Welcome to this anti-hyperthroscopy course. As far as my disclosures, they're available on the website. My topic is hyperthroscopy in the professional athlete, pearls and pitfalls, and I suspect that my expertise falls more on the pitfall side. To reference Mark Twain, who said, experiences are the thing that tells me I've made this mistake before. Well, on that front, I've got lots of experience that we can share with you. Or as my father's chief of surgery said to one of his residents, he said, son, you don't have to learn all the complications for yourself. You can read about a few of them. Well, I can certainly share with you some issues that perhaps you can avoid. Hippocrates said, he who desires to practice surgery must go to war. And we know that many of the greatest surgical innovations occurred during military conflict, but some of this spills over into sports medicine, as illustrated in the remarkable case of Alex Smith and his return to professional football. As someone said, there's no better clinical laboratory than the fields of athletic competition. In 1994, we published the Sopan technique for performing hip arthroscopy. That was also the year I did my first bona fide athlete. This is a Division I basketball player from the state of Kentucky that got undercut on the court in February of his sophomore year, landed on his greater trochanter, had groin pain, made it through the season. They made it to the Sweet 16 of the NCAAs that year. About a month before his junior year, he still got groin pain. And his only problem is he can't dunk. And a 6'7 basketball player who can't dunk isn't much use to his basketball team. He'd had three MRIs, also all diagnosed as atypical AVN. And a month before his junior year, we decided to go in and take a look. And I remember I was sweating bullets because his trainer's looking over my shoulder. I didn't know what we were going to find. And what he had was this unstable articular fragment off the medial side of his femoral head, which we excised a month before his junior year. And he was the league MVP and league leading scorer that year, which is much more of a credit to his ability than to mine. He went on to a successful NBA career, ended by a foot injury, but not because of his hip. In 1997, I was asked to come to a university to operate on one of their athletes. And they said, hey, if you're here operating, why don't you give grand rounds? So I gave grand rounds. And when I got done, the chairman of the department stood up and proceeded to give me his perspective on hip arthroscopy. He thought it was a triumph of technique over reason, and there was no place for it. And I remember kind of sputtering and saying, I don't know. We've got some things that have worked that hadn't all worked. Well, sometimes it takes a while for things to come around and get a small sense of vindication. Five years later, when the athlete I operated on ended up being the first African American to win a gold medal in the Winter Olympics. In 1997, the Houston Oilers also moved to Nashville. And for the first couple of years, they were the Tennessee Oilers and somehow ended up being their team doc. And sure enough, training camp the first year, one of our offensive linemen starts developing left hip pain. We inject his joint, and he makes it through the season. At the end of the season, I'm looking at having to scope his hip, and I'm thinking, great. How is it that the only Yahoo in the league that scopes hips just happens to have somebody on his team that needs a hip arthroscopy? I thought, this is going to be a short NFL career. But we ended up scoping his hip, and here it is. A lot of articular fragments, which we excised. He got better, became a starter the next year. The sort of joint that you wouldn't think would have much longevity to it, but 20-something years later, he's had both knees replaced, but somehow he's still percolating along with his hip joint. Now, subsequently, I presented this case at the NFL team physicians' meeting at the Combine in Indianapolis, and I remember one of the trainers who's still with us today that came with the team from Houston said, you know, back in Houston, we had a couple of these guys with these groin symptoms and never seemed to get better, because I wonder if some of them might have had a hip joint problem. And it wasn't until years later it finally dawned on me that it wasn't that I was the only Yahoo in the league scoping hips, had somebody with a hip problem. There are a lot of NFL players with hip problems. We just weren't any good at diagnosing them. In 2001, we published the first scientific article on hip arthroscopy in athletes. We found the mean improvement was 35 points on 100-point modified Harris-Hipps score, and 93% showed demonstrable improvement. These were simple debridement procedures, and they showed the greatest improvement in the first month and pretty well peaked by three months, and those results were pretty well maintained for five years out. Well, as somebody once said, nothing ruins good results like follow-up. When we looked at our 10-year results, we found, sure enough, the median improvement was 45 points, 87% return to sport, but a third of these ended up getting converted to a total hip replacement at an average of six years. So it was after five years that the wheels started to fall off. We realized our results weren't really durable. Fortunately, Professor Gons came along and taught us about FAI as the underlying etiology for many of the hip problems we saw in young active adults. And really, FAI is the 600-pound grill in the room. That's what we deal with the most. Dysplasia is a distant second. We think of dysplasia in sports and activities where range of motion is a premium, such as dancers, gymnasts, and figure skaters. But I would also throw wrestlers in there. We see problems with dysplasia in wrestlers as well, and they can come back from a corrective PAO and compete successfully. When we published our earliest experience with FAI in athletes, we looked at the first 200 athletes with FAI, and we found that 95% returned to sport at the professional level and 85% at the collegiate level. And there's a couple of important take-home messages in here. And first of all, I don't think that means that we're doing a better job surgically in the professional athletes than the collegiate athletes. But as we all know, there's a lot that goes into our surgical successes beyond simply what we accomplish in the operating room, namely the intensity and quality of resources available, the motivation of the athlete, etc. And secondly, we know as clinicians that there's a lot that goes into our care of patients beyond what we can accomplish simply as mortal human beings. In 2002, Frank Jobe gave the Kennedy Lecture at the AOSSM annual meeting in Dallas, and he reflected back on Potter Stewart, one of the Supreme Court justices, where the Supreme Court was ruling on the definition of pornography and obscenity, and Stewart famously quoted that, I can't define it, but I know it when I see it. And Dr. Jobe felt that, really, that is somewhat parallel sports medicine, so you could probably lump sports medicine with obscenity and pornography. But really, sports medicine is more of a philosophy, and from my perspective, it's a comprehensive team approach in the management of athletic and fitness-related injuries and illnesses with an emphasis on injury prevention, facilitating and optimizing recovery. And really, this is just a blend of science and art form directed towards practicing good, old-fashioned, simple medicine. John Chapman was the longest-tenured dean of the School of Medicine at Vanderbilt. He was an eloquent orator, and he said the most important skill of a clinician or scientist is communication, because it doesn't matter how brilliant you are or you're diagnostic or human, if you can't communicate it to your patients and your colleagues, then all the rest of that is lost. Well, Dr. Andrews may be the most remarkable surgeon I've ever witnessed, but he's also one of the greatest communicators, because in the professional world, docs are usually lumped as either being the team's doc or the agent's doc. Well, Dr. Andrews is masterful at keeping everybody on the same page, communicating with all the various components, so he's not saying one thing to one person and something else to somebody else. Everybody's hearing the same message. I'm reminded of what my father would say, that if you never lie, you never have to remember what you said. And another sort of protective way of looking at this is the truth is protection against a poor memory. Well, there are unique considerations of treating elite athletes, and as I reflect on some of the exceptions we make in how we treat elite athletes, I think it's critical to remind ourselves that you really have to be careful any time you're making exceptions to your normal standards of care. You're really setting yourself up for exposure. But the exceptions are a reality. Namely, professional athletes have a lot more time and resources available to them to dedicate to their recovery. They're highly motivated, and that can make you look good. And by definition, to get to that level, you pretty much have to have a high pain tolerance, and that's both good and bad as far as some of the destructive behavior that can occur to their bodies. This is definitely a case of do as I say and not as I do. This is a professional wrestler. He doesn't have left hip pain, but he has recurrent groin strains and SI symptoms. He only wrestles once a year during WrestleMania, and he gets a portion of the gait. But at this point, he really can't go, and again, he has no hip pain, and he's interested in me taking the spurs out to see if we can give him better motion in his hip, and his hip's quite stiff. And I say, listen, you've got a painless stiff joint. If we take out those spurs, I worry that we may give you better motion, but now you're having pain. And this was just a few months before WrestleMania, and arthroplasty wasn't an option at the time. He said, well, you know, I can't do it the way it is, so why don't we try? So sure enough, we went in, took out the spurs, got him a little better motion, made it through WrestleMania. Made it a couple of seasons before he ended up going ahead and getting an arthroplasty, but definitely not something that I would ever sort of present at my boards or anything of that nature. Now, I remember back about 2006, one of our veteran offensive linemen, he's had some chronic back pain. He's got multiple-level degenerative discs in his thoracic spine. He went over to see Craig Brigham, who was one of the remarkable spine surgeons who passed away at a young age, who looked at him, evaluated him, and our lineman said, well, you know, is it going to get worse if I keep playing football? And Craig reminded him that you don't play football for your health, and I think that's a perspective that's important to remember with some of the things that athletes at all levels are subjecting their bodies to. But we do remember that athletes have a finite life of their competitive athletic career, and it's a quickly closing window of opportunity where they can generate substantial income that they'll never see again. So sometimes you may choose to be a little bit short-sighted for economic reasons, but it's important that the athlete is part of that decision-making process, and that they understand the potential consequences of what the future may hold for them, and certainly that applies at the professional level, sometimes at the elite level for people who have dedicated their whole lives to their sport or athletic pursuit, but also at the collegiate level, a lot of folks where their education is dependent on an athletic scholarship, and I oftentimes emphasize to them, you know, you're not going to have a long athletic career, so you really need to make sure and focus on your education. Make sure when you leave college, you've got an education that you can count on because you don't want to be having to rely on your body for future endeavors. And unfortunately, this can even trickle down to the high school level because there's some kids where their athletic prowess may be their ticket to getting a college degree and a college education. I always point out that by the time an athlete lands on my doorstep, it's unlikely that their hip is ever going to be returned to normal. There's lots of things we can do to diminish symptoms and perhaps improve the longevity of their joint, but it's never really going to be restored to a truly normal native virgin hip that they had before the onset of their damage. I really like what Dr. Andrews would say about an ancient antique vase that if you drop it and shatter it, you can put it back together, but it's never really the same antique vase that it was before. I think it's important not to be in a hurry to operate on some of these folks. I think an enthusiastic surgeon matched with an enthusiastic patient can be a recipe for disaster. There are numerous studies, especially looking at FAI, that report poorer results with longer duration of symptoms, and that implies that perhaps earlier intervention is preferable, but do you really need to operate on them right away? And from my perspective, I think the answer to that is no. Remember that regardless of the suddenness of the onset of symptoms, FAI is the culmination of the cumulative effect of a disorder that's been present since childhood. The problem has been developing long before they first become symptomatic, and they've been compensating long before the joint first becomes problematic. These compensatory problems may obscure the underlying joint disorder, and that's where a supervised rehab process can assess and address these compensatory problems. That can go a long ways towards reducing symptoms and improving function, and sometimes regain their ability to compensate. In general, once a joint becomes symptomatic, really it's unlikely that the problem's just going to get better and go away. Sometimes you'll see somebody, and it's evident from the beginning that really what they need is surgery as the most definitive course towards their recovery, but that doesn't mean that their only choices are to either suck it up or do surgery. There's a lot of things you can do to help modulate their symptoms. If their symptoms are stable, I think a non-operative approach is appropriate. If the symptoms are worsening despite conservative measures, then I think it's wiser to recommend surgery rather than just wait and see how much worse it gets. I think it's especially important to emphasize to your athletes that just because you're not recommending surgery does not mean that this isn't a serious problem. I've had a number of folks who were referred to me after they've failed conservative treatment, and I've talked to them about surgery, and they're kind of shaking their head going, wow, I need surgery, and all I did was do therapy and rehab and try injections, and now I need surgery. So I think it's important as you're initiating the treatment algorithm, which oftentimes starts with conservative treatment, that you tell them on the front end where this could potentially be heading. Now, I'm not opposed to judicious use of intra-articular corticosteroid injections. This can help reduce the symptoms and allow for more effective supervised physical therapy. You can do a better job of correcting some of those compensatory disorders, and again, you can regain the ability to compensate, and at the very least, it puts them in a better position for successful surgical recovery. And I also view an injection as sometimes just the last line of non-surgical treatment before moving forward with surgery, and when you present it from a perspective of trying an injection compared to surgery, sometimes trying an injection doesn't sound like such a bad idea. I think a one-time injection's not going to compromise their long-term outlook. Now, I think a multitude of injections is ill-advised. You're not going to dissolve the joint, but you're just treating the symptoms and not addressing the underlying problem, and that can have substantial negative consequences down the road. What about orthobiologics? Well, I think to say that the science behind these is incomplete would be an understatement, and there are a lot of people out there purporting all kinds of claims with orthobiologics. Many of these are well-intentioned, but some of them are more nefarious, and you have these young professional athletes with a lot of loose money in their pockets, and there are a lot of folks that are happy to separate them from that loose money, and that's where, as a team physician, it's important to know your athletes. It's important to know what they're thinking. It's important to know what they're putting in their bodies, and that's the difference between a team physician and a specialist, and I think the most consummate example are flight surgeons, and flight surgeons aren't usually surgeons, but they're physicians who are embedded with the flight team, and oftentimes, and they live with them day in and day out, and oftentimes, they'll detect illnesses or disorders with these pilots before the pilots themselves realize they're an issue. Now, as we look at the orthobiologics, and mainly these are PRP and stem cells, and really just minimally-manipulated stem cells, you have to ask yourself, well, remember, what's the role of these? And they really have two general categories, either to potentiate healing or to modulate the symptoms of osteoarthritis, and FAI is a structural problem, and that's where all the injections in the world aren't going to correct the structural issues that these athletes are facing. I also think it's wise to be temperate in your enthusiasm for biologics that are available today, especially in the hip, because the hip responds differently than other joints such as the shoulder or knee. This is just a professional football player. He comes to see me. He's fresh off $50,000 worth of various injections, and we don't know exactly what all he had injected, but now he's ready for surgery on his hip, and we put him off a month or so. I was more worried about the prospect of developing an infection with all those injections, but we put him off, did his corrective surgery. When he follows up in about eight weeks, he's just got more stiffness and more discomfort than I would expect at that stage following the surgery, so we just repeated an X-ray, and he's got some of the most proliferative heterotopic ossification around his hip that I've ever seen, and it's certainly convenient as a surgeon to blame it on all those injections, but I've never seen anything like this, and we know that the hip is just more susceptible to HO, and we've seen other cases to lesser magnitude in patients who've been treated nonoperatively with various types of injections. Now, lastly, I'll comment on evaluating complex hip disorders without benefit of ultrasound. It's like practicing cardiology without a stethoscope. This is your single greatest adjunct to your history and your physical examination, and this isn't unique to professional athletes, and it's not unique to athletes at all, but why is this? Because I sure don't need ultrasound to be able to examine somebody's knee and tell if they've got ligament or cartilage damage, and first of all, all hip problems are complex. As we've alluded to, they have coexistent pathology, compensatory disorders, coincidental findings, and I tell people it's a good day when I see someone and all they have is an isolated intraarticular hip problem, and also hip symptoms can mimic numerous other disorders. In that 2001 article we published, we found that 60% of intraarticular disorders went unrecognized for an average of seven months of treatment before a diagnosis was made, and if you think that's antiquated data, more recently, John Clohissy from Wash U, they looked at young adults with non-arthritic hip disorders, namely FAI, and they saw an average of 4.2 healthcare providers before a diagnosis was reached, so these are elusive problems. MRI shows you signal changes in the soft tissue anatomy around the joint, but ultrasound actually reveals structural changes in the tendons and muscles and things of this nature. Sadly, I don't know how to turn an ultrasound machine on, but for you young people, ultrasound can be a great learning tool as you can inspect and see what's going on with the structures around the hip, especially in a dynamic fashion as you're putting the hip through range of motion. We use ultrasound-guided injections both for diagnostic and therapeutic purposes. For diagnostic injections, it's critical that the athlete be able to generate their symptoms prior to the injection so you get a meaningful response to how they do after the injection, and sometimes that includes sending them over to therapy where they can put them through various functional demands to make sure they can create the symptoms before doing the injection and send them back afterwards. Also, we're often investigating multiple sites looking for the principal pain generators, and as a clinical pearl, make sure and start with the area of least discomfort or least suspicion first because sometimes you'll be surprised at how much of a response they get, but also if you start with the area that hurts the worst, that may obscure how much the other components are contributing. It's important to reassess and record your observations between injections because if you try to ask the patient a couple weeks later, all they remember is they got these different things injected. Now, not everybody has one of these, and I'm not talking about the ultrasound machine, but Beth Bardowski, our nurse practitioner, who when it comes to ultrasound and ultrasound-guided injections around the hip, as far as I know, has more experience than anybody in the history of the world. This is just one of her satisfied patients who posted this video. Here she is aspirating fluid from his hip before an event, and then as he sits up, you'll see the smile on his face, and as his boss comes in and they're both grinning, Beth gets a nice photobomb opportunity in the background. So when it comes to ultrasound, I like to paraphrase Carl Malden in the old American Express Traveler's Checks ads, ultrasound, don't leave home without it. Greetings from Nashville, and enjoy the course.

hip arthroscopy

professional athletes

challenges

conservative treatments

ultrasound

orthobiologics