So this is a real fastball, so keep your ears peeled. This talk is potentially the softest and also most important thing that we might distill down for anyone that is endeavoring to take on the hip. These are my disclosures. So the uniqueness of hip dysfunction is sort of why I think it still remains that we have to focus on reminding ourselves to listen to our patients as we select patients for surgery in hip preservation surgery or hip arthroscopic surgery. Potentially the reason can be the symptoms of our patients can be difficult to assign in this joint versus other regions for them as they report it. As we've had an explosion of publications on the technical performance of surgery and sub-diagnoses, whether dysplasia or impingement or labral tear, it is very easy if we bucket our patients into the tissue diagnosis group that we miss the story that's led us to find that diagnosis. And maybe I'll make just a short comment on potentially this could be an impactful thing. They may not know why they started hurting when they come to our office. So if we revert to this study as an answer before we understand their problem, these are frequently barriers to good outcomes. A challenge in listening to your patients is that you have to listen sort of with two mindsets. One, to figure out what tissue may be correlating with their pain complaint in the moment. And we are supremely interested in the hip and understanding what structural defect and or structural combination of mechanical function with their demands have led to the terminal tissue damage. So it's a parallel struggle in the listening to the history. Far different from someone collided with my knee. It's now swollen. I've heard the pop and here is my problem. Here we don't know exactly how to listen to them, describe their symptoms. And we are also listening both for what tissue hurts today that we may repair and or recover and what structural functional mismatch may have led to this problem. We might consider in varus knees the idea of how quickly we would reject the notion of degenerative meniscal surgery in the setting of a severe varus limb deformity in the medial compartment. At the same time in the hip, we must think constantly about as we take our patients history, what do you do every day during which time that you're doing that, what do the problems arise and what problems are they? We then have to consider the manner in which they do these things and then we have sophisticated studies to help us understand why their mechanical structure may not be compatible, thereby leading to some tissue damage that we could fix. This is a complicated history to take. I think just some buzz questions for those of us that take these histories, you know, when might we think a patient's telling us about a non-arthritic hip problem? What about start up deep anterior hip pain or years of migratory periarticular symptoms requiring conservative care? One year my IT band's sore, one year my hip flexor snaps, one year my low back is sore. These patients may not present directly with the story of the problem but they may circumvent the problem with their symptomatic tissues of the day. This allows them to hide before treatment is there. Frequently they can't verbalize to you what their problem is and then the C sign, which really is a history augmenter more than a physical exam as they gesture, as Dr. Bird taught us so many years ago, to that deep area where they're feeling their conflict. Certainly intermittent activity related pain that resolves with rest and predictably returns a sporting activity in the region of that C sign puts us into an appropriate history taking position to think about application of non-arthritic diagnoses from a historical perspective. When might we look elsewhere? Well I think that the patient with constant aching pain unrelated to activity has told you their diagnosis in many cases either of a severe synovial disorder or arthritis, radiation of pain below the knee, menstrual correlations with the pain, polyarthralgias or associated osteoarthropathies, testicular symptoms, or gestures to body areas above the inguinal ligament or deep in the medial adductor compartment are areas that occur during history taking and in the astute office for the patient-physician relationship you're paying attention to these. We expand our history in the area of the hip. We want to have multiple office personnel interact with the patients because they definitely tell your staff different things than they tell you and you can pre-take that history to figure out exactly where this patient may come in on their symptoms. From a patient reported outcomes perspective, yes we can study them and indeed we had a good conversation about minimal clinical important difference, but these studies, questionnaire instruments have questions about sexual function, anxieties, disruptions in their lives, the problem so we use these as clinical tools as well. We also try to assess whether the patient is capable of surgery. Are they holistically on balance inside their life? Do they have self-responsibility for what's going on and are they capable of even seeing past the problem? So I think a short term, when do we operate with athletes when they tell us about a hip story? Well in in-season if they just can't play or off-season they just can't seem to get started with a proven hip dysfunction. So we're looking for them to actually show us that this is a hip problem. We do not shut down actively successful athletes to operate on structural diagnoses of the hip. Cartilage labrum injury with experienced team identifying intermittent pain in the anterior joint. This is a reasonable time for the story to go and we know there are some radiographic and some age determinants that may help in the history. Relatively speaking something we hear this in their story as they tell it to us at the beginning this is something that we want to consider potentially maybe not to get involved. So to keep on time just some comments concerning complications to look at it in the opposite direction. Recent studies on complications and learning curve from New York as well as other portions of the country demonstrate that as multiple cases are added and concentration to high volume centers occurs our complications go down but it does not seem to be related to the type of procedures performed. One would argue that potentially these are just simply expert centers learning how to take histories better in selecting their patients. So what's the worst prognosis? PROs but below the 50th percentile when we're starting out, concomitant osteoarthritis, someone that tells you I just got to get out of this pain, secondary gain issues along with the story, a friend or a relative that describes a high pain tolerance in the individual sitting in the office that you're addressing, achy pain with long periods of sitting and job life demands they just plain don't like. These are all things that are historical things that should make you scratch your head. So in conclusion the patient history taking portion of our learning curve is currently understudied, likely a factor that exceeds reported technical failures in published revision studies as poor history taking. Correctly aligning the patient's goals, accurate diagnosis of non-arthritic hip pain, joint symptoms and technical mastery will result however in predictably good outcomes. And thank you very much.

hip preservation surgery

hip arthroscopic surgery

listening to patients

diagnosing hip dysfunction

patient history taking