Okay, so I'll talk about a couple of my worst days in the OR. Abdominal compartment syndrome and suture-anchor arthropathy. Disclosures can be found on the Academy website. So for many of us, being in the OR is probably what we enjoy most about being a surgeon. Here I am with my team and I think, yeah, we have fun, we do good cases, we have good teamwork, camaraderie, but the OR can also be a source of frustration, disappointment. Obviously, if you have any complications, that can be very stressful at times as well. And so I would say that a couple of these cases were those for me. Josh Harris did a nice systematic review on complications in literature. This was published in 2013, so this was a while ago. So it'd be interesting to see if that's changed in the past decade. But he outlined about 6,000 cases. In 6,000 cases, he found these complications. You can see on the bottom is probably the more common ones. Chondrolateral injury, nerve injury, heterotopic ossification, but extra-articular fluid extravasation does fall on that. And then the next group, you can see perineal skin damage. We talked about AVN, broken instrumentation, DVT infections. Above that, femoral neck fractures, dislocation, hypothermia, pulmonary embolus, and then on top, death and vascular injury. So extra-articular fluid extravasation, I think when you do a literature review, you'll find that that probably happens most frequently when you're doing iliopsoas releases. And I don't know about everybody else here, but when I was first starting practice in 2008, 2009, we used to do psoas releases on like everybody. It was like part of the FAI treatment. We'd treat the central compartment, repair the labrum, release the psoas, not repair the capsule, and then do our osteoplasty. So that was a common thing that we did. So we would usually do it in the central compartment. Back in the 2010-12 era, I think some people talked about doing peripheral compartment as well as at the level of the lesser trochanter. Those are the most common. It's kids. So this is at the level of the central compartment. This is post-total hip replacements. And you can see that if you extend that capsulotomy, you can see the iliopsoas muscle and tendon. I use radiofrequency, and I'll just kind of hug the anterior aspect of the joint and then just lengthen the iliopsoas. I probably do like two of these cases a year, not too frequent. This is the way I used to do it. I probably don't do it as much like this anymore. I try to stay out of the joint as much as I can. But this is a pretty simple case. Doesn't take very long. You can also do it extra articulately, which if you can find it, looks great. So here you can see on the left is the joint capsule. On the right, you can see the psoas tendon and the psoas muscle adjacent to it. But I think what I find is post-total hip replacement, sometimes that differentiation between capsule and psoas is hard to make because the tissue is just so scarred, and you can't really tell what's what. So I think that this is not as easy to do. So I probably don't do this as often, but when you do find it like this, it's pretty gratifying. And then at the level of the lesser trochanter, a lot of surgeons prefer this just because you can stay out of the joint. So if you're dealing with post-total hip replacements, rather than having to violate the capsule, just if you find the lesser trochanter and just start lengthening the psoas, I think that this is a good option too. Obviously, if you're at the central compartment, it's probably about 50% muscle, 50% tendon. And as you get down to the lesser trochanter, more distal, you're probably close to 100% tendon. There is a theoretical loss of weakness and inability to straight leg raise following this. But I think that the patients that we treat usually have a lot of weakness as a result of pain. And so for whatever reason, once you alleviate the pain, I think their weakness is from pain, and it just seems to get better. Again, it's not a common thing that I do, but it does come up every so often. But this was a case of a patient of mine that we were indicating for a psoas release for post-total hip replacement. And we were doing at the level of the central compartment. But I want to pull up the anesthesia record because this is pretty interesting. We started our case at 7.59. And you can see, as we got into the case, probably about, I think about a half an hour into it, you can see that the systolic blood pressure got a lot higher. And so the patient became hypertensive. And I can remember, intraoperatively, as we're releasing the psoas, I can remember a couple things. One is that there is this pretty thickened psoas bursa. And when I was looking at it, I was like, man, it looks like there's a straw going into the retroperitoneal space. In the meantime, there's a little bleeder that we were chasing. And so in order to get the bleeder, sometimes you're increasing the fluid. And this is probably going on longer than you think. And then all of a sudden, there's more and more fluid going into the retroperitoneal space. Just kind of an overview in terms of what we're dealing with from a vascular perspective. You can see, as the femoral artery comes down, there are some branches that I think are a little bit more proximal. But I think this is what you're worried about, is that profunda branch with the medial and lateral circumflex. And this is kind of right in that sort of middle third of the iliopsoas. And so that's what you want to be aware of. And so he went from hypertensive and then went to extreme hypotensive state. And I remember at this point, the anesthesiologist was saying, we're having a hard time inspirating the patient. And at that point, we kind of felt like the belly was much more distended than probably we'd ever seen. Probably we'd ever seen. And so I think eventually, we got a hold of that bleeder. But the patient at that point had pretty significant abdominal fluid extravasation. And so we had to call our general surgeon to go ahead and do it. He ended up doing like an X lab and just releasing like probably about three or four thousand liters of fluid into the belly and retroperitoneal space. And from a hemodynamic situation, like the patient was much more stable, like didn't take very long for that to happen. But recognizing it was, you know, obviously this felt like it took forever. But fortunately, this is in the hospital and the general surgeon was like right next door, like about to scrub into like a lap coli. And then the OR staff was used to doing like general surgery cases. So they just like converted like very quickly. And that was pretty fortunate. But like in an ASC now, like you're just like, man, you would be doing it yourself or trying to figure something out. So it's maybe Joe has some perspective because he probably deals with some of this area a little bit more. But just in terms of just kind of a review of your neurovascular anatomy, again, you want to stay away from that central third. You know, it's either at this point, it's either you want to go at the lesser or you want to go more centrally, central compartment more approximately because you just don't want to get into these vessels here. So this was a survey study that was done in 2012. Again, this was a decade ago now. And the survey was how many surgeons had dealt with or seen intra-articular or intra-abdominal fluid extravasation. And it was about 50-50. So like of all the surgeons that are on this list, of many of which we know, half of them had seen it. And I think there's a couple things that they had highlighted in this paper in terms of recognition intraoperatively. Again, similar to my case, hypertension, then hypotension, abdominal distension, and peak inspiratory pressures just due to fluid extravasation within the abdominal cavity. They just have a hard time inspirating them. And then hemodynamic instability. They've also reported in the PACU or in post-op, sometimes they'll recognize a drop in core body temperature as well as abdominal pain or distension that in some cases they'll just monitor them in either a recovery room or in a monitored bed setting unit. And then some patients may describe shortness of breath. I think for prevention, a couple things. You know, I think at this point in my practice, like psoas tenotomies are not a part of my routine hip scopes. You know, again, I probably do a couple a year from my total joint colleagues who've had persistent snapping and pain or weakness with their iliopsoas. So it's pretty infrequent. I'd be curious to find out what the other guys are doing. Obviously, keeping an eye on your pump pressure and not having it too high, especially in this space. And then doing serial abdominal exams. I remember Brian Kelly used to be pretty keen on doing this. Like, I don't know if he still does it all the time, but he used to do it like all the time. And so, you know, I don't know if he's ever had any issues with it too. Yeah, so it's, and I think it definitely was much more common when we're doing psoas releases. I don't know if it's as common now because I don't think you have as much communication between the retroperitoneal space without it. You know, but again, you want to think about the safe zone. You got probably a 15 millimeter difference between the inferior femoral neck and the medial and lateral circumflex vessels. Your safe zone is, again, you want to be either proximal or distal third to stay away from that. That central third is kind of where you want to avoid. That's where the vessels are coming into. Anybody else on the panel have experience with this? It's impressive that this happened just with what is really, you know, a simple procedure. It shouldn't be a short, simple procedure. So it's scary, you know, how much, how quick it can happen. Yeah, so that's why, like, whenever I talk to patients about this now, I'm like, well, how bad is your pain really? Shane, just out of curiosity, I mean, you got lucky because you're in the hospital. Yes, for sure. Again, you showed all these and I'd echo to the audience. These were all, notice all the cases you showed are on total hips. So that for me is the indication and the sole indication for iliopsoas tenotomy. But that being said, say you were, because I've done a number of these in our ASCs. If it's a healthy, older individual, they'll let us do it in the ASC, which I much prefer. So at that point, what would you have done? You know, I was asking my general surgeon about it. He's like, oh, you just do an X lab, like you'll be fine. I'm like, man, I don't know if I feel comfortable doing that. I mean, what's that? Yeah. But yeah, I think, you know, if the patients are totally floundering and that's the cause, I mean, I think you got to try to get the fluid out. I mean, either by aspiration or, you know, make an incision. Do you guys ever do anything like that, Joe? I haven't had to do it yet, but sometimes we do. We'll do the PAO first and do the scope second. And sometimes... Yeah, do you get fluid from that? Yeah, sometimes just a little. Yeah, and get a spinal needle and come down the, sort of on the inner table and aspirate. You can get out. I've pulled out like 100 cc's of fluid before. 100? 100, yeah. This wasn't in a case where, this was just to see kind of what was there. But presumably, if that's the, if you have an open incision there, you can do it that way. But I was kind of told to just be prepared to do a laparotomy. If you just kind of... That's what Dr. Bonner told you? Yeah, he said... Just do the laparotomy. Uncontrolled bleeding, yeah. He's had to do it before for other reasons. But yeah, so it's sort of something in the back of your head that should be prepared for. We had one when we do a lot of combined hip scope PAOs. And when we first started to, our PAO guy wasn't as experienced. So we would let him go first and then we would scope it afterwards. And we had one case, she was like a 16-year-old dancer. And she looked like she was pregnant after the surgery. And so we had to call in and do like a... They did a neck slap and took out like 2,000 out of her belly. So it's pretty scary. So just be careful. If you're ever stupid enough to do that, Joe, or you do the scope second, we started using a pressure sensing Foley in the bladder. And so that gave us an idea about the intra-abdominal pressure. But now we've gone away from that and do it the other way. But it's a pretty scary thing. And it's very dramatic. It's not like a little swelling in their belly. It's a ton. And I had one guy, he had Raynaud syndrome. And so after the case, we were finishing up and my PA was closing. And she called me back into the room. And he had like from here to here, like his whole side from the coldness of the fluid. You can see how far that fluid actually tracks. It's impressive. You know, it's impressive. And this was a standard. It was like an hour hip scope. And so it's pretty impressive with where that fluid goes. So we probably don't notice it as much. We see it more concentrated in some swelling in the thigh. But it goes a lot farther than you think. So just when you're, you know, in your first several years of practice, if you're just getting started, we used to just like we would keep track of traction time, we would keep track of how many bags of fluid we were using and how many came out in the Neptune. So that was just one of the ways that we tried to manage that early on. All right. Yeah, a question. What do you guys consider high pump pressure? You mentioned that. What do you consider? I know it's variable among us all. What do you consider high pump pressure? I think we'll go down the line. I run mine at 40. Sometimes I'll go up to 50 for bleeders on the acetabulum. But routinely, it's always at 40. I do 40 as well. I mean, if I have a bleeder, sometimes I'll put on a lavage temporarily. Same. 35. Sometimes we're running at 30, 25 occasionally. I will tell you, when I first started in practice, I couldn't figure out why everything was red all the time. So I just kept pushing up the pump pressure. In reality, this is the only time when I'm very, very religious about speaking with the anesthesiologist before every case. And they get really annoyed with me because I'm like a broken record. But I tell, if you keep the systolic under 100, you can keep your pump pressures down. Whatever reason, 100 systolic is the threshold. If it goes over, it bleeds. If it comes under, it doesn't. So I tell the anesthesiologist, look, I don't care what you do on my knee cases. Get it 200 over 100. I really don't care. But here, I care. So please keep it down. Obviously, I'm joking. But at the end of the day, this is the only time I ask the anesthesiologist, please keep the pressure systolic under 100. I mean, what I heard, Trav, is that they used to call you heparin hands. So that's why. Maybe that's why. It was all red in there. But I don't know. No question. For the first five years, it was probably right. Have you used, like, trinexamic acid or something just to avoid that bleeding? There are some points in the shoulder that are used. I mean, I have not used it. We use it in our PAOs. But I've not used it in a standard routine hip scope. I want to. But I'm more interested for a post-operative hematoma than adhesion formation. But we just have to get the ambulatory service center that's supportive of that working on it. If you've got the urea problem situation, but just think about where the fluid is. If you have abdominal parvus, parvus syndrome, which is a referred needle. So, you know, let's say you're an ASC with your genitals written around. It's just you can do it like an iliac crest. It's got a superior aspect of the iliac crest. It's just like you're going to harvest and then just go down on the inner cable. I mean, it's not, you don't need to do it. If you're trying to temporize or anything, that's where the fluid is. That's what's written. So you can just go over the inner cable and go into the pelvis a little bit. And you're probably not going to get it all without it. But if you've done a big X-slap, you can certainly temporize for a certain amount of time.

operating room

complications

abdominal compartment syndrome

suture-anchor arthropathy

iliopsoas releases