Hello my name is Travis Mack and I'd first like to thank Anna and the group today for giving me the opportunity to present this presentation on hip arthroscopy and preservation within a university practice. So the biggest question is, is there really a difference in a university hip practice and preservation practice versus another place? Some people think of universities as institutes of higher learning and they are, but does that really translate into something different in a clinical practice? I would say that this is where I practice is the University Orthopedic Center. It's really an outpatient surgical center that has clinics and surgeries much like any other private practice. So as far as my practice set up clinically, I would say there are very significant similarities. What about the patients? Are the patients any different? I would say that generally speaking these are my patients, high school football players. We have university athletes, female and male alike. This translates into female basketball players, football, both high school as well as collegiate football players. We take care of Olympic skiers as well as hockey players. We take care of professional players with the Utah Jazz. We're all Salt Lake professional soccer players. We also take care of older individuals who are still far more athletic than I am at the Huntsman World Senior Games as an example. But last but not least, really the bulk of our patients are just average individuals like myself who like to get out and think of them as recreational sort of weekend warriors if you will. And this makes up the bulk of my practice. What about specifics with the hip pathology? Well I'd say is a university hip pathology different? Well possibly. It probably makes up something similar for other high volume hip arthroscopists. 10% of my surgeries are on complex type of pathology. For instance, this individual who's an 18 year old pitcher who has a significant skiffy deformity. It was pinned. He got AVN on the left. He has a significant moderate slip on his right. He got a total hip replacement on his left secondary to the AVN but has a significant deformity on the right that was treated arthroscopically. What about this? Well this was an avulsion of the reflected head of the rectus which ossified and created a significant subspinous impingement. This was an arthroscopically difficult case. And then this individual who was a collegiate basketball player who had effectively a dysplastic hip and a large cam deformity but that dysplasia was secondary to the os acetabular or acetabular rim fracture that required arthroscopic fixation. So that's a what makes up my complex hip arthroscopy practice including, such as in this case, a true AMEC procedure where we transplanted the cartilage from the femoral head neck junction to his acetabulum. But again, a smaller percentage of my practice. 30% of my practice is revision. I think that may also be unique to a academic practice but other high-volume hip arthroscopists, I'm sure, see similar types of percentages. So this is an example which we saw which was referred to me. It was a 30-year-old individual who got arthroscopic treatment for his impingement at an outside institution and had an over resection of his anterior superior acetabular rim resulting in a significant dysplasia and he was put on a cane for ambulation which was previously normally ambulatory. And this was referred to our practice and treated in our comprehensive hip practice with a PAO. Another example of an arthroscopic problem for an individual who had a large capsulotomy and had subsequent instability and this was a nurse treated in outside institution by a local physician who was then referred to me for the instability and this was a subsequent capsular repair and placation that we performed to resolve her symptoms. But really 60% the bulk of my practice is just standard hip preservation. So individuals who have pincer deformities, individual who have cam deformities and we treat these in a fairly typical fashion like anyone else would. So again the bulk of my practice pretty standard FAIS. So as far as my hip team, I think that hip team is really really important for a successful hip preservation practice. My core clinical team constitutes both a surgical scheduler and clinical coordinator, my practice coordinator and then my lead medical assistant and an athletic trainer Mark Beasy who does my rehabilitation and coordination with my patients. We have a very focused hip preservation group and one of the benefits of academia is you have a lot of very sub-specialized individuals. So our hip preservation group allows me to evaluate individuals like this who was a ski patrolman who came to me for hip preservation on his right hip but with his dysplastic acetabulum, his small cam deformity, he had a significant under coverage of his femoral head. He was treated by my colleague Chris Peters with a PAO and returned to all of his activities including his career as a ski patrolman. In addition, this was a medical student who was treated arthroscopically twice by another individual with de novo and other cartilage treatments but really was not amenable to subsequent cartilage treatments. So he was actually treated concurrently with both Dr. Peters and myself with an open osteoarticular allograft transplant and an open hip surgical dislocation and cam osteochondroplasty. So these are the types of things that we can do secondary to the academic nature of our practice but really a comprehensive hip practice that can be created in a private practice as well. The next step for me in my practice was expanding the clinical team. I really do believe that hip arthroscopy is not a single individual or even a single clinical team but rather requires a whole cohort of individuals to take care of the patients. This is the expansion of our team so it's been both an open and arthroscopic hip preservation team. We have integrated spine and joint replacement colleagues since there's a lot of crossover with the pathologies. We also have a non-operative group of PM&R and non-op sports meds as well as radiologists that are specifically trained at the different techniques both CT as well as 3D MRI that allows us to evaluate using DES as well as T1 Rho and T2 mapping the cartilage sensitive sequences of the hip. PM&R I put separately because I really do think they're very very important separately from standard non-op sports medicine physicians. They allow the ability to treat complex regional pain syndromes, they about allow the ability to treat low back pathology that crosses over so having an individual who is excellent at both treating hip pathology non-operatively but also low back pathology is invaluable. This is where we all do it under one roof. I think recovery is key and this is something that we've been obviously increasing and implementing over the last 10 years of my practice and I think individuals the young adult hip have FAIS but really they want to get back to sports and being highly active and just doing surgery doesn't solve their problem but really teaching them how to address the neuromuscular pathologies and the kinematic problems that they've developed as a result of compensation I think is important. So we've established four subgroups so we have a sports performance group which involves both college collegiate as well as professional and high school performance groups. We have an adult fitness program that's run through our orthopedic center. We have tactical training programs for our local fire, police, DEA and other groups that are effectively higher athletes than I am. And finally a return to athletic activities is very specific so we have late stage and post physical therapy. We have personal sessions as well as joint programs to really get individuals regardless of their athletic level back to the sports that they want whether it be the aging athlete or high school performance or professional and elite athletes like Olympians. We have a sort of a circular group this is how I like to think about it so we have physicians and they're not necessarily at the top by any stretch I'd probably argue we're at the bottom because we're the least important but we have advanced treatment we have a group as we discussed we have sports performance team which is a return to recovery we use a lot of different modalities to evaluate individuals readiness to return to sport we have an athletic trainer group one that works directly with me as well as other athletic trainers that work directly with the team specifically that we interface personally with and finally physical therapists some that work with our professional Olympic athletes but also in the high school training programs and these are specifically trained a hip performance so the young athletic hip is unique and I think physical therapists can actually if untrained make the post-operative and pre-operative outcomes worse so it's very important that the physical therapists are therapists are excellently trained and when they are they can take up a hip that is significantly painful and turn it into a pain-free hip if done correctly what about research I think this is something that is very specific to academia oh there are a variety of under other individuals who do excellent research I think it lends itself well to a comprehensive and multidisciplinary approach and these are four individuals who have helped me in my own career Andy Anderson is on the top left and he is a biomechanical engineer who does a lot of force plate and analyses as well as biplanar fluoroscopy which allows direct evaluation of the hip in vivo Jeff Weiss is next and he's been a biomechanical engineer who's helped him with a lot of finite element analysis and modeling of the cartilage to roll Kano is a Japanese professor who's helped me help me with the cartilage aspects of my hip career and Dave Granger as well in the pharmaceutical chemistry group and these individuals together have helped me really try to broaden and expand the horizon of hip preservation we work through both the orthopedic research labs at a department of biomechanical engineering the pharmaceuticals of pharmaceutical chemistry research group as well as the cell sheet tissue engineering center and these are all different cohorts that are present in the University of Utah that bring their enormous facilities to bear to expand my research and last but not least the motion analysis mocap lab which lets us look at hip preservation in vivo and see what's really happening in individuals with biplanar fluoroscopy and motion capture next is our hip preservation and innovation section this is something that we're really trying to push the envelope on this is something that I believe is is specifically important in hip arthroscopy and preservation as we start to advance the field and learn more this innovation center allows us to build and very easily create through 3d printing as well as mechanical creation of whatever we decide to come up with and we can take it to this innovation center and actually create the biomechanic through biomechanical engineering and the machine machine program actually create the instruments that allow us to expand the field so I think innovation centers are important as something that we can do secondary to the multidisciplinary nature of the academic practice so what about my practice development I think this is probably germane to everybody whether they're academic or not we have established sort of a destination care hip preservation program because I think that the unique nature and the rapidly expanding nature of hip preservation lends itself to destination care programs what we're trying to do is rather than just have individuals dabble really try to focus patient care into specific areas of high-volume hip arthroscopy and it can be academic or not it doesn't matter but I do think dabbling in hip arthroscopy doesn't work well so we're really trying to bring everybody together we've tried to make patients lives easier traveling to get hip surgery is sometimes quite a bear and so helping individuals come in and have a very good experience both surgically as well as in the post-operative recovery program I think is very important we have a specific website to do this as well as care providers which help facilitate the patients flying in getting their care their stays transportation their visits accommodations they can stay for up to a month if they need to to get focused physical therapy that they can then translate back to their home recovery programs our physical therapists and athletic trainers interface directly with individuals at their home areas if they don't have a physical therapist that is familiar with these techniques then we can do virtual visits where our physical therapists can teach their physical therapists how to continue their care and we found that to be very useful I also think telemedicine has become something that's very important in the current day and age COVID one of the upsides of COVID there are very few but this is one of the upsides it's allowed to us to expand telemedicine into the mainstream and this is something that I incorporate in my practice significantly at this time it doesn't supplement the initial visit I think hip arthroscopy and hip preservation is a very patient-centric aspect of sports medicine and for me putting my hands on an individual and really talking to them in a face-to-face fashion is something that cannot be removed that being said post-operative care for individuals who have to travel for many hours to come see me is facilitated by this for instance if they're worried about their incision it allows me to directly look at it for a two-week follow-up again for to check incisions is quite easy the six-week follow-up I ask all of my patients to come back in person but the remainder of the visits can be done through telemedicine and a lot of my patients that are coming from a long way away find this very very helpful it needs to be coordinated carefully obviously so that they don't sit on the phone for a long time and don't feel like they're getting in an inappropriate care not the appropriate interaction that they want but it has been helpful and I allow my patients to choose what they would prefer last but not least is really delivering the information to the patient so if patients are coming from a long way away knowing what they're getting is very important and knowing how to prepare for their visit is also very important so we've spent a lot of time developing post-operative patient information packets pre-operative packets those are online and downloadable to allow patients to get ready for their surgical procedures it also allows them to get all of their information together so that when they come to visit me in person they are not left wondering what's going on examples meaning if they come in and they already have had x-rays and MRIs but they are not readily available then I can't formally and fully evaluate their hip so we collect all of that together through our hip destination care program so when the patient arrives they have everything streamlined and if they need to get other things that are specialized for instance ultrasound guided injections doesn't seem specialized but it can be for people in a rural community so those are all planned and detailed including hip specific CTS and MRIs are already ordered so if the patient doesn't feel comfortable getting it in their rural place or a rural location then they're all pre-authorized by the time they come to our our institution those are streamlined they're obtained and then I see them with all of the information already present so I can give them the most informative visit that they can can expect so that effectively details my entire practice academia as well as the hip preservation practice and I think it's always evolving but the most important thing is to really think about how a patient would want their experience to be and to really treat them accordingly so thank you for giving me the time to speak with you hopefully this has been helpful

Travis Mack

hip arthroscopy

hip preservation

university practice

hip pathologies