And could we kindly have the panel up now for the final couple of case discussions? Thank you. The other talk first. And I would argue, you know, hip replacement, you look at the age, right? I mean, 90% of these might last upwards of 30 years. And if we have somebody who's 30, and you're buying them five or 10 years, maybe that's not such a bad thing. So I think there's a lot of ways we need to look at things. It's not always about if it doesn't last 15 or 20 years, you shouldn't do it. And that is assuming they feel better. So we have a great panel here. We're going to present a couple of cases. So Femi is still up here, obviously, from McMaster. We have Winston Gwathme. He is here from University of Virginia. Sharon Haim from UCLA is up here as well. Mark Safran from Stanford University. And then Andrea Spiker down there from University of Wisconsin. So I'm going to up the tonus ante here a little bit and just present a case. So this is a 19-year-old Division I football wide receiver. He's in a top 25-ranked university. Over two years of pain, left much worse than right-sided anterior hip pain. He's tried anti-inflammatories. He's had cortisone injections. He was able to get through the season and played 13 games. He did play the bowl game. Had a decent season, over 400 yards, a couple of touchdowns. But he's just through the season this year having increasing limited hip mobility and a combination of sharp pains with torsional activity on the field, and then a lot of post-game achy pain. So if we look at his range of motion, pretty limited internal rotation, basically none. He gets to about 85 forward flexion. His impingement tests are obviously positive, but not only flexion-based impingement tests, but also abduction-based, which I think goes along and correlates with some of that torsional limited mobility. So here is radiographs. So obviously, he's got a center edge angle that's a little bit high, a pretty large cam deformity. You can see on the AP as well as the lateral radiograph, he's got this anterior area of ossification on the rim, and his joint space is not looking good. So if I had to ask Mark, all you've got is the radiographs right now, and you'll get some more information, but what's your gut on this in a 19-year-old kid who's able to play, but he's struggling and starting to worry about his ability to stay on the field? I mean, the key is that, as I always tell them, that arthritis is progressive and irreversible. And his hip is going downhill, and at what rate, we don't know. But that counts on part of the issue is impingement. That's part of his stiffness, but I think some of his stiffness may be arthritic-related as well. And again, get more information with more advanced imaging, but you'd sit there and say that no matter what he does, it's going to progress. But the harder he is on it, the faster it will progress, and they'll get to a point where he's going to probably need a joint replacement. Usually, a joint replacement's not recommended in somebody playing in the NFL or whatnot. But those are considerations that the harder he is on it now, the faster things will wear out. Yeah. And Sharon, would you look at this guy and just say, there's no reason to get any further imaging. I don't think you should consider any kind of surgery right now. I think you should just modify your activities. Or would you say, let's work it up further with some more imaging? No, I've seen this before on our football team, so I definitely would work it up further to get the MRI. I think that's an expectation, too, of the collegiate athlete as well, that we would continue to work up with the MR arthrogram, again, having a good discussion with him about the arthritis and the need for a total hip in the future. So if we get an MRI and a 3D CT here, you can see the labral tear. No surprise, everybody has them. Here's the grade 4 changes and cystic changes, primarily on the acetabular side. Femoral version was 5 degrees, large CAM deformity, which we knew from the X-rays, and then these pretty significant anterior areas of remossification. So Winston, you look at this. This is one of your athletes. Are you going to have a discussion and talk to him about the options for surgery? Are you going to tell him, I just think you need to start thinking long and hard about life going forward? Are you going to write off the option for surgery at this point? The frustrating thing is he's probably had a teammate who had a labrum tear, and he's going to perseverate on the labrum tear. And all this other stuff, the conjumelation, the femoral version, is going to mean nothing to him. And he's going to think that if you fix the labrum, he'll be just like his teammate who got back to playing sports. And so it's really hard. Trying to stress just the severity of this damage can be very challenging, because they hear what they hear. They don't hear what you say sometimes. And so that discussion has got to be in earnest, and it's got to be something to really explain what he's done to the hip in the past playing football. But he had a pretty productive season, so he thinks he's probably just close to getting back. And so I probably would take him down a surgical plan, I think, just because I do think he might get one chance to get this guy at least a reshaped hip that could give him some better overall mechanics. But I also would be very, very cautious as far as trying to explain to him that's going to get him back to his prior level of play. But I will say this athlete, he's 19 years old. He probably has dreams of playing in the NFL. This might be his ticket. And crushing those dreams by trying to explain this to him is a really hard conversation. Andrew, does it make a difference to you if somebody like this presents with predominantly mobility limitations as opposed to, I can't sleep at night because it hurts so much? Does the degree of symptoms off the field help direct you? Yeah, and I think, Chris, you're alluding to some of those very stereotypical, can't sleep at night is arthritic pain versus mobility is mechanical and dynamic. And I'd say the answer is yes if the patient is older. In a 19-year-old, very high-level athlete, I still don't think, even if he were having more arthritic or predominantly arthritic pain, that I would be offering him a hip replacement at this point. So I think there's the power, as Winston was saying, of reshaping that bone, of excising those fragments, of repairing torn tissue back to the socket in its anatomic location. It will make him feel better. And oftentimes, immediately, they wake up in the PACU and say that I feel surgical pain, but the pain that I was feeling is gone. And I think expectation-setting, as Winston said, is just going to be very important, because he has a terrible hip at this point. He's got an arthritic hip, but I think hip arthroscopy would give him a good chance at functioning well, pain-free for a while yet. Does it make you nervous that he played in 13 games in a ball game, and you might do a surgery, and then he doesn't? Well, the other question that I think is often pertinent to ask them is, could you do that again the way that you feel now? And oftentimes, the answer is no. That's what he said. So Femi, do we use the evidence here? Because obviously, the evidence would say, we're not preserving this hip, and we know where this hip is going to go. And the evidence would say that we're not going to have a long-term good outcome. So how do we wrestle with the evidence that's out there, an individualizing approach for this specific athlete? Great question. I challenge any scenarios, but I think the evidence-based practice really is the combination, once more, of the evidence that's best available, which in this case will indicate this is heading down a negative outcome in the short to midterm, but also the patient's values and preferences in recognizing that they understand that this is a decision for them, and then your personal expertise and ability. So if a surgeon believes he or she has a tremendous ability to help with this case and correct the morphological problems, and the patient is accepting of a procedure that is of value to themselves, then I think that you can say that you present the evidence and then have them interpret it and make a combined decision. But I think that this is one where, in the spirit of joint preservation, you really have an argument to say that it is worth a try to try and do your best and recognize that there's a chance you will get some pain relief. But in these cases, I say, will you be happy if you still have daily 3 out of 10 pain with everything you do? That's about the best job I do. And if they say, yes, if I can still have improvement, but it's 3 out of 10 level of soreness every day, I'll go for it. Then I'll say, OK, well, maybe we're there. Yeah. So if we look here, you can see a pretty big grade 4 defect anteriorly. Once you remove those bony fragments, you really have nothing left on the rim. So how many on the panel here would leave that rim as is? How many would do a labor reconstruction for a 19-year-old in a primary case? I think it depends on what you can get as far as a seal, a suction seal. If you can get one of those, I've seen you show videos of a good suction seal created with just the cartilage. But I'd probably do a recon. Mark. Yeah, I mean, I think if you go back to that 3DCT, if you take out those bony fragments, I bet you if you look, his anterior center jangle is going to be just plastic. So now he's being made just plastic. And I think in my hands, my only indication for doing a primary labor reconstruction is somebody who has dysplasia because they really need that labrum. So in that situation, I think that's bony. I'd give him some support. And I think it contains your microfracture as well, right? Because right now, you've got, basically, you can call it three sides that are contained. And the periphery is not. So you could also argue that it does that. So we did do a labor reconstruction. We did a femoris section, a capsule repair. Here you can see our imaging. And I think it's pretty important on these. If you look at the floor on the AP, I think that's something that I think is important to correct in these cutting and pivoting athletes. I think we all correct this lateral view. But it's that AP view that can really make a difference in terms of how they feel and how they move. He came back a year later. So you can see the bottom image is a year later. And I think that things have held up pretty decently. You can see we removed the bony fragment. The femoral head shape looks good. He was coming back to get his right side done this following year. And overall, he played 13 games. He played the bowl game. He had a PRP injection. He said his mobility was way better. He gets sore, but less pain. His production improved. He had 711 yards. He was the leading receiver on their team. A few touchdowns. He does now think that he wants to try to play in the NFL. And I tried to talk him out of that. But again, he had surgery this year. And his plan is to play this next year. So again, I think there are exceptions to the rule. There are exceptions to the evidence. And I think you also have to be prepared. I'll be perfectly honest. I think the team doctor surgeon that saw him there was like, I just don't know that I want to put this on me. And this is going to be a really hard hip to manage. And what do you think? I mean, that's kind of where it was. Because this is something that could easily go bad. And this is not the first case you want to be managing when you're out there practicing in your first couple of years. Because all it takes is one bad result, and you might not get another chance. Because you want to just, I know you're up next. If you wanted to briefly say where you're hamstrung with regards to where you're at and your ability to do this case. I think, luckily, I probably wouldn't be presented with this patient on the NHS. So that dilemma of economic analysis of 16 years won't be there. And these patients, whether they're playing rugby or football in the UK, would come in the private sector. So I'd probably do exactly what you did. But if this patient presented to the NHS, then it would be a problem. Then it would be a problem. All right, Chigis is up next. While he's getting set up, could I just ask the question for the older athlete? So let's say that patient, this one's a little easy in the sense that he's 19. Is this a personal question? I'm asking for a friend. I'm just saying. A guy you know. Let's say that patient, you know, looks 33. But at what point do you just say, give up the ghost and put in the hip? Is it 30? Is it 28? Is it 40? Help us understand that for that age group. Help us understand that for that active athlete that's not the college or NFL athlete anymore, but isn't quite ready to throw in the towel yet. Thanks very much for my friend. So I would honestly personally say that even at 30, it's going to depend on the activity that's bothering them. So if they're wanting to run marathons, I've got nothing for you. If you're wanting to play pickleball or play some basketball and your main problem is mobility, then I would at least offer it up saying, I don't know how long this is going to last, but it's an option for you. And again, if you come in and say, it just hurts all day. I'm having a hard time sleeping at night. Again, I'd say I've got nothing for you. So 30s, in the 30s, I'll still think about this. After 40, I think I'm just like, get your hip replacement. You can't take it anymore. That's my gut. Well, JT, one thing I'd say, you have a collaborative arthroplasty colleague who would actually, because a lot of times I'll say, you can't have a hip scope, but I can't find anybody to replace that hip. And it's a really frustrating patient too, this tweener. So in my community, I don't really have a good arthroplasty colleague who would be willing to replace that hip. It also depends on their expectations how long. If they say, I just need to get a couple more years because I'm going to get to the master's level, maybe it's worth the scope. But if they want something more long term, I use actually Chris's old paper where less than 50% joint space versus more than 50% joint space is the best data you really have to go by and likelihood of success. So if somebody is under the age of 40, most degrees of arthritis, I'll give it a shot for them. And if they get five years, that's great, or 10 years. If they're between 40 and 55 and they have over half their joint space remaining, I'll give it a go. If they have less than half the joint space, I'll send them to arthroplasty colleagues. And if they're over 55 and they have radiographic more than, well, any degree of radiographic narrowing, I pretty much just recommend go get a hip replacement unless what they want to do is pounding. That involves a lot of pounding. And maybe a biologic solution might be a short term solution. Got it, thanks very much. I'll just add one more thing there. And for those of us who actually do both, i.e. arthroscopy and arthroplasty in Europe, then this is a big conundrum. The issue is that if you land up doing an arthroplasty in a patient with less degenerative change or the joint space is still reasonably well-maintained in comparison with completely gone joint space in those patients, their PROMs actually on the data are worse. So if you want a perfect hip arthroplasty, then you probably should be waiting till you've got significant radiological degenerative change and then the other debate is whether you should be giving them a total hip arthroplasty or possibly a resurfacing. And potentially for these patients, resurfacing is a better option. So that's the other side of the debate. I'd also like to, sorry, one last point. I'd say occupation is important. I don't know if you've had this experience, but that older athlete who's also an orthopedic surgeon, they don't want a hip replacement. And so I think those, my patients who are arthroplasty surgeons have said, I want anything but an arthroplasty, let's do an arthroscopy now. And I think even if they ultimately need an arthroplasty, they feel better about having tried everything. So it's kind of an interesting side note. I also think sometimes that the arthroscopy can be helpful in convincing your arthroplasty surgeons that this patient's a good candidate. Because now you have photographs of what the articular surface looks like, even though the MRI might look okay, the x-ray shows some joint space, but the cartilage looks terrible. So I think that's something in your armamentarian to talk to them about as well. Cool, thank you very much. Moving on swiftly, last one. Okay, so this is a bit on the edges again. 38-year-old, works in the admin sector of the construction industry. Left hip pain for over a year. Deep seated, worse than activities of daily living, which require deep flexion and rotation. Impeding some of his activities of daily living, which is wearing socks and also his golf, which he's quite concerned about. No mechanical symptoms, past medical history, not significant allergies, and family history not significant either. Physical examination, I think gait is out-toeing. Trendleberg's was negative. Single leg hop test was negative as well. Iliopsoas clunk was palpable. Flexion up to 110. Internal rotation 90 degrees was 10. External rotation 90 degrees was 60 degrees. And the same thing on prone. And impingement and Faber test were positive. Okay, so I'll stop there. Andrea, what are you thinking from this clinical examination? So I think the gait is interesting in that the patient is out-toeing. That, to me, makes me wonder about the femoral version or torsion. Perfect, okay, so I think that's the first lesson here. In a young adult hip clinic, look at the gait, and basically look at the examination, supine and prone, and you wanna pick up rotational abnormalities in these patients with FAI. So this is radiograph AP and lateral, fairly standard, small CAM lesion there, good amount of joint space. That's the MRI scan. You can see the labral tear. You can see the impingement cyst. And a fairly clean joint with good articular cartilage there as well. And that's the CT scan. So you've got the astabular version of 22 degrees and a femoral version of one degree and a CAM abnormality with good amount of joint space posteriorly. So we'll go to you, Femi. Do you routinely get 3D imaging for your patients with FAI at your institution? It's been an evolution, to be honest, Vic. Initially, we had a lot of concerns about radiation exposure. I have a substantial pediatric practice as well, so having them having CTs was a problem. So we tend to use MRI-based version analysis as opposed to CT. With the new modeling coming out and the less dosing of radiation, increasingly now trending to use a CT. But that's been a journey that's just evolved over the last two years. But before that, it was all MRI and MRI-based version analysis. Let's just go through everybody on the faculty list. Mark, what are you doing at your institution? So when I came to Stanford 17 years ago, and we were starting, I started off with doing all CTs and when my fellows called me on it and I sat down with a radiologist and we figured out actually with regular CT that for every 1,500 CTs I got, I'd be causing one case of sarcoma. So I stopped routine use and I only get it in cases that I'm concerned about, about the anatomy, usually revision or very unusual anatomy. The other time I do get it though is that the MRI, we've looked at MRI versus CT for measurements of femoral version and the MRI is not as accurate because it's a longer acquisition time so that the leg can move. So if I really want to know the version, if there's really clinically suspicion, then I get a CT scan for that. What are you doing? Yeah, I think the same up in Stanford, UCLA. Not really doing CTs unless otherwise indicated or revision cases. Chris? Yeah, a lot of my early research was looking at 3D CT work and so I've been getting them for 20 years. I think the dose is low. I think the more you get them, the more I learn, at least for me personally. You'll see some of these pelvic X-rays that look like they're retroverted. You get the CT and you realize they're not at all. You get a better look, especially as Sharon said, in the revision situation, I think you definitely want to get a CT. You're gonna see what somebody else did. It's hard to see that on your plain radiographs, only two views or on your MRI, but I routinely get them. Okay, Andrea? I get them on every hip preservation patient, but we have a very low dose protocol, so it's about the same as two X-rays. And Vincent, what do you do? Not empirically, but for unusual cases, revision cases for sure. If I'm just worried about something I can't see on plain imaging. Okay, so let's show you this then, okay? Now this is what most of us, this paper most hip preservation surgeons would quote, that one out of six patients who are symptomatic with FAI will actually have version abnormalities, right? And this is the other paper that we recently published, that there is a lack of a universally accepted definition for the proximal axis of the femur, and that's caused a significant amount of confusion. So now the question to the faculty is, assuming that we get a CT scan for every patient who walks into your clinic, which is a low dose for hip preservation, what method do you use for measuring femoral antiversion? Because there are 14 out there. So Chris, we start with you. Yeah, so I had a radiologist basically just do a bunch of research looking at the different methods and I think you just need to make sure that you do it the same way every time so you know what to do with that data. So they use the posterior femoral condyles and they use the femoral neck, so not torsion. You can use torsion, tilt, version, but we use femoral neck. Okay. Yeah, we do the same. I spoke to the radiologist about this as well and that's how they do it as well. Yeah, so all our MRIs, actually we get femoral version measurements on, so we have somewhere to start on, but we are also doing femoral neck versus femoral condyles. Okay. Same. Vincent? Same. Okay, so Murphy's method in our experience seems to be sort of the most commonly adopted method, but one institution in Canada seems to be doing the Ryle's method all the time and they've obviously got their reasons, but there is a big debate out there and in the hip preservation world, we really need to come to a consensus as to which method we use for measuring femoral antiversion. And the problem is this, right, because so many of these patients are actually having femoral version abnormalities and then when it comes to their outcomes, especially with retroversion, you will have less than optimal outcomes in these patients with femoral retroversion. Okay, so now in this patient who's got a femoral retroversion of one degree, you've got a CAM and is fairly young and active. Mark, what are you gonna do? So, you know, when they have retroversion, if you will, not relative, but absolute retroversion, I send them to see our, we have a deformity specialist who do femoral derotational osteotomies, but at one degree, I've never been able to get him to do a femoral derotational osteotomy, so I just take that into account when I'm doing an arthroscopic CAM resection, realizing that what may not appear as big a CAM is now dynamically a bigger issue, and so I take that into account in doing my assessment and doing the surgery, and then I do dynamic assessment intraoperatively as well, both dynamically, arthroscopically, as well as fluoroscopically. So for this patient, you're thinking of an arthroscopy, when would you think of an osteotomy? Or when would your colleague think of an osteotomy? How bad has the retroversion got to be for you to do an osteotomy? So it's interesting, I've tried to pin him down on a number and I've not been able to do so, and he does it based on his clinical examination of both prone and supine measurements of hip rotation. So that's experience over objectivity. Yeah, it's not evidence-based. Yeah, that's the X in short. It's eminence-based, yeah. I get it, I get it. I don't think there's a number. I think if you're getting negative five, then you gotta start getting worried, and I think you can apply some of the slip capital femoral epiphysis data as well. And if you can get them to 90 and you can get them some internal rotation, for some patients that might be enough. So I think a lot of it depends on the degree of range of motion that they present with. Like if they have negative 20 degrees internal rotation or they can't get to 70 or 80 degrees flexion, that's one you worry about. And I think you also worry if there's zero cam, especially in a young female, you start worrying because what are you gonna do if you get in there? So if you have a big cam and some relative retroversion, I don't worry as much. If there's zero cam, then I worry there's not enough I can do. Andrea? Sorry, yeah. We'll come to you, Femi. Ladies first. Andrea? I absolutely agree with Chris. I also think the new thing is to think about the tibia. So the tibial torsion and factor that into the lower extremity alignment and use that as a determination as to when you're gonna address the femur versus not, or maybe you address both the tibia and the femur. Okay, Femi? No, I just say that a lot of the open colleagues, their indication for osteotomy is this failure of the arthroscopy. So they will not until say, you know what, go and try the scope first and come back and see me after that fails. So that's the first thing. Second thing is years ago we had an FAI study and we showed the agreement between radiologists and orthopedic surgeons to be 30% on FAI. So if you're looking at version and torsion and that analysis, it's great to have an orthopedic Delphi study, but if the radiologists see it differently, back to the same problems again. Cool. And that's why your range of motion is important. Yeah. John, what would you do, osteotomy or arthroscopy? Yeah, I mean, I think I agree with most of the panel. I think that arthroscopy is key in working with your radiologists, getting overall alignment so that you really have tibia and femoral alignment so that you can make a decision. I also agree with really the large cam and not having to worry about it too much. So I think if I have a large cam then arthroscopy for sure. With this one, I'm concerned because he does not have a huge cam on his X-ray, but he out toes when he walks, and that's what kind of concerns me is that he out toes when he walks, and I take that into consideration. Okay, so we have planned to do an osteotomy on him after discussion with our colleagues, both radiology and a pediatric orthopedic surgeon, and he's coming in three weeks' time, and I'll tell you how to do it. Okay, so take home messages from this. We obtained a 3D sort of imaging with slices of the knee in all patients with symptomatic FAI. So FAI is not just a problem with the hip. There is a lot to take home in terms of problems with the femoral version, and you really need to be measuring that. You need to have a standardized method of measurement for femoral version. Whatever it is doesn't matter, but have a standardized method, and then base your decision making on that. The focus when you're actually thinking of operative intervention should be on reduction of contact forces in the joint. So if it's a large CAM with five degrees, three degrees, you may get away with taking off that large CAM because that's what you're trying to do. And finally, you need individualized management and discussion with the patient because we do not have enough data to answer this question. Thank you, and well done for staying back. Thank you. Thanks.

hip pain

panel of experts

hip replacement surgery

CT scans

femoral antiversion

hip preservation surgery