Excellent talk, Ben. Thank you very much. Next up is Dr. Guillaume Dumont from Mexican Orthopaedics, South Carolina. I'm just gonna pretend like I'm raising the mic here to make myself seem taller, but it's not the case. All right, so we're gonna talk about revision hip arthroscopy and what to do when a failed hip comes to you. So my first thought when I was asked to give this presentation was pure shock because I didn't realize that hip arthroscopy could fail. This doesn't happen to me, but it must happen to someone out there. So I felt like, well, I'll just ask my friends and colleagues for some content to help me out through this journey. Just kidding. So here's my disclosure, also on the AOS site. So just setting the stage for why a hip arthroscopy can fail and why we can see this in increasing numbers. We all know the story, right? There's a lot more hip arthroscopy being done now than there was 20 years ago. That number has risen meteorically and we're probably gonna see some more of that. So with more primary hip arthroscopy, we're gonna see more revision hip arthroscopy. They tend to fail early within 6 to 18 months. So this is kind of when you're gonna see these folks. At the end of the primary hip scope, this is the celebratory high-five. Everyone's happy. Everyone did a great job. This thing is gonna go perfectly fine. It always does, right? Then you send your patient off into the wild. You have to let them go. You give them a little bit of a cross finger, maybe a little bit of prayer and give them a big hug and send them on their way into the wild. But what happens when things go wrong? Because this happens, right? Sometimes it's a few months after surgery. Sometimes they come back about 12, 13, 14 months after surgery and things just aren't right. They might have had an injury. They might not have had an injury. Who knows? So first, so general philosophy points, right? So if you did the first surgery and this is your patient, stay calm. It happens, right? If someone else did the first surgery, well, same thing, but be gracious because it does happen. Generally speaking, so we want to stay organized and have a systematic approach when we're looking at these patients, just like we would for a primary patient, someone who's never had surgery before. We really want to know if there's been a trauma or another injury, right? Or if this is just sort of ongoing pain since the initial surgery or pain that's kind of randomly come back. Imaging, so I always start with just new x-rays and I get a three-view series, false profile, done 45-degree lateral, AP pelvis. And you really want to be critical here looking at joint space narrowing because if they're starting to have joint space narrowing or worse joint space than you had before the initial surgery, that might be your answer. And also be critical about the FAI correction. Is it good? Is it perfect? Is it great? That can kind of give you a lot of information. And if you have your arthroscopic photos, which I would of course encourage you to keep all of your own photos and videos, or if you have the other surgeon, the primary surgeon's photos, that can give you a lot of information. Sometimes the operative report for some patient that may have come from somewhere else may look great, right? The x-rays may look okay, too. And then you get the photos and you sort of like, what's going on there, right? You've all seen those. So if the patient is still in physical therapy, let's say this earlier on in the course. So are they doing too little therapy? Are they doing too much therapy? Are they sore every time they leave therapy for the next 36 hours? Sometimes doing a changing the physical therapy regimen or changing to a different physical therapist who may have more experience with hip arthroscopy patients. Maybe a good idea. And aquatic therapy has been helpful for patients with some more soft tissue discomfort. Ultrasound injections, just like they're helpful for primary evaluation, may be helpful here when someone has pain after hip arthroscopy for two things. One, confirm where the pain is coming from, right? But two, hopefully, possibly, avoid another surgery. Because as much as we think we can do great things with surgery, and we can, the best case scenario is if someone's got a good surgery and they don't have to have a second one. If we can keep second surgery away with a simple injection, that'd be a great thing. Usually the patients come in, say, doc, something's going on. We just got to get an MRI, right? So is that the way to go? It's okay to get another MRI, but be prepared for an abnormal report and be prepared to explain that to the patient and navigate that further afterwards. So I'm more inclined to get a new MRI early if there's been a repeat injury or trauma. And in those cases, a lot of times I'm really looking at the capsule to see if the capsule repair has de-hissed or failed. Once you have that MRI, and likely the abnormal report that comes with it, it's really much harder to navigate the landscape of not doing a revision surgery because the patient will have in their mind that there's something wrong with the hip that needs to be fixed. Hip scope recovery is a process, right? So not all your patients are 18 year old males with large CAM lesion that recover in three months, right? So keep that in mind, and I think it's good to be there to encourage the patient and tell them that some of this sometimes is normal. The recovery curve is not a straight line. It could be ups and downs, and ultimately if they end up better than where they started, that may be the end goal, right? So if we do end up getting an MRI, and we have our prior videos from surgery, and this is what we found at the time of the index procedure, was this chondral flap. And the new MRI shows this subchondral edema anteriorly. You can see some chondromalacia there. Is this someone you're really going to help with the second procedure? Who knows, right? I mean that subchondral edema and chondral damage like that is really challenging to fix. So just going in there a second time may not do you a whole lot of good. And when I'm approaching these discussions with the patient, I think it's good to be encouraging and be supportive and reassuring, but also you have to have a dose of honesty and realism during your conversations. So really, I mean, does this revision hip arthroscopy help at all? Should we even consider it? Well, the data that we have through multiple reports shows that it does help, right? But it doesn't help as much as index procedures. And so we should ideally do the first one as perfectly as possible and avoid having to do second surgeries. This is a slide from Josh Harris that really outlines sort of an algorithm looking at how to approach the revision hip scope structurally, first starting in layers from the bone, moving through the soft tissues, including the labrum, the capsule, the muscles, and even extraticular factors, right? One of the things we'll see common during a revision procedure is adhesions. Sometimes these are really elusive on MRI. We really may not see much evidence of this on MRI. They're probably way more common than we give them credit for, right? How many hip scopes that have done perfectly fine, that are doing okay, that never had a revision have adhesions? We just don't know that. They're more common, it seems like, in patients who've had an either under-repaired, poorly repaired, or non-repaired capsule. So here's an MRI of a patient that had a fall after surgery, and we see a big capsular defect anteriorly. And then, arthroscopically, we could expect something like this. So this is someone who, if they had a repeat trauma, would likely benefit from repeat surgery for repairing the capsule. And if the capsule tissue is really deficient and thin, sometimes augmentation of those tissues can be helpful as well. So, other things that could come with a capsular problem. So sometimes the capsule is not the problem in isolation. So this is looking anterimedially over the femoral head. You see the labrum sort of in the corner, and we're lifting the capsule where there's a big capsular defect. That's the iliopsoas that's frayed like that. So the capsule is a problem, but then the iliopsoas is piercing through that area. It's frayed. So the treatment for this was really debriding that tissue and ultimately doing an iliopsoas tenotomy in a patient who didn't have dysplastic features or an aversion, and they did well. So, moving on to bony problems. These are really common. We know that's the most commonly found things at the time of revision. Hip surgery is residual impingement, so be aware of it. I really like using 3DCT, especially for revision cases, because let's face it, they don't want to go back a third time, right? So if they're having a revision procedure, the bony correction really needs to be perfect, and I think this is a good tool to use. Remember the subspine region, the anterior inferior iliac spine. This is often an area that's been ignored so that it can really contribute to impingement on the acetabular side. The false profile is helpful to look at that, and also CT can be helpful, too. And then intraoperatively, using dynamic assessment or any of the tools that have been discussed previously to make sure that the correction is as perfect as possible. Now, how about too much resection? How do you deal with that? Well, if it's just a little bit over-resected, maybe, you know, you can help that. But we know that these patients don't do that well. We know that these are hard problems to treat, and if we have something like this, you're probably not going to treat that with a revision arthroscopy, and that's most likely treated with cold hard steel. If the problem initially was dysplasia, or if the problem now is dysplasia, since they've had the surgery, maybe a little bit of over-resection on the acetabular side, again, send them to someone who can treat the problem. Revision arthroscopy will not treat dysplasia the second time around. How do we handle the labrum? There's been a lot of debate and discussion over the course of, you know, a decade and a half of repair versus debridement versus reconstruction, and really, if you frequent social media much, you might feel like, wow, you're just sort of really inadequate unless you're doing a lot of reconstruction, right? But I think there's a role for all these options, and I think if you're entering a revision setting, it's good to have every one of these in your tool belt, and in talking about selective debridement, this gets sort of a bad rap, but we have to remember that the early experience in hip arthroscopy, which we have 10-year outcomes on from various pioneers in the field, a lot of that included selective debridement and correction of impingement, and these can do really, really well, and I would argue that a good, clean, selective labral debridement in the setting of a good correction of impingement can do really well and can likely often be superior to poorly done reconstruction in the wrong hands. Reconstruction is a fancy surgery, and we've got to remember, fancy surgery is not for every surgeon or every patient. So, other things can hurt around the hip. If you have symptomatic gluteal pathology, I think it's important to address this, but remember, if you're treating pain in multiple compartments of the hip, it can likely lead to a more challenging recovery after the procedure. So, in summary, try to do it right the first time. That'll avoid the revision altogether. If you've got to do revision and talk about revision options with the patient, stay calm. Try to find the specific reasons for the pain. It makes it easier to treat the problem if you know what you're dealing with, and also, we're getting really good at finding which hips we can treat, but finding the right patients to treat is sort of the elusive art sometimes. Thank you.

revision hip arthroscopy

failed hip surgery

systematic approach

trauma

imaging results