Okay, so this is a talk I actually gave at the ESCA conference in May, actually two years ago now, but that this is still kind of germane to what's going on in the hip. And I don't think a lot of people have looked at it, at the patterns of damage in different sports. And I think the patterns of damage have probably more to do with the type of pathology that they have in the hip rather than the type of sport necessarily. But certain sports people go towards based on their anatomy. So that if you weren't doing the splits or doing splits by the time you're 10 or 12, you're probably not going far in ballet. And so you're going to do the splits if you have dysplasia or hip laxity, and probably not if you have big FAI. But we'll go ahead and talk about that. So first of all, FAI has increased our awareness of non-arthritic hip problems in individuals. And so we talked about FAI as it's classically described as internal rotation, but the more you flex the hip, the less internal rotation necessary to cause impingement. And certainly if you adduct and internally rotate, you require even less internal rotation to cause impingement. But you can also impinge in straight abduction, depending on where your CAM lesion is, and depending on where your pincer is and how far overcoverage, if it's anterior superior coverage, overcoverage, or straight lateral overcoverage. And that's especially true in the athlete. So as I said, certain sports, you have advantages based on your morphology, right? So basketball players tend to be ectomorphs, and football players tend to be endomorphs. And, you know, you're not going to see guys like Refrigerator Perry here, as an old picture, being a horse jockey like Bill Shoemaker there. And so there's certain body types that allow you to do well in your sport. And the same is, I think, true with football. So, you know, if you're hyper lax, you're going to probably do well in hyper lax activities and sports like gymnastics, synchronized swimming, and alike. So again, size and flexibility of sorts. Certain sports, you have advantages for laxity, such as dance and gymnastics, including rhythmic and gymnastics and regular gymnastics. And again, in synchronized swimming. And so those individuals, if they don't have good hip flexibility, which either is going to be afforded by having less coverage of the femoral head, so by a dysplastic socket, or have generalized ligamentous laxity. So as I was saying, if you can do the splits, you either have congenital laxity from a collagen disorder, like Ehlers-Danlos syndrome, or benign hypermobility syndrome, or you have to have dysplasia, because you can't abduct here, she's abducting beyond 180 degrees in the splits. And, you know, the only way you're going to do that is if you're subluxing your femoral head out of a normal acetabulum, or if you're, or if you just have a very shallow acetabulum. So here you see protrusio, you know, and you're not going to see protrusio in dancers, because you just got so much overcoverage that you're not going to be able to move that femoral, move the femur enough, there's not going to be enough clearance. So this was originally a way to classify sports in high-level athletics for, as it relates to the hip, and this was proposed by Daniel Nawabi, and what had been modified some. And so you can see there's the sports, you have your cutting types of sports, like soccer, basketball, lacrosse, field hockey. They've also added in snowboarding and downhill skiing, your flexibility sports that we kind of already talked about, and martial arts to some degree. You have your contact sports, football, rugby, wrestling, your impingement types of sports, where you're doing a lot of crossing over or hyperflexion and rotation. That's ice hockey, that's a catcher in baseball, that's water polo, equestrian polo crew, and swimming the breaststroke. Also seen several weightlifters and bobsledders, and your CrossFit people fit in this too, your hyperflexion people. Then you have your asymmetric overhead sports, that's what I call the unilateral arm dominant sports, where you're throwing or doing something in one direction each time. You have your baseball players, softball players, tennis players, golfers, volleyball players, and then those that are doing the throwing events or field events in track and field, also fencing, badminton, and the like. And then your endurance sports, which have a different set of issues related to the hip usually, your track athletes, your cross-country runners, other types of running, cycling, swimming, but not the breaststroke, and then cross-country skiing and biathlon. And so in impingement sports, this is some video that we did of water polo players, you can see the egg beater motion in the hip. Sorry, I don't know if that sound is coming from ours. Sorry, that's from our video there, sorry about that. But ice hockey can give you impingement, again, flexion, you've got your goalies that do the butterfly goalie type of activity. Water polo players, we actually found that 97% of our water polo players had the anatomy of impingement. Crew and rowing, you have that hyperflexion, the baseball catcher hyperflexion, bobsledders, breaststroke, and swimming as well. Your cutting sports also include soccer, football, basketball, lacrosse, field hockey, and downhill skiing and snowboarding. And then your asymmetric sports that you may see impingement in, your racket sports, the baseball, volleyball, golf, field hockey, and fencing. And so we know that, you know, we talk about CAMFAIs occurring mostly in males. When it was originally described by Beck, males are around 20 years of age, and isolated pincer in females, closer to 40 years of age. And when you look at the pathology pattern of CAMFAI, initially it's labral sparing, as you see in this video, then the CAM lesion can abut against the edge of the acetabulum, and about the articular cartilage, and the articular cartilage starts to delaminate, and you can get your chondral lesions that tend to be deep, and they tend to occur anterior superior. So in that 12 to 2 o'clock position, or 1 to 2 o'clock position, those chondral lesions tend to go quite deep, up to a centimeter or two from the rim of the acetabulum. The pincer, on the other hand, you get crushing of the labrum, you get a chondral injury that's only about three or four millimeters from the rim, but you also get the so-called chondrocu, where when you start to level on the femoral head junction, the levering leads to contralateral chondral damage as well. But that tends to be a narrow chondral injury pattern. There may be some delamination of this, but it tends to be more global, not just in that 1 to 2 o'clock position, if 3 o'clock is straight anterior. You see micro instability, though, in your laxity types of sports, and that is where you get to wear either straight anterior or straight lateral. But we test it with extension and external rotation. Let's see if this video runs. Sorry, let me see something for a second. And I'm going to come down here for one second, see if, where's that video? Here it is. Oh, it's not showing. All right. I want to show this video for a second, so I'm going to So when you, Codex not working, sorry none of them is working I don't know why but so we'll go back to the video. So if you hyper, if you extend the hip the femoral head comes anteriorly if you externally rotate the femoral head comes out anteriorly and so this micro instability is not you know we talked about dislocations being posterior in sports we see more anterior instability or micro instability and so hyperextension and external rotation lead to that. And what ends up happening though with that with the pattern of damage I'm gonna see if this video runs here that with the excessive motion of the femoral head relative to the acetabulum you're going to get a labral chondral separation and you're going to start to wear down the articular cartilage from the inside going outward so it's going to be a gradual wearing down as opposed to the impingement which is where you get the outside in type of injury pattern where you get that delamination so you don't see the delamination instability. So again initially the instability pattern you get the labrum is spared but you get a labral chondral separation you get a narrow area of chondral injury that tends to be thinning and it tends to occur either straight anteriorly or straight laterally and so here's a patient that had some instability you can see the this is from a posterior lateral portal you see the femoral head you see the acetabulum you can see the labrum is here and you can see this damage at the labral chondral junction and right here where my arrow is it's a so-called psoas u so that's at the three o'clock position on the acetabulum that's straight anterior so that two to three o'clock position is where you're going to see your instability pattern damage that's not where you're going to see your FAI damage and then you'll see this video is not running either I apologize ligament of Terry's tearing it's also frequent frequently seen in the instability patients with traumatic pattern of damage those tend to be more of a posterior subluxation and this is where you see a person where they're trying to stop short with their knee extended in their hip flex so there's Bo Jackson with the left leg while the right one is getting caught there and Serena Williams again this stopping short she's on grass so that's not going to happen but I've seen it on people in hardcourt or even field hockey when they're wearing clips wearing cleats if they grip hard and they're in this position and their hip is their waist has been forward they get a posterior subluxation and so these are the groups that I've tended to see this in football lacrosse again with the cleats and the and the turf and in tennis and so that can cause a posterior subluxation with ligament of Terry's tearing and a posterior labral chondral avulsion like a Bankart lesion none of these videos are running I apologize I would have had more time to know I would have be able to set it set it up but but I apologize I'm not going to be able to show that so sorry let me escape from that go back to here all right so what we did a study with a guy named Kota Shibata from Japan who was a visiting scholar here looking at the patterns of damage and and he broke it down into categories your straight anterior was between 2 and 4 o'clock your straight lateral was 11 to 1 o'clock your posterior laterals were 9 to 11 o'clock and and then from 11 to 3 o'clock here is your anterior to lateral and it's as I said loud the anterior or lateral which you see with the impingement here is listed as 1 to 3 o'clock so using 6 o'clock posterior and what you see let me actually go back to this what you see is that when you look at instability here it's straight anteriorly and then less so straight straight anteriorly is where it's most prevalent you see some anterior anterior lateral and lateral in effect if you look at the lateral ones which is the third arrow from the left or fourth arrow from the left there's hardly anything that's straight lateral other than that there was one CAM patient that had some lateral change as well so it's almost always straight lateral it's almost always instability and you also look again with straight anterior it's almost all instability and then they had anterior and posterior which is the arrow on the far right and again that was instability it was a bit of a smidge of all of the different ones but that's also instability only and so there you can see is your group the yellow is pincer only the CAM is the blue and the purple is combined FAI those are almost always interlateral 70% of the time on the combined FAI is where the damage is on the acetabulum when we looked at our elite athletes this is 96 college pro and Olympic athletes that we looked at and you look at the patterns of damage and the types of impingement or types of damage that they have and and their diagnoses 92% of the male athletes had combined type FAI versus only 45% of the women had combined type of FAI when you look the alpha angle then would be higher in the men than compared to the women the tonus grade was also a bit higher because we know that CAM is really associated with development of early arthritic types of changes and then the lateral center edge angle was about 37 so we'd go along with your combined FAI whereas if you looked on the the women only 26% had isolated pincer and 40% though had instability and again some of that instability might have been a dysplasia related so you look at the center edge angle on average was only 33 and so when you look at the laxity sports with instability they end up having a narrow chondral damage enter or lateral labral chondral separation and they would have femoral head chondromalacia which I didn't really get into but from the subluxations and ligamentaries tearing and the contact sports you can have the posterior labral chondral separation ligamentaries tear and femoral head chondromalacia for subluxation but also impingement and so the cutting and impingement sports which give you the FAI this is from Beck's original article showing if you look at the clock face 12 o'clock being straight lateral 15 o'clock if you will the straight anterior that you see between 12 and 2 o'clock that the number of patients and the depth so this is the number of patients up here but the depth measuring up to 10 millimeters 12 millimeters from the acetabular rim at the one o'clock being the most and then a little bit less at the 12 and 2 o'clock positions so you get these deep chondral damp areas of damage with the labral chondral separation initially that's anterolateral whereas the pincer you tend to see just two to four millimeters of chondral damage again more globally though from a little bit seven o'clock eight o'clock nine ten o'clock and then more lateral and anterolateral and so that's a crushing partial labral injury and shallow chondral injury so that's the short talk on damage there so if the tool will get rid of his back screen then we can have a good discussion on stuff like questions a serious conversation here so I don't know if there's any questions about that or questions on anything I think make make had some make Flynn had some questions to ask right so let's have open discussion on anything it doesn't have to be about doesn't have to be about a hip or FAI or anything so where's the chat function nothing yet huh nothing yet I probably confused everybody. All right. We've got a question. All right. So James Liu, can you talk about the challenges you faced as a junior attending coming out of fellowship? You want to start or you want me to start? Yeah, I can start with that. I'm assuming I'm a little bit closer than you are. You wouldn't know if you do it based on hair. And I interviewed at Pitt for a fellowship with Steve as a fellow, so I know I'm closer than he is. So obviously, I'm at the Cleveland Clinic now. I started my practice out in Tucson at University of Arizona. And my biggest challenge early on was really finding mentorship. We were at a point of transition out in Tucson where one of my partners, Rob Hunter, who's a good friend of mine, was transitioning away from the university and was going back to New Mexico or Colorado, sorry. And then we had Bill Grana, who's one of the most important figures in sports medicine, was also my partner at the time. And Bill was really winding down clinically and certainly had some time for mentorship but did not have a ton of time in terms of where he was at in his career. And so for me, that was the hard part, was trying to find my way as a brand new attending, essentially the sports medicine guy at University of Arizona, and trying to establish and build a sports medicine practice while teaching residents and fellows, trying to do research and cover teams as I was doing. And the biggest challenge was trying to get my foot in the door at the University of Arizona with the athletic teams, which had been taken care of by private practice docs for a long time. But I think at the end of the day, you just want to practice good medicine, take very good care of your patients, and be very responsive to everyone around you. So when athletic trainers send you an athlete, make sure you pick up the phone, give them a call, talk to them about their athletes, involve them with their care. Same thing about primary care physicians and other referral sources who send you patients. Get back to them and see everything initially before you start whittling down your practice. When I came out, I did everything. I did hip, shoulder, elbow, knee, foot, and ankle. And slowly, once I came back to the Cleveland Clinic, I began to get rid of some things that I just wasn't doing as often. And so that was the way that I really kind of built things, eventually got involved with the University of Arizona teams. Again, just by being there, being available, and working hard. And obviously, continuing to be involved. I'm a big proponent of AOSSM, as is Steve and as is Mark. And that's where I've now found a lot of my mentors. And obviously, being back here at the Cleveland Clinic, I have plenty of mentors here at home. But that's also a way to stay connected and continue to establish yourself. My thing would say, if you're going to be a junior attending, and if you're talking about being an attending at an academic type of institution, the real challenge, I think, is that what you learn in your fellowship, you're going to learn multiple ways to do multiple things. And you need to find your own way of how to operate and how you want to do something. You might learn six different ways to do an ACL. And you're going to have to try a bunch of ways to do the ACL until you figure out what works best in your hands. So one of the things, when you come out as a young attending, especially if you have a fellow, the fellow wants to operate. And the young attending needs to still figure out how to do it themselves. So what I would encourage is, what we've done here, when I've hired somebody young, is not start them with a fellow, but have them start with the residents and all, and let them do smaller pieces until they are comfortable doing their own, finding their own way. And then after a couple of years, then working with the fellows so that they don't feel the pressure of giving up the case and not knowing what to do or how they want to do it themselves. So that was kind of, I think, one of the bigger challenges when you're first starting out, especially coming straight from fellowship. Would you agree with that, Latul? Was that a challenge for you? Yeah, absolutely. And you definitely have to hone your craft. You have to establish a name and establish a reputation. And so you got to spend some time actually doing the surgeries. And again, I think that's great advice. Yeah. So that would be, as you come out of fellowship, don't sit there and say, I have to have a fellow because I feel like that's a level of prestige or love. I mean, in all reality, I think not having the pressure of having a fellow there so that you know the way you like to do it best and figure out what works best in your hands. Because it all may seem easy now because you got it all set up the way you want or the indication set up the way you want. But once you're on your own, all of a sudden, sometimes things don't, you know, it's not quite the same because you don't know that Dr. Cohen's going to be coming in and bailing you out or that you got to figure out the way you want to do it best as opposed to, you know, as opposed to the way you have to do it. You know, as we were talking about with Dugas the other day, right? He said, you know, you're going to do it the way Dugas wants you to do it. When you get out and practice, you can figure out the way you want to do it on your own. So, Steve, we're just talking about what's the biggest challenge when you first get out into practice or get out and come out of your fellowship as a junior attending, what, you know, what was your biggest challenge that you faced for that? Yeah, I think my fellows have probably heard me say this. When nobody, and you mentioned it, Mark, when nobody's over your shoulder anymore and you look over your shoulder and they're looking at you, I think that's the biggest thing. I think having the confidence to know that you were trained appropriately. I think one of the more challenging things is when, you know, in your first year and a patient says to you, how many of these have you done, right? I mean, that's a really difficult question to answer. When you're in your first year and maybe it's your first month, right? So, I think, and I don't know what your guys' thoughts on this, but, you know, obviously you always want to be truthful. And I would say to them, you know, if you're in your first year of practice, well, I've done, you know, a handful of these on my own, but I've done hundreds of these in training. So, I'm comfortable with it or, you know, I know, I'm, you know, I think you'll be in a good position. Good deal. What are your thoughts about how to answer that question? Oh, well, I was looking for a quote. Jimmy Andrews actually had a great quote for that. Let me, I'll tell you, Latul, you answer and I'll pull you up this quote because this was so good I wrote it down. Yeah, I think, you know, I didn't get a whole lot of those questions early on, you know, like for like my first ACL because, you know, that didn't come along. But I think the way Steve sort of tackled that in terms of your training and, you know, that I've been practicing orthopedics or not, or been doing orthopedics for the last, you know, five years as a fellow and that I'm, you know, highly trained, you know, by some of the masters in the field to do this procedure. But ultimately, yeah, you know, I think it's hard, the very, if your first ACL walks through the door and you say, I've not done any of these before, I'm not sure that patient's going to stick around. And, you know, I don't know how to answer that other than, you know, sort of what Steve, you know, sort of mentions. I just was fortunate that my first few cases, no one really asked until, you know, I was sort of at this for, you know, six months, a year, where I could actually say that, you know, how many I've done. But it's crazy how that changes. Like people ask me that now, and I say, you know, I've done too many to count. I stopped taking count a long time ago. And so. Well, that was close. But Jimmy Andrews' comment actually was, oops, his comment actually was too many to count and not enough to stop. But, yeah, I mean, you want to be truthful with your patients. But, you know, the reality is that's why you do a fellowship. So you can sit there and say, look, I took an extra year of subspecialty training just, you know, on this procedure and feel very comfortable doing it. You know, and that's, you know, I mean, you want to be honest with your patients. So there's some patients that will sit there and go, you know, that's totally fine. Some want the guy that, you know, did, you know, 1,000 or 10,000. So, you know. And I guess the other thing to kind of go back to Meg's question about, you know, you know, going into your real jobs. I mean, a couple things. Number one, when somebody asks for a second opinion, encourage them. Just, you know, say, hey, look, I have no problem with that. If you, you know, in the back of your mind, you may say, gosh, you know, I'm well trained. I can do this. And I, you know, why do they need to see somebody else? Eventually, you get beyond that. And Pat McMahon, who was in University of Pittsburgh when I was there, always said, you know, the majority of people who, if you encourage them to see another opinion will actually come back to you. So, I think, you know, if somebody asks for another opinion, don't, you know, kind of your natural inclination would be to, you know, kind of be a little salty or just to be a little bit, you know, unnerved by it. You know, I think that's okay. You know, as you get into the higher level sports world, it's, you know, if they don't get a second opinion, you're surprised. And I think staying organized when you first go into practice with your record keeping, you know, being prepared for, you know, the boards, your board collection, those are all things that are really important when you first get into the job. Yeah, I mean, I would agree about the second opinion thing. I mean, I know some very well-known, very high-profile surgeons that athletes, you know, from their college say, I'm going to go get another opinion. And they get offended by it. And, you know what, that's one way to look really bad. The reality is people are going to get other opinions. I encourage it. I always say, you know what, another set of, it can never hurt to have another set of eyes. And, you know, and basically just be upfront and honest. And a lot of them will come back because they didn't hear the same thing. Sometimes I'll see people and, you know, especially about things like the hip where it's a newer evolving area. And I'll say, you know, I'm the third opinion. Unfortunately, you know, they went to two different docs. They got two different opinions. And they come to me and I say, well, you may get a third opinion. And it may not be in line with either of the other two. So, you know, the things I, the comments I would say about the piece of advice, I've got more than one piece of advice, which maybe you don't want. But I think, you know, here's Steve and Latul's comments on it. And actually, I think Will Workman's on here, too. I thought I saw him on there. So, I don't know, Latul, if you can unmute him. But the advice I'd give is, first of all, the three A's still apply, right? Be available, you know, just be available. And that's far and away the way you're going to build your practice, the fastest and easiest. That they know you're going to take the patient and help take care of the patient as best you can. Ability, you know, it's, ability is the last thing, right? It's being available, it's being nice. And ability seems to be the lowest on that list, but still an important factor. And what I see, I've seen some really bad surgeries by some people that, and the patients don't sue because, you know, the doctor was very, very affable. But you want to be open and honest with your patients. You want to be, you want to follow with the three A's, availability and affability are the first two. And then the other thing is, you know, don't talk bad about anybody in your community. You know, I mean, that's not a good thing. Don't be throwing stones because odds are you weren't there and you had no idea what the situation's all about. So, you know, I would be very, very careful about not, I'd be very careful about what you say. So, you know, if a patient says, well, did this doctor do something wrong, say, you know, I wasn't there, I don't know, I can only tell you at this point this is what I think may need to happen or need to do, or if you say, you know, that's not the way I do it, but, you know, everybody has different techniques. But that would be my bits of information. I don't know, Latul and Steve? Yeah, yeah, so two points. The first, you know, on second opinions, you know, I agree with what was said. And also, you know, I try not to abandon the patient and I actually try to give them names of people who I think will give them a good second opinion. And maybe not even people who are in line with my thinking, but people that I think that I respect locally. So I have people at, you know, university hospitals and people at Metro Health or other major system and one other person in private practice that I will offer up as a second opinion and, you know, in surprise, a lot of those patients do come back and I think they appreciate not being abandoned or me not being offended by them going out to see a second opinion. You know, and I agree, you know, never, never abandon your patients. You know, certainly, you know, you have complications, you know, manage those patients, understand that. Again, be open and honest about, you know, sort of what went down. You know, go out of your way to, you know, answer any questions. Never, ever, ever get angry at a patient for a complication, whether it was their fault or yours. You know, it's not the place or time, just work on getting it better and getting them the help that they need. Yeah, I think a comment I would just add about, you know, when they ask you about another physician. I think that is absolutely, if you, I think if you don't remember anything, don't ever badmouth another physician, even if you don't necessarily agree with what they did. And you could just say, hey, look, that's how they treated you. We can't do anything about that right now, but we can only move forward. And, you know, because, you know, ultimately, they weren't, you weren't, you weren't there when it happened. You know, the worst case is when, you know, you see somebody, they get a second opinion, they see that other doctor, they have surgery, they have a complication, and then they come back to you. Right? I mean, your natural thing would be like, well, you know, I wasn't good enough the first time around, but it's just not worth it. You just say, time to move forward, and whatever you can do to try to help them get along. Hey, Will, you there? Hello. Yeah. Got any comments, advice? I, and this is, this is a topic I probably could talk on as opposed to hip instability. But I, yeah, I think everything you all said is, I don't have anything to say different about that, just by point of reference. I've been in practice now, it'll be 20 years this year, and I still feel like I'm getting my skills to the point where I'd be ready to, you know, turn things over to a fellow. It's, it, and I didn't, I didn't go into academics for several reasons. But one, I really wanted to get out and do things on my own and not be slowed down. And kind of get comfortable with what I'm doing. And, you know, 20 years later, I'm still doing that. You know, I would say that what I try to remember when I'm seeing a second opinion or somebody has things to say about a surgeon or another doctor they've seen, I try to imagine that that surgeon's in the room with us when I'm making my comments. So that, because there's sometimes where you just, I mean, there's clearly something that's gone wrong. And you, you can't just say things look great. But, you know, you say, well, I may have done things differently, or this and that. But if, I try to remember if the other surgeon's in the room. And it just, it doesn't do anybody any good, as you guys have said, to, you know, to just disparage another doctor. And, yeah, second opinions happen all the time. Like the tool said, I mean, if you can offer them somebody that you think is good for a second opinion, I think that's helpful. I was thinking when you were talking about, you know, getting out of training and doing stuff on your own, I can still remember. I don't know if it was my first case. But it was a, it was just a I am rotting of a tibia, which, you know, you're doing tons of them in training. And all of a sudden, I'm in the OR in the middle of the night with nobody over my shoulder. And it was pretty dang scary. And, you know, from that till 20 years later, where, you know, I do all kinds of stuff. It's just, it's an evolution. There's all kinds of things that happen. I don't, there's, you know, there's practice management issues. There's all kinds of stuff that you have to work through. I don't know, just be patient. You got to work hard. I think the three A's still apply. I do like to think that ability matters, Mark. But I agree. I mean, and one thing that I've heard Andrew say, which I really like, is, you know, you hold on to your patients tight, and you hold on to your complications tighter. And I think he's a master of that. You know, you don't, if the patient has a problem, and he tells stories now about some pretty bad problems he's had. And you don't abandon the patient when those things, you got to take care of them. And tell the best you can all the way through. Yeah. And that is my most humbling experience, where a patient has had a complication. And, you know, I was the reason for that complication. And they come back, and they have full confidence in me doing their next surgery, or managing the complication. And to this day, that still shakes me a little bit. But I think that's how you build relationships in the beginning, by taking care of your patients. And, you know, they have that confidence. And, you know, and I never take that lightly, for sure. And actually. The only thing I would add is about, we were talking about, you know, not having done many. I mean, that doesn't necessarily change throughout your career, because new procedures come about, and things like that. And I, you know, it's funny, you still get asked, you know, how many ACLs have you done? Like, you know, it's like, well, why are you here if you don't think I've done any or something? You know, you have to. But I mean, you know, new procedures come about, and you may not have done many. And, you know, I remember hearing patients come in, and other doctors said, well, you don't really want a doctor doing one on you, unless they've done 60. I'm like, well, I wonder if that doctor told their first 60 patients that that was the case, right? So, I mean, you just, you try to, you're definitely honest, as the, you know, I've only done this many, you know, and I agree with right out of fellowship, you know, you've definitely had a lot of exposure to it. And it doesn't, the question doesn't always come up. But you're better off, I think you feel more comfortable with yourself, if you tell them, you know, you're more straightforward about your experience with it. If they move on, fine, there's going to be other ones. And, you know, you're going to be in the career for a long time. The other thing I would actually, you know, you guys probably do medical legal as well. It seems to me, when I've done some medical legal stuff, where the patients really sue and are pissed is when the doctor lies or tries to cover up the complication. If you got a complication, own up to it, be honest with the patient about it. And again, you, you know, it's much less likely that I think you'll get sued in that scenario. I mean, I know a lot of hospitals sit there and say, don't admit to fault. And, you know, but patients want, if they, you know, some patients wouldn't sue. They even say, I wouldn't have sued if they would have just said, I'm sorry. Right. But, but a lot of the, you know, legal advice is don't admit, you know, just go straight to your legal department. And I'm not so sure that that's the right thing to do. When you talk to the patients and when you're doing this medical legal reviews, a lot of times it's the patient, you got to be honest with the patient, you know. Yes, there's a complication, you know, we're going to do everything we can. As you said, don't abandon that patient. So that's where they get pissed. And don't be afraid to say you don't know about some difficult things. And there's, you know, and I've become more and more comfortable with that. You know, obviously I have a big patella femoral pain practice. And, you know, all the time I have patients come in and I'm not entirely sure what their pain generator is inside the knee when I first see them. And they ask me, what do you think is going on? And I have a lot of patients that I just look at and say, I have no idea what's going on with their knee, but I'm going to try my best to, you know, figure it out. And I think they can appreciate that. I always say, I don't know where your pain's coming from. You should go see Latul Farrow. Yeah. And, you know, and I think early in my career, I think I was very afraid to say I don't know because, you know, obviously we're the experts and really we should know. But the reality is we can't know everything. And it's about getting that information or getting them into the right hands of people who can figure out what's going on. I agree with that. I used to like to say, I don't know, to try to get rid of patients, but that's not the case. No, what you just learned, what you need to say is you need to go see Latul Farrow. Yes. Cleveland Clinic. This is his address. I'm all over that. So here we go. There are a couple of hip questions here. Can you comment on the management approach to the patient with borderline dysplasia, a large labor and a large CAM? Yeah. So the key with this, and you see this a lot with borderline dysplasia with hypertrophic labrum and a CAM lesion. And what a lot of people do is they look at the CAM lesion. They don't realize that the person has borderline dysplasia. They do their FAI surgery. They oftentimes join the two anterior portals. They cut the iliofemoral ligament. And then those patients are worse because they're now unstable. And they might have had some instability to begin with. So the key is you want to make sure you measure your anterior and lateral center edge angles. Make sure that they don't have dysplasia. If they do, you know, I'm a big believer in not cutting the iliofemoral ligament. But if you're going to cut the iliofemoral ligament, then you need to repair it. And I think you also need to be very careful to try to repair and save the labrum. Because if you do a labrectomy in those patients, you will make them more unstable. And that's the only group of people that I do a labral reconstruction as a primary procedure on. If I have an irreparable tear and a borderline dysplastic, that the labrum needs to be fixed. So, and then Ian, what was the, I measured the chondral damage. I used a etched probe. And that tells me, that tells me what the depth is of the cartilage. I measured that on everybody. Because anybody that has more than seven millimeters of exposed bone from the acetabular rim, I'll do a microfracture on. M. Pelton, two questions for Dr. Saffron. How often are you doing procedures of the deep gluteal space and for atrial femoral impingement? And how do you roughly work them up indications? So, rule number one, I've always taught. I don't know if the tool or Steve has done this. But when I was trying to get our surgery schedulers or clinic schedulers to help sort through what was people that I could help and people I couldn't help. I used to say, groin is good and butt is bad. If they have butt pain, I don't want to see them. And in all reality, you know, because you're trying to do oftentimes, you know, nerve pain is a very distinct pain. And those are the people that are coming on narcotics more often. And it is a pain that you need to really respect. But I don't do deep gluteal space surgery. I send that to somebody else so that I don't have those, that kind of patients in my practice, to be honest with you. I don't, you know, so I don't do the deep gluteal work. I see a lot of people with piriformis syndrome. And 95, 98% I'm able to get better with injections and rehab. And I send them out for piriformis surgery. For atrial femoral impingement, you see it a lot on MRI. And a lot, a lot of times is the pain actually coming from there. And though I was literally two, three weeks after the original paper on ischiofemoral impingement came out, I had a patient with it. I sent an email to my, to the Mahoran group. One other person in the Mahoran group had heard of it and actually had a patient right then as well. We were trying to figure out how to treat the patients. And we did a CT guided injection in the ischiofemoral space to make, confirm to relieve their pain. And when it did, basically the thought was how to address it. And the other surgeon thought he would take down the quadratus femoris and debris the quadratus femoris. I was a little bit worried about the circumflex femoral artery. I'm causing AVN because the patient I had was a collegiate athlete. So, but my patient was having trouble just walking around campus. So I ended up doing a lesser trochanteric excision arthroscopically. And so we were the first ones to do that procedure. And I told her she would probably always be weak. In all reality, after about six months, she had almost all full strength back. By two years, and it did take a while for her to get back to what she wanted. Her goal was to be able to jog three miles a day, which she did end up doing after two years, which was for her a big change because she couldn't walk across campus. But, and so what I found, though, since that surgery is that the majority of people between a CT guided injection with some corticosteroids and working on the stretching and strengthening their hip external rotators, the vast majority of those that have symptoms from it don't need surgery. So there are some people with large series out there, but I found that I've probably taken care, 90 plus, again, 90, 95% of the patients that I see with tissue femoral impingement end up getting treated non-operatively. And then, do I think there will be an expanding role or adoption of endoscopic proximal hamstring repairs in the future? And the answer to that is probably. I mean, it's actually a pretty easy operation to do as long as you get over the fear that you're putting in the scope near the sciatic nerve. But once you get past that, it's actually a pretty easy operation to do. I went down and actually saw Carlos do one on one of my patients. And, you know, he did, he was doing partial repairs initially, and now he's doing complete tears because they're retracting, you know, just, you know, four, six centimeters, and he's able to put some anchors in and get primary repairs. And, you know, it's, you can see better, and you can, and you don't necessarily have as much of that sit pain and scarring there. And obviously, keeping those portals clean and dry seemed to be much easier. But I don't know, Steve, you're an open hamstring guy. Do you, do you think there's a role for endoscopic hamstring? And I know the tool stopped doing hip arthroscopy around that time. But I don't know if Will, Will's willing to try anything. So, let's see if Will's done endoscopic, almost anything. Okay. Steve, what's your thought? Yeah, I mean, I just don't have any experience doing them endoscopically, you know, putting the volume of anchors in. I'm sure it's possible and very doable. And I could probably see the transition to doing the partial repairs maybe initially first. Because, you know, I think your risk is much less. And, you know, Bob, who's our fellow, we've done two in the last two weeks, partial, you know, they're fairly straightforward open. You just go in, you debride it, and you clean up the tendon and the bone, and you re-anchor it. But, you know, I guess I'd have to see the ease of it. I haven't, I don't have the experience to make that comment. And I'm opposite to you, Mark. I get more butt pain than I groin pain. So, it's definitely different. Yeah, I think, I don't see that many hamstring evulsions. For me, it's kind of like carpal tunnel. Like, I do a carpal tunnel occasionally. I think an open carpal tunnel is pretty easy to do. I don't see a reason to go to endoscopic carpal tunnel. Kind of same thing with the hamstring repair. And it kind of goes along with the posterior hip. I mean, I've learned a lot from Hal Martin. I do, you know, I study it. I read it. I think it's important to understand it. It kind of goes to the question that Bob has on there about transitioning to team positions. I think it's really important as a team physician that you try to learn about as much as you can all the different diagnoses so you can properly dispo patients, get them to the right people. But I send my, you know, butt pain that I think is going to be, that's confusing or hard to Hal Martin, but I read his stuff. And I don't, as much as I do like to try things, Mark, I agree, I think for something like that, I just don't ever see the, nor do I want the volume of posterior hip pain to kind of transition to doing an endoscopic hamstring. I think that the open ones work well, and the scar's fairly cosmetic. There can be issues with, you know, sit pain and nerve pain back there, but I don't know. I don't know if I'm quite that crazy yet. We'll see. Yeah, I mean, I look at it, and I, when I saw him do it, and it's, you know, I've seen Hal do the deep gluteal space, but that's just not a part of my practice I want to develop. But, you know, before we get to Bob Jacks, I'll just, Josh Everhart, if an athlete has a traumatic hip dislocation, do these usually need surgery to return to high-level sport? Do you recommend acute or delayed arthroscopy? And so, a couple of things that, that's a really good point, Josh, and actually, we just wrote up kind of a review on this that we're submitting. The reality is, if the hip concentrically reduces, I don't think you need to go in there and fix the labral injury, that usually goes along with it. But if there's a loose body, I think you need to go in and remove the loose bodies. And there's some studies that have shown that even if the CT or MR doesn't show loose bodies, if you have a traumatic hip dislocation, you'll go in there and find loose chondral, chondral loose bodies in there. But again, if it doesn't affect reduction, I don't generally just go after that. People worry about do you cause AVN, and the couple series that have been out there that have scoped acute dislocations have not had any cases of AVN, so I don't know that that's, that that's a huge concern. So, if you have a non-reduced, non-completely reduced hip dislocation, then you got to go in, you got to do it acutely. If they're still having some pain later, you can always do the delayed. But, you know, what you want to do is make sure you get MRIs acutely, you know, before you do the surgery, and then you want to be able to follow just to make sure that if they do develop some AVN as part of the natural history of a traumatic hip dislocation in and of itself. But I don't know that you have to go in and repair the labrum. A couple of those poster hip subluxations I had done were people that actually were having still, still were having symptoms, and so they were delayed from their subluxation. In fact, neither time was it actually recognized that it was a subluxation of the first two that I did. And when we scoped their hip, actually several times, it's actually was missed as a hip subluxation. And you'll see the ligamentaries tear, you'll see the chondral damage on the central femoral head, and you'll see the Bankart lesion. And so if I'm in there because they have persistent symptoms, I don't know if it's the Bankart lesion or if the ligamentaries tear or the chondral. So I try and repair it all, remove any chondraloose bodies, and I do repair the posterior lateral labral tear. So, and then, so Bob Jack, our final question, what advice do you have as we move into, oh, no, there's another one. What advice do you have as we move into our roles as team physicians? I think the role as a team physician is you got, it's a team job, right? And it depends on what, where you are. If you're a high school doc, you may be the only doc, but you got to work with your trainer, and it's about communication and support for your trainer. And you got to work as a team. If it's at the college level, you know, or the pro level, you've got several docs, you got several trainers, you got therapists. It's all about communication and doing the right thing. Above and beyond all is that you want to do the right thing for the player. But, and you got to have documentation. You want to make sure that what you do is that you document. There's a lot of components to it, which is why you do sports fellowship and you help cover teams. You know, can you reduce a shoulder dislocation on the sideline? Yeah, I think that's not a problem. You got to discuss it with the patient ahead of time. You got to make sure they have follow-up so that you get imaging post reduction. But I think, you know, those types of things and learning about dealing with your trainers and working in a team environment is critical. And again, you got to feel comfortable also asking for help. But I'll go to Steve, what are your thoughts there? Yeah, I've got to run to another meeting, an MLB meeting real quick. But the one thing I will say is be available. Jim Andrews is, you know, he's obviously the epitome of a team position. And his answer is always be available. Whether it's at 9 o'clock at night or 9 o'clock in the morning, be available to answer questions to parents, agents, coaches, players, you name it, be available. Learn from the docs that you're working with. Bob's our fellow, so I know he's going to, you know, you'll have two, three docs ahead of you like Mark said. Listen, learn, soak it all in and, you know, work your way up. But don't have the motivation to work your way up. Just all those things will happen as you become available and you learn and you provide good care. So, Mark, thank you again for this. It's been great. And what a great experience for the fellows this has been. Thanks, Steve. Again, I appreciate you and the tool and everybody being on and helping out. And Will, you know, also coming in and helping out. Appreciate it. Everybody willing to help educate. Latul, have you got any words of advice to roll as team physician? Yeah, you know, I guess more of what's already been said. Yeah, I stepped into a very interesting environment out at University of Arizona. And, you know, University of Arizona is primarily taken care of by private practice docs in town. And so, you couldn't come in as the quote unquote academic guy like a bull in the china shop thinking that was your right to cover the athletic teams. That's not how I went about it. You know, I asked to be involved, understanding that it was a privilege to be involved taking care of athletes. And basically, I just kind of worked my way in. Again, being responsive, having a phenomenal relationship with the other team docs and one who ended up being a big mentor of mine even though he was not part of our academic group, and it worked out well. And it's, you know, you win more flies with honey than you do with vinegar. And I think, you know, practicing medicine, being humble is going to be important. And I have the mindset that being a team doctor means being in the training room, on the sidelines, and on the field. It's not something that I think can be, you know, done well from your office, basically. And, you know, our junior college that we took care of out there had never really had a presence of the team doc on campus. And when I showed up, I said, well, we're going to do this differently. You know, as I said, I need a space in the training room where I can see athletes on campus. And it was a great way to build a practice, whether it's your high school, your college, because, you know, people see you on campus, they become very comfortable with you. And before you know it, the athletic director's coming in, like, well, who's that? Well, can doc see me for my knee pain? And you have professors who come in, and they see you. And that's how you build your name in a community. And I think, you know, that's what really worked out for me in Tucson. And that aspect of I miss it, I miss sort of the Pac-12. We had a great time when I was out there. But, you know, it's, and that's my piece of advice. Again, you know, just being available, because what you're not willing to do, trust me, there is someone else out there willing to do. And before teams decide to change contracts and things like that, you really want to make them think twice about if we leave this practice or if we leave this doctor, is it really going to be greener on the other side of the fence? And so you really want to make their lives as good as possible so you don't lose those relationships. That's really the fun part of my job is taking care of athletes. Will? Yeah, I don't think I have much to add. I really like the comments you guys made. Latul, I agree. You know, I've had the fortune of taking care of, I guess, all levels, high school, college, and professional. And I, my longest running tenure is with my local high school that I've been on the sidelines now for 18 years. And, you know, that's probably the last one I'll give up as long as they'll have me out there. And, you know, just as a team doc, being available, it's not about, you know, finding the injuries that you can operate on. It's about taking care of the athletes. And there's plenty of stuff that we can't take care of, or I can't. And, but knowing about how to dispo them properly, get them to the right care, I think is a really valuable thing that's overlooked. Because people don't know. We're the ones that know. And, you know, you build trust by the, over time, them realizing that all you're there to do is to take care of them, and there's not an ego in the way. Yeah, I would, I think one of the other things is, you know, about being a good team physician, which hopefully you will have learned during your fellowship, is actually communication with the athlete. And communication, I think you want to come and communicate with your trainer and have your plan of attack, you know, it confuses athletes if you give them multiple different messages. And so making sure everybody's on the same page, that you've discussed it with your team, what you want to do, you know, or what the plan is going to be, and that the athlete gets a consistent message. Because that's, you're just like your patients in clinic. If you give them multiple different messages, they're going to say, you guys don't know what's going on, and they're going to go somewhere else. I think you want to make sure that they have a, you know, a message. And listen to your team, and make sure that you guys come up with the best plan. They'll oftentimes look to you as the captain of the team, but, you know, listen to the team. Again, realize a lot of times you're going to come out of training, and the trainer that you're working with, more often than not, is going to have a whole lot more years of experience in being on the sideline than you are. And so, listen attentively, and, you know, share knowledge. You'll, trust me, early on particularly, you're going to learn a whole lot more from the trainers, and they're going to learn from you. So, I would probably state that as well. I see some heads shaking there agreeing with that. You, Latul and Will, you guys agree with that? Yeah, I was thinking, I think Latul was an athlete too, and a lot of the fellows were former athletes, and Mark was an athlete. I remember back, I mean, the trainer was basically the doctor, and I think the, you know, the, and they're also the ones that spend the majority of the time with the athletes, and have really, and I think the one that spends the most time with the athletes is the one that they trust the most, and I really try to be there. If the communication that you're talking about, Mark, is happening, I try to have the trainer there with me, or if not, then I go through the trainer with the athlete, to the athlete, so that there's not too many people telling them that, but absolutely, I mean, at all levels that I've worked at, the learning from the trainers and relying on them, because of that, I mean, they've dedicated their lives to being with the athletes all the time, and we show up for games, and maybe the training room won't come out, but they're there with them all the time. It's one of the most special relationships, I think, working relationships there is, the team doc and the athletic trainer, and it's one of the things I enjoy most, and I'm still friends with every single athletic trainer, from my second year at orthopedic residency, being on the sideline, deep relationships, I'm still friends with them to this day. Yeah, and you have some special relationships, especially when you travel with a team or whatever, it's actually, you know, it's a great camaraderie, and it makes all the difference in the world, so. So, there's one last question from Ron Otsman, how do you treat ligamentaries during hip arthroscopy for instability? I debride it, I don't think, I haven't seen a need yet to do a reconstruction, so I just debride the tear, but with that, it's 4.10, this is the last of the lectures of the Misfits Lecture, as described by Mark Miller, the Multi-Institutional Sports Medicine Fellows Conference for the COVID pandemic. It may make a reappearance if there's another surge. If there's a surge, keep your eye out for another series of lectures, but otherwise, I hope all the fellows have found this useful and worthwhile. I know Steve Pavlett, one of our physical therapists, the head of our physical therapy here, stated his appreciation on behalf of the therapist, and I know I've heard from others at Stanford here, the athletic trainers and PTs, that they've enjoyed this. So, hopefully everybody's enjoyed this, found this to be useful and enjoyable, and I want to thank you all for sticking it out to the bitter end, and Latul, I thank everything about you except for that background, and on that, I'm going to sign off. Yeah, well, thank you, Mark, for everything. This was a monstrous undertaking to get together, and it was just not something that was, you know, quote, unquote, thrown together. This was a high-level endeavor, and I appreciate that. I appreciate the opportunity to be involved, and thank you, Mark, for the great educator and mentor that you are. And so, I appreciate, we all appreciate you. Thanks a lot. Great work, guys. Thanks so much. Thanks, guys. You all take care. Be safe.

sports injuries

hip damage

pathology

anatomical features

femoroacetabular impingement

non-arthritic hip problems

damage patterns

labrum preservation

endoscopic hip procedures

team physician