplasia that don't need a PAO and some that definitely do, and again, for the long-term health of the joint, I would agree. So we only have time for one more case here, so I skipped over the one before this, which was a core muscle injury case where the patient had clear FAI anatomy, but had no interarticular symptoms whatsoever, and so he was just treated with surgery after field rehab and injection. But this is a 27 year old football running back, had a posterior hip subluxation, oh hold on a second, sorry, that's the summary here. There it is, 27 year old football running back, right hip pain, he was, they were at a third and goal situation, tried to get a short game, landed with his right knee flexed and slightly adducted. This isn't the player, but again in this position, he's landing on his knee, his hip is flexed and a little bit adducted, okay. He felt some pain with that, but he played the next play because it was, you know, fourth and goal from the one, and then came off on the sideline just saying, you know, his hip feels tight, doesn't feel quite normal. So they put him through some sideline drills, some jogging back and forth, cutting side to side, hopping on his leg, and so forth, and he said he felt fine. He didn't feel like he subluxated or dislocated his hip, got an x-ray, he's in the stadium, and they looked normal. So they put him back into the game, finished up the game. Next day, he had more tightness and soreness on the post-game check, and so he came back, came over to the Stanford facility. His neuro exam was normal. He had pain with hip flexion and internal rotation. He had increased pain with the impingement test. He was also accentuated if he did any posterior or posterolaterally directed force on examination, and he had these radiographs, and if you look really closely, you can see what looks like maybe a posterior wall fracture line. We got this, we got an MRI and CT here on the MRI cross-sectionally. You'll see as we move along this posterior edema, you can see a rim fracture posteriorly, and here on the CT scan, you can see this relatively non-displaced rim injury. And you can see again more clearly this posterior wall non-displaced fracture. So you got a 27-year-old football running back, posterior hip subluxation most likely with this non-displaced three centimeter long posterior wall rim fracture. Whoops, what would you do? So we got five minutes of discussion time, so. Huh? So, yes he does. I don't think I would fix that fracture. Would you go in and do a reduction in fixation? Yes. Most, almost all of them. Occasionally one. Bernie Gorey, a couple months ago, meeting where he was talking about the elbow. The pressure force for failure of the bone is higher than the pressure force for the contractile system. And what happens with these, when one punches out the posterior rim, they don't hit the one in the center. They hit the rim in a particular surface. And ultimately, they play to a particular surface in a particular area. These are the ones where if they go bad, they go bad first. It'll take a long time. But outside of that, because you worry about all these different things. We've got a myriad of problems. A lot of them don't show up on the CV until months after initial injury. So you've got fractured, fractured,

hip pain

athletes

femoroacetabular impingement

FAI

corticosteroid injection

arthroscopic procedure

labral tear

hypermobility

periacetabular osteotomy

PAO

physical therapy