Welcome to the Athletes' Hip, New Trends, Controversies, and Contemporary Surgical Management webinar series. Before we get started, we'd like to review a few items. First, if you need to adjust your audio, please refer to the Audio tab in User Devices Audio Settings. To submit questions throughout the evening, please click the Questions tab, type in your question, and click Send or hit Enter. Next, a special thanks to our course chairs, Drs. Gwasi, Kluskone, and Ngo for their work on this online educational opportunity. And lastly, here are AOSSM's upcoming meetings, which include the AOSSM AAOS Orthopedic Sports Medicine Review Course, Baseball 2020, Youth to the Big Leagues, Managing the Developing Player, and the Advanced Team Physicians Course. With that, we'll get started with this evening's program. Thank you all so much for joining us. Good evening, and thank you. Welcome to the AOSSM's first CME webinar series on the Athletes' Hip. Remember that there are four parts to this entire CME series. The discussion will be on the Athletes' Hips, New Trends, Controversies, and Contemporary Surgical Management. First up tonight will be Jorge Chala from Vincit. Thank you to the American Academy of Orthopedic Surgeons for the opportunity to present today. My name is Jorge Chala, and I'm an Assistant Professor of Orthopedic Surgery at Rush University Medical Center and an attending physician at Midwest Orthopedics at Rush. I was tasked to talk about hip anatomy, what do we need to know. And there are several challenges when we're talking about hip anatomy because we know the hip joint has several layers. The 3D anatomy is quite complex. The symptoms can be equivocal because we have so many layers between the skin and the joint that the symptoms can arise from any of those layers. And we can also find a lot of incidental findings in imaging when we are trying to study these patients. And one of the main challenges that we find in the hip, specifically, is that we have dynamic problems that have to do with lumbar spine problems, the pelvic tilt, and extra articular impingements. And the first thing we need to understand when we're treating patients with hip problems is the anatomy of the neurovascular bundle to avoid heterogenic injury. We know that the location of the neurovascular bundle are located in the junction between the inner 2 3rds and the lateral 2 3rds between the pubis and the ASIS. The most commonly involved nerve, at least for hip arthroscopy that gets injured, it's a sensitive nerve that arises from the ASIS all the way down to 2 1⁄2 centimeters. It has a wide variability, and it's called the lateral femoral cutaneous nerve. And it's important to understand its location to try to avoid heterogenic injury. But as it is highly variable, sometimes its location can change depending on the anatomy of the patient. For the purpose of this talk, and for didactics, we're going to divide this into a central compartment anatomy, peripheral compartment, and greater trochanteric space. The key steps will be outlined as follows, capsulotomy, central compartment treatment, and peripheral compartment, which is the way in which we do hip arthroscopy to be able to better understand which are the key anatomic structures that need to be addressed during this procedure. And the first step we need to understand is how to gain access to the hip joint. And for that, we need to make a capsulotomy where we are going to be disrupting some of the ligaments of the capsule. And this is probably the most important ligament, which is the ligament of Y of Bigelow, which is most commonly the one that is disrupted during a capsulotomy, the pubiofemoral ligament, which is located distally, and then the ischiofemoral ligament, which is posterior. There are multiple options for a capsulotomy. Interportal capsulotomy has been the gold standard for many years. And a T-capsulotomy was introduced to try to be able to visualize the cam deformity in an improved fashion all the way down laterally. There are other techniques, such as outsiding techniques, that can be done to perform the capsulotomy. And this is how it looks like when we're doing a capsulotomy during hip arthroscopy. This is a view from the mid-anterior portal and counting the capsule one centimeter distal to the labrum to be able to preserve a leaf of capsule that can be repaired at the conclusion of the procedure. And when we do a T-capsulotomy, we try to be in line with the fibers of the ligament of Y of Bigelow because we want to try to avoid having heterogenic damage of the fibers of the capsule. The intent nowadays is to try to disrupt as less fibers as possible when doing the interportal capsulotomy. So therefore, this means that we are trying to do a very small interportal capsulotomy. And then as long as we're going parallel to the fibers of the ligament of Bigelow, then we're going to have a lesser or a minor disruption to the biomechanics of that capsule or tissue. In the central compartment, there are four structures that need to be taken into consideration when we're treating patients with hip disorders. One is the labrum, the cartilage, the subspinal space or pincer, and the ligamentum teres. In this video, you can see the importance of the labrum and how the suction seal can affect the biomechanics of the hip. You can see a normal labrum and the suction seal, even without any other soft tissue structures, is pretty significant. When you have a segmental defect, you can see how there's no suction seal, and when this has been reconstructed, the suction seal has been restored. So it's critical to try to recapitulate the anatomy and the biomechanics of that labrum. You can see when, for example, there's a cyst in the labrum, how you can see this during hip arthroscopy. And it's important to address the whole pathology of the labrum during the index procedure. In regards to the cartilage, one of the main things that we see, which is different from other joints, is that sometimes there might be a detachment of that cartilage from the bone. We call that a chondrolabral junction dysfunction, and this is the functional unit of the hip, and it's important to restore this with the use of anchors and sutures in the event that they are distorted. This will change depending on the pathology that we're treating. For CAMFAI, 90% of the damage of the cartilage is going to be on the superior portion of the hip. For a pincer FAI, it's more mixed, where the posterior and superior portions will be the most commonly damaged. And for dysplasia, again, the superior portion will be the most commonly damaged because of the loads that that surface is going to see due to the fact that hip has undercoverage. The subspinal space is critical. We try to minimize the damage to the capsule here again and try to maintain as much capsule as we can superiorly to our resection of the rim to try to avoid capsular deficiency at the end of the conclusion of the procedure. And for this, we try to only make a capsulotomy or only try to work within 5 or 5.5 millimeters to try to avoid breaching the superior portion of that capsule. In the event that there is a significant subspinal impingement, then other techniques can be utilized extra articulately trying to address that subspinal impingement through a small T incision on the capsule. And you can see in this picture that the subspinal space is a virtual space because the separation between the labrum and the capsule is actually nonexistent. And this is one of the key steps in hip arthroscopy to try to develop this plane in order to put our anchors to secure the labrum. However, it is extremely important not to damage the labrum or too much capsule in the process of cleaning the subspinal impingement. The capsular thickness has been shown with Filippon et al to be thickest between 130 and 215 when we look at the clock, and it can be as thick as 1.5 centimeters. And therefore, again, it's important when we are addressing subspinal impingement not to penetrate the capsule through its whole thickness because this will not allow us to close the capsule at the conclusion of the procedure. Finally, the ligamentum teres has been shown to be important in high degrees of flexion for internal and external rotation. And some authors have suggested that it's also important for people that have borderline dysplasia. And therefore, it's important to always check the ligamentum teres as this can be damaged and produce micro instability of hip. We have done an anatomic study trying to define the attachments of the ligamentum teres. And as you can see here, there are six attachments to the acetabulum fossa where the ligamentum teres is attached firmly. For the peripheral compartment, it's important to address the CAM impingement throughoutly. It's important to try to restore the alpha angle to a goal of 42 degrees. We do this by trying to match the beta angle on the bottom of the hip. At the conclusion of the femoroplasty, it's important that we have done a dynamic exam trying to understand that no other areas of the bone is impinging because we know that if we fail to address the CAM comprehensively, this can be a cause of failure of hip arthroscopy. At the same time, it's important to understand where the vessels are to try to avoid the heterogenic injury of those vessels within the femoral neck. We have shown in several studies now that a partial resection of the CAM will not restore contact pressures, and therefore, patients can remain symptomatic despite the fact that the labrum has been repaired. Finally, capsular closure is key to try to restore or recapitulate the anatomy of the capsule as we said in the beginning of this talk. Some of the key concepts for restoring this and for the rehabilitation is that we need to try to avoid excessive external rotation and extension because as we saw in our study for capsular closure, 35 degrees of external rotation while in 10 degrees of extension can break the sutures of the repair jeopardizing the outcome of the surgery. Thank you, Jorge. Next up, we have Michael Banfie from Kerl and Jobe Institute will be talking about evaluation of the hip joint. Hi, I'm Dr. Michael Banfie from the Kerl and Jobe Institute in Los Angeles, and I'll be presenting the evaluation of the patient with hip pain. These are my disclosures. In the outline of my talk, I'll first start with the presentation of the patient with hip pain and how we can utilize their history to assess intra-articular as well as extra-articular pathologies. I'll then go into the physical exam, imaging studies that are frequently utilized, the purpose of diagnostic injections, and then an algorithmic approach. Regarding the presentation and history of their pain, it's really important to assess the patient's characteristics. As you can see, the two patients on the right-hand side are very different athletes. They are likely to have different bony morphologies as well as capsular ligamentous structures. So when you're assessing their cause of pain, it's very important to assess what sport they play. Is it worse with activity? What's the age? What's the sex? How did the pain start? Is it chronic? Was there an injury? Is it positional? Are the mechanical symptoms giving way? Radiation of pain? Pain at night? And the reason this is important is because not all pain is really hip pain. Sometimes it can be referred pain. Hip pain can also present in the anterior region, the lateral region, as well as the posterior region. The differential diagnosis of hip pain is quite large. Just anterior groin pain can be a multitude of things. Femoral acetabular impediment is probably the most common in my practice with associated labral pathology. But micro-instability can present with anterior groin pain, iliopsoas bursitis, loose bodies, and osteoarthritis, as well as many other pathologies. Similarly, lateral-sided hip pain can be referred pain from the back, but also can be trochanteric pain syndrome, incorporating gluteus medius and minimus tears, as well as trochanteric pelvic impingement. Finally, posterior pain can present as proximal hamstring pathology, ischiofemoral impingement, gluteal syndrome, piriformis syndrome, and sacroiliac dysfunction, but again, can be referred pain as well. And then finally, we need to keep in the back of our mind that there's also the presence of atypical hip pain. And this is pain associated with femoral acetabular impingement that doesn't present with typical anterior groin pain. This is pain that presents 10% of the time laterally, or 10% of the time posteriorly. And our diagnostic injections can really help us differentiate these types of pain. When you have the patients present, just hearing their history can help direct your physical exam. This 18-year-old water polo player with pain only with the egg beater is likely going to be our FAI case. The patient that's a previous ultramarathon runner who has this lateral-sided hip pain changes in her gait. She may be gluteus medius abductor pathology. The 49-year-old female runner with radicular symptoms all the way down the back of her leg, we're thinking more lumbar radiculopathy. The 24-year-old female dancer, pain with dancing, feelings of giving way, we're thinking micro instability. And finally, the 26-year-old baseball player that really doesn't have groin pain, but more abdominal pain, pain with sit-ups, pain with running, we're thinking core muscle injury. So this will really allow us to make our physical exam honed and streamlined. But to give us a complete exam, I'll go through all the findings that we can see on a physical exam. So first we'll start with the standing assessment and gait assessment. This allows us to have the patient show us physically where the pain is. For example, on the left-hand side, I'm having the patient show where his pain is, and he cups his hip in the classic C sign. This is very classic for femorostatic impingement. This is pain that starts in the groin and radiates laterally as well as into the back of the hip. We can also assess their gait. We can also get a baiting assessment at this point. If they have a high baiting score of 9, this is likely going to suggest some sort of micro instability as well as a collagen disorder. When we're looking at their gait, on the left here you see a normal gait, no evidence of antalgia, no evidence of abnormal foot progression. As opposed to the left-hand side here, this patient has a Trunellenberg favoring the left side, and she has abductor pathology. I then progress to the seated assessment. This allows me to assess my femoral as well as acetabular aversion. I'm also able to assess hip flexor strength in the seated position. You can also perform a neurovascular evaluation at the same time with regard to an examination of the lumbar dermatomes of the lower extremities. I then progress to the supine assessment. For my patients with FAI, this is really the most important assessment for me. I will assess range of motion. I'll assess tenderness. I'll also perform a resistant sit-up from concern for a core muscle injury. On the upper right-hand side, you can see two impingement maneuvers. The first is the common flexion adduction internal rotation exam or the impingement maneuver. That's on the upper left-hand side. When you hyperflex internally rotate, now you're impinging the femoral neck up against the subspine, so this is termed the subspine impingement test. There also are dynamic tests both in external rotation as well as internal rotation. These are the classic McCarthy tests that can also be utilized. The Faber test is important as well as the posterior impingement test. This is where I bring the patient off the edge of the bed. I have the hip extended. The hip is externally rotated, and we can assess for pain in the posterior region. I also think the Stinchfield test is very important to distinguish between interarticulate pathology and extraarticulate pathology. In my classic FAI case, I typically will start with a log roll. This will help me assess, is this a femoral stress reaction from a cross-country runner. I then progress to my range of motion assessment. I'll proceed into the impingement exam. This is where he's symptomatic. I then proceed into the Faber exam followed by the Stinchfield. This is a very quick assessment that will allow me to get a good exam of the anterior aspect of the hip. One thing to remember with the posterior impingement test is if they don't have pain posteriorly but have pain anteriorly, this is actually an apprehension test, so we should be thinking micro-instability in that case. I then progress to the lateral assessment. This will allow me to palpate the greater trochanter. You need to remember that there's four facets on the greater trochanter. Of those four, only the posterior facet is the one that does not have a tendinous insertion. This is the location of the trochanteric bursa, so if they're more painful posteriorly than anteriorly, this is likely more a bursitis picture as opposed to tendon pathology. I also think that another important point is to assess the OBERS test both in knee extension as well as knee flexion. Knee extension allows you to assess the TFL. Knee flexion takes the TFL out of the picture as well as the IT band and assesses contracture of the gluteus medius. Finally, if you're concerned about posterior pain as well as a good assessment of their version, I think that a prone exam is also very important. This allows you to assess their femoral inversion, but you also can palpate the ischium SI joint with hamstring pathology. You can palpate the pudendal as well as the sciatic nerves, and you can perform an ischial femoral impingement test. If that's positive, I generally will combine the giant stride test when the leg is extension with the giant stride test and they have pain. This is consistent with ischial femoral impingement. Regarding radiographs, in my clinic, I typically will always obtain a standing AP pelvis, modified 45° lateral, as well as a false profile view. The false profile view allows me to assess anterior coverage as well as the presence of a subspine. When we're looking at the standing AP x-rays, we really are utilizing this to assess the acetabulum. I'm able to see my tonus angle. I'm able to assess my lateral center edge angle. Tonus angle you want to have under 10°. Lateral center edge angle should be between 25° and 35°, and you can also assess acetabular retroversion if you have a positive crossover sign or a prominent ischial spine. This can suggest that. Regarding the modified 45° lateral, this has been shown to be the most sensitive to assess our CAM lesions, and this is what I'll measure my alpha angle on. Progressing to advanced imaging, MRI versus MRI arthrogram. This is somewhat of a controversial subject. Now that we have plenty of 1.5 as well as 3.0 Tesla machines, an MRI is most frequently utilized. The MRI is still less sensitive than the MRI arthrogram to assess labral pathology by around 20%, but I think that the most important reason to obtain an MRI is it can easily see cystic changes. It can assess AVN, and it can really help you not perform surgery on patients that you can't help. Regarding the arthrogram, I think this is most important in the revision settings if you want to assess the capsule. Regarding arthrograms, we're trying to utilize these to assess cartilage, still not great. This study out of the University of Utah looked at 64 hips underwent surgical dislocation and found only a 22% sensitivity to identify cartilage delamination, so if you really want to utilize a study to assess our cartilage, you really should utilize the DGEMRIC studies. The DGEMRIC studies are very useful, but they're time-consuming, so they're sometimes hard to obtain, but T2 mapping is also something that can assess cartilage at risk. Regarding CT or computed tomography, I think this is extremely useful in almost all of my patients, but particularly in revision settings. This can allow you to assess acetabular aversion. You can really see the size of osteoacetabuli, and if you have settings where there's a large amount of heterotopic ossification or a residual CAM lesion, this helps you find that as well. There are some proprietary software systems that will take the CT scans and develop a software map for you, where you can see the location of the CAM lesion, see the retroversion or anti-aversion of the acetabulum, it'll assess your femoral torsion as well. That is really a useful technique to help evaluate the bony morphology of these patients. Finally, with regard to diagnostic injections, if I have a patient that has a positive impingement exam, they have an x-ray associated with femoral acetabular impingement, but they have an equivocal MRI, the diagnostic injection in the office is very useful. You can just place a needle at the intersection between the head and neck junction under ultrasound, inject some local anesthetic, and if the pain goes away, this can confirm the diagnosis as being intraarticular. Furthermore, if you're trying to distinguish between extraarticular causes of pain, lumbar radiculopathy versus intraarticular causes of pain, the diagnostic injection is very important as well. We have another talk focusing on that, so I will not belabor the point. So in summary, I just want to finish with an algorithmic approach. This is a paper by Dr. Brian Kelly out of HSS, and he very nicely describes the hip anatomy as a four-layer system, layer one being the osteochondral layer, layer two being the labrum capsule as well as ligamentous structures, and layer three being the contractile or muscular layer, and layer four being the neurokinetic layer. This layer system allows you to think of the hip in a way that will explain why someone that has femoral or acetabular impingement without labral pathology will present with a core muscle injury and how it's very important to address all layers as one unit in that if you're going to address the core muscle injury, you likely need to address the underlying cam impingement so that the range of motion effects of cam impingement can be negated so that the core muscle injury can appropriately heal. These are my references. Thank you very much. Thank you, Mike. Great job. Please attending, remember to type in your questions. Next up will be Dr. Bhatia, who will be talking about injections and biologics in the interticular portion of the hip. Thank you very much. I'd like to thank ASSM for allowing us to have this opportunity. My talk this morning is going to be on ultrasound-guided hip injections as well as biologics and how we incorporate these into practice. These are my disclosures. Nothing is pertinent here. We all know that hip and groin pain really can have a variety of etiologies. When you're seeing people in the office, one of the most critical things to define early on is the true nature of where the pathology comes from. Various tools can be used to help identify this, including your physical exam. The ultrasound-guided interarticular hip injection, I think, is one of the most valuable tools. In fact, its diagnostic capabilities are so pronounced that some insurances nowadays, especially some that we have here in Illinois, actually require an interarticular injection to confirm an interarticular source of pathology prior to proceeding with hip arthroscopy. The benefits of an ultrasound-guided injection is you get real-time diagnostics. It's easy to learn, as we'll talk about today. It's much cheaper to the healthcare system and the patient. The cons are you need an ultrasound machine and you need to spend time learning the approach. This is a study that we recently presented at the Academy. We essentially did a cost-minimization analysis of ultrasound-guided interarticular hip injections versus fluoroscopic-guided interarticular injections. We noted there was a dramatic cost difference, as one would expect, mainly due to the fact that the procedures were being done in the office as opposed to a procedural suite. Ultrasound-guided injections, the code that's used for this is 20611. It's different from the standard code that we use for large joint injections. Various types of ultrasound-guided hip injections can be done. Very commonly, interarticular steroid injections can be done for arthritis and FAI syndrome. Additionally, you can also do interarticular PRP injections for these two pathologies. Pulse injections are sometimes very helpful in patients who have internal snapping hip. Peritocin injections are also helpful, and the ultrasound helps differentiate between the bursa and the gluteus medius. Then ischial injections can be done for hamstring tendinopathy, and then ischiofemoral injections can be done for ischiofemoral impingement syndrome. The pearls for doing ultrasound-guided hip injections are to get comfortable with the ultrasound machine and hip anatomy, and most importantly, to know where the neurovascular structures are at all times. So, from an interarticular standpoint, as I mentioned, this can be done for a variety of reasons. The diagnostic capability is highly underutilized, I think, in many cases. When doing the injection, it's important to visualize where the capsule is and to visualize that mentally in your head. That's a very important structure because we're going to want to make sure our needle pierces through this in order to provide the patient with an effective dose of the agent. So, this is how I set up patients for ultrasound-guided injections in the office. First, I have them changing the paper shorts with nothing underneath. We then cut a window from the ASIS down to the mid-thigh. The ultrasound probe is first placed transversely on the femoral neck to help identify the femoral head. We're essentially looking for a spherical-shaped structure, and then it can be oriented longitudinally along the femoral neck to identify the profile. And you can probe with your finger to identify the location of where your trajectory will occur. We then prep our skin, then insert a spinal needle, usually at least 3.5 centimeters in length at a 45-degree angle, and you can watch this needle come in very precisely. And the capsule is this linear structure that you see in this profile view, and it's very important that the needle go right to the head-neck junction. So, once you hit bone, you back up a little bit, and you can confirm you're in the joint every time. This is what it looks like in a real-time view. So, again, our needle is coming in, and it's injecting our solution right at the head-neck junction. So, peritrophic injections are also used, very common, can be treated for, you can use them for greater trunctured pain syndrome or external snapping hip. This is a very nice study that was done by John O'Donnell, it's a level one double-blind randomized controlled trial, where they randomized patients to either steroid or leukocyte-rich PRP. It's important to note that physical therapy was given to both groups. Now, they did notice that the patients who had a single leukocyte-rich PRP injection had superior outcomes with benefits sustained at two years, as opposed to having a transient benefit with the steroid. So, it's a very important adjunct for gluteus medius tendinopathy. Iliosous hip injections, we typically do this for internal snapping hip. And, again, the iliosous in these situations often will jump, and in some cases it can cause the repetitive snapping can cause quite a bit of inflammation of the tendon. So, injections are very, very helpful for this pathology. Specifically, you can do an ultrasound-guided iliossos sheath injection, which has the same approach, but you're really just injecting the sheath and the profile of the iliossos tendon. It's important to know where your vasculature is, as this is an extraticular injection. Ischial injections are sometimes used for a hamstring and ischial bursitis. This is a paper that showed decreased risk of the sciatic nerve in the lateral decubitus position. So, in summary, ultrasound-guided injections are a very useful part of my practice. My approach is to, many times, utilize this injection as an intermediate step between an FAI-specific PT program and surgery. I have a higher threshold to inject in teenagers with juvenile cartilage. In most cases, it's an anesthetic dose with a small amount of steroid. And the best advantage is that patients often love real-time diagnosis. Leukocyte-rich PRP is sometimes done in cases with recalcitrant tendinopathy. If you'd like to read more, these are excellent resources for additional reading. And thank you very much for your time. Thank you, Sanjay. Next up will be Benedict Wachuku, who is a co-director of clinical research and sports medicine at Hospital for Special Surgery. He'll be talking about biologics. Ben? Hi, my name is Benedict Wachuku, and I'm an attending sports medicine surgeon at the Hospital for Special Surgery. I'm a clinical instructor at Weill Cornell Medical School and the co-director for clinical research for the HSS Sports Medicine Institute. And today, I'm going to be talking to you about hip biologic injections. In the field of hip preservation, painful conditions are commonly underscored by biological derangements. As part of this talk, I will describe some biological solutions to common biologic problems of the hip. As you would expect, the literature on hyaluronic acid alone in the management of mild to moderate hip osteoarthritis is somewhat mixed. This 2018 paper out of Europe, published in the European Journal of Orthopedic Surgery and Dermatology, suggested that a single injection of hyaluronic acid was effective in decreasing pain and dysfunction, with benefits sustained out to 12 months. Another study, which was a systematic study of the effects of hyaluronic acid on hip health, a systematic review of randomized control trials, demonstrated that with a synthesis of the available randomized control trials, the literature favors hyaluronic acid over nothing for improvement of pain. However, meaningful difference over saline could not be demonstrated in the available literature. Overall, there is a relative paucity of data with regard to the use of PRP alone in the management of intraarticular hip disorders, and specifically mild to moderate hip osteoarthritis. I believe that this 2018 systematic review does a nice job of summarizing the clinical efficacy of PRP based on the available literature. The graphs show that PRP alone is effective in diminishing pain on VAS pain, with peak effect at 6 weeks, with gradual return of pain thereafter, although at 12 months, pain scores are generally lower than they were prior to injection. There are increases in functional patient reported outcome measures, and this appears to be sustained out to 6 months after injection. But for the hip, there is a much more limited sample set, and the available literature does not support a synergistic effect of HA and PRP when used together. Perhaps the best done study on this topic is a 2016 AJSM paper that found that PRP alone was more effective than PRP and HA. This graph outlines nicely this relationship. Specifically, PRP alone provided more significant pain improvement that was sustained out to 12 months. This relationship was also demonstrated on the Harris Hip Score and the WOMAC. Bone marrow aspirate concentrate is another important option for hip conditions. Overall, there is a relative paucity of evidence on the use of BMAC. Several technique papers have been written on the use of BMAC with hip labor repair, however. BMAC use has also been well reported for the treatment of avascular necrosis, and I will highlight this at the end of the video. The use of biologics is perhaps best reported for mild to moderate hip osteoarthritis. This slide is a review of the most pertinent findings. The basic take home is that PRP appears to be the best supported biologic option for mild to moderate hip osteoarthritis. Some studies have shown benefits to viscose supplementation, however the clinical significance of these improvements are indeterminate and it is not clear that hyaluronic acid is superior to saline. Additionally, PRP and HA together does not appear to be superior to PRP. For Gluteus Medius Tendinopathy, the literature is a little more developed with regard to the use of biologics. PRP has the greatest amount of support in the evidence base. I want to highlight two studies. The first paper was a randomized controlled trial comparing PRP and steroids for chronic gluteal tendinopathy. The authors found that approximately half of the patients who received steroids had achieved the minimal clinically important difference. This was compared to 82% in the PRP group, however. The group then followed up their 2018 publication with a more recent paper reporting two year outcomes. They found that at 24 weeks, 16 patients had failed steroid injection and crossed over to receive PRP. These patients receiving PRP then went on to develop significant improvement after the PRP injection. This data informs me that it is reasonable to try steroid injections as a first treatment. For patients failing steroid injection, PRP is then a very good treatment option. Similar to gluteal tendinopathy, PRP has been most commonly reported for the treatment of chronic hamstring tendinopathy. Studies have demonstrated that PRP can be a good adjunct for partial hamstring injuries and is helpful for reducing pain and improving functional outcome. Moving on to avascular necrosis, there has been a fair amount of literature on the use of biologics for avascular necrosis. A 2016 study showed that 8 out of 22 patients still progressed to subchondral collapse. A 2017 study showed no significant difference in core decompression with BMAC versus core decompression with normal saline. In contrast, however, a 2017 study showed that when core decompression was done with BMAC, there was a decreased incidence of progression to total hip arthroplasty. Thank you very much for your attention. Thank you. Next up will be Dr. Byrd from Nashville, Tennessee. Everybody knows Tom Byrd, and thank you again for helping us out as a faculty member, Tom. What I'm going to share with you is more of a personal perspective. What I reflect on is innovation out of necessity, because I'm the sort of guy that likes to do everything I can. Because I'm the sort of guy that likes to do everything the exact same way every time forever. So I didn't just wake up one morning and have this wild idea of trying something new. Any innovations that we've done were simply because the alternatives were considerably less appealing. My disclosures are available on the AOSSM website. We certainly credit Jim Glick with being the father of hip arthroscopy as we know it today. He devised the lateral acubitus position, which is popular around the world. We did our first hip scope in Nashville in 1990. At that point, I'd never heard of hip arthroscopy, much less done one or seen one. One of my partners had a 16-year-old kid with loose bodies in his hip two years following closed treatment of an acetabular fracture. And she was going to do an arthrotomy to remove these and asked me, what do you think about trying to take these out with the arthroscope? And I thought, well, as long as we don't do something dumb like cut the femoral nerve, we'll try. And when it doesn't work, you can simply flip them over and do your arthrotomy to take them out. This is that first case in 1990. I just used the techniques that Dr. Andrews taught me about taking loose bodies out of other joints. We used the largest shaver we could find. We got the largest cannula from the shoulder set to flush them out. And some of these we had to freehand. We just got some pituitary ronjures from the spine set. But it worked. And once a year over the next couple of years, I'd have somebody laying on my doorsteps with loose bodies that were removed. And after a couple of years, we had three of these cases. And one of the physical therapists came to me and said, you know, I've rehabbed these folks with loose bodies in the hip because I think my brother's got loose bodies in his hip. He'd been in a motorcycle accident 14 years before. I had to quit work framing houses because he never knew when his hip was going to give out on him. We did all these studies, which didn't show anything. I thought, well, maybe you've got some sort of radiolucent loose body that we just can't see on these studies. And after 14 years of symptoms, it didn't seem premature to say, let's take a look and see what we can do. Well, I fully expected it to be a normal hip scope. And I thought, if I'm going to scope a normal hip, we might as well make an educational video out of it. So this is that case in 1992. I'm putting the scope in the hip, expecting to see a normal joint. And what we find is this bucket-handled tear of his labrum flipped up inside the hip, which we excised. And after 14 years, his symptoms were gone. And that's when a little light went off in my head and said, you know, there's other things inside the hip that we're just not very astute about identifying. And that's what set me on this track today. As an aside, a quarter of a century later, he's still pain-free with normal x-rays. So labral debridement is not always a bad operation. In 1994, we published our technique on the supine approach. And that was based on just a dozen cases. So I emphasize to the young people that you don't have to be part of a big organization, and you don't have to have done thousands of something before you may have something meaningful to contribute to the scientific literature. I remember when the paper was accepted, the editor sent me back the acceptance and also noted on there that the need for the lateral position will become obvious. Well, I'm still sort of waiting. Also in 1994, we did our first bona fide athlete. This was a Division I basketball player from the state of Kentucky who got undercut on the basketball court in January of his sophomore year, landed on his greater trochanter in the middle of the groin pain, made it through the season, then made it to the third quarter. He was able to complete 16 that year, but by November of the following year, he still got joint symptoms. And his only problem is he can't dunk. And a 6'7 basketball player can't dunk as much use to his team. He'd had three MRIs that were diagnosed as atypical AVN. And we thought, well, if you can't go with it the way it is with your mechanical symptoms, we'll take a look. I had no idea what we might find. What we did find was this unstable articular fragment off the medial side of his femoral a month before his junior year. And that year, he was the league MVP and the league leading scorer, which is much more of a tribute to his ability than to mine. He went on to a successful NBA career that was ended by a foot injury, but not because of his hip. 1997, I was invited, or I was actually asked to come to a university to operate on one of their athletes. And they thought, well, hey, if you're here, why don't you give grand rounds? So I operated on the athlete, I gave grand rounds, and when I got done, the chairman stood up and proceeded to give me his perspective on hip arthroscopy. He thought it was a triumph of technique over reason, and there was no place for it. Well, I sort of sputtered and shrugged my shoulders, and I don't know, we've got some things that have worked, that hadn't all worked, but sometimes it does. Sometimes it takes a while to get a sense of vindication, which I got five years later, when the athlete that we'd operated on ended up being the first African-American to win a gold medal in the Winter Olympics. So again, things sometimes take a while to come around. 1997, the Houston Oilers moved to town and became the Tennessee Oilers, and somehow ended up being the team doc. Well, sure enough, in training camp that first year, one of our offensive linemen develops hip pain. We inject him, he gets through the season. We get to the end of the season, he's still having hip symptoms, and I'm looking at scoping his hip, and I'm thinking, great. How is it that the only Yahoo in the league that scopes hips just happens to have somebody on their team who needs a hip scope? I thought, this is gonna be a short NFL career. We scoped his hip, we went in, a lot of articular fragments, not the sort of findings you would think would be good for a durable hip, but he responded well, became a starter, and 20-something years later, he's had both knees replaced, but he's still sort of percolating along with his natural hip joint. Now, subsequently, I presented this case at the NFL team positions meeting at the Combine in Indianapolis, and I remember one of the trainers who had come with the team from Houston, who's still with us, said, you know, we had a couple of these guys back in Houston with these groin problems that just never seemed to get better. He goes, I wonder if some of them might have had a hip problem, and it wasn't until years later that it finally dawned on me that it wasn't that I was the only yahoo in the league scoping hips, it just happened to have somebody on their team with a hip problem. There are a lot of players in the league with hip problems, we just weren't any good at diagnosing them. Now, this is one of the papers I was most proud of, Prospective Analysis of Hippothros with Two-Year Follow-Up. That doesn't sound like a lot, but remember back in the 90s, evidence-based medicine was just making its mark, and people were still publishing papers with three- and six-month follow-up, and I tell people I've only done two smart things in my life. One was marrying my wife, and the other was early on with this hip stuff, I had no idea where it was going, but I didn't want to get years down the road and be wondering how these patients did, so we started collecting our data early on, and I encourage young people, keep track of your data early in your practice, because you never know how your practice is gonna evolve, and with today's software packages, this is pretty easy to do. Fast forward a few years, this is the first paper I ever had the courage to submit to JBJS, Prospective Analysis of Hippothros with Ten-Year Follow-Up, we had 100% follow-up on all patients, I submitted it, and they rejected it. They didn't offer any revisions, they just said it was not contemporary, I'm like, not contemporary? This is ten-year follow-up. They just rejected it. So I shipped it over to Clinical Orthopedics, and they accepted it pretty much as is, and again, sometimes it takes a while for things to come around. But I remember years later, the editor who had rejected my paper sent his daughter to me for treatment, so at least I felt a small sense of vindication, it just took a while. In 2001, we published the first scientific article on hip arthroscopy in athletes. Mean improvement was 35 points, and 93% of these showed demonstrable improvement. Remember, these were simple debridement procedures, and they showed the greatest improvement in the first month, they pretty well peaked by three months, and those results were pretty well maintained on those that were five years out. As someone once said, nothing ruins good results like follow-up. When we looked at our ten-year follow-up, the improvement was still outstanding, 87% return to sport, but a third of these ended up getting converted to a total hip replacement, an average of six years, so it was after five years that the wheels started to fall off. And we realized our results really weren't durable. Fortunately, Professor Gans taught us about FAI as an underlying etiology, so we had something we could address, hoping for more durable long-term outcomes. Now, I first heard about FAI in 2003, I was running a course at the Learning Center in Chicago, pontificating about an athlete with a labral tear, and somebody in the audience stood up and said, that athlete's got FAI, he's got this bump on his femoral head that led to the tearing. And I remember thinking to myself, that's the stupidest thing I've ever heard. Fortunately, I was wise enough not to say it, I just thought it, so I sort of came into this FAI thing sort of kicking and screaming. But just to show you that that door swings both ways, I first met Professor Gans in 2003 when we were both speaking at a program at the Eport meeting in Helsinki, Finland. At that point, hip arthroscopy did not exist in mainland Europe because Professor Gans didn't believe in it. After I lectured, Professor Gans approached me and said, you know, I'm not ever gonna do this hip arthroscopy stuff, but I may send one of my young partners over to visit with you. So he sent his young partner over, he stayed at my home, and it wasn't until he was there a few days, I figured out that Michael Leunig was Professor Gans' son-in-law, and I thought, is this some sort of setup? Which it wasn't, but it really just speaks volumes for Professor Gans when he was at a point that he really didn't believe in hip arthroscopy, but he eventually was able to at least cautiously embrace it. Now, I'll finish with a few reflections on labor management. Historically, I had to have a compelling reason to repair the labrum because the results of the debridement weren't all bad, the healing capacity of the labrum was uncertain, repair techniques were primitive, and the rehab process was the only one. While there are a growing number of studies reporting on superior results of labor repair over resection, they all have methodological flaws, but the bottom line is there are no studies that suggest that debridement is superior to repair. So in today's world, I have to have a compelling reason not to repair the labrum, the healing capacity's excellent, the techniques and technology for repair are advanced, and the rehab process has been streamlined and much less onerous. But as we look at this journey from resection to restorative techniques, keep in mind that history does repeat itself. My father was a general surgeon. He began his career as a medical officer in the Stonewall Jackson Brigade of the 29th Infantry. He oversaw the medical evacuation of Normandy Beach. The 29th was the tip of the spear for the D-Day invasion. They lost 75% of their officers in the first 24 hours. Fortunately, he was part of the 25%. When my father passed away, I remembered going through some of his papers, and I found this paper written by his chief of surgery, Dr. Barney Brooke, and you have to remember that at the beginning of the last century, all surgery was ablative surgery, amputations, abscesses, the occasional tumor, and Dr. Brooks wrote about performing a gastrojejunostomy, and he had two surgeons watch him, and they said it was indeed a strange sort of operation because nothing was removed. I think in today's world, we've reached that where we're no longer just doing debridement procedures in the hip, but we're generally doing preservation, restorative procedures for long-term durability of the joint. Greetings from Nashville, and thank you very much. Thanks, Tom. Next up will be Kristen Taylor from Midwest Orthopedics at Rush. Again, none of our operations succeed without excellent rehabilitation. Kristen? My name is Kristen Taylor. I'm a physical therapist with Midwest Orthopedics at Rush Physical Therapy. The topic I'll be discussing today is rehab following hip arthroscopic surgery. I just wanted to take a moment and say thank you for allowing me the opportunity to speak with such amazing individuals. So the literature tells us that chronic hip pain leads to inhibition of the gluteal muscles and deep core muscles, painful facilitation of hip and pelvic floor musculature. There's decreased unpainful hip internal rotation range of motion. We have decreased lumbopelvic stability, poor lumbopelvic rhythm, and changes in mechanics throughout the chain. So when these patients present to us post-surgically, it's important to treat them as an individual, not as someone who just had a run-of-the-mill surgery. So things to consider is the length of time from injury to surgery, any lumbopelvic girdle dysfunction they may have developed, any kinesiophobia they may have developed over time, and any sport-specific or activity-specific goals. It's important to know that their goals in their recovery in order to make it a successful recovery in their minds at the end. This was a research article that was written by Powers and colleagues, and it was really interesting. They used fine wire electrodes into the gluteal muscles, specifically the gluteus medius and gluteus maximus, as well as the TFL. And they looked at the activity of these muscles during these exercises. And this group of exercises are exercises that we as physical therapists use on a very regular basis. They're very functional, and they're things that are very well-known and widely used. And what I found really interesting was there was a significantly greater activation of the TFL during side-lying hip abduction, lunging, hip hiking, and squatting activities. So what this brings to light is when we're choosing these exercises and these plans of care for our patients, it really should be individualized. If we have someone who has too much activity of the TFL, we wanna wait on these exercises until later when they're really able to appropriately facilitate their muscles. So postoperative day one, this is one of my favorite days. It's a good education day. We actually, in our clinic, do ask a caregiver to come back with the patient. And this is a day where we go over their post-surgical precautions. We do any transfer training. I really start my gait training day one. I wanna make sure that we avoid any over-activity of the hip flexor. And I actually will have the caregiver go through the passive range of motion. So I'll do a few repetitions, and then I'll ask them to go through 15 to 20 repetitions. And I think it's really important to do this to make sure that the caregivers are safe in both their body mechanics, but also with any post-surgical range of motion precautions that they may have, but also to see the interaction between the patients and the caregiver to make sure that really we're gonna be able to have them doing this passive range of motion on a day-to-day basis. But first and foremost, the biggest thing that I want on day one is the buy-in from the patient and the caregiver. So what I say to all of my patients day one is, you get me a couple hours a week. The rest of the time, the rest of the hours in the week are really up to you. So your recovery is only gonna be what you put into it, minus the hours that you work with me in therapy. Our post-surgical protocols have typically between three and four phases. Phase one is your protection and education phase. The surgeons take great care in making sure that they close that capsule and they provide a very stable hip joint. So it's really important that we protect this surgery and protect this capsule in our beginning phases. Weight-bearing restrictions throughout the literature, it was anywhere without a microfracture, was anywhere between weight-bearing as tolerated day one up to a 20-pound flat foot weight-bearing precaution, anywhere between three and four weeks post-surgically. Pretty consistently across the board, the microfracture was a six- to eight-week non-weight-bearing protocol after surgery. And that's why it's really important to hone in on that avoiding of the overactivity of the hip flexor. This is where we're gonna start to progress our range of motion in a very pain-free range. And pretty consistently across protocols and across the literature, I did see a flexion to 90 degrees and extension to neutral limitation for the first three to four weeks. External rotation, some surgeons prefer no external rotation and others will allow up to 20 to 25 degrees of external rotation in this first phase. This is where we're gonna really start to begin our neuromuscular re-education and really start just turning on those muscles that have been turned off. And we're gonna address the soft tissue. So I'm really a hands-on, I was a firm believer in hands-on. This is a formal collegiate dancer. And you can see she has a pretty significant anterior pelvic tilt here. So when I ask her to do a posterior pelvic tilt, you can see I'm an athlete, I'm gonna do it. So she does it, but not without compensation throughout the chain. She has a forward flex trunk, she has flexion in her knees. So without addressing these soft tissue limitations, these flexibility limitations, these patients are going to continue to use these compensatory strategies that they have developed. And working off of that, here's two of very many research articles that have been published regarding changes in gait mechanics and changes in alterations in muscle activity throughout the chain in persons with FAI. So it's really important to take a hands-on approach with these patients. And again, I start day one. You want to facilitate these movements and break these compensatory strategies. Phase two is your motor control phase, weeks five to eight. You're moving towards full active and passive range of motion. Surgeon dependent, you can begin your mobilization of the capsule between six and eight weeks. You're gonna continue your soft tissue mobilization. You should absolutely have normalization of your gait pattern. Working on your proprioception throughout the chain. And this is where you're gonna start to advance some of your resisted training. So this is where we're thinking about our proximal to distal control. I am a firm believer in whole body recovery. So most times I have my patients working on multiple things at once, but I'm also keeping in mind the stages of development. I'm not gonna take someone out of a quadruped position and move them into a single leg stance position. I'm gonna move them appropriate throughout the chain when they can demonstrate the proper stability and mobility in those stages of development. Phase three is your advanced strengthening phase. It's weeks eight to 12. You're gonna continue to progress that neuromuscular control. You're gonna start to teach the self-mobilization for the soft tissue so that patients can appropriately mobilize at home and in the future without physical therapy. We're gonna continue to work on those proprioception and mechanics throughout the chain. Sports specific testing typically is somewhere between 10 and 12 weeks, depending on your surgeon. But this is when we're gonna get a little more dynamic with our strengthening. So we're gonna make sure that we're utilizing our anterior, middle, and posterior chains. We're gonna do a little more perturbation throughout the chain, and we're gonna really challenge these individuals as a whole body instead of just a hip joint. Phase four is your return to sport and return to activity phase. This starts anywhere between 10 and 12 weeks. I really like to take my patients into a more fatigued state and then start to do a little bit more balance because this is going to simulate a little bit more of the demand that's gonna be placed on them when they are back into their activities or sports. This is where we're gonna really focus on our sports specific and activity specific activities. Return to running is anywhere between 10 and 12 weeks, depending on your surgeon. Agility is anywhere between 12 and 16 weeks. And return to sport is somewhere around six months. So it's really important in this phase that we understand the demand that's gonna be placed on the hip joint of these individuals when they return to sport. It's also really important that we understand the demand that's gonna be placed on their bodies in their training and in their game specific activity on their game day. And it's really important that we take this core to floor approach and whole body approach when treating these patients in order to have a very successful recovery from their surgery. So our clinical pearls are get the patients by in day one. Individualize your care for each patient. No two patients are the same. Neuromuscular control at the pelvis is essential. Take a hands on approach and remember that hip rehab is not linear. Thank you. Thank you, Kristen. Again, none of our surgeries could ever be done successfully without the rehabilitative portion of our recovery. Again, eloquently done. The next section, again, I would like to thank all the faculty for your great talks and again, for staying on time. The next section of this webinar will be an interactive question and answer program. So please, everybody, type in your questions. I'm going to come off the webcam. I'm gonna ask a question and then the faculty would come back on to the website webinar so that they can answer the questions. That would be great. So our first up question from the audience is to Dr. Banfi. Dr. Banfi, one of the questions asked is, how do you assess femoral and acetabular version from your physical examination? What are your plurals to us in terms of trying to figure out the version in our patients? Well, I think that it's a really quick and dirty assessment and you're seeing if someone is overly antiverted or retroverted and it's mainly with the femur that you're looking at this. To really get a precise assessment, that's where our CT scans are gonna come in and that's how you're gonna assess your acetabular version as well. But I think that just on their initial gait analysis, if they are intoing or out toing, that's gonna tell you if they are respectively retroverted or antiverted. And then the other handy test is when they're in the prone position. I believe it's technically called Craig's exam or Craig's test. And the idea is that in that prone position with the knee at 90 degrees, that's technically neutral. You have to fill their greater troch. So if their greater troch is already at the most lateral position, then if they're at neutral, that's kind of our standard, 10 degrees of femoral antiversion. However, if you're able to externally rotate them and they go to about 50, 60 degrees and that's gonna be excessive antiversion. And likewise, if that neutral position is actually external rotation, so they're bringing their leg in, then you know they're gonna be retroverted. But then that's gonna really dictate what you're thinking about the patient. Is this gonna be more of a instability issue or along with their x-ray, they may have some slight retroversion of their acetabulum that you're assessing. And so their retroverted femur may be compensating for that. So you're just utilizing this to put everything into one big picture. Thanks, Mike. Hey, listen, Dr. Bhatia and Dr. Wachugu, if you could come on. There've been multiple questions asked about the importance of utilizing injections with steroids. Do you commonly use that in your practice now? We've talked about PRP and BMAC, but a lot of the mainstay of people's practices are using steroids. So are you currently using them quite a bit? Jorge, also, please tell us your opinion as well. Are you using steroids as part of your differential diagnosis in terms of the hip pain? Sanjay? I think you're muted, Sanjeev. Sorry about that. Here we are. Yeah, so that's a great question. In my practice, limitation for a lot of biologics is often the cost profile. So the first-line treatment for whether it's an intermediate step between physical therapy and surgery, or if it's an osteoarthritic patient, we're trying to treat them therapeutically, is usually steroids. And I do have a higher threshold for steroid use in younger people with juvenile cartilage. Typically, I use a very, I try to avoid it if we can, but if we do have to do it, I use a very low dose. But yeah, the cost profile is certainly a limitation. Yeah, in my practice, I've transitioned away from using steroids in patients under the age of 30. So similar to Sanjeev, I do ultrasound-guided injections in the office. And so I'll use physical therapy as my first-line treatment. And then for diagnostic purposes, I'll do a purely lidocaine injection just to make sure that I'm very confident in diagnosis. I find that the lidocaine is helpful for me for confirming the exam and that the hip, intra-articular hip is the source. And it's also helpful for the patient to be more confident in their diagnosis or in their decision to undergo surgery. In patients who are somewhat older, 35, 45, I will use steroid and I do counsel them that I will wait after doing the injection if it doesn't give them long-lasting relief towards doing the surgery. One of the machine learning studies that I published with Shane did show that patients receiving steroid injections had decreased patient-reported outcomes at two years. With regards to biologics in hip osteoarthritis, I have had some success with PRP, but to Sanjeev's point, it can be cost-prohibitive. And in patients who have hip arthritis who are not a good candidate for hip arthroscopy or for a hip subchondroplasty, I will offer them HA, which can occasionally be approved by their insurance. Yeah, same thing for me. I think it's very similar to what Ben does. If I get a sense that the patient will not have surgery within three months, which is what the shoulder and knee literature support for decreased outcomes and also increased failures, then I would probably do a cortisone injection. But if not, I try just to use lidocaine, two cc's from a diagnostic perspective. And also so that the patient understand what should it feel like in the event that he or she has a successful procedure. Great, thanks. So listen, if Tom Burt could pop himself up on this screen, that'd be great. The question that I wanna ask the panel is, Dr. Ngo has just written some great literature about the fact that these people tend to do better with a shorter duration of symptoms preoperatively if we operate on them. So are we doing six months? Are we doing nine months? Are we waiting a year, Tom? How quickly you pulling the trigger if someone has FAI, label tear, inflammation in the joint and is miserable. Are you waiting the six months like the insurance companies want or? Not necessarily. As you know, there's a growing amount of literature that says the longer the duration symptoms, the poorer the results and people extrapolate that. But therefore we should be operating on it more quickly. The best I can tell somebody is I think it's unlikely the problems are gonna get worse and them not know it. So if the symptoms are stable, I don't see a sense of urgency to rush in and do something right away. The dilemma with that thought process is that we see so many people in MRI shows a label tear, now you're saddled with this MRI showing a label tear. Am I doing them a disservice by not sending them off to get surgery right away? I think there is a place for at least trying to modulate the symptoms with the conservative program. My experience has been once somebody truly becomes symptomatic from FAI, it's unlikely the problem's just gonna get better and go away, but that doesn't mean your only choice is to suck it up or do surgery. There's a lot you can do from a non-surgical standpoint, modulate those symptoms. And I think I would play devil's advocate. I'm pretty liberal about the idea of trying an injection in a young person's joint. I think that the dilemma I'm faced with on a weekly basis are these young teenage girls with pincer impingement where the labrum's getting crushed by the pincer lesion and they're painful literally for years where their mother brings them in, they gave up cheerleading and dance, they won't go shopping because their hip hurts and the labrum's a very hardy structure and it'll get crushed for years before it actually tears badly enough to show up on an MRI. And I think for a lot of these young people, I'm very willing and in fact will encourage them oftentimes, let's try a cortisone shot one time. And a smart guy once told me, anytime somebody presents you with an option, your first question should be compared to what? What are the other choices? Well, if the next step's gonna be this big quack I'm gonna put on their hip, all of a sudden maybe trying to shot one time doesn't sound like such a bad idea. From a diagnostic standpoint, we use a combination of a short acting and a long acting because sometimes you've got to send them over. We talked about how important rehab is. We'll send them to therapy and we get them over there and make sure they can do things to make their hip painful. But a lot of times, me moving around in the office, I'm not generating the type of force they are in athletics. So having this comfort, do the injections, send them back to do those things to be as certain as we can how much relief they got. Cortisone has no diagnostic value. It's the anesthetic that has a diagnostic value because some people maybe just weren't gonna respond to the cortisone, but also sometimes you may get a little bit of a systemic effect in the cortisone injection so that doesn't help you a lot one way or the other. The last point I'll make is there was a study that was published that said the response in an intraarticular injection is not prognostic of the success of arthroscopic surgery and therefore you shouldn't do it. Well, that's a bunch of dumb because the injection doesn't tell you whether they'll do well with arthroscopic surgery. All it tells you is, is it a hip problem? Because you can inject the most arthritic hip and they're gonna get relief from an injection, but that doesn't mean they're a candidate for an arthroscopic procedure. So it really just tries to differentiate, is it a joint problem or a problem outside the joint? I've carried on too long. Okay, panelists, one second. Kristen, I'm gonna let you respond. Hold off one second, okay? Jorge, one sentence. How long are you waiting for your patients? I think three months is a reasonable time. Okay, good. Sanjay, how long? After an injection, I would say two months. Ben? Three months. Michael? Six weeks. Six weeks. Damn, things are good on the West Coast. All right, Kristen, tell us why we're wrong. Tell us that we're full of crap, that you can make these patients better without us operating on it. I don't know that I could tell you that you're wrong, but really these patients, when they've had this prolonged, this chronic pain and it goes on for a really long time, they get these kinesiophobias and they get these competitory strategies and they end up coming into the clinic and you're not sure what it is. Is it the back? Is it the pelvis? Is it SI joint? Is it hamstring? Because they've got a little bit of everything going on when it goes on for longer and longer amounts of time. But also in the clinics, we're seeing more and more insurance limitations as far as the number of visits that they can have, whether or not they're having surgery. So we're having that limitation placed on us as well. So I think it's kind of just important to consider all aspects, but I agree with you guys in that if it's pretty clear cut in what they have and they've tried some conservative therapy and conservative measures and it hasn't gotten better, I'm no magician. I can't fix what's broke inside of there. I can try to work with the mechanics throughout the chain and really try to facilitate the appropriate movements, but if that's not working, then surgery is more appropriate. Ron, asking how long you give it is like asking how much a putt's gonna break. It depends on how hard you hit it. How long you give it depends on how they're doing. If they're showing gradual improvement, you can give it an indefinite period of time versus you see some people on day one, you know that they don't have a chance of getting better and that you can go through the motions if you just want to or the insurance company tells you you have to. But oftentimes it's evident that they're really in trouble with their hip, but that's where your physical therapist is so astute at doing a functional assessment because often you'll see somebody who's clearly in trouble with their hip, but everything around their joint is such a mess. That's where they may need an intra... We call it two-pronged attack. We'll put an injection in their joint to get the joint quieted down so maybe they've got a better chance of responding to physical therapy just to get them in better shape to get over the operation because people don't come to the surgeon wanting therapy. They come to the surgeon wanting surgery and trying to sell them on that concept because by the time they see us, oh, I did three courses of therapy and that just made it hurt worse. And they weren't doing the right therapy. I agree. Right, so one of the next questions has to do with PRP around the hip joint. So Jorge, are you currently using PRP a lot in your hip joint? Is it part of your practice? Is it something that you do every once in a while? Do they have to walk in with a certain amount of money on their credit card before you inject them? When are you pulling the trigger to do PRP? I think as it has been said before, it's a stepwise approach where we try to do cortisone or lidocaine injection. If they don't get better, I try to get something authorized such as HA. But in the event they fail everything and or they wanna try something else, I think PRP can be a good option. There's at least 14 randomized clinical trials for me showing that it's better than their counterparts, but there's not such literature for hip. So I'm hesitant to offer something that will cost the patient a lot of money and for which we don't have a lot of data. You know, the West Coast is pretty, you know, biologics heavy, but I feel the same way with regard to the financial burden of it. But one thing that I've found is in my young athletes that are in season and are planning to have surgery after the season's over, a leukocyte core, you know, basically a plasma-based PRP actually has a great anti-inflammatory effect. And I think it's healthier for the hip than the cortisone. I'm a little bit weary of cortisone in the young patient too. So, you know, one of the questions that have been asked is ultrasound in your practice. Are you guys functionally doing all the ultrasounds yourself? Or are you letting primary care doctors do the injections and then have them come back to you? So each one of you four, please tell me. And also Tom, if you could come on and tell me whether or not you're doing them or whether or not you're having someone within your practice do the injections. So we'll start off with Ben. Yeah, so I do all my own injections in the office under ultrasound guidance. And, you know, I like the tactile feedback that I get of examining the patient prior to the injection and then, you know, doing a diagnostic, showing them their anatomy. And then, you know, I let them sit for a little bit and then I go back and I re-examine them. I find that much more reliable. And for the patient, you can often say, you know, you're gonna get this injection, come back to me a week later. Maybe the patient doesn't come back and then they forget exactly the relief that they had with the injection. I think it's very helpful for me and I do it for everyone. Yeah, I do the same thing. I use ultrasound in clinic. And I also like to show the patients, you know, where everything is going into the structures of the hip. And I find that patients actually really like that, understanding that you're actually putting the medication where it belongs. And I think it's a nice trick and pro for patients. I would agree with that. I think that it does two things. One, I've seen a lot of patients who had either fluoroscopic guided injections or ultrasound guided injections by non-surgeons and they had zero relief from that. Either the injection wasn't in the right place or the patient wasn't shown how effective that the injection actually is. And then I think the second thing that it does when you do it yourself is that it's a nice step in the surgeon-patient relationship and giving them confidence. Yeah, I agree with all that as well. I would say 90% myself, you know, particularly if it's intraarticular, I do all those. Some of the other stuff, you know, like cysts in the operator externus or even iliopsoas sheath, I don't have a lot of confidence that I'm in the right spot. So I usually will send those over to one of my primary care colleagues. I guess I'd offer three comments. One, I don't want to sound like I'm too liberal about cortisone in young people, but a one-time injection, I'm certainly happy to try and often encourage them to, but repeated injections can certainly be harmful. Certainly if you've got an arthritic hip and cortisone helps, great, but in young people, but at least a one-time injection, I'm not opposed to. On orthobiologics, remember we use orthobiologics for two purposes. One is to potentiate healing and the other is to modulate the symptoms of arthritis. So in the management of FAI, orthobiologics don't have a lot of role in my practice because that's a structural problem and all the PRP injections in the world aren't going to solve a structural problem. The other thing we're learning is the hip joint is different than the knee, especially when it comes to the risk of HO. We've seen a few significant issues with HO following orthobiologic injections. It's not common, but it's one more repercussion around the hip to be thinking about. Last on the role of ultrasound, to me, assessing complex hip problems without benefit of ultrasound is like practicing cardiology without a stethoscope. You're missing an incredibly important instrument. The sad part is, I don't know how to turn an ultrasound machine on, but I've got a nurse practitioner who, as far as I know, has injected more hips than anybody in the history of the world and I put her up against anybody. I think it's critically important for young people to be very familiar with ultrasound. Number one, it can be a revenue producer and there's nothing wrong with that because you're using it to the patient's benefit. You mentioned about response to fluoroscopic guiding injections. You ask them to get pain relief and they're so busy telling you how horrible the experience was that, to me, it's an incredible service you have for the patient. You can do that right there in your office. But I think it's a great learning tool because you can see all the structures around the hip. You can learn so much as a clinician. I think it's critically important for the young people to be really dialed in on ultrasound and that's coming from, like I said, a gray-haired guy and I don't know how to turn the machine on, but I certainly respect its importance. Linston will offer a couple of comments. Yeah, I certainly would agree with that, Dr. Burden. I learned how to do my ultrasound guiding from Beth as well. It's been huge for my practice. My question that I just unmuted myself for is, how often do you guys use ultrasound guiding injections in the post-operative hip or is it something you would use in somebody who's struggling after hip arthroscopy? Would you use cortisone or PRP for somebody who's four or five, six months out or how soon would you use it? There's a certain portion of the patient that has anterior capsular tightness or maybe even a scarred iliopsoas and so I'll put a little cortisone around that area at the six-month mark. Maybe that's 20% of post-operative patients. I would agree that I think it is helpful for capsulitis and especially the anterior region of the hip, especially near the rectus sometimes as well. So yeah, around six months if they have any residual pain, I think it's a helpful tool and then yeah, that's primarily it. I'd say 80% like to see me or having difficulty following hip arthroscopy. Most times it's just some sort of adjustment in the rehab. So they'll actually see the physical therapist first. So by the time they come to see me, the therapists have sorted out the things that need to be corrected and they'll already have a plan and most times I'm just like, that sounds like a good plan to me. But beyond that, there's certainly an important role with the use of these injections as far as people having difficulties after surgery. And Winston, I think you mentioned that four to six-month point. You don't want to get too quick because as they say, you want to save a little dry powder. You don't want to use everything up and somebody's struggling the first six weeks after surgery and you keep throwing stuff at it. Well, that didn't work and what next? And the next thing you find yourself leading to repeat arthroscopy. So being temperate, not in a rush to use these things, but a lot of options. And we talk so much about ultrasound in the hip because hip problems are just harder to sort out. I don't need to inject somebody's knee to tell them that their knee hurts. I'm I can figure that out without injecting it. But the hip, there's just so many other things going on around the hip. Thanks. One last question for Kristin. I'd like Kristin to come back up again. You know, Kristin, one of the things that hip arthroscopies have problems with is the understanding of functional return to play criteria. Could you give us three or four hints for us as to what we should be doing with our patients in our office at that four or five-month time so that we're not looking at time as a parameter, but we're looking at what function what functional tests should we be asking our patients do to get them back to their sports? Yeah, in the clinic, we do have things that we look at and we kind of look at it globally, kind of no matter what their sport is, but we'll have them holding a front plank, a side plank, single limb hop, a cross pattern of a single limb hop, single leg squat, and we'll even hop test them as well to see if there's a difference between the uninvolved limbs. So some things are sort of kind of general that we use a lot for knees and things like that as well, but we're looking at sort of pelvis all the way down when we're looking at those things. We're looking for those alterations, you know, the wobbliness, the valgus, the hip drop, those sorts of things before we're gonna let them progress into a more aggressive or competitive scenario. Well, so it really almost sounds like you use a lot of the criteria for an ACL reconstruction. Really close, yeah. And, you know, we're looking at mechanics throughout the whole chain, whereas sometimes I feel like in the ACL criteria, we really hone in on genu valgus and we kind of look more at what the knee is doing versus what we're doing kind of shoulder all the way down. So yeah, so we use those as sort of just a general thing going back into a more competitive situation, but we'll use similar things in our clinic. Well, that's great. If I could have all the panelists come back on again, that would be wonderful. Again, on behalf of AOSSM, you know, myself, Dr. Gwathney and Dr. Ngo, we can't thank you enough for all your hard work and all the knowledge that you've imparted on all of us. There are no further questions here. And Alexandra, who's been working very hard behind the scenes, will have a slide. Please make sure that you understand this is a four-part webinar series. This is the first part. Yes, you get to see some of us back again. And this is a CME course, so please make sure that you are typing in your comments, because we really would like to make sure that we continue to strengthen our program. And again, I can't thank the faculty enough for such a great job tonight for staying on time and being so responsive to us. This has worked out great. So, Alexandra, if you bring up that last slide, and we'll call this a do. Thank you very much. And thank you again, Shane and Winston, who've done just a fantastic job with us. Thank you, everybody. Yes, thank you. Thank you. Thank you very much. On behalf of AOSSM and ESSACAS, thank you to our course chairs, speakers, and all of you for joining us this evening. For more information about AOSSM, please visit sportsmed.org. And to complete this educational activity and access your CME, please visit education.sportsmed.org. If you have any questions regarding tonight's webinar, please feel free to email me, Alexandra Campbell, at alexandra.aossm.org. We look forward to tomorrow's webinar, Intra-Articular Techniques, and hope that you'll join us for that, as well as webinars three and four next week, on Wednesday and Thursday. All webinars within the Athlete Tips series begin at 7 p.m. Central. And again, on behalf of AOSSM and ESSACAS, thank you for joining us, and have a good night.

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