four years of history of right hip pain. She had a hip scope three years prior to seeing me that had relief for two years, had recurrent symptoms, but at this point can't run, has pain walking. Impingement and labral stress tests were positive. Her internal rotation was to 40 on the symptomatic side, 60 on the non-symptomatic side, and her external rotation was 80 bilaterally. These were her radiographs. Synergy angle was 16. Tonus angle was 14. Mild to moderate arthritis. So kind of, you know, what do you do for an individual like this who clearly has dysplasia? This was her MR arthrogram. 90% relief of pain with the intra-articular injection, labral tearing, chondral wear, post-surgical change from the hip scope. So, you know, what do you do with her? And basically she was at the end of her eligibility center for PAO, and I saw her at a five-year post-op. She was doing well with recreational activities, so just her equal opportunity. Yeah? How many would scope her at the point after she's? Okay. You're saying scope versus PAO? So for the track and field athlete, let's, a show of hands, how many people would have scoped a patient, knowing that I already did, but how many people would have scoped a patient versus how many would do a PAO? So let's just, how many would have scoped that track and field athlete? Brian and I are the only ones? I don't know. I think that's the sort of thing, again, you have to collaborate with somebody who does PAO. And as I said here, I'm not a hip preservation, so I'm a sports medicine guy, so I don't do PAO, so it's not proper from inside. You don't need a PAO, you just go to the hip. That's where you gotta collaborate with somebody who's experienced and knows not only how to do a PAO in the basement, but when it's okay, to maybe not take that as an index of procedure. Okay. Do we get a show for PAOs or no? Huh? Is everybody else for PAO on that? So would everybody else have done a PAO? On the track and field athlete. So all those that would have done a PAO on that athlete. I'm sorry, what was the question, Mark? No, I was gonna say, all those who would have done a PAO on that track and field athlete. I think the board answered would probably be closer to the PAO than Mark Scott. Yeah, no. Well, but I think this is kind of point in case, this particular case where if she had had a PAO instead of the scope, would she have had a better looking hip at this point? Yeah, my guess is she probably would have. I mean, to me, that was beyond my limits of what I would do, would have done if she came to present to me initially as a gymnast. I mean, I might've had that discussion about this is not gonna be a long-term answer. Maybe a scope will get you through, but a PAO, I know that a tonus angle like that and a center angle like that is biomechanically not a good environment that I'm gonna give her any long-term solution. Are you talking about the gymnast or the track? I just was mentioning about the gymnast because he was asking if she presented to me when three years ago with a center jingle of 16 and a tonus angle of 14 and no arthritis, would I have scoped her or would I send her for a PAO? Yeah, because I think this is why I think the PAO would have been indicated for the track athlete because of what we're seeing in case four. The activity envelope is so important. I mean, if we did a PAO and then stopped her and then stopped her sport, that's the other issue is because we have a third, we have a secondary layer, which is PAO and then return to full collegiate sport for four more years or PAO followed by sports cessation. Because I think that the impact associated even on this particular case, there's a lot of arthritis. I don't know, Andrea, with the amount of arthritis here, even though the age group for the PAO, I've seen PAO centers around the country decline this particular case from PAO saying there's arthritis already. So no PAO. So I think that that's always my question about, because the PAO often seems like a mic drop, but it's not always a mic drop. Many times they still hurt or many times they don't go to sport or many times you still have progression of arthritis. So how do we make a decision that, like to Shane's point, if Mark had done a PAO, could we predict that without sports stopping, that PAO would have delayed progression of arthritis in some way? I think you can say yes based on the long-term literature after PAO. So they have good 20-year data that shows progression rates compared to the natural history studies where people had dysplasia and they didn't get a PAO. You can see there's a significant difference in the progression of arthritis. So I would say the answer is yes, that we could predict that she wouldn't have worn away her cartilage if she had done it. I don't think the Antegna scores in any of those long-term studies. So there's not really a good tracker on what they did after the PAO. Yeah, and I'd say a lot of those patients didn't go into collegiate sports, but I think that's, unfortunately, I don't think it's something we can repeat now. Like if we see a collegiate athlete, we can't say, well, we're gonna randomize you to not get a PAO because we wanna see what happens compared to somebody who does. So I think we have to base it off the best literature that we have. But I think it is something that I would say yes, I think we could have prevented arthritis if she had the appropriate surgery the first time around. So when you counsel patients, Andrea, what do you tell them in terms of their chances of going back to sport? So I think the more recent literature shows that it's upwards of 80% return to sport. But we were talking about this before, it depends on what does that mean? Is it the same level of elite collegiate competition? Is it professional competition? And there's a huge variability in that, but it's about 80%. Mark, can I just ask a question? We have a lot of sports people here, a lot of people taking care of teams, okay? It is a sports meeting. Yeah, how many people here take care of or took care of this year a collegiate sport? Raise your hand. Okay, how many people, because we know our registries, I take care of a college, how many people had an active athlete who had had a PAO on their sports teams? Raise your hand. So two, okay. I just don't think there are a lot of people out there with PAOs playing collegiate sports. Yeah, certainly, yeah. All right, Thomas? And I was just arguing like for that previous case, it doesn't matter if it's 80% or 40% to go back to sport, because the treatment isn't just about getting back to sport, maybe you could do a scope, and yeah, they got back to sport, and then three years later, they're getting what looks like that. Right. Versus you did a PAO, and maybe they didn't quite make it back, but they probably got a better joint long-term, and that's where our focus has to be on the long-term. Yeah, and having that discussion is a tough discussion, because you sit there and they, you know, again, they're about now, right? I mean, so they're not always about, 20 years from now is like ancient history, you know, for them, but when they, you know, when you tell them when you're 40, and they look at you sideways, like, you know, 40, I mean, my goodness, so. I've certainly had that conversation, and I don't want a PAO, I just want to have more discussion. Well, why don't I have a PAO, and you have a PAO, sir? But if you're at the scope of this country. No. Yeah. For young people, most of them want to take a nap. Yes. You know, when do you get to this point where patient decision-making is guided more by you than the patient himself? It's shared decision-making, right? I mean, you got to have that discussion with them, and a lot of times when I have that discussion with our student athletes, I'm like, you know, let's bring your parents into this discussion as well, and they can oftentimes temper it more as far, but if I have that discussion just with the athlete, and again, after the age of 18, they don't need to have their parent there, but more often than not, they're happy to have their parent there, and the parents will temper them back down and say, you know, some parents, some parents are like, no, they need to get back out on the field now, so, you know, there are those parents there.

right hip pain

hip scope surgery

impingement

PAO procedure

shared decision-making