medicine surgeon at Mount Sinai in New York City. I'm privileged to be with you to discuss why hip preservation fellowship matters. Before we get into this though, I first want to thank Anna for having me as a course faculty for this year's Managing Modern Athletic Hip Injuries lab course, as well as thank you to John Cristoforetti and Alston Stubbs, the co-chairs of this year's course, for inviting me along this year to be a faculty and to discuss my experiences during my training as a hip preservation fellow and to discuss why hip preservation fellowship matters. Here are my disclosures. I'm an associate editor for the Journal of Cartilagin Joint Preservation. I sit on the editorial boards of Arthroscopy Sports Medicine and Rehabilitation, as well as the Journal of Sport Rehabilitation, and I'm a committee member at AOSSM, as well as the Society of Military Orthopedic Surgeons. I want to share with you my story and give you my background as to why I am here speaking with you today about hip preservation surgery fellowship. I did my orthopedic surgery residency at Boston University, which was followed by a sports medicine and shoulder fellowship at Boston University, and then a second fellowship in sports medicine and cartilage restoration, where I did significant cartilage work at the University of Pennsylvania. Then I actually did a third fellowship in hip preservation surgery at Harvard. This came about because during my sports training, I was exposed to hip preservation surgery and hip arthroscopy. I enjoyed the cases, the pathology, and the patients, and I wanted that to be a significant part of my practice. Discussing with many leaders in the field of hip preservation, they suggested and highly recommended a third fellowship, dedicated fellowship, in hip preservation surgery. We will get into more of that. What is hip preservation? Hip preservation, this is my definition here, it involves treatments, both surgical and non-surgical, intended to relieve pain, improve function, and delay or prevent the onset of arthritis. Really, in hip preservation, we're dealing with pre-arthritic hip conditions, and these are our general goals here. The conditions that we deal with are extra-articular, as well as intra-articular. Extra-articular being that of tendon muscle injury or dysfunction. Intra-articular can be anything from instability, which can be caused by acetabular dysplasia. You don't have appropriate coverage of the femoral head by the acetabulum, or from ligamentously lax patients. Impingement is different types, a CAM type, which is asphoricity of the femoral head, where the lesion on the femoral head and adjunction can engage the labrum during activity, as well as a pincer type of impingement. You have overcoverage or a retroverted acetabulum, and all of these can lead to various articular cartilage lesions and defects. Non-surgical management consists of focused physical therapy, as well as injection therapy, corticosteroid, or orthobiologics. Then, the main procedure types are open versus arthroscopic, and this is why I believe that a hip preservation surgery is very valuable. Even if you're not going to be performing the open procedures in your practice, it's very valuable to have that experience in your training. We'll take a step away from medicine for a moment. I'm not sure if many of you identified this gentleman, but this is Malcolm Gladwell, author of Outliers. In Outliers, he discussed the 10,000-hour rule, and we'll go through it here. He stated that 10,000-hour rule says that if you look at any kind of cognitively complex field, from playing chess to being a neurosurgeon, or in our case, a hip preservation orthopedic surgeon, we see this incredibly consistent pattern that you cannot be good at unless you practice for 10,000 hours, which is roughly 10 years if you think about four hours a day. So, you cannot be good at something truly until you dedicate 10,000 hours to that task. Well, this is supported by a very well-known famous Japanese martial artist who said, in your training, do not be in a hurry, for it takes a minimum of 10 years to master the basics in advance to the first run. Never think of yourself as an all-knowing, perfected master. You must continue to train daily with your friends and students and progress together in the art of peace. So, don't be hurrying your training. Take time to get the appropriate training. Michael Jordan would echo that, and his comments here speak to getting the appropriate training prior to dedicating those 10,000 hours, where he says you can practice shooting eight hours a day, but if your technique is wrong, then all you become is very good at shooting the wrong way. So, get the fundamentals down, and the level of everything you do will rise. Do things appropriately. Get the appropriate training in the beginning. Dedicate those 10,000 hours to something done appropriately, and with the appropriate training, and doing it the right way. Dan Coyle, famous author of the Talent Code and the Culture Code, states that although talent feels and looks predestined, in fact, we have a good deal of control over what skills we develop, and we have more potential than we might ever presume to guess. So, the development of skills and having control over that. So, this gentleman here, I'm sure many of you do not recognize, but this is actually a good friend of mine, Zach Diossi. He played at Brown University prior to the New York Giants, which is where I played at Brown University. I actually helped recruit him to Brown. So, Zach, why are we discussing Zach? Well, Zach was drafted out of Brown University as a fourth-round pick in 2007. He drafted as a linebacker, had a wonderful combine running a sub 4'6", 40-yard dash, and benching 225, 26 times. What did Zach say? Zach said, I want to have a long-lasting and impactful career. So, he sub-specializes a long snapper. He was drafted as a linebacker. He sub-specializes a long snapper. He learned how to do that task, and he did it over and over again, and he became the best long snapper in the league. Became captain of the Giants from 2012 to 2020. Was a two-time Pro Bowler, two-time Super Bowl champion, and enjoyed 13 very successful seasons in the league by sub-specializing. Back to medicine. This study by Alan Daniels and Christopher DiGiovanni. Dr. DiGiovanni, interestingly enough, was my foot and ankle doctor when I was an athlete at Brown. He's now the chief of foot and ankle surgery at Harvard, but they had this study that evaluated fellowship training and sub-specialized fellowship training as emerging as a necessary component of contemporary orthopedic surgical education. In this, they found that, if you look at the top line there, nearly 90% of orthopedic surgery residents plan to pursue sub-specialized fellowship training. This is a very different and drastic shift from, say, 30 years ago, where fellowship training was not the overwhelming norm, but now it is. Now, getting that sub-specialized training is now the norm, with nearly 90% of trainees doing that. We're going to jump into this study here from the Journal of Hip Preservation, titled The Education and Training of Future Hip Preservation Surgeons. In this study, they surveyed high-volume hip preservation surgeons and got their perspectives on the current and future training of surgeons entering the field of hip preservation. They surveyed 16 high-volume surgeons, and high volume meant that these surgeons had a mean career volume of over 1,000 cases, which is about 162 cases a year, so to give you some sense of the volume that they were performing. As you may or may not know, the ACGME does not have a formalized recommendation for hip preservation case minimums for residents or fellowships in their training. Having said that, an orthopedic surgery resident, after five years of orthopedic training, is going to have, on average, eight hip arthroscopies under their belt. They're going to have participated in eight hip arthroscopies during that training time. Now, why is that interesting here? It's because those 16 high-volume orthopedic surgeons, hip preservation surgeons, suggested that in order to be competent in joint access, so getting into the joint to start the surgery, you needed to have participated in 20 surgeries, already double, more than double what residents get in their five-year training, just to access the joint, have competency accessing the joint, almost double. Label repair, about 34. Astabiloplasty, ephemeroplasty, common with FAI, ephemerostatin impingement procedures is 54. Label reconstruction, over 100 surgeries. Encapsular closure and plication, 54. These same 16 surgeons were asked, what is the ideal way to begin hip preservation training, if you want to do that as part of your practice? They said, without question, nearly 90 percent said a dedicated hip preservation fellowship is the appropriate way to get that training. What was the ideal cases for a sports fellow? So, they asked these surgeons, if you, what were the ideal cases for a sports fellow in a sports fellowship that has exposure to hip arthroscopy and hip preservation? Again, sports fellowships don't typically have open hip preservation exposure, they just have hip arthroscopy, minimum invasive exposure. And these hip preservation surgeons said, for a sports medicine fellow in a sports medicine fellowship, 67 would be ideal. 67 hip arthroscopies. Well, it's very different if you look at what they suggested for a hip preservation surgeon and a dedicated hip preservation fellowship. That top line is actually, represents hip arthroscopies, that says hip preservation, that's hip arthroscopies. They suggested that a hip preservation fellow in a dedicated hip preservation program should have, ideally, 129 hip arthroscopies. That's double the sports fellowship already. PAOs at 36, and I can tell you, in my training, I had far more than 36 periosteolar osteotomies that I participated in. Hip arthroplasty 116 and other open preservation procedures, 83. So, you can see just the recommendations and the experience that you're going to get and gain by doing a dedicated hip preservation fellowship is so significantly greater than having hip exposure as part of your sports fellowship. And then they recommended one year dedicated hip fellowship, over 50% of these surgeons surveyed recommended that. And all of this training, right, all this training is trying to get us to the place where we are appropriately indicating and executing surgery. And I would say that it's extremely valuable to have that experience as a dedicated hip preservation fellow learning and training with both open and arthroscopic minimally invasive hip surgeons on appropriately indicating and executing surgery. It's a complex joint, and the pelvis is complex, and to learn it from a, and to appreciate it from an open perspective, to have that open procedure, to see that CAM lesion in front of you, to really fully understand and appreciate acetabular version, femoral version, and how they interact with one another with regards to instability and impingement is invaluable when you're learning both the open aspects and the minimally invasive approaches from surgeons who specialize in these regions. So, this is my experience during my fellowship at Harvard Hip Preservation Program at Boston Children's Hospital. There was Youngjo Kim, who has 21 years of experience, Travis Matheny with 15 years, Yimeng Yan with 13 years, Eduardo Novice with 10 years, and then Thomas Wurtz at the New England Baptist Hospital with seven years of experience. The breakdown was two of them were dedicated open surgeons, two were dedicated hip arthroscopists, and one, Youngjo Kim, did both minimally invasive arthroscopic hip preservation as well as open hip preservation. And their combined experience is 66 years, and this is significant, right? So, the wisdom that they have, the amount of surgeries under their belt, the amount of patients they've seen, and they're all academic leaders in the field. The number of research, the volume that they have, and the way in which they approach the various hip pathologies from both an open and a minimally invasive perspective is extraordinarily valuable for someone who's going in and sticks in those foundations in hip preservation. And so, this is the experience that I had, and I think I would recommend that for anyone else who is really seriously considering being a hip preservation surgeon. I'm a minimally invasive surgeon, but I had those arthroscopic surgeon, but I had those experiences with the open procedures, which I think is extraordinarily important. And again, the mentoring that you also gain from having this, for doing a dedicated hip preservation fellowship, and then the exposure and experience you get to the academic and research world through the Anchor Study Group, as well as ISHA, the Hip Preservation Society, the Journal of Hip Preservation Surgery, and then, of course, Anna, who's very involved in arthroscopic surgery and the pursuit of hip preservation. These are the hip preservation fellowships that I'm aware of, that are probably the most well-known and have been around for the longest, that will offer an open-end arthroscopic hip experience for a dedicated one-year fellowship. The fellowship that I was in at Harvard, hospital special surgery, Duke University, American Hip Institute, Swedish Medical Center, and then there are various international fellowships. So thank you. I really enjoyed this. And again, I want to thank John Christopher Reddy and Alistair Stubbs for inviting me to be a course faculty member and to talk about why hip preservation fellowship matters. Please, if you have any questions, please reach out to me. My email here at Mount Sinai is listed. I look forward to hearing from you and to discussing. And of course, I look forward to seeing all of you and spending some time together in Chicago shortly. Thank you.

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