Hip Arthroscopy

Episode 19 - Hip Arthroscopy

Dr. Chehab:

Welcome to IBG'S Ortho Inform, where we talk all things orthopedics that help you move better, live better. I'm your host, Dr. Eric Chehab with Ortho Inform. Our goal is to provide you with an in-depth resource about common orthopedic procedures that we perform every day. Today it's my pleasure to welcome Dr. Shah, who will be speaking about hip arthroscopy. As a brief introduction, Dr. Shah graduated with honors with degrees in economics, chemistry biochemistry from Loyola University here in Chicago. He then attended the University of Chicago for medical school and continued his training in Chicago at Northwestern Feinberg School of Medicine for his orthopedic residency. He furthered his training with a fellowship year in St. Louis at Washington University School of Medicine, where he specialized in joint preservation, resurfacing, and reconstruction. Dr. Shah joined IBGI in 2011, where he has treated thousands of patients with disorders of the hip and knee. In 2013, Dr. Shah launched our same day total joint program, which has become an industry standard and a model for similar programs throughout the United States and internationally. Dr. Shah routinely performs minimally invasive patient specific total knee replacement, partial knee replacement, and knee arthroscopies. Dr. Shah also offers advanced treatments, including minimally invasive and muscle sparing, total hip replacements, hip resurfacing, and hip arthroscopy, which is our topic for today. Dr. Shah enjoys treating active athletic patients and helping them return to their high level of activity using novel cutting edge surgical techniques. He provides the continuum of care for the hip and the knee from minimally invasive arthroscopic procedures to complex revision reconstruction procedures. He has written numerous research articles and book chapters. He has published surgical and video techniques for advanced preservation and reconstructive techniques. Ritesh is known in our group as an outstanding and innovative surgeon and a consummate team player. Ritesh, welcome to IBGI's ortho form, and thank you for being here today.

Dr. Shah:

Oh Thanks Eric. Yeah, thanks for the nice introduction.

Dr. Chehab:

So we're here to talk about hip arthroscopy and disorders of the hip that are treated with the arthroscopic. So let's start with the hip anatomy.

Dr. Shah:

Yeah, sure. So the hip joint in, you know, usual terms is a ball and socket joint. And the ball and socket is they're covered by a group of ligaments. The labrum, which is a common term that we'll talk about today, is a gasket for the hip joint. So the labrum sits kind of like a bumper cushion on the rim of the socket. If you were to look at the socket, like a face of a clock, it would be kind of that rim that sits above and around the socket, and that labrum can tear and cause a lot of pain for patients. When we think about kind of the procedures he outlined for the hip labrum, tears and hip problems can be addressed arthroscopically or with symptomatic treatment, that's nonsurgical. And then if things progress, that's how arthritis happens. A lot of patients ask, you know, what is hip arthritis? Hip arthritis is basically the lining of the hip. So the lining of the socket, the lining of the ball, that cartilage wearing away results in hip osteoarthritis. It then goes on to other procedures that we're not going to talk about today, but lots of patients get,

Dr. Chehab:

Yeah, okay. So the labrum is this rim of tissue around the socket, it can get injured or torn through trauma or through daily life?

Dr. Shah:

Yeah, I mean, interestingly enough, it’s torn through trauma. So some athletes that patients know just from, you know, either celebrities or athletics have torn the labor is common ones, you know, people think about Isaiah Thomas for the Cavs. Then there is Andy Murray, who's a women winner tennis player who had a labrum tear and has an amazing documentary on prime, prime video about, about his hip. And then you have patients like Lady Gaga for example, that are celebrate dancers. So a lot of athletes, a lot of dancers can get it, but also people like us, people are regular people who kind of living regular life, who sit, who sit to stand, who transition, who pivot, and they start having pain with these repetitive type procedures. And even more common than trauma are the patients that are coming in with these repetitive type activities. I can give them pain things like yoga and et cetera.

Dr. Chehab:

Okay. And so the other side of this is arthroscopy. We're here to talk about hip arthroscopy. So we sort of reviewed some of the anatomy of the hip. Let's review what an arthroscopy is.

Dr. Shah:

Sure, yeah. So arthroscopy in general terms is it's one of the coolest procedures that orthopedics has to offer, to be honest with you. I agree. It's done through two really small incisions or three or four depending on which joint you're talking about. For the hip in particular, it's done to two or three small incisions. These incisions about four or five millimeters in length, so not particularly big incisions. And then we use three, four and five millimeter instruments to go in there. An arthroscope is basically a camera . But the camera is angled in a variety of different ways to be able to see different parts of a joint. So we use a camera to be able to look, through one of the incisions. We have a bunch of these HD monitors throughout the operating room that we can look through. So the surgery's actually done, although the surgery is done through these small incisions, the surgeon itself, himself or herself, they're actually looking at the monitor to do the procedure, which is really, really neat.

Dr. Chehab:

Sounds like a video game.

Dr. Shah:

It is. And to be honest you know, from a surgical standpoint the trauma that we give patients using arthroscopes is very minimal but what we can do inside the hip joint is amazing.

Dr. Chehab:

Yeah. I mean, before the arthroscope, anything that was treated like this had to be done through larger incisions, muscle dissection and adding a lot to the recovery.

Dr. Shah:

Absolutely. And, and some things you couldn't access. Right. So there's some things that even if you didn't open you couldn't get there.

Dr. Chehab:

Right. Right. So what type of conditions can be treated effectively with the arthroscope?

Dr. Shah:

Yeah. And the h for hip arthroscopy, there's a lot of conditions. So I'll kind of go through the common ones. The common ones are nowadays more common and people are more aware of them than they were even a decade ago. The common ones are labrum tears. So that's a gasket that we talked about that can tear a big word femoral acetabular impingement. It's kind of mouth will, but it's a fai . So that's where there's a misshapen ball to the ball and socket joint, or there's over coverage of the ball from the socket, and that can cause pinching or impingement, which can lead to a tear. So those two things commonly go hand in hand, fai with the labrum tear. But then there's other things, other things are loose body. So those are loose pieces of cartilage that can be floating in the hip, usually from a traumatic accident or traumatic injury. That can be chondral defects or cartilage defects that happen. Those are kind of areas that are focal areas of loss of cartilage that then we can address to try to regrow cartilage then there’s synovitis. So a lot of inflammatory tissue can occur in patients and some patients it can be pretty problematic. Scar tissue from previous surgeries can be addressed arthroscopically. And then there's a couple of specific things. So avascular necrosis, which is kind of a, another big term, but basically it’s, here the blood supply to the ball can be affected. And if it's a focal area, a small area that can be addressed with a combination of arthroscopy with a small incision to address that and then gluteus tears. There's a lot of patients we're seeing right now with gluteus tears. Not everybody that has a gluteus tear needs surgery, in fact, most don't. But if they do need it, that can be addressed arthroscopically as well.

Dr. Chehab:

Okay. So just to summarize what you were saying with the arthroscope, we can address labrum injuries, this concept of femoral acetabular impingement where the ball and socket are a bit misshapen and not so congruent. You mentioned loose bodies, loose pieces of cartilage. You mentioned cartilage defects. You mentioned synovitis, which is inflammation within the joint. You mentioned also scar tissue from previous surgeries, and then some of these less common but very problematic conditions such as avascular necrosis in a small area where you can perhaps restore blood flow with a combination of the arthroscopy and other techniques.

Dr. Shah:

That's correct, yeah.

Dr. Chehab:

Okay. Okay. So that's important for the listener to know if we're going to focus on just at the beginning the most common things that you're treating with the arthroscope would be what?

Dr. Shah:

Yeah. The most common pathologies that we see are patients who have labrum tears and patients who have impingement.

Dr. Chehab:

Okay. And that's that femoral acetabular problem where the ball and socket misshapen and so they pinch against each other. And, and what are the types of femoroacetabular impingement that you see?

Dr. Shah:

Yeah, that's correct. So the femoral acetabular impingement or fai, there's mainly two types that categorize as two types. But most often we see a mix of both. So the first type is something called cam fai or cam femoroacetabular impingement, and that's where the ball of the ball and socket joint is misshapen. So either the ball isn't perfectly round like it should be, or there's a focal area on the ball that has kind like a bump that's formed and that can cause the ball in the socket to pinch causing labrum tears. And we know that labrum tears can and do most often lead to osteoarthritis in the future, future in the hips. So that's kind of the etiology of a labrum tear and osteoarthritis at connection. The other type of femoral tam impingement is PSR type femoral ta impingement. So PSR type fai is more, emblematic for the socket side of the ball and socket joint. The socket can cover the ball a little bit more than it should. And in that situation, then we can address that arthroscopically as well to prevent the hip from pinching and once again, leading to labrum tears and leading to osteoarthritis in the future.

Dr. Chehab:

Okay. So if a, is there a big difference in how a patient may present with cam type impingement or, or pincher type impingement? Or is it basically a similar presentation, but something that you need to know in terms of how you address it?

Dr. Shah:

Yeah, I think, you know, the, the most common things I think, especially for the listener, I think what's important for them to know is there's a lot of patients that suffer from hip pain and hip pain generally for these conditions is pain that's localized in the groin of, of the hip joint, so kind of towards the front of the hip, which again, a lot of patients don't recognize. They may think it's other issues not related to the hip joint, but actually that's the most common location for hip pain. Some of the patients also have pain, what we call lateral, so on the side of the hip, kind where that bony prominence is. And then occasionally we'll have patients that actually have buttock pain. So most commonly it's pain in the front and the groin or sometimes in the side. The most common situation they'll come in with is not actually pain when they're like running or jogging.

Dr. Shah:

The most common situation is actually pain when they're sitting. So that's sitting and sitting to transition pain. It's a lot of patients who think, oh, it's a groin pull, haven't really worked out. Maybe I'm a little stiff. Things like that, that a lot of us sort of would imagine this would be, if that keeps happening or that that thought keeps happening or that feeling is there for a while, you, you, I think it's important to get looked at. Because that can be impingement. That can be a labrum tear. Now when we think about other activities, right, other activities patients will talk about is pain with pivoting. So simple things, we all in the morning, today, in the morning, right. You go to the kitchen and you turn, pick up a cup of coffee and when you turn to have pain, right? , so that pivoting causes pain, pivoting causes pain in the shower.

Dr. Shah:

If they play any racket, sports, any of my tennis players, my, my racquetball players now, pickles really been growing a lot. So pickle ball and paddle those patients and pivoting type things that can cause pain. Golf, golf is something we see a lot, right? It's , particularly in the spring season as it starts up. And then, and then the really athletic folks, so the folks that are runners are patients that I see a lot with this type of pain. Initially, for all of these athletic patients the pain starts similarly sort of pain with these sitting type maneuvers or a day after they've run or kind of later on in the evening. But as things pick up, as things progress, now of a sudden they're getting pain during the activity itself.

Dr. Chehab:

And so when they come to you, what are some of the things that you're looking for on your physical exam, for instance?

Dr. Shah:

Yeah, the most common sort of symptoms that they present with are pain in the groin. Okay. Pain with pivoting, they'll have some soreness. Initially, they'll kind of say it's insidious onset, kind of slow onset pain, aching type pain that then progresses. And some of the patients will have mechanical symptoms. So those are symptoms that we'll talk about that include things like locking or catching or instability where the hip feels like it's giving on them or buckling on them that's not as common. Actually, soreness and achiness is the most common thing that we see. And then on a physical examination, so you know, you have the one end of the spectrum is you have patients coming in with symptoms and then we have to kind of get evaluated. So they come in and the most common next evaluation is a physical examination that I perform.

Dr. Shah:

So in that examination, we look at sort of common things. They're gait occasionally we'll pick up sort of subtle limbs that kind of go away with time as they walk down the hallway. But subtle limbs are not, not uncommon, particularly when patients get up from a sitting to a standing position. And then when we examine them on a table, we'll take their hip and they're lying down flat on their back and we'll take them hip and the take them through a range of motion to see if there's any stiffness. Commonly there's some, some asymmetrical stiffness to the side that's affected. And then usually they'll have some pain with particular movements, things where we rotate the hip, flex the hip, bring the hip into some abduction, they'll have some pain. Sometimes we call a figure four position can give them pain. So that's where they're sitting sort of like, you know, cross like cross lying down.

Dr. Chehab:

Yeah. And then what do you see on x-ray? What, what are some of the diagnostic tests that you'll do to, to make a diagnosis that a patient has femoral acetabular impingement and a possible label injury as a result of that? Yeah,

Dr. Shah:

Great question. So commonly look, come, it'll get a couple of x-rays, right? So a couple of x-rays include like a pelvis, x-ray and a, and two or three specific views of the hip. And on that x-ray, what we're looking for is scarcity or roundness of the ball first. And so we look at the roundness or some angular measurements that we make to see is the ball round the way it should be, are there any boning, prominences, is there any bumps or anything like that there that we see on x-ray? And that's how the cam type, right? That's how the ball side of the ball and socket joint. Now the socket side, we do other measurements to see is the socket over covering the ball, under covering the ball? Is it covering it just right. Are there other issues there? And, and those two things will allow us to know is there impingement? Some other things on x-ray, you know, the AVAs necrosis mentioned. Yep. Sometimes we'll see that patients will come in, they'll have seen somebody who says, I think you have a labrum tear. We end up seen them in x-ray and we find out they actually have small lesions of avascular necrosis. And so that's a whole different situation than we have to kind of talk about. So x-rays, X-rays are really important.

Dr. Chehab:

Okay. So, so as part of the workup so far your, the symptoms that the patients present with your physical exam findings, generally achiness in the groin and loss of motion and disturbances in gait and disturbances in transitioning from sitting to standing or things like this. And then radio graphically on a simple x-ray, you get a lot of information about the shape of the ball and the shape of the socket and whether or not they're fitting together well or not, and whether they might be pinching together. That's

Dr. Shah:

Exactly right. Yeah.

Dr. Chehab:

And then the next step would be, I assume if you're going down this path, would be further soft tissue imaging, which is best accomplished with an mire. And, and so tell us about MRIs of the hip, because it seems like when people get an MRI of any joint, I'm just going to speak for myself with the knee and shoulder, it generally sounds like a bomb has gone off in the joint when you read the report and many patients get freaked out simply by the language that's used in the report. So what are some of the things that you're looking for on an MRI of the hip that you would see commonly that might be viewed as kind of scary to the patient, but not quite so scary to you? And, and then what of the things that, you know, what, hey, this is really something we got to be taken care of.

Dr. Shah:

Yeah, no, another, another good question. So, you know, if we are clinically suspicious that there's a labrum tear present and x-rays don't show that there's any severe arthritis osteoarthritis, then in that situation we commonly say, let's get an MRI. And usually for the hip we get what's called an MRI arthrogram. So an MRI arthrogram is an injection of contrast in the hip capsule by the radiologist, and then subsequently get a closed MRI. It's important on the hip. Two, you know, there's open and closed MRIs and, and open MRIs for certain group of patients may be fine, but on the hip, a closed MRI gives you just far more information.

Dr. Chehab:

It's, you need that high resolution that can get with a closed MRI. That's right. Yeah.

Dr. Shah:

That's absolutely right. Yeah. And then, you know, on the MRI, and it's particularly nowadays with the electronic health records being so available for patients, right. As treating doctors, what we commonly find is the MRI imaging report with the radiologist has read this and radiologist is very good at reading detailed MRI reports. That's kind of their job. That's what they do. But when it gets to the patient, oftentimes you read a patient may read the report and oh my gosh, it sounds like, you know, there's 15 things going on in the hip when it may actually be isolated to two or three clinical important things. That, and all the other things may be simply just things that people find. Right. If you were to go

Dr. Chehab:

Disrupt descriptions essentially of a normal what is otherwise a normal FI or very typical and common finding that people have that they don't have any symptoms.

Dr. Shah:

Absolutely. Right. Yeah. And, and so, we'll, we oftentimes, you know, tell patients that you're going to get an MRI arthrogram. If you get the report, it's fine to look at it, but wait till we have our discussion <laugh>, just so, just so they understand exactly what the important clinical findings here are and, and what can be addressed. So usually in an mri, arthrogram, the important things that we find in the hip when we're looking for hip issues are, you know, labrum tears, right? An MRI is wonderful at identifying in a very bi binary fashion. Is there a labrum tear or is there not a labrum tear? Right? So it's very good at that. So we know that the labrum is torn or it's not torn, it's, it's predictable. Right? The second predictable thing is location. It's very good at identifying where the lab is torn.

Dr. Shah:

So those two things are great. Then there's a lot of descriptors that a radiologist may look at or I may look at and say, on this particular cut, on this particular slice of the MRI imaging, I'm seeing a whole bunch of descriptors. How is it torn? Is it displaced? Is it severe? Is it large? Is it small? All those things. And I'll tell you, all of those things in the operating room are completely not predictable. So the two things that I kind of tell patients we focus on is, is it torn, is it not torn? And then where is it torn? Those two things are very predictable. Everything else is sort of unknown until we, until we look

Dr. Chehab:

At it. So in some other joints with tissue that's similar to the labrum on mri, it's common to find a quote torn labrum in the shoulder or meniscus in the knee that isn't producing symptoms. Like, in other words, they're about 85% or 90% of patients who get, have a normal shoulder, who get an MRI, who will have a labral tear, even though they feel completely normal, where you just take people off the street and what's the incidence in the hip?

Dr. Shah:

Yeah. Great. Another great question. They did this awesome study, so it took like 4,000 asymptomatic people, meaning they had no pain, right? So

Dr. Chehab:

These are just people off the street, volunteers don't have any pain

Dr. Shah:

And got MRIs on them  and a good 20 to 30% of patients had asymptomatic labrum tears. And truthfully, those we would do nothing about.

Dr. Chehab:

Exactly. Okay. Yeah. And then with pa, when you identify a patient with a labrum tear and femoral acetabular impingement, do you take them straight to surgery? Or what are some of their options?

Dr. Shah:

Yeah, so it depends on kind of what their activities are like. And it depends on what their goals are. So there, there's very good evidence now, and we didn't have this even seven years ago, right? but there's very good evidence to that now that if you're a very active person in impact athletic sports, that if you have a symptomatic hip labrum tear, then most often you are going to end up needing that fixed in order to return to the level of play that you're used to. So that combination, I think it doesn't mean we just go straight to surgery. We have that discussion. I think it's still important for patients to be treated non-operatively initially. I think that there's a few reasons for that. One. One is physical therapy can help ameliorate some of the symptoms. And then if you feel better, you may say, okay, I'm going to wait.

Dr. Shah:

Okay. Or may choose not to do anything. There's a subgroup of patients that do well with that. Then there are other things that we can do that are non-operative injections of cortisone in a particular group of patients, usually a little bit older. Cortisone injections can help again, manage symptoms and avoid surgical care. And we can do deep tissue massage work. There's some soft wave or sound wave technology the patients are using that can be helpful for the athletic folks to kind of get them back to some sports. The important thing to recognize as a patient is the question I get asked every day, several times a day, right? Is. Will the labrum heal by doing all of these things? The short answer to that is no. Right? So direct answer to that is labrums not going to heal, but you may get your symptoms to be resolved, in which case then you may say, okay, I'm fine with living with a labrum tear.

Dr. Shah:

And the biggest risk you run, run, particularly if you're an impact athlete, is you might end up developing osteoarthritis down the road. Butthat is not immediate. That is something that if that happens, can be years and years down the road. And the athletic folks, the people that are very athletic, the conversation I have with most of them is, you know, the data kind of just supports the fact that at some point you're going to want to get this fixed if you want to return to that level of play. And they did a good study in the United Kingdom about this that really showed at both one year end frames and at five year timeframes that in that subgroup surgical care resulted in better outcomes at a much higher level, better return to plate, a much higher level. And interesting enough, because England has nationalized healthcare cost is important to them, it's actually the cheapest as well to kind of do surgical care for that subgroup.

Dr. Chehab:

Oh, that's a really interesting study and it's certainly compelling making a case for the high level athlete who symptomatic with a label tear. Do they also have femoroacetabular impingement in that group, or are they without that

Dr. Shah:

Condition? Yeah. Great, great question. Pretty much everybody in that group has femoral TA impingement.

Dr. Chehab:

Okay. So that, that may be the differentiator between, you know, in the high level athlete maybe considering earlier surgery because they have both the lab tear and the presence of femoroacetabular pinch, which obviously isn't going to go away. It's a misshapen fixed problem. That's correct. That's right. Okay. Well, so with physical therapy and injections in some of the non-surgical treatments, that can help many patients resolve their symptoms and maybe avoid the need for surgery. But for those patients who don't get better with that, or who may be better served with earlier surgeries simply because of their athletics and their activity level and the presence of femoral acetabular impingement, if they're opting for surgery, what's the surgery like? What, what's, what can they expect the day of the surgery? What can they expect the week after and the couple of months after?

Dr. Shah:

Sure. Yeah. So I love this surgery, right? It's a, it's a, I love doing it. I love taking care of patients. I love getting these people back to the things they enjoy, love seeing the pictures and videos and you know, we see them down the road and so it's fun, it's fun kind of getting them back. But, if you look at the surgery, surgery itself is not the hard part. Okay. So the surgery, the recovery on the other hand is hard. So I'll kind of go through that. So surgery's about an hour and 10 minutes. It's two small incisions, occasionally three anesthesia. Usually it's an outpatient surgery for the, I mean the largest majority of patients. Like 99% of patients it's outpatient. So they're kind of doing it in the surgery center setting or in the hospital setting, either scenario.

Dr. Shah:

And after the surgery, so about an hour and 10 minutes surgery in the operating room for about an hour and 40 minutes or so. And then usually about an hour after surgery, they're heading home. So that's kind of the day of surgery, right? so they kind of come in about an hour, hour and a half before surgery and they're kind of leaving about an hour after surgery. That is not the hard part. Right. And most patients will tell us they're not having a lot of pain afterwards, that's also not the more difficult part. Pretty much every patient that I treat that has hip labrum tears, plus or minus impingement that we're doing hip arthroscopic surgery for is a very active, is a very independent and a very motivated patient. So the psyche of the recovery is the hardest

Dr. Chehab:

Part. Okay.

Dr. Shah:

Okay, because we have to slow them down. And the basic concept that I tell patients is that I'm, my job is to go and fix the structures that are torn and correct the issues that you've had, but then your body is to heal that. So unlike when I do outpatient hip replacement surgeries where my job is different, my job there is not to cut any muscle, not to cause any damage and replace a hip in that situation, healing time is actually less. Right? Right. In this situation, even though it's the most minimally invasive surgery you can get on a hip the healing time is actually longer and, and it's longer because I'm repairing structures and their body has to heal it and there's no way to speed up biology. And so what I, what I tell patients is our job in the first couple of weeks is to protect the hip while the labrum is healing.

Dr. Shah:

And then subsequent to that, it's your job is to work with therapy to get strong and get back to the things you want to do, but in a safe manner so you don't injure yourself again. The timelines for that are in the first three weeks, the patients use crutches, so there's some touchdown weight bearings. They're not putting full weight down, but also not completely off of it, little bit of weight. They're wearing a hip brace, which protects the hip from extremes of motion, so it doesn't cause a re tear to the labrum that we just fixed. Yep. And then they're using a machine to move their hip back and forth to prevent scar tissue and they're doing physical therapy. And that physical therapy initially is all around making sure that some of the muscles that can be irritated from the surgery kind of stay calm.

Dr. Shah:

So it's kind of a controlled therapy for that. Some deep tissue work and et cetera. The next three weeks, that was the first three weeks, the next three weeks, the patients are off crutches. So at three weeks they're done, they're full weight bearing, they're still wearing a brace, they're done with that machine that moves the hip back and forth, and they're doing what we call phase two of physical therapy. It's a little bit more strengthening work. And then subsequent to that, so three weeks after that, it's a six week mark. Patients are done with their brace, they're full weight bearing at that point. They're usually cycling, they're usually you know, walking, elliptical machine, things like that for exercise. And they're working on phase three and four of physical therapy, which is specific to big muscle groups, small muscle groups and the nuances to get them back to the athletic endeavors that they want to do in life. Most patients, similar to like if patients have had family or friends who've undergone anti cruciate ligament or ACL surgery similar to shoulder rotated cuff surgery, because these are soft tissue surgeries, they take a while to heal. And so generally I tell patients that expect between six and nine months for you to be fully healed and be back to everything you want to do.

Dr. Chehab:

Okay. So just to review that timeline, about three weeks on crutches after the procedure with able to, with the ability to bear weight, you don't have to be totally off of it that you wearing a brace anywhere between three and six weeks. Six weeks. Six weeks brace for the brace. Yeah. And then slowly, gradually increasing muscle strength, hip flexibility with the expectation that by six to nine months getting back fully into sports would be about that timeline. That's right. But otherwise, pretty functional relatively early on by six weeks able to do some cycling, doing some walking and relatively functional with activities of daily living by six

Dr. Shah:

Weeks. Yeah, absolutely. And all the people that work in most work settings are back to work around that time.

Dr. Chehab:

So like laborers or, or,

Dr. Shah:

Or, yeah, so the, the, the one, the patients that we don't let back go back full to full duty or we sort of give them restricted duty are patients who are laborers or patients that are pushing, pulling a lot, lifting heavy weight. Okay. Those types of patients, you know, our, our police officers, our fire persons, we, we don't want them to, to kind of get back and injure themselves too

Dr. Chehab:

Soon. Okay. And what can they expect as the outcome?

Dr. Shah:

Yeah. So if this is the key to this surgery right, is number one is a well done procedure. So having done a lot of these, I think it helps surgeons identify the right type of patient that's going to do well, right? So number one, identification of the patient. And you want, as a patient, you want the three things to be married, the three things you want married, or number one, you want to make sure your symptoms are consistent with what this pathology is, right. Number two, you want to make sure that the imaging that they've had done is consistent with your symptoms. Right. And number three, you want to make sure the physical examination that I've performed kind of marries all three as all as long as all three things are there, then, then we know that doing this surgery will be good for you and you will do well with it.

Dr. Shah:

I can, I can tell you that the majority of patients, 90 plus percent of patients that have this surgery when it's done well for the right reason and all these things combined, and you know, I don't want to downplay physical therapy, I want to talk about that for a minute too, but they, they get back 90% plus patients get back to full activity at the range they were at, at the level they were at, and they're very happy with it. The timeline is key, right. That timeline we get let them go back at five months, but they're not themselves till about six to nine months. You got to give it some time to really get there. Yeah. The other part of this as just talked about the psychology side, the psyche of this, right? It's just, which is having the motivation to go back sometimes if it's an injury, like a sudden injury that happened, there's apprehension to return back to the ski slopes

Dr. Chehab:

Or you don't want to happen again.

Dr. Shah:

That Right. So that takes a while too. And then, and then the third thing is, is physical therapy. And I really don't want to downplay this. I think that as surgeons, we talk about surgery a lot, but I think it's very important that for a patient to recognize that if you're going to go and get hip arthroscopic surgery to get your labrum fixed, make sure you've devoted time and that you're committed to the physical therapy afterwards. Because if you don't do those two, then you won't be happy with the outcome.

Dr. Chehab:

So you have to be ready to commit to the surgery and the six months of physical therapy that come after the surgery to get the outcome that you're seeking. You have to be ready for the whole

Dr. Shah:

Package. Yeah. And the four and the, and the formal physical therapies, three months. Three months. But they do sports specific rehab and you can do that with a sports specific rehab specialist, which is awesome for a lot of patients. Right. For other patients they do that on their own.

Dr. Chehab:

Okay. The expected outcome from this procedure is quite good where athletes return to the pre-injury level of sport in the overwhelming majority of cases. But what are some of the potential complications or some of the pitfalls that can happen for patients undergoing labor and repair and the setting of femoral acetabular impingement?

Dr. Shah:

Yeah. Another, another really good question. So I spoke a bit about indications for surgery and what that means is, you know, patients that are indicated to have surgery performed. I think one of the big red flags, red herrings that I think is important to recognize, particularly as a patient, but even as a surgeon that's doing this, is what you gain with experience is you really find that patients who have significant osteoarthritis should absolutely not undergo this procedure. Okay. those patients do not do well. And I will see those patients as second opinions, as third opinions or something and they'll have had this, the surgery performed and they're wondering, you know, why didn't I do well? And the most common reason they do, did not do well is nothing to do with the surgery itself, but it was the fact that they should not have undergone it. So osteoarthritis is a, a big red flag and one where we should, you know, avoid this surgery for those patients. Other red flags are things that include you know, high level or moderate level hip dysplasia. Hip dysplasia is where the socket doesn't cover the ball as much as it should. And in that

Dr. Chehab:

That's something you're born

Dr. Shah:

With, that's something you're born with. Yeah and in that situation as well the part of the world that phases hip dysplasia the highest is Japan and the Japanese studies all show that patients who have moderate or high level hip dysplasia actually don't do well with hip arthroscopic surgery. So sometimes patients will have undergone those and, and they're, you know, seeking advice. Those are really the two sort of big things that really come out more often than not. If we look at complications from the surgery itself, because it's arthroscopic surgery, the odds of having any of the complications actually minimized quite a bit. So for example, with infection right there. There's always a risk that an infection occurs, but with arthroscopic surgery, there's fluid that's running in and out of the hip joint effectively washing the hip joint out while we're working.

Dr. Shah:

So the odds are very low, it can happen. The other things are you can get some numbness the side of the thigh, you can get some swelling in the thigh. Those, all those things all kind of go away. You can get numbness to the private parts. That has gone away as we've done the surgery differently. So not using a post and some things during surgery can minimize that there's pain. Right. The pain level actually isn't very high for the majority patients, so that's not an issue. The biggest risk with hip arthroscopic surgery is a labrum repair then usually that happens in patients who either had an injury again or in patients where the impingement that they may have faced hasn't been corrected all the way. So that's one reason why that can happen. And the second risk is osteoarthritis, that if arthritis in the hip progresses, they may need something more down the road like a hip replacement or hip surfacing type procedure.

Dr. Chehab:

Okay. So what do you see on the horizon as some of the newer techniques or more innovative ways that we might be able to address lab and pathology and femoral acetabular impingement? Are we kind of there with the arthroscope?

Dr. Shah:

Yeah. I think, again, arthroscopic surgery's amazing. I think there'll be advances from the instrumentation side there. I think that, you know, when you look at hip arthroscopy, if you're looking at the surgery itself, you put a 70 degree arthroscope in, so that's 70 degrees different from how you're looking. That angle is odd. Right. So that already in itself is, is

Dr. Chehab:

Interesting. So a big wide range of you that you can have with a 70 degree

Dr. Shah:

Arthroscope. Yeah. So you can see the hip and then, and then you have a variety of instruments. But I think instruments can be tailored and made better. And, and, and I think that that's one avenue of, I think innovation improvement. I think the big thing is prevention. I think that, you know, when we look at the number of kids and I have four kids and one of them super young not doing anything athletic. She's one. But all the other three boys, they're doing quite a bit. And when we look at all these kids that are doing all these sports, right, our id, our goal here is to make sure that they do all these things safely in a good manner and, and really get back to things well, but prevent injuries. And I think that's going to be important is making sure an appropriate stretching program, a good rehab program to prevent these injuries  in the first place. I think that's where most of the innovation should be focused is trying to get these patients prevention Yeah. Not get, not akin injured.

Dr. Chehab:

My guest today is Dr. Ritesh Shah, who's been speaking about hip arthroscopy and labral injuries and femoroacetabular impingement. Raquesh, thank you so much for being

Dr. Shah:

Here. Thank you Eric. Yeah.