All right, third case, a 19-year-old female, a track and field athlete, she's a jumper, so high jump, long jump, and recently she decided she wanted to start to try to do the triple jump, so she was starting to train in that, developed some left hip pain, but she noted that when she started doing triple jumps, she was training one day a week and then started to ramp it up to four days a week, doing a lot of plyometrics. And in her history, no history of true trauma to the hip when it started, but it had been progressively getting worse, but she said she did sprain that hip about three years prior when she landed wrong, and her hip was hyperextended, basically was out of the sport only for a week before she returned back to competing and training. She did therapy for three months, and basically she has pain when she hikes, when she does activities of daily living, or when she tries to do kind of a butterfly stretch, when she's seated and her feet are together and hips are flexed and abducted and externally rotated. On her examination, her Trendelenburg is positive on that side. She's got good strength in iliopsoas, similar range of motion, she's got increased external rotation compared to the other side, as measured in flexion, but similar internal rotation. Her Faber is a little bit more lax on the left hip compared to the right, but has positive impingement labral stress tests. Her iliopsoas, you can elicit snapping on clinical examination. Her hyperextension, external rotation tests, and her posterior apprehension tests bother her. She's 5'11", she weighs 170 pounds, and her Baton sign, she's got seven out of nine Baton signs being positive. These are her radiographs. Again, it's the left one that bothers her. She has a posterior wall sign. Her center edge angle on the symptomatic side is 23. Her tonus angle is 16. And her MR shows that she had an MR arthrogram. She got 50% pain relief with the intraarticular injection, and it does show a labral tear. This is her CT scan. So for those who like to get the CT scans to look at the acetamide, I'm sorry I don't have the full rotation, but just kind of gives you a good AP and kind of lateral view. She's got a moderately deficient anterior wall, no significant CAM lesion, and low AIIS. So hip microinstability with a history of remote trauma, so prior trauma, mild trauma, in the setting of borderline dysplasia, retroversion, and maybe we have a discussion of whether or not that's true borderline dysplasia with a tonus angle of 16 as opposed to the fact that her center edge angle is 22. She has retroversion, clearly. She has a labral tear, low AIIS. So a little bit – Male Speaker 3 Do you have an answer for her femoral version? Dr. David Engelman Yeah. Her femoral version, I actually don't remember the exact number, but it was not – it was within range of normal. But we get – every patient that gets an MRI at Stanford for the hip, we assess their femoral version, and so it didn't stand out as being abnormal. So time for discussion. Okay, sorry I didn't give you a lead time here. So a lot of discussion going on, some good discussion, and a little bit more of a controversial type of case. But Shane, what do you got? Male Speaker 4 Yeah, so we're thinking that, you know, in the setting of microinstability, you know, get her as well as borderline dysplasia, retroversion, labral tear. Obviously try to get her through the season if at some point either she's too symptomatic or she's at the end of the season. I mean, this one kind of smells more like a PAO candidate, just given that she's a jumper, she's a track athlete, she's a land-based athlete. All the impact, I think, you know, with a high Beaton score, she'd probably be better off with, like, in scope with some sort of a PAO. Dr. David Engelman And what do you – I'm not going to ask you to quote me the PAO literature, but I mean, the likelihood of getting a person that, you know, is an explosive athlete that has to take their hips through extreme range of motion, right? When they land, they land in deep flexion, if you will, right, with their feet extended. About getting them back to doing jumping-type sports at that level, an elite, you know, D1 level, with a PAO, do you think that – is that possible? Dr. David Engelman Yeah, I mean, I think the literature in the PAO side with elite athletes are pretty good. I don't know the exact numbers, but I think the ones that I've seen from St. Louis are pretty impressive. So, and I think anecdotally, our patients tend to do well with them, especially these particular athletes. I don't know, does anyone have any other feelings about it? Dr. David Engelman I don't know anybody have any other feelings about it. Dr. David Engelman Yeah, no, I agree. So yeah, Andrea? Dr. Andrea Smith One other thing that we don't talk too much about is lumbar flexibility. So if somebody has more of a stiff back, they will lose quite a bit of motion after a PAO and may not be able to get into those deep flexion positions. But a young, otherwise ligamentously lax female who's got a very mobile lower back, they will be able to tilt their pelvis out of the way, even if you give them a little bit more coverage and still gain that hip flexibility. So that's something to think about as you work on these patients is to look at their spine. Dr. David Engelman Yeah, no, the hip-spine relationship is certainly key to consider. So briefly, actually, you know, we treated her conservatively. She still had symptoms. So we took her to the OR. She had a ligamentum teres partial tear. We did a AIS of spine decompression. Here's her labral tear, straight anteriorly, which we did a labral repair on, and then did a capsular plication on her, and told her that that may not be the only answer. For me, the tone of saying, I won't do hip arthroscopy for somebody with a center jingle of under 18, or a tone of single greater than 16, 16 is my upper limits. After that, again, I think that they don't do very well. And some people would say maybe 14 is probably the right number. She did return to collegiate track. She completed her four years of eligibility at Stanford. So any, yeah, Steve? Male Speaker 1 Good question. You know, we talk about, like, the speed of getting a PAO. It's not like we're aiming to over-cover them, right? We're just trying to get more coverage, and it's maybe trying to get the bone anatomy to be more than normal. Do you really see, when you have the PAOs in the back, do you really see that there is loss, there is emotion on the patient? I just don't understand that concept. Yeah, I think that's a good point, Steve. And I think, I mean, we can dial it in. So if you're doing this in a young athlete who you know has to have a ton of motion, I'd say, on average, the goal of coverage for a PAO is probably somewhere between, like, 32 and 36 degrees of a center edge angle. But you could certainly say, OK, on this patient, we're going to dial in, like, a 28 to 30 degree center edge angle. A little bit less ideal that they're close to borderline, you know, that 25 or under. But that's certainly something that you could work on. And there's so much variability in acetabular coverage and, you know, antiversion and retroversion and lateral coverage that you can play with a little bit. But I don't, to answer your question, no, I don't see a lot of loss of motion, except in my older patients. So we do PAOs in patients even into their 40s. And I think once those 40-year-olds get that stiff back and they can't move their pelvis as much, then sometimes they lose a few degrees of flexion or abduction because of the PAO. Are you able to precise, be that precise that I want to get it from 28 to 30, you know, with your PAO? Are you able to, is it that, what you find, what you think you got in the operating room is what you got in the recovery room? So, no. But there are software programs now where you can actually link a measurement device so you take a fluoro shot and then it measures your center edge angle. And the lo-fi version is that you can put your K-wire pins in, get a shot, send it to PAX, break scrub, measure it, and then before you put your screws in, you can adjust it. So there are ways to do it. Okay. So.

19-year-old female

track and field athlete

left hip pain

labral tear

hip arthroscopy