Yeah, oh yeah, I know, I hear you. Is this thing, oh yeah, do this here, okay. All right. So my worst day in the OR, I don't have any pictures like Travis, but actually I'm gonna move through, it didn't update, but we'll just, we'll start with, so mine started on day five. So I had, my administrative assistant called me and she said, I think we have a problem. I just spoke to Dr. So-and-so, or patient So-and-so's father. He was an electrician in the clinic, fortunately at the time and he stopped by her office because they happened to be friends. And she said, I think we've got a problem. I said, well, what, I mean, what could possibly be going on? I haven't heard anything. She said, well, he thinks that his daughter's been, was sexually assaulted in the operating room. So of course I, you know, almost passed out and this is like first year, half of practice or something. So really early on. So going back to the beginning, uncomplicated surgery, 22-year-old softball player, you know, pretty straightforward, went fine. And she was from, she stayed overnight in our recovery care center. So the next morning had a little bit of, you know, numbness in the groin, but nothing abnormal. I mean, we know 50% of people have something like that. So nothing, nothing alarming or anything. She was having, I guess she'd had some numbness. So she was had, when she was going to the restroom, was wiping, I guess, too aggressively, got some irritation, went to her primary care provider day three and primary care provider told her that she had been sexually assaulted and sent her to the UNC emergency room for, to have a rape kit done. And then now we're here at day five. So, I mean, incredible amount of trauma that's going on with this family. Certainly we're all, we all are experiencing that and no worse than, I mean, the father and the patient. I mean, he was completely in complete disarray. He didn't know what to do, obviously. So we all got, even within a week, it was resolved, baby came in and it wasn't even one of the bad injuries that you get, but, you know, we talked through it and of course they understood what had happened, but I mean, they really were convinced that, you know, that somebody had assaulted their daughter during the surgery. So obviously that made me one of the first people to start going post-free. So, really, I mean, really, really severe event. And even from, not even really that bad of a complications we talked about, we're like a routine, you know, we talk about this as 50% of people get some type of numbness, right, or something. So, and that's obviously what can spiral, now we're spiraled from that, so. I don't know, anybody have any thoughts on that, on that case or any similar crises? This is like mildly interesting to me because it has not happened to me, but I was talking to, at the other FAI session yesterday, Alston Stubbs said that he had one of his patients, and I think he'd be comfortable with me telling this. He said that he had a patient that was, you know, a couple years ago, that said that they filed a sexual complaint against him because of someone telling her, apparently one of the circulating nurses was a friend of hers, and told her that she was completely exposed in the operating room, which, of course, they are. Yeah, hips operated on. Right, and, you know, it was very interesting, so I do my best to obviously cover it with a blue towel, you know, the perineal area, obviously, with a blue towel or something. But, of course, at the end of the day, at some point, he gets exposed, so it's not just you. I mean, this is something that we probably should think about. Bruce Levy's come up with something, and this is a plug for him, which I've actually shockingly found somewhat helpful. It's called COVR, C-O-V-R. It's like this little underwear that you put on, that the patient puts on in the pre-op holding area, and it can expand or contract, and so he's out there, he like pitched it to me, and honestly, up until this, I was like, Bruce, this is crazy. Come on, man. I'm not using your thing. But between you and Al Stubbs, maybe I'll start. Well, then, I was talking to somebody else last night, another high-volume hip arthroscopist about this case and this day, and they had the same experience, just like this. So, I think, yeah, yeah. I think that, for me, the takeaway is, like, it doesn't have to be the catastrophic pudendal nerve disaster. It doesn't have to be long traction time. I mean, we know that this happens in a lot of patients, and in some situations, it can obviously spiral into disaster. And even though it was resolved, I mean, even the week of severe trauma the family goes through or, you know, and what if it wasn't resolved? I mean, what if it had even gone further? It's scary. Anyone in the audience have this happen, out of curiosity? Yeah, there you go. I have a woman who, in pre-op, is wearing underpants, and in post-op, is not wearing underpants. I understand why someone's wearing underpants off to a post-op. Yeah. So, I had thought that the operacy was to kind of prepare them for that situation. It was more of a group on family with their underpants on, but when you wear your underpants off, there's a huge amount of underpants on, so it was similar to what we were talking about. So, a lot of pre-op, it's not that complicated in that respect. So, the expectations is important, I think, so. I don't know if this helps or not, but I'm usually not in the OR like when all the positioning's going on. Yeah, me either, yeah. My PAs and like, surgical, I mean, maybe I should be observing this to some extent, but I've kind of left them to do it, but I guess that if you're not there, then you don't see what's going on, but at the same time, if you're not there, then I guess you're not implicated in it, so I don't know what's better, but. Your name's on the op note, though, Shane. Oh, you're implicated. You're implicated. You're implicated. You can say what you want, but you're the captain of the ship. I think that it does raise the point of just pre-operative counseling for all things, right? So, I mean, I think early on in your practice, you tend to try and minimize the risks because you don't want to lose the case, right? So, you're worried about saying things like ABN or progression of arthritis or nerve palsies, and I think if you lay it on the table and you have that expectation and then you document that in your note, I think that's the better way to do it. So, even though it may seem like you're overselling the potential complications, I mean, it can happen, and I always tell people that statistics apply to populations and not to people, so if it happens to you, it's one out of one. You don't care if I told you it was one in 500,000, it could happen, so just have a very clear discussion about that and then, you know, for Chad's situation here, let them know that that area's gonna be exposed during the time of surgery and so they can mentally prepare for that. Yeah. Yeah, I just got a few slides just going over the post. Obviously, this, you know, when a post-free system was available, that's why I switched to that immediately, but, you know, we know a lot about what the post does and remember, there's the two types of injuries. There are the compression neuropraxias and then there's the soft tissue damage and I've had one, you know, probably 3,000 hyperearthritis at this point, but I've had one other soft tissue injury and these two cases are far and away like the worst experiences in my professional life, so I think it's, you know, we talk a lot about the nerve, but it's the soft tissue injuries, I think, that are, you know, that are, in my experience, have been the ones that have been more catastrophic and, you know, we talk about like it, you know, it probably happens more than we think. You know, self-reported from the patient is not adequate. You know, we know it can happen at very high rates and the question of it being, I mean, you have to question the validity of saying it's temporary. I think that's not really taken into the patient's perspective on what it means to them. There's a lot of things that are temporary. Infections are temporary. DVTs are temporary. There's a lot of things that are temporary. That doesn't necessarily make it, it's just that we shouldn't try to eliminate it, so. And it's going to happen, you know. It's definitely, if you do enough, and I think, you know, people that, you know, Winston and others, you know, talking about, when you do enough, you feel, you guys have all done a lot of scopes, so you're in this number of arthroscopies and you can see that when you do it, do enough of them, you're gonna see this happen, so. If it hasn't happened yet, it's probably going to. But, you know, I think one of the nice surprises of the post-free surgery is that that post wasn't good for the surgeon either. That traction time, you know, it creates stress, and that stress drains your energy and your focus, and even little bits at a time can take that away. I think the lateralization can sometimes create excessive tension on the tissues, making it difficult. And it's in, you know, it's in your operative space, too. So, you know, you don't realize it, because it's like having a pole in your living room or something, it's always there, you just learn to walk around it, right? Until it's not there, and so when you realize when it's not there, you really are in a much more ergonomic position. So for me, obviously it changed my practice. I moved to a post-free system and have, you know, maybe used a post two or three times since I guess it was 2017 now, so. I mean, we're, you know, we're getting up to over, you know, about 1,000 cases. It's highly reproducible. Rarely ever have to put in a post. Only occasionally, I actually needed some lateralization and put it in more for that, and even then, you look down, you see it's really not even on the perineum. It's more working as a lateralization vector. You know, some of the learning curve, this video here shows some of the learning curve with the hand position. If you haven't done this yet, you go on to Intern Dellenberg. It's your, you can see the anterior lateral portal doesn't change much. It's your anterior portal that does. So the first few cases, you know, I was like, boy, something's not right about this, and I realized this is my arm was really, you know, much higher. So, you know, if you're a shorter person, you'll need to find a special, you know, there's some beds that really get low. Not all of our beds do, so that's a modification that can help so that when you're dealing with the Trenellenberg position, but I know Slaad and some others have now gone to using very little Trenellenberg, so that's really probably not even a significant barrier anymore. I don't think you can probably do it without that, too. You know, I think it does give you a little bit greater working space. So, you know, especially that first image there, you get a little, just a little bit more traction. Then you can enter where you're not having to really enter over top of the femoral head and then risk injury to the cartilage, but again, you can still be away from the labrum. So I like that, especially in, you know, training environment, too, then it's a little bit safer. And I do think, although we've measured it, but I'm confident that we have seen fewer atrogenic cartilage scuffs and things from it. And you can get a lot of space even in a deep hip, too, so it's not, you can still distract them quite a bit. I find that you can get it medially better, too, because you don't have the compression of the medial tissue. So, you know, this is a labral tear that's really all the way down to the, you know, down into the whole, into the transverse acetabular ligament. And so I don't know that before I could really repair these pretty routinely. And now we actually see a lot of them, and we do repair a lot all the way down in there. And then in the peripheral compartment is, in the capsule repair, it's nice. So up above, I think there's a little bit more space without that compression. You don't, again, medially, not having that compression helps you in that area as well. And then the other nice thing is you can get, you can get distraction and adduction when you're in the peripheral compartment. So you can bring these supralateral cams that are often hard to get to and miss. You can bring them to you rather than having to go to it. And you can see the curvature of the head. You can see right where that cam starts and stops. Makes that far, far easier. And again, it's something, you can't get both of those often without, if you have a post stem. But one of the things I think that excited me the most about being able to get rid of the post was it enabled complex hip arthroscopy. So this is a double-double, as we call them, which is a labor reconstruction, a capsule reconstruction. And there's, you know, there's a lot of traction time in a case like that. And it's complicated enough as it is. And having not, again, not having to worry about that as a risk is of high value. Allows us to complete these more challenging cases. You know, I think the osteochondral allograft technique is something that, you know, by the time you're doing a labor repair and everything hip, and then you go to do an allograft here, you'd be getting into, you know, quite a bit of traction time. And talk about a delicate technique in case. You know, we're getting this little wafer in there and without breaking it and so on, you have to be, you know, again, nice and calm. And if you're worried about your, your, you know, the traction time to your dental nerve, that's what would be affecting. I don't know that I'd be comfortable doing that, you know, with a post. But again, something we weren't able to do before. And now we can do not, not only can we do it, we can do it safely. And then bilateral hip arthroscopy. And we've done a handful of these. And I think it is, you know, patients really do like it. It's something we never could, you couldn't do it before without a post. It, you know, it's, it reduced the cost of the surgery. It's more convenient for a number of them. And, you know, the, I think we've done about 25 and I don't think there's, there's maybe one, I think one or two that wouldn't do it again. The other ones are very resounding, would absolutely do a bilateral again. So, so that's a nice service to be offering to the patients. And then my, my two partners who do PAOs there, you know, they do, they do a single table kind of scope in PAO and, and, you know, without the, without the post it enables that to function a little bit better too. So, you know, again, the worst day in the world was there was a post related complication for me. So I'll never, I'll never go back. It's definitely better for the patient, but it's also better for you and it's relatively easy to convert. So you guys have any closing thoughts or any questions from the audience? Yeah. Thanks. So the, we presented a paper yesterday in the HIP conference about this actually. And so your comments on the distraction distance is accurate. You can, you get, I wouldn't say you get more distraction necessarily, but you can get equal distraction, which much with much less traction. So the traction distraction ratio is substantially better. We'll come out, we're going to show the actual reduction in injuries, nerve, nerve palsies down the road, but we haven't actually done that data analysis. So I can't tell you with certainty that's going to be the case, but I suspect it will be anecdotally. That's the first thing I tell you. The second thing, you don't need Trendelenburg. I do all of mine with just straight, flat, normal, the same way you do it every time. And I will tell you, it doesn't do any difference. You can get the same distraction. There's no difference. You do not need Trendelenburg. You can use it if you want to. I know this bed does, but you don't have to. I got so used to using it, I just use it, but I agree with you, I don't think. So I don't use any Trendelenburg. It has the same equivalent outcome. And I use a regular bed with a little pad underneath it. So you don't have to get a fancy bed either. If your ASC doesn't want to buy a big bed, you don't have to. The second thing, or the third thing is, I still worry about traction. So I maybe would say you don't get perineal pressure, but you still get pressure over the superficial perineal nerve on the foot. That's true. Axial traction still comes from somewhere. So you still get some numbness on the top of the foot. So don't just dispense with concerns about traction time. Yeah, we do loosen the boots in between sessions if we're doing a big case like this. So there are issues. And to your point, like that's nice, because with this, you can let traction off, put it back on, loosen boots, et cetera. But don't just like, now I can do it for four hours and don't worry about it. Yeah. If you stay flat, do you have to bend the joints? Nope. So I will say the only, the two to three times it hasn't come out, distracted appropriately, there's a little trick you can use. You don't have to vent. I've never had to vent to get it out, but I have had to do a little trick, which is to disrupt. So we've looked, using our traction monitor, at the holding force and the max force. So you have to break the suction seal. That's where the majority of the traction comes from, to break that suction seal. And then the traction force dramatically declines to half. So once you break that suction seal, you're good. You can vent it, that's option one. The other option actually is if you put your hand on the ASIS to hold the pelvis while they're under traction and just flex the knee, it will pop. So that little extra pressure to break the suction seal, and you just do it under traction like you normally do. If the hip doesn't distract at all, just pop it and it pops out and then you don't have to touch it again. Because now the holding traction force equivalent in the hip distracts. So it's just that maximal traction that occurs with the suction. So you have to break that. So that's a little trick you can do. I mean, I think I've gone to venting pretty much everybody now. I didn't, I only used to do it when I couldn't get it to distract. And now I pretty much do it routinely. I think at least in my practice and Travis obviously has some tricks that he just talked about that are also very effective. But I think, you know, since I've switched over to the same bed that Chad uses, it has a tensiometer on it. And so you can kind of get an idea about how much pressure you're pulling. And since I started venting routinely, I think I've used less, even less than what I was doing before. So I do think that it allows you to just kind of open it with even less pressure, which then decreases your risk of pressure on the foot and things like that. And then in terms of these beds that have a more rigid foot hold, you don't, only for the intra-articular work do you really need those cranked down. Once you get into the peripheral compartment, you can loosen the boots and that does seem to decrease the foot pain that they get and compression on the top of the foot. But to echo what Travis said, it's not just pudendal nerve issues. I mean, you are putting everything else on traction, including the sciatic. And there have been reported cases in the literature of sciatic nerve palsies from traction. And this is one of these, some of these tables, the fine traction is very powerful. So at some point you got to know when enough is enough because you could just keep cranking that thing till the cows came home, you know? Yeah. Do you vent sterile or before you prep? So I usually will do a prep stick, use one of the needles, vent it, pull my traction, set it, and then reprep and then, you know, do a final prep. That's the way that I've done it. Yeah, I just do it before I start, so I just prep. Clearly there's several ways of doing it that works well. Okay, so I'll talk.

surgeon

sexual assault

post-operative numbness

pre-operative counseling

post-free system