These are our own disasters. That's sort of the purpose of this ICL, which is to show you all the crap that's happened to us, so maybe it doesn't happen to you. So in that, in the interest of time, this is a case of mine. It's called Beware the Early Post-Op Pop. Disclosures are on the Academy website. So this is a 16 year old female who came in to me complaining of groin pain for over two years. Kicking a ball, squats, sitting for prolonged periods. She couldn't really play soccer anymore. She'd failed non-operative modalities and she had a slightly elevated Baton score, positive at four out of nine. So we obtained a CT because I was worried about potential dysplastic features. The numbers are as follows. So fairly reasonable coronal center edge angle, similarly with a mid-sagittal center edge angle, and her version was slightly elevated normal at one, two, and three o'clock, at least from my perspectives, about five, ten, and fifteen degrees. Hers was slightly elevated. Her McKibbin index, the combination obviously of the greatest version as well as femoral neck version was fairly normal because she was four degrees retroverted, so I thought that was going to be fairly protective and helpful. A neck shaft angle was elevated. So we went through and did surgery on her. She had a standard FAI, did not touch the acetabulum other than to scrape it to repair the labrum, and then performed a very gentle femoral osteochondroplasty. Four weeks postoperatively she came and reported playing timber with her younger brother on her bed, which she described as standing up and falling backwards over the back of the bed. And she said that she felt her hip extend and she heard a pop. She had pain, then felt very better very quickly. I said you know it's maybe it could be some of the sutures, probably scar tissue. Take it easy and follow the protocol as we have. She was walking around and again she had rapid resolution of her symptoms. So she felt better and kind of continued the path as we expected. Until about six months post-op she went back to play. She returned to soccer, felt great for a few weeks, and then started feeling intermittent pain and slipping. She kept playing until eight months post-op and then she felt a big pop and fell to the ground. She came in immediately after that into my clinic and these are her x-rays basically unchanged. But at that point she'd been complaining of these symptoms and that this was significant enough that it concerned me. So I suggested getting an MRI and this is what we see. So at this point maybe I'm gonna move quickly to the great Dr. Mather. What are your thoughts here? So this is your patient or in this case unfortunately mine. What are you thinking? It looks like there's a loose body or maybe down in there the capsule looks you know not great down the coronal. Yeah I'm not excited. I'm definitely like saying some words. Dr. No, I'm sure you have some familiarity with these. Yes, same concerns. One, you can see a lot of fluid so I think the joint effusion suggests that there's some sort of inflammatory event. The bone edema is not a good sign. Labrum looks retorn. Capsule certainly is disrupted and I can't tell if that's a cartilage flap or if that's like an anchor floating around. Yeah but that's kind of what I would think what I was thinking. So what's your plan in terms of Dr. Mather? You're seeing this and you've heard the two experts already tell you what's going on potentially. What's your plan? Are you gonna let this one fly? You're gonna go do surgery and if so what are you gonna do? Yeah I mean I'm probably gonna do surgery at this point. There's you know soft tissues are disrupted and I don't think it's gonna heal at this point. So Mike, what are you gonna do? I mean I think the thing that was a little concerning on her initial x-rays is her you know and she looks a little like posteriorly uncovered. So I you know at this point in a hip that's kind of borderline, you got to make some determination of do you think you can fix it arthroscopically. Use the mic. Can you guys hear him or no? I said the you know if it's borderline the big question is can you fix it with a scope and go in and fish out that loose body and re-repair her labrum and kind of placate her capsule or do you need to think about doing something from a socket perspective to provide her with better stability with her instability symptoms. So that's gonna be your big point of kind of determination what you're gonna do next. Okay. Can you go back to the plain x-rays trip? Which one? These? Yeah. Use the mic guys. I mean she's got a crush. She got like a kind of cranial crossover. She's got an extrusion index of probably 50% you know posterior superiorly. In our practice this is one that if they have instability we're probably doing a anteverting PAO to provide them with additional coverage in the back and then you know fixing the capsular stuff and probably fishing out that you worry about that potentially being a chondral fragment from like where the ligamentum inserts on the head especially with the edema there you know and she had some kind of instability event you know that would be what probably how we would approach it but I'm sure I'm in the minority with that. No that's perfect. So I'm gonna push a little bit on that mic. So you talk about doing an anteverting PAO. This is a shallow socket overall. Her she's already anteverted so at 1, 2, and 3 she's 18, 20, and 21. Her femoral neck version is retroverted but her acetabulum is anteverted so is this somebody you would still think about and I know I'm throwing this at you fast so is this someone you'd still think about anteverting with those numbers? Yeah I mean I think we you know the CT scans are great and I think sometimes we get a little bit we lose focus on the functional position of the pelvis when they're weight-bearing and so this girl when she I assume those were weight-bearing weight-bearing AP x-ray correct so when she's weight-bearing she's she looks like she's you know posteriorly uncovered whether that's from you know additional pelvic tilt or or a difference in her pelvic incidence or something that's leading for her pelvis to be in that position when she's standing so I think in her that's the that's the big question I think for these because this is a borderline hip that failed and we're I'm gonna talk about that as well because that's the bane of my existence but you know for sure we would probably I would probably at least have her see our our PAO guy. Okay I think another another point I would make is that she to me she doesn't really have like a true retroverted acetabulum like she's got just a little bit of you know as Mike mentioned cranial retroversion but I should she definitely to me doesn't look like she's truly retroverted but that being said with a negative four femoral retroversion was it negative four? Negative four. And a 21 degree anterversion I mean she definitely has like a what a 15 degree McKibbin index so she's definitely more retroverted than than anything in terms of her total anterversion femoral version ratio and I think that it's interesting like we've looked at some of our patients with three-dimensional imaging and found that it they don't necessarily have to have you know true acetabular retroversion based on just plain x-ray parameters and so I think that even though that's like a severe case I think they're much more subtle ones that that I think we're starting to to figure out I think this probably falls in that category. So Shane what are you gonna do then? I mean I would do the scope first you know address the labrum address the the the capsule figure out what's going on the loose body assess the cartilage you know if it is a cartilage issue then have some cartilage options available either bio cartilage de novo or or prochondria something like that and and then I would plan to have my open guy probably consider doing a PAO reverse PAO. Okay lots of options here so I'm gonna show you guys what I did so this is my conclusion here this I'm a cart my cart cartilage is a large part of my practice and I see this not infrequently unfortunately in my kiddos because peds is a fair amount of my practice too so my conclusion with this was this is an acute osteochondral fracture that the bone marrow edema here is likely due to a subluxation event and that each this girl chipped off a piece of a cartilagin bone and the bone is reactive to the osteochondral fragment and I think that's what that was I have the benefit of retrospective understanding as well but that's that was my thought process going in avian maybe but it was a pretty minimal osteochondral or osteochondroplasty so I was I didn't think that was a high likelihood but of course possible we I was worried about that for sure so we went in that was our concern and these are the pictures so that's where it came from not phenomenal so that's her that's the tabular side correct done lower correct so what we did and that's sort of going through the process here forgive me so I didn't have videos the acetabular side I apologize but what what Shane's bringing up here and I don't know if you guys see the pointer so she completely avulsed I shouldn't say avulsed but effectively severed in a radial fashion her labor repair and admittedly we all talk about the the one patient that changes our practice this is one patient that has changed my practice so at this point you know I was doing a lot of through and through base stitch repairs and I don't know if this is appropriate or not to have this change my practice but I've kind of gone away from that in the sense that it doesn't capture as much labral tissue and maybe it does roll it back a little bit more I don't know whether that's true or not depending on the tensioning but she effectively completely ripped through her labrum in a radial fashion so I had to do a label reconstruction segmental on her not exactly what I wanted to be doing it on a 16 year old girl but that that's what that is the reconstructions on the bottom right segmental tied in using a semi T allograft and then her capsule what the inner portal I mean Shane's done some wonderful work looking at the inner portal in the T her inner portal of course was the one that effectively tore through the T was fine yeah it's always that way yeah what's that said it's almost always that way exactly yeah so and and so I do a T capsulotomy and this is also influenced me I make a very much smaller inner portal since this and extend my T because I really don't want to have this happen again so we did not do anything interestingly with the osteochondral defect my thought process and we'll see if it plays out was to the 16 year old kid and I see this a fair amount in my kiddos they have especially with patella femoral stuff when they dislocate their patella and they have that little osteochondral defect that you chip off the patella or the lateral femoral condyle it fills in very well so that was my hope with her maybe it's a prayer without any substance but we'll see so at this point we're gonna freshen up the capsule make sure there's a reasonable excursion with the the capsular dehiscence which there usually is at least in my experience we're kind of quick taking out the scar tissue taking out the stitches and then doing a direct repair of the inner portal capsulotomy and I put in eight stitches here because I did not want her to have that happen again so that's effectively how we treated this obviously taking out the loose body and that was a the my treatment protocol there so but what are your thoughts on high strength versus like a Vicryl? So I use high strength in all of mine now. Number two, a number two non-absorbable. So maybe that's wrong but I will say that I've been happier with it. Interestingly Tom Bird presented some cases in his complications yesterday at one of the at the FAI group and he has done similar problems with Vicryl. So he's now gone to doing the same thing. So there maybe there's a trend. I don't know it made me feel better about my plan because usually Dr. Bird does reasonable things. So hey Travis do you think do you think yes if you had things to do things differently if you had an image earlier? Yes is the answer. So now the where the early. I'm not saying you did anything wrong of course. No no I believe you. My glass house is huge. At the end of the day I will say that this was a learning experience and that's the point of this. You know at the end of the day I think when now when I have patients that say in a hyper extension moment yeah yeah they complain of a post-op pop I would have imaged are four weeks which I almost never do but this is an exception. Would you say that's the change your practice from this case? Yeah yeah yeah it's tough because you get that well I did this I had this pop but but you're I think that playing the playing the timber the going So I think what happened putting this all together actually the timber was the capsular rip yeah and then she played with it right and the kept the osteochondral fracture happened eight months later right when she had a violent rotation during soccer so I probably could have avoided that had I repaired her capsule at four weeks right again would you have gone and repaired it yeah yeah yeah I would too yeah I think it depends on like the the mechanism of injury you know like something fairly traumatic like that or a motor vehicle accident or significant fall makes me consider doing an MRI sooner but if it's just like you know it's whatever doing a lot of walking and now I feel a snap and pain like I'm just like just agree it's it's not something that sometimes I think they don't tell you what they did because it might be embarrassing to them yeah so I think if they're very clear I was just was walking I did this but if they said I don't know I don't know something happened yeah my patients are all proud of their absurdity so maybe that says something about me I don't know so a couple thoughts on this hyper mobile hip beware of this honestly be very careful we get baiting criteria hamstring flexibility etc on all of my hips period it has been very useful to me it helps me understand what I'm going into concomitant extraticular hip apology is a very close correlation with hypermobility so be careful with a history physical exam always check the baiting fa I can occur with minimal osseous morphology in these individuals they're super physiologic they're hard individuals to treat she was not actually super high but four out of nine is positive a soccer player not a dancer so sort of that middle range doesn't make me super happy but at the same time that doesn't scare me too much I always start conservatively she was two years of this and obviously consider surgical intervention but be careful and always close the capsule in the process so those are my thoughts there don't ever touch the psoas tendon in these individuals risk of repairing this stiffness and over tightening obviously is a risk these are capsular repair risks I know there's somehow still controversy out there about whether you should repair the capsule I repair everybody maybe that's wrong you know never say never never say always but currently I'm always doing it I think at the end of the day stiffness is a risk potentially but it's a heck of a lot lower risk than this but I really don't want to have this happen as far as cost of repairing it's really not that costly eight stitches four bucks each if you use the non high-strength non absorb it's 32 bucks fancy suture pass or maybe a couple hundred bucks so it's pretty simple pretty easy if you get fast I wouldn't do it all the time it actually doesn't add much time to the case so about five ten minutes on average I think you have a better price point for your sutures and I do it's all consistent with what you charge so I'm in Utah we don't charge very much yeah I don't know it's technically demanding like anything if you get comfortable with it it becomes pretty easy I think as far as patient specific parameters we did some we looked at this there was really no difference in terms of instability risk factors with or without tears this is what using traction a distraction techniques intraoperatively females obviously more so than males females having with an increased hamstring flexibility are at risk and females obviously with increased bait and score at risk they pull out much easier in the operating room so those are individuals you might want to consider being a little more careful in the capsular repair are there any benefits to repairing as far as not repairing sure you get out faster it's lower cost and it's easier but holy smokes if you repair it they have better patient reported outcomes this was shown by our group as well as others they have lowered dislocation subluxation rates and most importantly for me you get asleep at night so that's my thought interporter we already talked about so in the interest of time to skip this a smaller interportal for me now extending with a T because I do not want that this to happen again Shane actually was the one that taught us that who needs the repair from my perspective these people definitely need repairs high baiting criteria definitely need repairs you look at this and you say okay that looks like a you know borderline a dysplastic hip this probably needs a repair significant anterior under coverage this probably needs a repair if you're gonna even do it with a scope actually who doesn't well maybe this person this is one of my professional athletes so he probably doesn't or maybe you know but then again who knows maybe he does so is it this guy is it this person or is it that person so very different people very different requirements of their hip same same potential hip but different requirements so thought processes on that how about this person so this is also one of those people I'm not gonna tell which one it is but those two hips are those individuals very different so we have a much shallower hip with a big cam but do you repair this one again same same type of person different hips so you have to think about the athlete what they do in athletics but also what the hip is and merge the two so last but not least if you get into the operating or pull with your hand and that happens I would suggest repairing it so we're gonna kind of skip through this and I'll move on to something more interesting thank you all just quick are there questions out there anyone want to answer yeah sure Mike you want to take that in the in a post-operative like revision setting I always do an arthrogram so I think it helps to show capsular defects better it also shows adhesions and then the other thing that you can see in the post-operative setting in this case that if the capsule didn't fail sometimes the stitches do and so I've had a handful of patients that everything looks great their exam is really good but they complain of pain get an MRI scan and you can see actually one of the capsular sutures is broken and you get in there and you see a little suture end and it's acting like a foreign body reaction in the joint you go and you take that out capsule is healed and they do great just by removing the suture so that's one of the dangers I think of using non-absorbable we may have to fish out a suture maybe once a year and I do about 300 a year probably less than Shane and Chad do but and but so I kind of take that as my medicine so if once a year I got to go fish a stitch out I'd rather do that I switched to visceral to at one point and I had a couple of seromas post operatively from people that had visceral intolerance from visceral yeah and Mark told me that it was because I was using dyed visceral instead of and I didn't know that I totally I mean he's smarter than I am but I just so I kind of abandoned the visceral at that point because I didn't want to deal with that stuff so I just you know take my lumps once a year and go fish a stitch out and other than that I've been using non-absorbable anybody else differ on the MRI if it's an acute trauma like I'll just get a plain MRI so if I saw someone that's like you know over the weekend I played soccer and I had a pop and I fell down I'm there in the office on crutches I'll just get a plain one because usually the the amount of joint effusion will just basically function as an arthrogram and give me the information that I that I that I would benefit from an arthrogram plus that if it's acutely traumatic they're probably gonna be pretty irritated if you then go ahead and put more contrast in yeah same same for me and this isn't my case of my worst day in the order but it's one of my most unpleasant patient experiences was missing one of those by not getting an arthrogram afterwards and it was actually more of a like a capsule a it was interesting case where she had them a boss the caps off her subspine you know we did a partial subspine resection but she a boss the whole thing off and it couldn't really see that without die and then yeah kept we kept saying well everything looks fine looks fine and then but you know it wasn't so yeah it was definitely that's what that's one of these that changed my practice to now get using arthrogram in the post-surgical setting what about over tightening do you guys have any concerns about that I don't know that I don't know that you can over tighten it yourself I think you could I think you could over constrain it and then that's a source of a rupture but I think that they heal and they get tight I don't I don't know that I'm I think if I'm gonna tighten them that much they're gonna run through that repair I don't worry about that too much honestly at the end of the day when you do an osteochondroplasty you're decreasing the relative volume that is contained within the capsule anyway that so the capsule becomes slightly lax and I have no data to support that by the way but you know I think at the end of the day if you unless you you're trying to placate you just saw it so so it's side to side maybe the scar tissue tightens it up a little bit but I'd rather than be tight than loose yeah I mean I think rather tight than loose I think you can over tighten immediately so like your your most anterior medial stitch if you really crank that down and get too much tissue there they'll lose external rotation and they don't like that you know I mean so that's where they'll struggle on the post-operative setting about being able to open their hip up so you just got to be careful with that that's the one that's the one place that I think like laterally I don't think you can really over tighten them do you think you can stretch that out with PT I think you can I think you got to be aware of it though so there but that that is probably the one stitch that's the most important that you don't kind of take too much tissue is that that more medial stitch that's really kind of getting into the iliofemoral ligament but yeah go ahead I guess I have a couple couple ways I've kind of changed my practice one is that I don't do as much of a wide like placation as I used to do I think Travis is right I just try to make sure I've got a good full thickness bite I think that's the most important thing and then I tie my stitches and extension especially the inner portal one so I'll go ahead and pass on my inner portal stitches first put them in extension and then tie just to risk having like a anterior flexion contracture I do think that patients get tight especially if if they don't focus on restoring their their extension this you know as they're as they're going to like for me like two to four weeks I try to get them to reestablish their normal terminal extension when they're walking because if they don't develop that they have a hard time progressing from their rehab because I end up circumducting their their gait and so forth and and I think some of these things may persist we actually have done some gait studies where even at like six months like their hip extension is not quite as normal as I think we'd like to think it is and so it's it's definitely a point of emphasis for me to try to get them to to fully extend their hip because I think that it's just like having a knee flexion contracture if they have a persistent contraction in the knee it just leads to an inefficient gait and I think it's sometimes develops other trunk abnormalities and and knee abnormalities as a result of it especially for your high level athletes I think you really have to reestablish that extension phase of gait otherwise they they have they don't feel right when they go back they can't they can't activate their glutes if they can't get extended and so it's a prerequisite for any reasonable hip function yeah and then maybe that contributes that this lag in there include I think it does yeah yeah okay

femoroacetabular impingement

surgery

labral repair

osteochondral fracture

capsule

patient's specific needs