Welcome to the Athlete's 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 and use your device's 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. Gwathmey, Houskone, 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. Well, thank you. Good evening and welcome to the AOSSM, the Athletes' Hip Webinar. My name is Dr. Shane Doe, and I will be your moderator for this evening's webinar. Tonight is the third episode of four on the introduction of the extra-articular hip, and each speaker will have 10 minutes for each of their assigned topics. We're very honored today to have our first speaker, Dr. Brian Busconi from the University of Massachusetts, and his topic will be on core muscle injuries. Welcome and thank you for attending the third session of the Athletes' Hip, New Trends, Controversies, and Contemporary Surgical Management. Our discussion tonight will be an introduction to extra-articular disorders, and my topic will be core muscle injuries. Again, my disclosures can be found at the AOSSM website. Core muscle injuries really are a confusing term, and over the past decade, there have been multiple terms to talk about this disorder and pain above the peripubic area. It's noted that these injuries are exertional only, and that they oftentimes encompass a group of muscles that have been injured, including the rectus abdominis, the adductal longus, and the posterior wall of the inguinal canal. My goal today will to give you a good idea of the definition, the physical exam, as well as treatment options for core muscle injuries. As you've heard in the previous lectures, again, what's key is on your physical examination to determine whether or not this is their primary problem or is this multifactorial. Again, you want to ask your patients, where is your pain? Show me what you call your hip, where did it start, and where is it now? It can be very confusing for the patient. Remember, they'll come in telling you that it hurts in multiple areas. The abdominal pain differential is actually quite long and can be difficult for many orthopedic surgeons because we're not very operative dependent in this area, and therefore, it can be confusing to us in terms of what's going on anatomically. It's a poorly understood field. Honestly, the understanding of core muscle injuries lack a lot of specific tests. We all have our own favorite tests. There are a few well-designed clinical trials. There could be multiple other pathologies going on, and there's oftentimes a lack of agreement in terms of diagnostic criteria. Remember, though, what's consistent in all of this thing is the understanding of the inguinal canal, specifically the posterior wall, as well as the muscles that surround that area, including the rectus abdominis, and here you can see the direct rectus sheath, as well as the adductor longus and adductor brevis tendons. They all have a vital role in and around the mobility and strength around the pubis area, and they are affected by what's going on at the hip joint itself. Mechanism of injury is postulated to be a hyperextension injury with a hyperabduction of the thigh, where the anterior pelvis becomes a pivot point. What's important to understand is that there's a sports hip triad, as Freely talked about in 2008, in which you have FAI or stiffness in the hip joint. You get compensation, and therefore you get other problems that can occur. The question comes in is whether or not the athlete is actually symptomatic from the FAI or whether it's these compensations that are giving the patient their symptoms, and that becomes important in terms of the overall athlete's treatment. Inguinal disruption is described if three of these five points are present, pinpoint tendinitis over the pubic tubercle, palpable tendinitis over the deep inguinal ring, pain and or dilation of the external ring without any obvious hernia, pain at the origin of the adductor longus, and a dull, diffused pain in the groin. Physical examination becomes very important. There's no real palpable hernia that's palpated, however, the patient has a lot of problems with firing of the rectus and the adductors. We know that when patients come in, and we saw this in our first session, that hip pain oftentimes is a C sign, but core muscle injury occurs really above the pubis bone. They'll point to the area above the pubis or in the area of the adductor longus. I find that resistive sit-ups are a crucial part of my examination, as they will oftentimes show me whether they have pain, and I do these with their legs straight, with their hip and knees flexed and their feet on the table, and hip and knees flexed with their feet off the table. Adductor pain becomes very important also to differentiate as to whether they're having patients and really want to do resisted adducted maneuvers. It's important during this examination that you do feel comfortable for a indirect hernia. Bone studies should be used to exclude other conditions, as well as confirm the diagnosis of core muscle injuries. Radiographs become important. Bone scans I don't use too much, and MRIs are really the mainstream of my diagnosis. Here is the technique which I currently employ in my practice. If you're going to look for athletic pubalgia or core muscle injury, you want to screen the pelvis initially with large field views, and then you want to have smaller field views focusing on the pubic symphysis, looking at coronals, stirs, sagittals, and obliques. I find that the coronal T1 stir, sagittal, obliques are your best imaging around the symphysis pubis, and that it will show tears of the rectus abdominis, as you can see here. Fluid, they'll show on the coronals. Secondary cleft signs, which are micro tears of the origin of the adductor longus and other adductor musculature. Again, it's very important to not only take a look at the rectus attachments, but also the adductor tendons as well. Of course, while you're doing this, you can also evaluate for concurrent pathology, especially FAI in the hip joint. Non-operative treatment options, they include rest ice. In my practice, I oftentimes will use steroids to help differentiate whether the pain is coming from the hip joint or from the attachment of the rectus of the adductor areas. There are people who talk about PRP injections and stem cell injections. I just currently don't use them in my practice, I use steroids. And again, this easily is done, the area of injury is palpated, and you're able to directly go into that area, and then you can do a resistant sit-up afterwards and see whether it takes away the pain or if the pain is around the hip joint area. Same thing for these same injections in the adductor longus region. Here physical therapy after conservative management really is one which is structured to focus on decreasing the pain and strengthening the posterior core of the pelvis. By fixing the anterior pelvic tilt, oftentimes these patients can get through a season or get through what they need to in a conservative care fashion. And if they have pain afterwards, there's a possibility they may need surgical intervention. Post-season, however, this is a totally different talk, as well as the talk that may occur if the athlete is in between seasons. These are very important times that if they're going to fix something, and they can fix their core muscle injury, it's a good time to fix it. And these are discussions you're having with the team, the coaches, the athlete, in terms of getting them back on the field of play. Surgical options include open primary repairs, laparoscopic repairs, and with the adductor tendons can either be repairs or releases. In our practice, we have three primary goals to reinsert the rectus abdominis to the pubis, stabilize the interface between the rectus and the conjoined tendon, and reinforce the posterior wall of the inguinal ligament. Here's an example of the incision, and we take the spermatic cord away after we go through the fascial layers. And here you can see the actual hernial defect. And here you can see me pointing out the rectus tendon, where the weakness of the posterior wall, and then what I'm going to attempt to do is bring this down to the symphysis pubis to re-tension that rectus area. Once that's been re-tensioned, then I do a repair of the posterior wall of the inguinal canal, which you can see very well here. With the adductor tendon, I do not do a lot of reinsertions and repairs. I do a lot of releases. They've been very successful in my practice in terms of taking care of the adductor pain without a loss of strength in return to full function. I do this release such that I do not affect the musculature that's coming behind the adductor longus. And also, I will put, you can see with my forceps, I will put a stitch between some of the fascia in there so that this does not go down too far down their leg. We did do a study to look at this with a three-year follow-up, and what we found was that if indeed you chose the right people to have this procedure, there were very few re-operations needed, and honestly, on all outcome scores, there was significant improvement. Post-surgery rehabilitation, again, in my hands takes about eight weeks. I'm unable to, unlike some of the European literature, get athletes back within three to four weeks. I have a four-phase plan with which follows out and allows them to slowly return to sports and plyometric activities. So again, groin pain is not a single energy, but is part of a syndrome of pelvic instability and pain. You need to include both your diagnosis of back problems, FAI, and groin problems, and an ability to recognize all these things will give you the correct diagnosis and the appropriate treatment plan. Thank you. Thank you, Brian. Our next speaker is Dr. Winston Gwathmey from the University of Virginia, and he'll be speaking on gluteal tendon injuries. Thanks, Winston. My name is Dr. Winston Gwathmey. I'll be speaking about gluteal tendon pathology. The disclosures. Gluteal tendon tears have often been called rotator cuff tears of the hip. This is a paper from 1997 in which the authors looked at 50 consecutive femoral neck fractures. They found tendon tears in 22% and thought they looked awful close to the rotator cuff tears they see in the shoulder, hence the name rotator cuff tear of the hip. Taking that a step further, the supraspinatus and infraspinatus of the shoulder act very similarly to the gluteus medius and minimus in the hip. Additionally, the deltoid in the shoulder acts as a shoulder abductor, similar to how the tensor fasciae latae and the gluteus maximus act on the hip. Finally, the actual arthroscopic appearance of the rotator cuff tear of the shoulder looks very similar to the endoscopic appearance of the gluteal tendon tear. The gluteus medius and minimus take their origin from the outer surface of the ilium and insert onto the greater trochanter of the femur. The minimus is deep to the medius. There are four named trochanter facets. The anterior facet is where the gluteus minimus inserts, whereas the lateral and superior posterior facet is where the medius inserts, as well as some fibers in the posterior facet of the greater trochanter. The gluteus medius has two parts, an anterior lateral part and a posterior part. The posterior part is slightly thicker than the anterior lateral part, and they are separated by a thin band of tissue. On the femoral trochanter, the anterior lateral part inserts more into the lateral facet, whereas the posterior part inserts in the superior posterior facet. The gluteal function in the coronal plane is to abduct the hip, both the minimus and the medius. In the sagittal plane, the minimus acts as a weak hip flexor, whereas the posterior fibers in the medius acts as a weak hip extensor. In the axial plane, the gluteus minimus acts as an interrotator, as well as the anterior fibers in the gluteus medius. The posterior fibers in the gluteus medius help to stabilize the femoral head from the acetaglum. The gluteal tendons are very important as far as maintaining pelvic balance. When you have gluteal dysfunction, you have these telltale Chandelberg side or Chandelberg gait because the one side of the pelvis will dip. Gluteotropic pain syndrome is the most common tendinopathy in the lower extremity. It's a disease spectrum similar to rotator cuff syndrome in the shoulder. It ranges anywhere from tendinopathy to full thickness tearing. It should be noted that trochanteric birth situs very rarely occurs in isolation. There's usually some underlying condition. It's most prevalent in older women. It's often bilateral. As far as risk factors, again, older women, especially those who are obese, who have concomitant arthritis, are most at risk for greater trochanteric pain syndrome. The pathophysiology is similar to other tendinopathies within the body. There's cumulative microtrauma as well as decreased vascularity with age. There's also some element of compression of the iliotibial band against the trochanteric facets. There's variable involvement in the medius and minimus with many times partial tearing occurring in the anterior fibers and undersurface of the gluteus medius tendon. Again, it's a spectrum disease ranging from tendinopathy to partial tears to high-grade partial tears to full thickness tears. With chronic tears, there may be retraction atrophy. This is a partial articular gluteal tendon avulsion described by Dr. Noh. It's very similar to a pasta lesion in the shoulder. However, it should be noted in the shoulder, you have the interarticular view arthroscopically, which you might be able to see this tear from. In the hip, you might not be able to see it quite as easily because it's hard to get to the undersurface of the gluteal tendon. Looking at MRIs of gluteus medius and minimus tears, it's important to look at all the sequences. Here's a high-grade partial tear of the gluteus medius on the posterile left facet. It's important to use all sequences to characterize the architecture of the tear. Fatty atrophy does occur with chronic tears. This is similar to the shoulder. The gluteal declassification has been applied to the hip. Here's a paper from Dr. Noh. They found they had worse results with higher grades of fatty atrophy of the gluteal tendons. Elements of the patient's history, it's important to recognize that oftentimes it will present with lateral-sided hip pain, insidious in onset, worse with prolonged standing and walking, usually worse by the end of the day. A lot of times these patients report difficulty sleeping on that side at night. On the physical examination, the hallmark will be tenderness of the greater trochanter. Sometimes the gluteal tendons will be tender as well. They may have pain with favor testing because you're stretching the anterior fibers of the gluteus medius and the gluteus minimus. They will probably have some weakness in hip abduction. With more severe cases, they might develop the Schindelberg's side or Schindelberg's lymph, as you can see in the video. Ben Dome and his group described a resistant ventral rotation test. This was highly sensitive and specific for gluteus medius anterior fiber tears. When establishing a treatment algorithm, many patient factors come into play. It's important to recognize that many patients are asymptomatic with gluteal tendon problems, and so not all patients need surgery. The quality of the tear, the size of the tear, the quality of the muscle, all this stuff is important when it comes to making a treatment plan. It's also important to look for concomitant arthritis, both in the hip or the lumbar spine, when you're trying to establish a treatment algorithm for this. Non-operative treatment is first line for most cases, especially tendinopathy and partial tears. Physical therapy, stretching the iliotibial band, working on public stabilization. Corticosteroid injections have obviously been utilized heavily in this patient population. There's not really great long-term data supporting utilization of corticosteroid injections. It does help. It's probably short-term, and you do worry that repeated corticosteroid injections might have a detrimental effect on the tissue quality. Biologics of PRP have also been described. For the most part, there is not great literature out there for PRP, but there are some studies that support its utilization, and certainly I've used it with some good results in my patients. Once you decide on surgical treatment, you should do this in patients who are refractory to conservative treatment. Those patients who have gait abnormalities or are significant in weakness. Those patients with high-grade partial tears or full thickness tears are typically amenable to surgery. Open, endoscopic, and augmented repairs have been described. And the muscle quality ends up being pretty important when you're trying to determine what type of repair to do or whether to repair at all. Dr. Odom and his group tried to predict the need for surgery. They found in this paper that those patients with a Trendelenburg gait or weakness in abduction had a higher risk of needing surgery. The gold standard for this has been open surgical repairs. A lot of this comes from the arthroplasty literature. Using an iliotibial band split similar to the tilt-hip arthroplasty approach, both bone tunnels and suture anchors have been described. The results from this have actually been very good. Most of the papers report excellent results with 90% in this paper of 72 cases with either pain-free or minimal pain. Another paper by Dr. Davies and his group looked at 22 patients and had excellent outcomes at five years. This is a paper looking at both the clinical outcomes and the imaging outcomes at 4.6 years after gluteus medius and minimus repairs. They found excellent improvement in modified Harris hip score as well as a low failure rate on MRI. They also noted that muscle atrophy does have a negative impact on the functional outcome. With the evolution of advanced hip arthroscopy techniques, endoscopic repairs gained some popularity. The greater tricoteric space is very similar to the subacromial space in the shoulder. Rotator cuff technique can be applied to the gluteus medius and minimus tendon tears as well. The results are also very good for this. This is Dr. Kelly's, one of the first studies that was reported, and all 10 patients that he had operated on with this condition had excellent results. Ben Doan and his group looked at 15 patients, and they showed an average improvement of 30 points in all scores with good excellent results in 14 to 15 patients. When trying to compare open versus endoscopic, there's been some research looking at this as well. For the most part, the outcomes are essentially equivalent. There have been some reports of increased complication in the open group. I think when it comes down to it, it really serves with preference and also the size and quality of the tear. Some surgeons will prefer to treat the partial tears or non-retracted tears endoscopically, while the larger, more retracted tears, those atrophy would be better equipped to handle with an open approach. Augmented repairs have gained some popularity lately. A lot of times when you repair these tendons, the repair site is pretty tenuous. The tissue is not exactly the most robust, and you want to augment the repair. Both open techniques as well as endoscopic techniques have been described to help support the repair site. What do you do when you have a chronic tear or a failed repair with atrophy? This is a really big problem for people. Dr. Whiteside described a gluteus maximus transfer. Here he transfers the anterior fibers of the gluteus maximus tendon to the greater trochanter. That helps to stabilize the gait, helps to stabilize the pelvis, and improves some hip abduction strength. Vendome is a case series of three patients in which he did a gluteus maximus and anterior fascia moda transfer to the greater trochanter, and had good results in two out of the three patients he did this on. Obviously, we need some more research on this to see if it's going to be a good treatment algorithm. In summary, gluteal tendon pathology covers a broad spectrum of disease severity. It's analogous to the roads that are cut from the shoulder. Tendonopathy and low-grade partial tears are minimal to non-operative treatment. Higher-grade tears, complete tears, in those patients who are refractory to continuative treatment do well with surgery. Open and endoscopic repairs offer similar efficacy. You definitely have a worse prognosis with muscle atrophy. And there's still a big problem with chronic abductor deficiency, and so we're still looking for better techniques to treat that. Thank you for your time. Winston, thank you. I appreciate that. That was excellent. Our next speaker is Dr. Chad Mather from Duke University. His topic is on the treatment of hamstring injuries. Thank you. Well, I hope everybody's doing well this evening. I'm glad that despite the circumstances, we could still get together to share this valuable educational content. I'm excited to be able to cover a topic that I'm passionate about, very interested in, the proximal hamstring tear pathology. Humeroid exposures. I'd like to think of proximal hamstring pathology across the spectrum, starting with tendinopathies that you often see in younger patients and athletic patients. You then start to see more chronic partial thickness tears or high-grade tendinopathies. If you turn this MR on the side, it looks a lot like a rotator cuff tear, and that's really what many of these are. They maybe are better termed high-grade partial thickness or near full thickness tears and oftentimes act that way with that type of pathology. Then we get into the category of full thickness tears with minimal retraction. This is an example of an acute one here where there's just a few centimeters of retraction and largely the tendon is still at the level of the ischium. Then have your classic full thickness retracted acute tears with large hematomas and the painful initial post-injury state. Then lastly, the toughest of the group, more of the retracted chronic full thickness tears. To start with, it's important to cover the anatomy of the proximal hamstring. As you recall, there are essentially two primary tendons at the ischium, the conjoined tendon and the semimembranosus tendon. The semimembranosus tendon wraps around anteriorly and the conjoined tendon is more posterior. There is a clear interval where fat can be found that delineates the two. Of course, the sciatic nerve is very close by. It's also important to understand the functional pathology. While many of these do begin as degenerative conditions, both at the footprint or at the musculotendinous junction, as I've observed in younger patients, it's the functional pathology that often leads to this. It's important because it's the other side of the functional pathology we see with FAI. For both, it is the inactivation of gluteal muscles. In FAI, the gluteal muscles don't externally rotate, leading to more internal rotation and impingement. In hamstring pathology, they don't do their job in extension, leading to a hamstring dominant pattern and overload of the proximal hamstring. That, combined with tightness, really loads that proximal hamstring tendon complex and can lead to, if not to tears themselves and a minimum of symptoms where a degenerative tendon is present. Symptoms are often seen with cramping in their function. That's what you look for separate from buttock pain. I want to hear that they have difficulty with acceleration, difficulty with stairs, things that are more specific to the function of the hamstring rather than just sitting or buttock pain. In the chronic state, with chronic tearing often, I also look for neuropathic symptoms that may dictate whether the nerve is tethered or adhered into the area of previous injury. Also, the location of pain is typically right at the tuberosity but also can extend down into the hamstring belly. I like this test here on the right, this proximal hamstring stress test, where you flex the leg at the hip and then extend the knee. That loads the proximal hamstring. This will often separate proximal hamstring pain and pathology from sciatic nerve or other buttock-related pain. The treatment I'm going to talk about is primarily for these tendinopathies and chronic partial thickness tears, your chronic injuries. You want to start by ensuring that you're delivering a biopsychosocial approach. These are often chronic problems. Understanding their pain coping skills and surrounding psychosocial issues will assist with treatment. I definitely start with education, having them understand how the hamstring works, that it's a hip extensor, that it's used in acceleration, so they understand how it's driving some of their symptoms. We then talk about activity modification, whether some of those things can be modified to reduce the level of pain. With rehabilitation, the focus should be on glial activation and strengthening as well as hamstring stretching, both of these being to decrease the load on the proximal hamstring tendon. Also want to pursue a level of pelvic control and core strengthening as well as classic eccentric strengthening. PRP, I've used in the past. It is an option, although currently the literature does not support this. There is one randomized controlled trial finding really no benefit in the PRP group. Operative indications for the tendinopathy is chronic pressure and thickness tears, a real failure of non-operative treatment and severe enough disability to warrant surgery. On the more acute side, we generally identify operative indications as having greater than 2 centimeters of retraction or high demand or both. Early post-acute injury, I would say, is an indication. These injuries do better when repaired earlier. If you see them in that early post-acute injury period, this is a good time to repair them. In the chronic setting, I think cramping is a great indication for your operative indication. This is a big muscle. When it shortens and cramps like many short muscles will, it hurts a lot, a lot more than, say, the biceps. Even if you can get that muscle out to length, the graft or other repair technique in that chronic setting, at least it's going to address that cramping, even if it doesn't return them to full strength or full activity. With the surgical treatment options for proximal hamstring tears, we've got endoscopic repair, which I'll utilize primarily for the tendinopathies, chronic partial thickness tears, and then the minimally retracted full thickness tears. Then have your classic open repair, typically utilizing a transverse incision, a gluteal crease, and then the bigger open repairs for the T incision utilizing a graft will primarily be used for these chronic tears, full thickness chronic tears. Outcomes, so there's several published studies on the outcomes of open repair, and these are the highlights as it pertains to full thickness traumatic tears. Acute repair is superior primarily for sports function. With chronic repair, you get near normal, but not quite normal ADL function. Allograft reconstruction is equivalent to direct repair. There's a high rate of tendon healing with a study from Shahal et al in AJSM showing 100% healing on MRI. But in that same study, the patients had 78% strength in the contralateral hamstring, 85% return of support, and then 45% having decreased performance. So good outcomes, but not perfect. On the chronic tendinopathy side, most of this work comes from Jim Bradley, and it's got longitude outcomes even up to seven years with open repair. So again, some of the highlights in these patients is they did not have significant limitations of ADLs and a higher rate of return to running, but did have limitations in accelerate and with accelerating and cutting pivoting. The return to support was up to 11 months and when subjectively asked, they did have estimated strength of over 75%, almost all the patients. There was a 5% reoperation rate. And both of these studies was noted that sitting pain remains common. And I would say this is something I see in my practice as well. And I think is potentially a contraindication of surgical repair is a primary or sole complaint of sitting pain because it may be due to that tendinopathy, but you often trade that for some additional scar related sitting pain. And so again, looking for those functional complaints are key to the proper and ideal indication for surgery. Outcomes of endoscopic repair are important to evaluate as well. So we're doing more and more of these. And we just submitted this paper for publication. This is a mixed consecutive mixed cohort with minimum two year followup, primarily refractory insertional tendinosis with a mean age of 53, it was 67% female. In this group, the mean postoperative IHOP-12 score was 82 points and 80% of the patients achieved the patient acceptability symptomatic state or an IHOP score of 63. 77% were able to return to their prior baseline activity level and a 7% or one patient re-rupture rate. A fairly high return to sport, 100% that had been participating in organized sports returning, 72% returning to the recreational sport and 90% overall satisfaction. As far as postoperative management rehabilitation, one thing to keep in mind is that these patients have a high rate of DVT with acute tears and the study with Miller et al recently published OJSM, a 6.9% of patients in this cohort had symptomatic DVTs and half of those were diagnosed preoperatively. So it's important to assess the risk factors, counsel all patients and not just your surgical ones. It may be appropriate to anticoagulate some of them or screen them. As far as perioperative protection, I'll use a HENGD brace locked at 90 degrees at night only. I will not use a brace during the day or with weight bearing, but I do utilize partial weight bearing for six weeks. For us to return to sport, I'll let them start to jog approximately four months. But again, this is really very, very much dependent on their gluteal activation and recruitment as that protects their repair and allows them to return to functional activities in a safe fashion. So in summary, there's a spectrum of proximal hamstring pathology. Remember chronic injury is very common. Non-operative treatment of those should be focused on biomechanics and the biopsychosocial approach. For acute tears, acute repair is recommended if possible, except in higher risk or low demand patients. And endoscopic repair is technically feasible and safe. Thank you. Chad, thank you very much. Wonderful talk. Our next speaker will be Josh Harris from Houston Methodist. He'll be talking about posterior hip pain. Thank you, Josh. So the title of this presentation is posterior hip pain and I'm Joshua Harris. I wanna thank AOSSM for the opportunity to present during the athlete's hip. Here are my disclosures. And so before we begin, I really wanna direct everyone to a terrific textbook that was just published at the end of last year by Dr. Hal Martin and Juan Gomez Hoyos. It's a very, very comprehensive book that looks at posterior hip pain, which we're gonna be talking about for the next 10 minutes. And I would recommend everyone getting this book. So like most things with orthopedics, it begins with anatomy. This is a posterior view of a right hip. Looking at your different bony landmarks, up at two is your sacroiliac joint, at seven is the posterior aspect of your greater trochanter and 20 is your ischial tuberosity where the proximal hamstring number 19 attaches. And in this posterior hip is what we're gonna be talking about for the next 10 minutes. As you can see here, the lighthouse is really your ischial tuberosity. Anything medial to that is frequently related to your pedendal nerve. Anything lateral to this area is gonna be related to ischiofemoral impingement, which we're gonna be mostly discussing or your sciatic nerve, which is number 14. Looking at the different clinical diagnoses that you can see, this goes back to that ischial tuberosity lighthouse, which you can see is number four. Anything medial is your pedendal nerve. Anything lateral is ischiofemoral, which is number three, or your sciatic nerve, which is number two, or a trochanteric bursitis or greater trochanteric ischial impingement, which is number eight, or the piriformis, which is your number one. Something that's not covered in those previous two cartoons more relates to the vasculature. And whether you're coming from a prone supine anterior or posterior, if you're operating around the lesser trochanter, you have to be cognizant of your medial femoral circumflex, which is the primary blood supply to your femoral head, or even your first perforator on that distal margin of your quadratus, as you can see here. There are over a dozen different posterior hip disorders, and they involve all the different layers of your hip. What we're mostly gonna be discussing here is ischiofemoral impingement. As you can see here, it really covers four out of the five. Traditional ischiofemoral impingement has primarily been described between your lesser trochanter and your ischium. And this can potentially compress your sciatic nerve. It can compress your quadratus femoris. However, this is incredibly common in cadaver specimens. In 10 degrees of extension, 10 degrees of adduction, about 84% of cadaver specimens will demonstrate ischiofemoral impingement at only about 30 degrees of external rotation, as you can see here. The more you externally rotate, the more it compresses the space down. The more you internally rotate, the more it opens the space up. Greater trochanteric ischial impingement can also occur. This is more with a flexion, abduction and external rotation position. The presentation of patients with ischiofemoral impingement or with most posterior hip pain is pain posteriorly that's lateral to the ischium. Patients will frequently shorten their stride. And on physical exam, this can really be demonstrated with your long stride walking test. Sciatic nerve symptoms are common. This can be a Tenell's with just tapping on the sciatic nerve in the ischiofemoral space or even a double crush phenomenon, even with patients with concomitant lumbar spine pathology. Patients with ischiofemoral impingement will also frequently have proximal hamstring tendon problems. And as you can see here, both on the axial cut and on your coronal cut, that attritional friction from your lesser trochanter rubbing on the hamstring can cause a proximal hamstring tendon problems. Patients will also have butt pain with sitting. They'll also have lack of hip extension. They'll feel like they are unable to really get their leg back. This is really from premature coupling anteriorly. You can see this in arthritis. You can see it inversion abnormalities or even post arthroscopy. You can see it with an overtightened ischiofemoral ligament and overtightened capsule repair. However, probably the biggest positive for a patient presenting is a positive response to an ischiofemoral injection. If their pain goes away, that really does confirm that the ischiofemoral impingement is a potential source of their symptoms. On physical exam, you wanna check for ischiofemoral impingement both with or without proximal hamstring tendon problems. If it hurts on the ischial tuberosity, it's their hamstring. If it's lateral to the tuberosity, that's gonna be ischiofemoral impingement. And you really wanna make sure this reproduces the chief complaint pain that brought them to the office. If that's their pain, then that's what you need to evaluate. If they say, well, yeah, this hurts, but this isn't why I came in, you need to evaluate something else. On MRI, you can look at your quadratus femoris and ischiofemoral spaces to really determine if ischiofemoral impingement is a possible diagnosis. However, remember that this is a static test really evaluating a dynamic phenomenon. We've looked at the presence of edema in that quadratus femoris space. And in patients that present with posterior hip pain, about a quarter of them will have edema, or I'm sorry, a quarter that have edema will actually have symptoms. And be very, very careful, especially in ballet dancers and gymnasts. We looked at this in a group of professional ballet dancers and every female professional ballet dancer did have edema in that quadratus femoris space. And so be careful of that and treat patients, not just an MRI. Playing radiographs can also be very helpful, especially in patients with a valgus hip, with an increased neck shaft angle, there's a higher prevalence of posterior hip pain secondary to ischiofemoral impingement. Measuring femoral aversion, whether that's either with a CT or an MRI, it's very helpful in evaluating these patients. However, I think one of the best ways to really evaluate this is with 3D printing. You can do this with CT, you can do this with MRI, you can also do it with EOS plane radiographs to really demonstrate to patients, to residents and fellows, and to preoperatively plan to really make sure that you get this surgery right, because this is a complicated area and three-dimensional evaluation is incredibly helpful. Treatment is largely non-surgical for ischiofemoral impingement, and it really boils down to understanding the etiology. These patients will frequently begin with either an intraarticular or peritrocanteric cause, which leads to a Trendelenburg gait. And then by correcting this Trendelenburg, usually with physical therapy and abductor strengthening, it opens up that ischiofemoral space and allows the ischiofemoral symptoms to resolve. And injections can be incredibly valuable in getting patients through a therapy program. Surgical treatment can be done both with a scope or open, can be done either from supine or from prone, and they each have their own advantages and disadvantages. Any lesser trochanteric resection is obviously gonna violate the psoas, and so that has to be taken into consideration with both preoperative planning and postoperative rehabilitation. Ischioplasty is going to, by necessity, involve either releasing and then repairing, or primarily repairing your hamstring. The sciatic nerve proximity has to be taken into consideration, and neuralysis is frequently a part of your procedure. If approaching from anteriorly as we're doing here with live flora, you can see that a curved burr is incredibly helpful to make sure that you plane the lesser trochanter perfectly and you don't leave residual lesser, and also you don't notch your femur. Retaining your iliopsoas can be done. A neat little technique published by Dr. Matsuda just last year in arthroscopy techniques shows that you can actually, with a suture anchor, retain your iliopsoas while also planing your lesser trochanter. The scope does have its advantages. Whether that's supine, anterior, or posterior, you can also evaluate your joint, any cam or pincer impingement, labrum, also your glute med, your abductors can be evaluated, and it significantly magnifies nerves and vessels, and so you can really do a good job in preserving nerve structures and avoiding any iatrogenic injury. Big disadvantage, though, is swelling around the abdomen, pelvis, perineum, and thigh. Also, your dynamic exam may not be as good with a scope as it is with open. However, I'd be remiss if I didn't mention other body systems. Don't forget GI, GU, and OB-GYN causes a potential cause of posterior hip pain. A big one is don't miss your pedendal nerve. Post-arthroscopy, pedendal neuralgia can be shown here. As you guys can see, there is a point where the pendental nerve can be compressed. However, also after open proximal hamstring repair, be careful with retractor placement as we know that the pendental nerve can be less than three centimeters away, on average, 2.5 centimeters from a retractor that would be placed right over your ischial tuberosity to expose that ischial tuberosity footprint. And so, in conclusion, the posterior hip pain diagnosis is really based on a good understanding of your anatomy combined with HNP and imaging, very analogous to our Warwick Agreement for femorositabular impingement and labral pathology. Initial treatment is largely nonsurgical and usually successful. Surgical treatment can be done either open or with a scope with inherent advantages and disadvantages and good short and midterm outcomes. Thank you. Josh, thank you very much. Our next speaker is Dr. Michael Salata coming from University Hospitals in Cleveland and he will be speaking on the approach to the failed hip. Thank you, Mike. It's my pleasure to be a part of this meeting. I'm gonna be speaking to you about the approach to the failed hip arthroscopy. I'm Mike Salata from Cleveland, Ohio. And I hope that there's a few things that you might be able to learn from this presentation. These are my disclosures. They have nothing to do with this presentation. So complications versus normal post-operative issues I think are challenging to determine. There are many issues that can occur when performing hip arthroscopy and it is critically important to have a thorough and detailed preoperative discussion with your patients as some of the things that may occur, including muscle soreness are not really complications but normal post-operative issues. And as your practice evolves, so will your post-operative issues as you get better at doing osteoplasties. Some of the things that we'll talk about won't quite be as applicable. There are many issues that can occur when performing hip arthroscopy. The reported incidence of complications is less than 1.5% for all arthroscopic hip procedures. This was a study performed in 2003 that showed this. And Griffin and Biller have also showed some of these complications. So when something goes wrong, you have to try and figure out what or who is to blame. Was it the wrong diagnosis? Did you take not enough bone, too much bone? Is there heterotopic ossification, counter labral adhesions, labral issues, capsular issues, or other issues, including DVT or poor therapy? Certainly the wrong diagnosis can find us all. This is a dysplastic hip that you can see clearly on the left side of the hip. And if you try and treat that arthroscopically, they may fail and require revision to PAO. Mystisplasia is one of the most common things that I see in my practice. I like to use the acetabular inclination or the tonus angle. If it's above nine, I start to get a little bit concerned. Certainly if it's above 12, it's something that you really should refer them or consider a PAO if you do those. Trying to evaluate for femoral or acetabular version issues, certainly if they're posteriorly uncovered or if they have excessive femoral retroversion or retrotorsion, this can certainly lead to a problem. Otherwise, things like capsular laxity, lumbar discomfort can always be problematic and be sources of the wrong diagnosis. In terms of evaluating for posterior uncoverage, this crossover sign is one thing that people use for acetabular retroversion. Certainly this has been disproved by Ashish Bedi and I results where they looked at 38 well-positioned pelvises and found that only 19 had focal or global retroversion on CT scans. So it's really important to consider three-dimensional imaging to try and avoid some of these pitfalls. When you're thinking about the hip, there's instability and there's impingement and they can overlap. And so just because you have impingement doesn't mean that you can't also have dysplasia. So both of these things can coexist and it's something to really be cognizant of. Femoral retroversion, as we noted, has been shown to be a relative risk for failure after camera section. This was a study by Brian Kelly's group and this is important to try and think about these things if you aren't already. Other causes of pain can be seen here and these are also things that you need to think about if you feel like you may have made a misdiagnosis. You can take too much bone. As you see here, first of all, this hip probably shouldn't have been scoped because there's too much arthritis there, but also you don't wanna do too adequate of a resection as you can see here. Residual femoral acetabular impingement is the most common reason for hip revision preservation surgery. And the biggest thing is visualization. So in order to, you have to be able to see what you're doing in order to take the bone away. This can be corrected fairly easily if you haven't taken enough bone. Here you can see this is my preferred technique. We're looking from the anterolateral portal and working through the modified mid. We have two traction sutures in the capsule and I've kind of slid my camera down the neck and I'm looking up the view so that you can see this. And really you wanna look at it from multiple directions. You're really trying to create a three-dimensional shape. And so looking at it from just one view is often not enough. You can spin your camera here as I'll show in a few seconds. And you can really see that you can look both up the pike here and also down the neck from the other view. And I think this, you can get all the way to the vascular pedicle there to be sure that you've got adequate resection. And here I'm just showing you how we can flip from views and see from multiple directions is very helpful. Bony resection too much is the bigger sin. There really is no bailout for this that's reliable. So when in doubt, take less and really see what you're doing. And also use a fluoroscopy, especially early on so that your x-rays don't wind up in this talk. You wanna avoid resecting more than 30% of the neck width. This, you wanna try and attempt to maintain the normal convexity to concavity relationship. As Mark Philippon says, you want a blue slope not a black slope because they can lose their suction seal when they get into flexion. Over resection of the rim can lead to instability. There are many reports of iatrogenic dislocations and this is probably under reported. Certainly if you have a retroverted socket with posterior uncoverage and then you take a bunch of bone from the front now you've made that hip globally unstable. We looked at a study where we looked at a cadaveric study and the resection in the area where the labral tears are usually seen from the 12 to three o'clock position. And we found for every millimeter of bone there you take one degree off the lateral center edge angle but almost two degrees off the anterior center edge angle. So you really have to be careful with this. And then Shane Ngo did a study showing that you're actually concentrating the contact forces here which is kind of counterproductive to what you're trying to do in preventing arthritis. Heterotopic ossification, the overall risk is about 8.3% without prophylaxis. With prophylaxis of an anti-inflammatory I use Indosyn but other people have used others such as naproxen that drops it to 1.8%. And this is important also to remove as much debris as possible and limit capsular trauma. If you get it, wait till it's mature and then you can resect it and this can be very effective. Anchor issues, certainly these can be problematic. Perforation into the psoas fossa is a problem. This can be seen on imaging and removing that or doing a psoas lengthening or decompression in this area can be helpful to eliminate this problem. Subchondral anchor placement can be a problem. You wanna look into the joint while you're drilling so that you don't put the anchors into the subchondral plate as you see here. This can be a cause of pain and can also lead to degeneration of the joint. If the labrum is gone or resected, that can be an issue. Capsular labral adhesions we'll talk about. Those happen probably in everybody but it's really important I think to eliminate these especially in the scar former. So you can see up top where there's a wall of adhesions. You can see those kind of thick bands there. You can see this is after we've kind of laced those adhesions here, the labrum itself is healed but the patient had a good clinical outcome after the adhesions were laced. In my practice postoperatively on an MRI arthrogram I think they're very easy to see as you can see there. Labral issues, if you take it out or it didn't heal you can do a reconstruction and that's been really eloquently described by several authors and the outcomes can be very good for this. Here's a case where a patient had a labral deficiency from previous labral repairs at an outside institution and we ended up doing a circumferential reconstruction and the patient did well. This is just a little video showing that. I'm gonna save it for now just based on time constraints and I'm sure it'll be covered in other lectures. Capsular issues can be a problem. Certainly if you don't close the capsule it can be an issue. There've been improved clinical outcomes in many studies with closure of the capsule as it restores more normal joint kinematics and eliminates micro instability. Here you can see a nice fluoroscopy from Steve Aoki and one of his postoperative patients. You can see this is just with normal axial traction. He had not closed the capsule. He went back in and closed the capsule and then you'll see in the video that it restores the normal kinematics on the fluoroscopy. This can be seen on an MRI arthrogram. Patients will complain of their hip giving out or popping. Certainly if you did repair the capsule and it didn't heal or re-ruptured that can be a cause of pain and so you wanna try and endeavor to repair that. Sometimes the capsule is gone either by yourself or somebody else and you can reconstruct it. Here we are measuring the defect. We put anchors above the labrum. Here you can see those anchors in place and this one we used a acellularized human dermal graft to reconstruct it and you can do this and it can be helpful as technically demanding and it really is a salvage procedure. Traction issues can be problematic. Iatrogenic labral injury is reported less than 1% to 20% of the time often due to poor distraction. Using a small cannula, venting the hip, doing an air arthrogram and if they're non-distractible going outside in can be very helpful. Overzealous traction can lead to pudendal nerve palsy. Currently, I use a postless distraction technique and this has eliminated that problem in my practice but other nerves can be at risk. There are other issues including abdominal compartment syndrome especially if you open the capsule over the iliopsoas or if you're doing this in the setting of a PAO. DVT is about 3.7%. Early mobilization, TED stockings and prophylaxis can be helpful. And finally, rehabilitation is critically important for this surgery. Identifying a very good physical therapist in your area and helping to work with them by lecturing to them about what you're doing, having them observe you in the OR can be very important. Basically, limit weight bearing early but not non-weight bearing early. Deep and soft tissue releases an early hip range of motion and avoiding active hip flexion can be very helpful. Look for patterns of deviations and identify those as problems. Thank you for your attention. I appreciate it. Excellent, Mike. So at this point, we'll get all the speakers to go ahead and turn on your webcams and we'll go through a series of questions. The first question we got from the audience was directed to Winston. Winston, when you're treating patients or you're indicating them for gluteal injury and gluteal repair, do we actually do any work inside the joint? What's your decision-making as far as treating interarticular issues simultaneously? I think a lot of it comes from your diagnostic algorithm. I tend to use differential injections and try to determine whether the joint's symptomatic or not. I mean, if someone has clear underlying FAI that's driving some of their symptomatology, a labral tear or something like that, especially somebody who's a little bit younger, but someone who just has lateral base hip pain with an MRI that lights up on the outside of their hip, we've done an injection in the trochanteric space that alleviates a lot of their pain. I tend just to work within the trochanteric space, especially if I'm obviously I'm doing endoscopically. Yeah, I feel like if I'm in the joint for a long period of time, sometimes it can obscure the soft tissue out there. It can make it a little more challenging to get out there and do any sort of high-level work out there. So if I think the gluteal tendon's really the target, I'm gonna spend most of my time out there in the endoscopic, in the paratrochanteric space. And obviously if I'm doing an open repair, I tend not to do the joint at all. Brian, do you have any other comments on that? Yeah, I agree with everything Winston has to say. I do a lot of my repairs open because I just feel that I get a better repair. A lot of my patients that I'm doing these tendon tears on are in an older population that I may not be doing any FAI surgery for them anyways. So I tend to really isolate on that. Of all my patients, it's quite amazing. I was once hesitant to do these types of patients, but Tom Bird says this as well. These are some of my happiest patients, but you gotta wait nine months. They don't turn around and get better, at least in my hands, they don't get better quickly. But at nine months, there's, I'm gonna be a little bit disappointed with my COVID factor now, but it was one of the times that I'd get a huge hug that I changed these people's lives. So be patient with them and whatever your best surgical technique, I like a double row and actually look at it. So I won't go into the hip quite often. So what do you do, Mike Salata, if you got, let's say a 65 year old woman with an abductor tendon tear, and she brings the MRI report and she says, look, doc, I've got a labral tear. What are you gonna do about it? No, I think that really goes into the process of counseling the patients and really working with them preoperatively to make sure they understand the problem that you're dealing with. I think the majority of the time, you know, if you are really thoughtful and talk to your patients and tell them, you know, anybody probably over the age of 60, if you get an MRI is gonna have some amount of labral pathology and really trying to educate them about the location of their pain and why they hurt, I think goes a long way in terms of making sure they understand the diagnosis. And then for me, you know, as I already talked about, I rarely will enter the joint in these patients. I think the majority of them come in with lateral discomfort and they're happy with the explanation if you take the time with them. And Chad, what are you doing for, you know, let's say a 70 year old patient, pretty significant limb, maybe using a cane, you know, you get, you know, obviously lateral sided hip pain, you get an MRI, it shows a chronic massive retracted tendon tear. What's your, what are you doing with that patient? Well, yeah, most of those patients have pretty significant fatty atrophy. So repair is very likely to fail. You know, if they're thin and they have a good social support system, then I might try the glute max transfer. But that's, you know, that's even, that's significantly harder to get over than the abductor tear that we were talking about. So, you know, I tread lightly into those patients and a lot of them are fairly overweight. I think somebody that's just a lot to ask that look, you know, that transfer to do all that work. So usually what I talk to them about is trying to just use a cane. And definitely, I know they don't like that, but I tend not to operate in a lot of those patients. Winston, what are your thoughts on augmentation? Have you tried any of that? What's kind of been your experience? You know, I've, my thoughts on augmentation is that, yeah, sometimes that repair tissue is pretty tenuous. I haven't, I don't do a lot of augments myself. I've seen Javon and what he does endoscopically with some of his augments and it looks really nice. And I do like the idea that it can not only bolster the repair, but also reduce adhesions to the lateral band. And so I do like the concept of it. And I think I'm gonna probably use it in my practice more frequently. Yeah, I mean, I actually became curious about it as well, because I think what I found is that sometimes the way that these tendons tear are different than like your shoulder or rotator cuff. And if you do enough open, I'm sure Brian may have some thoughts on this, is that a lot of times I feel like the muscle kind of delaminates from the tendon. You know, and so then you're stuck with trying to repair muscle to tendon. And really, I think that that's where the graph, at least what I've been curious about, is to provide a little bit more of a scaffold. And so my preference is to do it open with a, like an acellular dermal graft. But do you guys have any other thoughts on that or any experience with that? We'll say sometimes that repair tissue is pretty wispy. You know, you put a stitch through, you're like, is this really gonna hold, you know? And so I do think having something to augment that would be super helpful. Yeah. Yeah, but I've had a good success with that as well. We'll get one of the muscles in good condition. Yeah, I think I found that to be a little bit more palatable than the glute max transfers. Just because the transfers, it's usually kind of an older population, their bone quality, bone stock's not very good. And then you've got like a non-anatomic repair and it just, I think my failure rate when I was doing them were probably 50% or greater. Yeah, so was mine, Shane, it was 50%. And the people that failed were miserable, you know? Yeah, it was super bad. I mean, there's no salvage. You know, I heard Dr. Whiteside speak one time and I was like, man, I don't know how you're getting the results that you do because I have not seen the same thing. Yeah. I think a lot of their glute maxes aren't very good either. One of mine failed, I look back at the MRI and her glute max was pretty marbled. So sometimes the muscles we're transferring may not even be very good. One of the things that I started doing when I first started doing endoscopic glute meds, I was just basically looking at that actual muscle tendon junction that you were just talking about, Shane, and I would put the scope in, look at that muscle tendon junction, and if it looked decent, I would do the endoscopic repair. If it didn't, I would immediately take the scope out and actually just open it. And those patients actually did better. I think I got a better repair, it was a stronger repair. And it's probably that muscle tendon junction because sometimes when you put that scope in, there's just not a whole lot of good tendon that's present. And I think that you're trying to repair muscle to bone and it's certainly a challenge. Yeah, I agree with you. And I think that's, you know, when I see some of these, specifically the gluteus minimus tears, that's where I kind of felt like, you know, I was just putting, you know, suture through muscle and I was like, there's no way this is helping, helping, helping this patient out. Josh, can I ask you what's your process for converting to open? Are you supine, you flip them lateral or? I'm supine and usually we don't change anything for the actual prep for the drape. We usually just have one of the nurses lift the hip up and then place a bump or a pillow underneath, depending on the patient's size. And it's usually enough. I usually sit down. We just convert and we use a lateral incision. That's usually just a couple of inches in length, go right through the IT band and you can see it. And if I didn't go into the joint, there's usually pretty minimal swelling because I'm only in the peritracheal space for no more than five to 10 minutes tops. And it's usually pretty easy to get down there. If you've done the joint before, like you said earlier, it can be a challenge because there's a lot of soft tissue swelling, especially if you clean off the fat pad, if you make a T-capsulotomy, the fluid can leak over there into your peritracheal space and make it a challenge. Great, so let's- And I just want to point out about these things too, that if you have a large work or comp base, that these can be very difficult to get back to work. So be patient with work or comp injuries, regardless of how well your repair is. In general, I find them take a lot longer than many of my other patients. So just be patient with them. Great point, guys. Let's shift gears and talk about hamstring. So Chad, what's kind of your ideal patient? You know, I feel like, you know, you get a lot of MRIs, you'll see a lot of reports that talk about tendinopathy, tendinosis, partial thickness tears. In your mind, if you're going to treat someone with a chronic partial thickness hamstring tear, what do you like to see? Yeah, you're right, there will be a lot of these. And I guess I was saying in my talk, if they're exclusively having sitting pain, that's a red flag, because they'll probably have sitting pain for a while after that. And they probably won't be quite as happy. What I really like for us is functional pain. So pain with acceleration, pain that's really from hip extension. And then, you know, people that I've had the most success with have been a lot of middle-aged triathletes and runners as well. They are the ones that benefit, tend to benefit the most from it. And what's your decision-making as far as open versus endoscopic when you're treating these injuries? I've gone to doing the work that needs to be done around the ischium, I'll do endoscopically. And then if there's work that needs to be done in the ply, I'll do that open. And so, you know, any minimally retracted tear or partial thickness tear, I'll have to do all endoscopic. And really, an early acute tear, I'll probably still do completely open. But much of anything else, I'll start with the scope, put the anchors in the ischium, and then make a transverse incision, get the tendon in. I find that kind of, you know, that's probably using the techniques that are best for, you know, where they need to be used. Any issues with fluid extravagation? Does it, difficulties when you convert from a scope to an open? It's not as bad as I thought it would be, actually. And you're not there very long. When you get in there and it's an acute, more acute setting, the bare ischium is really easy to see. It's pretty obvious right there. And the sciatic nerve's usually down in some scar. So you can have a working space pretty quick and percutaneously place some anchors, burrow that down, and then open it up. So, you know, you're certainly in there well under 30 minutes to do that part. I think we have a question from the audience here. What about an active patient with a four-week-old proximal hamstring tear with two to three centimeters of retraction with minimal pain and decent strength? Would you repair it or would you just observe it? I would not repair that at that time. At that point, that is now a healed tendon where it is. It's not gonna be any harder to repair in two months from then than it will be in a week from then. And so in that patient, I'll watch them, have them come back. And if they're symptomatic two months from then, then we'll fix it. But otherwise, we won't. And, you know, a lot of them don't need it fixed. Brian Busconi, do you have any other opinions about that? You're muted, Brian. Oftentimes, the, you know, I really take a look at how they're doing on their physical examination as Chad talked about. You know, there are patients who come in with full thickness tears who are just smoking the world, who, you know, come in with an MRI, knowing what they have, but their functionality is excellent. And, you know, I can't make those people better. Whereas, you know, the people who are in the hospital whereas, you know, the people that have difficulty sitting down, have a lot of weakness, pain, those people tend to get better. And in my hands, I don't do a lot of endoscopic repairs. You know, I do most of mine open. That's how I was trained and I feel comfortable. And I like to put in multiple anchors to fix these and they do very well afterwards. So I think in the scenario that you talked about, that's an excellent candidate to treat in a non-operative fashion. Mike Salata, one of your Cleveland Browns wide receivers has a partial thickness tear mid-season. What do you do about it? You know, I think it depends. Normally partial thickness, we're gonna leave alone. You know, a lot of things, you know, it's in the professional world. Athletes can coexist with a lot of pathology and perform at a very high level. So they, you know, if they were unable to participate in their sport or at the level, you might reconsider things. But for the most part, benign neglect is what we would do in good rehab with our very talented athletic training staff who we are eternally indebted to and always make us look good. But I think the important thing is, you know, not doing too much. And I think that goes along with some of the points that Josh made in previous, in his talk, where he said, you know, you don't wanna treat the imaging, you wanna treat the patient. So if a guy's still running a 4-3-40, got a partial thickness hamstring tear, you can usually leave that alone. Winston, what about, you've got one of your UVA football players, grade three hamstring injury pre-season. What's your treatment for that? I think the grade three, I think you have to define, is it an avulsion or not? You know, so if it's an avulsion off the ischium, and, you know, I would have a hard time believing that an elite athlete with a complete avulsion can have the same level of function without a repair. So, you know, I think it's gonna take a long time to give him back regardless. And so I think I'd probably end up repairing that because I like my outcome with a primary acute repair rather than a chronic repair later down the road, which I think you might need. And so, and Brian, what about, so let's talk a little bit about core muscle injuries. I saw a soccer player the other day with an acute adductor tear with probably three or four centimeters of traction, lots of fluid, tending to repair. Do you ever think about repairing these? Yeah, I think about them, and then I say, nah, I'm not gonna repair them. So yeah, I know the literature's out there that a lot of people talking about it, but, you know, in general shame when I see those patients, most of those patients have concurrent FAI, most of them have poor lumbar motion. And, you know, for me to try to pull this up in a situation in which they have multiple other things going around the pubis joint, I think is a little bit difficult for me to bite. So I tell them, hey, good luck. You know, one of my best stories was a wide receiver with the Patriots who I was working with and tore his adductor tendon during the season, and he came in to see me for an opinion as to whether he should get it fixed or not. And I got the MRI, and on his other side, the year beforehand, he tore his other adductor lungus tendon. And I said to him, you know, hey, how's your other side doing? Oh, great, it hurt for a little while, and then the pain went away. And I said, well, look at that, you now have a matching pair. So, you know, I just tend to shy away from it. And there are other people that are fixing it. I don't know if there's a right answer, but in my practice, you know, leave it alone. Mike, what do you do with an in-season athlete that's complaining of poor muscle symptoms? Yeah, I mean, that's a tough one. I think the, obviously, again, a lot of it depends on their performance and their ability to get out on the field. And, you know, you know that in a professional athlete, as Brian's talked about, it's gonna be six to eight weeks before they're gonna be back. So depending on, you know, what kind of season they're having and how they're playing. And they're, you know, a lot of it is shared decision-making with the player. You know, in our world, there's a lot of people involved in the decision-making process. And, you know, for us as team physicians, we're still physicians. So really we're taking care of the patient. And so, you know, a lot of folks can try and coexist with it, make it through the season and get it done at the end of the year. And then there are some guys that are really having trouble with it and need to get it, you know, taken care of more acutely. So a lot of it just depends on how they're feeling and what their desires are about it, if they want to continue to play or if they feel like they're not as effective. What about injections, guys? Do you guys have any feelings about, I know Brian mentioned cortisone. Do you guys have any problems doing cortisone injections around the area? I think cortisone can be helpful, especially in the short term, you know. I do think that the guys that are gonna need it done are gonna need it done. And so sometimes it can be temporizing, but I don't know, Brian's probably got the best experience with that. And I would, you know, like to hear what he had to say about it. Yeah, I mean, I, it's my opinion that the cortisone injections are oftentimes diagnostic and therapeutic, because it's very often with these football players that they all have pretty bad can deformities, have FAI, and then they also have their core muscle injury. Trying to differentiate what's gonna, what is going to be the most effective route of treatment is based upon these selective injections. We all do them. We all have ultrasounds with us if they're quick and they're easy. They're also very informative for the patients. During season, you know, we're trying to keep people on. As Mike has indicated, you know, football players need to stay on the field. It's the only way they're getting paid and they wanna stay on the field. So we're trying to inject as much as possible. I have not really found that my PRP injections in these areas have returned the players' back as fast as my cortisone injections have. So in general, cortisone and Marcane are my way to go. Pre-season and during the season. I just wanted to piggyback on one thing that Brian said. I do think it's very important for you as the treating physician of a player, irregardless of what level of sport they are, to help them make that diagnosis before they may go somewhere else to have a surgery done for their core muscle. Very often, as Brian alluded to, they have asymptomatic femoral acetabular impingement or asymptomatic CAM morphology. And I think that sometimes, you know, what can happen is if they end up somewhere, they end up getting surgery on two areas that they may not need. So I think that's very important to really parse out what the problem is. So that if they make it to a guy like Brian, you've helped them to, you know, kind of make that diagnosis and the player understands exactly what the problem is. Because just like in baseball players where you get MRI scans and they may have a lot of pathology of the shoulder, but it's not really an issue, the same can be seen in athletes of all sport where they may have CAM morphology and it's really not an issue for them. So I think that's really important sometimes. You know, if you have a hammer, sometimes everything's a nail and that's not always the case. Yeah, great point, Mike. Josh, let's switch gears a little bit. So you talked about ischiofemoral impingement. What is your preferred approach? You talked about different open endoscopic, either on the lesser side or the ischial side, repair, release of the psoas. What do you like to do? Yeah, so with true ischiofemoral impingement, these are typically older patients. And I think if you've identified the etiology, the vast majority of them have some peritrochenteric pathology in which they've got a dynamic Trendelenburg. And so really the key is making sure that they've maxed out non-operative treatment before you go in to operatively treat them. And so that's really primarily abductor strength. And so if you get to surgery, I've done it both ways, both from supine and prone. With supine, you can flex, abduct and externally rotate and bring the lesser trochanter to you and safely avoid both lateral femoral cutaneous and the femoral nerve itself and get down there actually very easily. As I said in the talk, the curve burr helps a ton. My worry is if I go posteriorly, whether that's from a supine or a prone approach is that if I'm on the top side of the quadratus, that the vasculature to the femoral head or if I'm on the bottom side, the first perforator is there. So it's a little more challenging to go through quadratus from a supine. You can get to it actually quite easily prone, but that does require you to flip the patient prone. And so if you're also doing anything inside the joint, it's gonna add probably a good five to 10 minutes to actually set that up in your case and some logistical issues with getting there. But my preference is supine, flex, abduct, externally rotate to get to my lesser. I've not done the repair that Dean Matsuda has done, but it can be done. And that's, I think, a very, very key preoperative discussion you have to have with the patient and the family and the physical therapist is that hip flexion weakness is going to be a problem. It's certainly a lot different to take the iliopsoas off of the lesser versus if you do a joint line fractional lengthening. And so hip flexor issues are a very, very big deal afterwards and you wanna talk to the patient about that. And so it's similar to the glute med repair on expectation management. These patients don't get better immediately and it does take several months. And I usually quote between at least six and nine months before the hug sign shows up. And they do well if you make the right diagnosis. And I think a preoperative ejection that diagnostically confirms that location shows that they're gonna do well if you do it. My numbers are certainly not remotely close to that of Dr. Martin in Dallas. And I think we can all thank him for all of his outcome papers that he's published. And I think that posterior hip pain is kind of the new frontier of hip preservation. I think in the next five to 10 years, hopefully we're gonna learn more about it. And Mike, so let's talk a little bit about the approach to the failed hip. I guess in your view, how do you prioritize like what to consider when you're dealing with someone that may have had a previous hip scope? I think it depends on if it's mine or someone else's. You get to know your practice pretty well in terms of what your pitfalls are. And like most of the people on this panel, I think everyone is probably hypercritical of your own work. So I think you tend to look at your own work a little different than you might look at somebody else's. But for me, getting some idea about what happened during the previous surgery, getting their intraoperative photos can be very helpful. Obviously your imaging, including three-dimensional imaging if necessary, is something that can be really, really helpful. I always tend to get an MRI arthrogram in the revision setting as a follow-up MRI scan, because I do think it helps to show capsular integrity as well as the presence or absence of those adhesions. And so on your clinical examination, if they're really stiff, they're probably a scar former, and then you have to worry significantly about those adhesions and getting in to kind of get rid of that scar. If you can see on their previous images that the labrum was everted with the repair or was fairly diminutive, then you may have to consider an augmentation or a reconstruction. And then obviously looking for bony residual deformity, such as dysplasia or residual CAM impingement. I think those are gonna be your main ones that you're gonna see. You might see some outliers like the perforated anchor or some subchondral anchors on occasion, but majority of the time, it's still gonna be, like most of the studies would suggest, residual CAM deformity is probably number one, and adhesions are in there. If you feel like they've done a really good osteoplasty and the labrum looks good. I think one of the things that's challenging is looking at a labrum after it's been operated on, because sometimes it can look abnormal. So I don't rely necessarily on that. You're kind of looking for some of the other things that you feel like you can fix to try and make it better. Chad, how often do you find that the labrum is the reason for failure? Or how do you sort of separate that out from the other potential causes? Yeah, I think it's, excuse me, I think it's rarely the primary cause of failure. When it is not functioning, it's, as Mike said, it's typically everted from capsule labral adhesions. And you could, in this case, you'll test them. You've seen they have no, they really don't have a seal. Initially, take out the adhesions, and then the seal's there. Sometimes you get in there and it looks horrific, and you peel back, carefully shave back the adhesions off and scar off the labrum, and then there's this robust, nicely healed labrum. So those are the times when the labrum is the problem. There are a few where it was a demeaning labrum to begin with, and it was probably never functioning well. But most of the time, it's either, like I said, residual FAI or the capsule. Winston, how do you work up your own patients that are having some issues post-operatively? So my own patients, like Mike alluded to, I kind of have a pretty good sense of my practice and my patients. I want to make sure I know who their therapist is and kind of know what they're doing from a rehab standpoint, make sure they're doing the right things for the protocol. If there's nothing I can tinker with in the rehab side, I definitely will tinker with that, talk to their therapist, see kind of how they're doing. I try to get the inflammation under as best control as I can, but ultimately, when it comes down to it, somebody that's still struggling six, eight months out from surgery, you got to figure out some way to provide them some guidance. And so a post-operative MRI orthogram, you have to really be careful to preemptively tell them how you're going to interpret it, because when they get the read and they have the picture that says the labrum has signal, you got to be able to help them figure out what that means. And so, you know, if I see something in MRI that looks suspect to me, I have to figure out, just like Mike said, what the cause is, is it adhesion? And I also really, really look closely at the capsule. That's when Mike says that we get a super critical of your own results, I'm staring at that capsule or how that capsule came together. And I certainly think that's a big part of why some hips just don't tend to do well, how the capsules heal. Josh, tell me, what are some pearls, like when you're doing the diagnostic portion of a revision hip scope? Like what kind of things kind of clue you in or tip you off? Like how do you interpret what you're seeing? Yeah, as soon as they go to sleep with muscle relaxation, I think one of the big keys Mike hit on with basically the fluoroscopic exam under anesthesia from Dr. Aoki, just seeing how easily that hip pulls out with axial distraction really gives you a clue to what should be a pretty relevant suction seal. And so that tells me, before I even put the scope in, what their seal is like. And then once I put the scope in, I'm very critical of capsule labral scar. So looking from the entire front to the end of the capsule, so looking from the entire front to the entire back and looking at the labrum in a revision setting, oftentimes, whether I did it or someone else did, the labrum just never really looks normal. And so capsule labral scar, I think, is a big part of pain. I will definitely critique the articular cartilage where previous anchors were placed. If they were peak anchors or if they were all suture anchors, definitely pay very close attention to that. The one thing that we've learned from Dr. Kelly is that anchor perforation over into the psoas fossa can be a real issue. But if you go into that area, you're frequently gonna have some fluid extravasation into the pelvis, and you're gonna actually violate your capsule. You have to actually get over there and see. And so that's one thing I really try to critique on my MRI before I intraoperatively try to go there. Dynamic exam for the peripheral compartments. I really know before I get into the operating room if it's gonna be a revision cam or if the cam has been adequately treated prior. It's not an intraoperative assessment that I'm looking for. And if it's a previous failed capsule, I will make sure that I mobilize both under and above. If it was just an interportal, I'll make sure it's under and above to mobilize that capsule properly so that it's able to be repaired without excessive tension. If I can't, then I've always got a graft available. And I think that making sure you've got good capsule labral adhesiolysis and capsule scar above the capsule and below is probably one of the biggest keys for doing a successful capsule revision. I have two quick questions. I think we're gonna have to sign off. Winston, give me some pearls on trying to minimize capsule labral adhesions in the primary hip scope. I think you gotta be careful about sort of how you address the labrum, the capsule beneath it. I think that, and also I really think that a good capsule repair, I mean, that's gonna be my pearls. I really believe that if you don't have a good capsule repair and there's no tension in the capsule, then it can adhese to the labrum pretty easily. So getting the capsule up off the labrum, I think is really critical for that. Great, and last question is for Brian to finish this off for this evening. There's a question from the audience about your treatment algorithm for the patient with the combined core muscle injury as well as a labral tear and FAI. What do you do about that patient? If I could just interject on one point that everybody made, you know, we talked excellently about what to do operatively. Remember that the most of these failed hip arthroscopies oftentimes are very poor physical therapy and have other psychosocial things going on in the background. So, you know, as Michael and Chad and Josh and Winston and you, Shane, you know, you really have to spend some time with these people, Kleenex moments to make sure you can get them through this. In terms of my workup of core muscle injuries and FAI, I really do emphasize the selective injections. It all depends upon what season that the athletes are getting back to, where they need to go, where their pain is. You know, a football player with FAI that doesn't have a lot of pain there but has a really significant core muscle injury, and as Mike knows, they're 10 weeks out prior to the season. I can get that patient back by doing a core muscle injury. May do their hip scope later on in the year. At the end of the season, if their hip is really bothering them and their core's not bad, I do the FAI beforehand. So it all depends upon season. It depends upon how you did in your selective injections as to which one I address first. Very rarely do I do both at the same time. I just don't feel that that is necessary. I think that's a lot of surgery and I think that, quite honestly, 90% of the people will tell you which one is the one that's bothering them the most. Right, so I think with that, I just wanna thank all of our speakers today. I think this was an excellent, engaging session on extraticular hip, and I'll turn it over to Alexandra to close out the evening for us. Thanks, Shane. Thanks, everybody. Thanks, everybody. Thank you. Thank you. On behalf of AOSSM and ISSACAS, thank you to our course chairs, our speakers, and all of you for joining us this evening. For more information about AOSSM, please visit sportsmed.org. To complete this educational activity and access your CME, please visit education.sportsmed.org. And if you have any questions regarding tonight's webinar, please feel free to email me, alexandracampbelle, at alexandraataossm.org. We look forward to tomorrow's webinar, which is the last in this four-part series. We hope you'll join us again at 7 p.m. Central. On behalf of AOSSM and ISSACAS, thank you again for joining us and have a good night. Good night. Good night. Come back tomorrow.

hip conditions

accurate diagnosis

labral tears

femoral version problems

acetabular version problems

revision surgery

dysplastic hips

capsular issues

labral pathology

surgical technique

rehabilitation

post-operative care