Hello, it's a pleasure to contribute a presentation to this exciting HANA course on managing modern athletic hip injuries. Thank you, John and Al, for inviting me. My name is Rich Santori, and I'm an adult recon hip surgeon in San Diego. As most of you know, I've had a longstanding interest in open hip osteotomy surgery for hip dysplasia in adults. Over the course of four decades, I've evaluated thousands of patients with hip dysplasia and observed that many of these patients were also hypermobile. I want to share with you some of our research findings and hopefully open your eyes to the role that hypermobility likely plays in many of our patients, not just those with hip dysplasia. How did I become interested in hypermobility? Over many years, it was clear that most of my patients with hip dysplasia were flexible, many to an extreme degree. Rick and I decided to do a prospective research study to demonstrate the prevalence. Our paper was published in JVGS this past November with data on over 1,000 patients. We demonstrated that nearly 80% of hip dysplasia patients have hypermobility. The architectural component of dysplasia is demonstrated here with a clearly dysplastic hip on the left and a normal hip on the right. These pictures depict the pre- and post-op appearance of a PAO with correction of the acetabular index and lateral center edge angle and appropriate management of the anterior and posterior wall relationship. Our PAOs are now being done routinely on an outpatient basis. Just 10 years ago, five to seven days in the hospital were routine. Our first outpatient combined scope PAO was done on February 4th, 2019. And here's a picture of the patient. Dawn Howie from Adelaide, Australia was one of our guests that day. She ate a rather large meal three and a half hours after the surgery. She had no pain and went home five hours after the end of her operation. Here you can see the progress that she made during her rehabilitation. This video shows her walking three hours after surgery, five days after surgery at the time of her first outpatient visit, and finally walking normally at seven weeks. Next, a patient's perspective on the day of her outpatient PAO. This interview took place three hours after the end of her surgery and just before going home. It is a different patient from the one presented just now. I feel very confident of going to my house and navigating the restroom and all sorts of things. And that in a nutshell itself is worth it. So you've already been out, you've done stairs, you've gone to the bathroom. No catheter, you've already eaten. I've already eaten, no nausea. We've incorporated the bikini incision into the outpatient PAO rapid rehabilitation protocol. Here you see the cosmetic appearance of the incision on the left and the incision covered by a bathing suit on the right. What are the non-orthopedic conditions associated with hypermobility? Well, they are numerous and include nearsightedness, constipation, nausea, low blood pressure, orthostatic hypotension, depression, anxiety and frustration, hernias, stretch marks, poor response to numbing injections, TMJ clicking and pain, mitral valve prolapse, reflux esophagitis, wide scars, varicose veins, bladder symptoms, pelvic pain, loose stretchy skin and chronic fatigue syndrome, among others. Systemic hypermobility is likely present yet not recognized in many orthopedic conditions, including shoulder instability, patellar instability, hind foot collapse, chronic ankle sprains, neck and back pain, scoliosis and many more. Female patients whose primary condition is hypermobility are commonly misdiagnosed with fibromyalgia, neurosis, hypochondriasis, perimental depressive depression or labeled as chronic complainers or drug seekers. When a diagnosis is made, it is often after many years of searching for an answer. The Hypermobility Syndromes Association in the UK calls it the 10-year diagnostic delay. I had the privilege of being a guest speaker at the London Hypermobility Club a few years ago. On your left, you will see Rodney Graham, a famous British rheumatologist who was the founder of the world's first hypermobility center at the University of London. To my right is Alan Hocking, his associate, who is now the CEO of Ehlers-Danlos Society. At the dinner that evening, it was a pleasure to have time with Johan Witt and Marcus Banks. The therapeutic approach for hypermobility includes, most importantly, recognition and acknowledgement by each of us of the impact of this condition on our patients. Next, education, followed by psychological support and appropriate subspecialty referral when needed. Now I wish to share with you a video that was voluntarily made by one of my patients to demonstrate the impact that appropriate recognition and treatment of hypermobility associated with mild dysplasia had on her life. My name is Grace Porter, and when I was 23 years old, I abruptly stopped being able to walk normally. Thinking that I'd just injured myself, I went to physical therapy, but in the course of physical therapy, I tore my labrum. My hips continued to get worse and worse. I got x-rays, MRIs, CT scans, even bone density scans, and I sought the expert opinions of orthopedic surgeons, hoping that they could help me. I went from a normal 23-year-old woman to someone who could barely work, walk, drive, or do basic life tasks. The pain was unbelievable. I was in agony every single day. At best, orthopedic surgeons would refer me to other experts, but more often than not, I simply wasn't believed. Looking in my scans could prove the level of disability I was facing and the amount of pain I was in. It was absolutely heartbreaking to be in so much pain, to not know what was wrong, and then on top of that, to not be believed by medical experts who I entrusted with my care. It took seven surgeons and three years before I found Dr. Santori, and Dr. Santori not only looked at my scans, but he also looked at my body, and what he determined was my mild hip dysplasia in combination with my hypermobility was what was causing me so much pain and disability. He offered me periacetabular osteotomies, PAOs, to help me restore my life. After undergoing the PAOs, I was able to get my life back. I can work, I can walk, I can drive, I live a normal life, but I can't tell you how much it meant not only to find somebody who could figure out what was wrong with me, but also someone who believed me, who believed that even though my hip dysplasia was mild, that my hypermobility was causing me as much pain as I claimed it was. It was such a dark time for me, all those years of not being believed. I was able to go on to have a happy, healthy pregnancy and a beautiful baby girl last summer. I know she wouldn't be here if not for Dr. Santori and the amazing work he does, but I also don't know if I would be here if not for Dr. Santori. The level of pain I was in, the level of disability I was facing, and then not being believed almost had tragic outcomes for me. I know the work he's doing matters, and it's my greatest hope that other patients who are hypermobile and facing a similar circumstance that I did will be able to get help faster, be believed by surgeons when they say that they're in pain, and have a route to be able to find their fix much sooner than I did, not taking years out of their life to have solutions. So I want to thank Dr. Santori for everything he's done for me, other patients, and I want to thank everyone for taking the time to listen. Thank you. Next, I want to share a video produced by one of my patients who underwent bilateral derotation osteotomies. She has a profound degree of hypermobility, as is the case with many of these patients. It took a number of years and multiple orthopedic consultations before the diagnosis was established and an effective surgical strategy undertaken. My name is Emma North, and today I'm going to tell you about some of the really important work that Dr. Santori is doing with the SHARP Hip Preservation Center and with the SHARP Hypermobility Center. Dr. Santori is a doctor who actually hears patients. He takes the time to meet with you, to really test you, to actually find the correct cause and diagnosis of your problems, rather than prescribe you pills and push you out the door. My story starts when I was 16 years old. I did varsity track and cross country in high school, and I started hearing a clicking noise. My pain became very severe. I went to my general practitioner, I went to sports medicine doctors, I went to physical therapy. It took a year and a half before they finally did an MRI of my leg, at which point I'd already torn through both my right and my left labrum. Before that, I'd been dismissed by doctors. I was told, essentially, you're looking for pills, your pain should not be this bad, you're young, you'll be better in two weeks, take some Tylenol. But it was so much more than that. My pain kept progressing, kept getting worse and worse until I could not walk without pain. I had both my right and my left labrum repaired, and I still was in pain afterwards, and my surgeon wanted to help me, but he really just said, I don't know what's wrong. It would be seven years before I would end up meeting Dr. Santori and getting the actual treatment that I needed. By the time that I met Dr. Richard Santori, I could barely walk. I could only walk with crutches, and even then, a very short distance, I'd had my life taken away from me. I say that Dr. Richard Santori saved my life because without him, I was really losing that spark to keep going. When I saw Dr. Santori, he told me something that I'll never forget. Your pain is real. You have a problem other doctors have not understood, but I know what's wrong, and I can help you. Dr. Santori recognized that all of my individual symptoms came together to form a comprehensive picture. It wasn't normal that I could take my legs and twist them all the way backwards, and that this was one of the underlying causes for why I'd ripped through my right labrum for a second time, and why I'd also tore my left labrum, and why I was losing the ability to walk. Dr. Santori connected all of these different pieces of my medical history together. I needed to have reconstructive surgeries of my femurs, and that I had hypermobility. Dr. Santori performed derotation osteotomies of both my right and my left leg. This year, I'll have my fourth surgery with him, and from these surgeries, for the first time in my life, I feel my leg in the right spot. I can walk again. I can ride my bike again. I can walk my dog. I can drive. I can work. I can sit. I can sleep. I've had my entire life given back to me because of Dr. Richard Santori and the work that he does. I owe my life to this person, and to Dr. Santori and to his team, that they have restored my ability to live a pain-free and happy life. Thank you, Dr. Richard Santori, for all of the work that you're doing. I know that the Hypermobility Center will have an enormous effect on people's lives, and helping doctors learn about this affliction, helping them diagnose it, helping them recognize it so that more people and patients like me can get the treatment and help that they need. Thank you. I hope that this presentation will inspire you to look at your patients from a different and enlightened perspective in the future, and to have a fuller understanding of the secondary manifestations of hypermobility. If you take the time to listen to your patients' life stories and show empathy and understanding of the role that hypermobility is playing in their lives, you will be rewarded with the eternal gratitude from your patients.

Dr. Rich Santori

hypermobility

hip dysplasia

orthopedic conditions

periacetabular osteotomy (PAO)