water polo player. He had acute onset of sharp left hip pain with deep flexion and egg beater kicking with water polo. He does have a prior history of also having some symptoms on the right side in the past, but currently was not having any pain. On his exam, his Trendelenburg signs were negative bilaterally, a little bit of weakness of the iliopsoas on the right side, which is not the side he's presenting with. His hip flexion was actually a little bit better on the left compared to the right. His external rotation was also a little bit better on the left as compared to the right. His internal rotation was only 10 degrees on the left and 15 on the right. His Faber was, I do it by fist height, so one and a half fist heights from the lateral joint line to the table. His impingement and labral stress tests were positive bilaterally. These are his radiographs. You can see he's got clear bilateral CAM lesions, got crossing signs on the right, actually more significant than the left. Posterior wall signs, he's got the retroversion of the acetabulum. His center of jangle is 24 on the right, 21 on the side that's symptomatic. You've got a guy that's got some borderline dysplasia with FAI, got an MRI or MR arthrogram on him. His alpha angle is 72 on the left. His femoral version was nine. There's labral tear. There's a measurement of his alpha angle. And so, you got a large CAM anatomy and labral tear in a patient with borderline dysplasia, acetabular retroversion, and again, he's a competitive water polo athlete. So, what would you do? Do you have a sense of what his tonus angle was? His tonus angle, yeah. I mean, if we came back here, yeah. So, I mean, I think his tonus angle was something like 10-ish. And is he in season? Yeah, he's, yes, he's in season. So, it's early in the season. Christopher Reddy taking over. There you go. Is this thing on? Yeah. Okay, so we had a good discussion concerning conservative attempt to get the patient back playing the season and potentially using either injection or rehab strategies to do so. We had some discussion about some of the open, hip surgery concepts surrounding longer-term questions, but in the borderline dysplastic was conservative if possible. Okay, so if you got him through the season, what would you, would you just say, just see how you go? Would you operate on and what, if you would operate, any special considerations that you'd be providing? Yeah, so Mark, we looked at this as a COVID athlete, right? He's 23, so we looked at it as a rising senior. I don't know whether we were wrong or not, but so much, I don't know of any seniors now that are graduating at 22. He actually was a junior, but that's all right. And. It's kind of like hockey, you know, they go three years before they go to college, you know. That would have been a sophomore. Yeah, exactly. At college right there. And so we said that if our conservative management didn't work based upon all the lines, and I told everybody just because my eyes are older now, it's hard for me to make a prediction based on x-rays as to where they're, whether or not they're a potential candidate for, you know, some more coverage with a PAO. So we talked about getting more studies, a CAT scan to actually help define a little bit better for tired eyes, to be able to decide whether or not this is a hip arthroscopy versus a hip arthroscopy with a PAO versus just a PAO. What will the CAT scan do for you one way or the other? I think it just helps me figuring out what my coverage looks like, Tom, that's all. You know, and then actual for planning, you know, being able to plan, you know, maybe this could be a stage procedure, maybe this could be, you know, just need one procedure versus another one. It just helps me mentally go through my algorithm to be able to do that. And we talked here, getting CAT scans is very rare, but the one time that I do get CAT scans is when I'm worried about coverage of the head. But as Dr. Bird said, you know, this is a sport water polo. I realized when I went by the Ohio side over there that I probably should have put a video of showing what egg beating is, but it's, you know, it's hip flexion with a lot of rotation. And so one of the concerns, obviously, about overcoverage is, you know, do you limit the motion and will that affect play? But we've got our resident PAO person over in the corner there, Andrea. You know, what would sway you to deciding on whether or not, well, first of all, do you agree with Dr. Biscone? And then second, if you do, what would sway you to consider a PAO in this athlete? Would you mind going back to the X-ray, the pelvis X-ray? So we're talking about the left hip, correct? The more symptomatic? The left is the one that's currently symptomatic, but the right one had been symptomatic in the past. Okay. So if you look very closely at that left hip on the X-ray, we were discussing at our table, the fact that we can't really see a posterior wall at all. So even though the lateral center of jangle is within that borderline dysplastic range, he's probably got very, very significant posterior undercoverage of this hip. And so he's probably a little bit more dysplastic than the lateral center of jangle would lead us to believe. And that's where, you know, sometimes that CT scan image will help you see that because you can spin the hip around and then look at it from the back and you'll be staring straight at the posterior femoral head. But I think you can see it pretty clearly here on the X-ray. One of the tricks that we discussed was inverting the image. So most PAC systems allow you to invert it so that the bone is black, the area is white. And that sometimes helps you see the lack of a wall, for example. So that being said, you know, if he's going into his senior or junior year and wants to get through the next couple of years of collegiate sport, a PAO, you know, is a huge recovery. I mean, it'll take him out for a year, basically. And it could ultimately end up, you know, giving him less motion in certain extremes that he needs for water polo. So if you're gonna do a hip arthroscopy on a borderline patient, I think he's probably your ideal patient. He's got a large cam. He's male. He has impingement symptoms. So I think just having a very, very extensive conversation about the fact that this might not be the definitive procedure, but could be something that could get him through the next couple of years of his sport and that he might need something else or alternatively could continue to damage his cartilage because we haven't really addressed the underlying undercoverage issue, then he can make an informed decision. And I've definitely had athletes who said, I don't, you know, this is just college for me. I'm worried about the rest of my life. And so if you tell me that the thing to do is a PAO, then that's what I want to do. So you can get, you know, athletes who come at it from both ways. If this were a female patient, female, high anteversion, high Baton score, I would not feel as comfortable doing a hip scope to get her through the next couple of years. Are there interoperative findings that you might also consider that might push you one way versus the other? Yes, but I think that's a little bit of a trick question because usually I've planned to do either the hip scope or the PAO. And so whatever you find interoperatively is not going to change, you know, that current plan, but definitely could give you pause. So the articular detachment associated with dysplasia where the chondral labral junction is actually intact, where, but the cartilage is detached more inferiorly. That's very classic for dysplasia. A hypertrophied labrum, not all dysplastics have that, but some do. But that's a sign that the labrum has been trying to cover the hip because there wasn't enough bone. Dr. Bird can comment more on this too, but there are certain signs that you can see in the hip that are also with instability. There's a femoral head divot, more anterior, far anterior, far posterior labral tears can be a sign of instability. Central wear can be a sign of instability. So there's a bunch of different findings. Actually, that was kind of what I was getting at. I mean, if you're looking to see more, is the pathologic change interoperatively or impingement related? So delamination of the articular cartilage dancers superiorly versus seeing posterior wear, like an inside-out wear pattern posteriorly if more sign of instability, you know, type of, whether or not that, you know, if you see one pattern versus the other, if you make you feel more comfortable about just doing the FAI surgery and taking it into consideration, obviously being borderline dysplastic that you need to be careful about your capsular management, but. Hey, Mark, how painful was his right side? Huh? How painful is his right side at this point? His right side, I mean, he had a positive impingement liberal stress test, but it doesn't bother him while he's competing. It did in the past though. Yeah, Josh. You've written on this before, but I think another interoperative measure that you can do is just a good exam under anesthesia. See how the femoral head distracts out of the socket. Look at capsular thickness or thinness. You can actually inject air at the start and then figure out what volume your capsule actually has in the joint. And so there are a lot of interoperative things that you can do that I think can provide prognosis, not necessarily change in management, but at least a little bit more of an educated discussion with your patient post-op and say, hey, this confirms what we thought. You were an impinger. I think you're likely going to do well, or we saw a little bit more signs of instability. I'm not really sure this scope is going to be 100%, so we'll keep a real close eye on it. So I think prognosis could be added as well. Yeah. John. Just one comment about the, and I agree with all that's been said, is the training for water polo and specific on land, as opposed to just having them in the pool, especially because these guys are usually super tall and they've got real long levers on their femoral side, just super long limbs doing this egg beater as you talk about. You know, you wonder as if you fix the cartilage and do a simple arthroscopic CAM, keep it simple surgery, you know, also modifying their training for water polo afterwards may prolong their ability to participate in the pool, but it's often that they can't separate out the squats, lunges, jumps, and leaps on land base that they're trying to do. So, which may be a bit more offensive to the stability of the hip than being in the water. Yeah. No, they definitely do some land-based work, but probably 80% of their time is in the water. I mean, and it's crazy. They wear weighted vests and they basically tread water for an hour or two at a time, just, you know, with weighted vests, that's part of their training. But let me ask, Andrea, you had stated they'd be out for a year if they had a PAO. Is that your land-based, what I call your land-based athletes, or is that, because I find that my water polo players and my synchronized swimmers, we get them back in the pool after their wounds are healed and they actually are back competing at a very high level, much quicker than the land-based athletes because they're not, I think, having the pounding. Is that the same? Yeah, that's an excellent point. Very, you know, it depends on the, I guess a better thing would be to say he's out for a whole season, a year's season. So, in younger patients, they do a really good job of healing quickly. I've definitely had patients come in at six weeks or three months and it's like nothing ever happened. They didn't have a PAO. They just are walking normally. They feel great. The rehab for a PAO, I do most of my PAOs with a scope, and I'd say the scope is actually the part that slows our return to sport. You're waiting for the capsule in the labrum to heal more than you are at the bone. But you're absolutely right. You know, I think once you get past the soft tissue restrictions of your hip arthroscopy, then the PAO, you know, shouldn't hold a water sport athlete back as much as a land sport athlete. But I still think it's probably gonna be a season, you know, a season out for him. Okay. Yes. I've seen more water polo than most of us, but the ones that I've seen that typically think of swimming as a fully packed sport, but most of the water polo athletes that I've seen have large hands. Huge. Water polo athletes have huge hands. We did a MRI study on all our water polo players, and super nice swimmers actually, 97% had FAI. So it was a huge number, which is why when we talked about the forces on the physis being, we thought it was from cutting and pivoting, it is forces on the physis, but these people, though they do some land-based work, most of their stuff's in the water. And so I think it's the rotational forces on the physis that may be causing, but some of my biggest FAI patients with huge delaminations, alfangles in the 80s, is not an uncommon thing in the water polo players. So, but, you know, as we were talking about with, when I was talking to Tishan, if they had, most of them don't, most of the high-level water polo players, and a lot of Stanford athletes go on to play in the Olympics, those guys, when they have the big cam lesions, have borderline dysplasia. Because if they have, you know, too much coverage, they just don't get the range of motion that they need to generate for the egg beating, and they can't elevate out of the pool, right? Because they've got to elevate up about, you know, two feet to do it, so they have to generate a lot of force. So they don't, they generally have more shallow sockets, but they have large cam lesions. Yeah, Josh? Can you come up with an answer as well about some of those kind of self-selecting processes? Right. You have to have enough under-coverage, you have an extra range of motion, but not so much under-coverage that it needs you out of time. Yeah, no. To get to that level, you have to have some degree of tolerance. Yeah, that's the perfect example I use. If you're 12 years old and you can't do the splits, you're not going anywhere in dance. So who's doing the splits? Those with dysplasia or those that are ligamentously lax, and they self-select, if you will, so. So moving on to what was done. So I gave him a cortisone injection with anesthetic and rehabbed him for three months, and he continued to have symptoms with water polo and lifting. So when the season was over, we scoped his hip. Let's see, here we go. You can see this is anterior superiorly looking from the posterior lateral portal. Big chondral delamination, pretty classic CAM type of pathology, if you will. And like the classic description from Gans and Beck is that you have this chondral delamination and initial sparing of the labrum and labral chondral junction. And so if you look here, sorry, you can see after we did the chondroplasty that the labrum actually was intact. And so here, just probing on it. Here's his CAM lesion in the peripheral compartment, CAM resection. And then again, I do this more laterally based than cutting the iliofemoral ligament, but either way, I think you need to be careful about managing the capsule because of his borderline dysplasia. And so we went ahead and closed up the capsule as well. And then he returned to water polo, and then they won the national championship, his year back. So any comments? Looks like Shane's ready to comment. Did you do anything about the cartilage? Any microfracture or just debridement? I did not. So I microfracture when it's more than seven millimeters from the acetabular rim, but sometimes in a land-based athlete, even if it's a smaller lesion, I will go ahead and microfracture, but not limit their weight bearing. But we did not microfracture him. Thomas. Just kind of going back to what Andrea said, when they come in, I'm just a college kid, it's not that critical getting back. That's really kind of more the basics. The problem there, I think, rarely has to do with the sport. The sport brought it to the head at a younger age. If they weren't doing the sport, it might not catch up with them for longer. And that's such an important message to drive home with usually kids and their parents, that the treatment's not just about, when can I get back to the sport? It's about a young person trying to give them the best tip you can for a long time to come. They rarely focus on what the long-term outcome is. When can I get back to the sport? I think keeping that perspective is so important every time you're having that conversation. Yes, we're talking about getting back to the sport, but that's not our sole purpose. Right, yeah. But as you say, you're right. They're looking at what's right in front of them, but not the long-term. So you gotta have those long-term discussions. And we did discuss that because of the undercoverage, this may not be the only, especially if he transitions from water polo to a more land-based sport, he may become more symptomatic because of that relative deficiency, if you will, in weight-bearing surface.

water polo

hip pain

labral tear

hip arthroscopy

periacetabular osteotomy