The Failed Hip Arthroscopic Patient: Principles of Revision- How to Succeed: 5 Tips in 10 minutes J. W W. T Thom homas as B Byr yrd, MD MD Advan anced Pr Pract ctit itio ioner Su Summ mmit it – The he H Hip p Orthop thopaed edic Summit t 2017 17 - Evol olving ng Techn hniq iques es Las Vegas as, Nevad ada Decem ember er 8 th th , 2017 017
Through the Eye of the Beholder
Ey Eye of the of the B Behol holder • Vi View the the case se thr through ough the the eye ye of of the the pr previ vious sur ous surge geon on – Wh What w was t s the di diagnosi sis a s and ho how w was i s it deriv erived ed? – Was i imagi ging g g good od/current nt? – Wa Was t s the sur surgery don y done qui quickly? y? – Wa Was pa s patient i in n a hu hurry y for or sur surgery? y? – Was th the p e pat atien ient c complia liant? – Wh What w was t s the st structure of of t the po post st-op p rehab? b?
Perfect Storm
Perf rfect Storm t Storm • Most hi ost hip d diso sorders a are m e mul ultif tifacto torial l ( ( “Perf rm” ) erfect ct s storm – Ma May ne y neve ver i ide denti ntify y all factor tors – FA FAI l I logi ogically y expl xplains 2 ns 2º joi oint nt da dama mage • But ho how & & why hy are some e athle letes lifelo elong com ompe pensa sators?
Perf rfect Storm t Storm • FA FAI – Rega gardl dless ss of of sudde suddenn nness ss of of symptom symptom onse onset, t, it i t is s cul ulmi mina nati tion on of of cumul umulati tive ve effect of t of di disor sorde der pr prese sent nt si sinc nce chi hildhood dhood – Isol Isolate ted intr ntraarti ticul ular pr probl oblem m unc uncommon ommon • Compensa nsating ng long ng before F FAI b I becomes sympt sym ptomatic • Com ompensatory pr y problems m s may y be be f first st pr presenting sym sympt ptoms
Perf rfect Storm t Storm • Gl Gluts uts over over-fir irin ing & & painf nful ul
Perf rfect Storm t Storm • Coexis oexistent nt D Disea ease – Hi Hip p & & Lumba Lumbar di dise sease
Perf rfect Storm t Storm • Coexis oexistent nt D Disea ease – Athl thleti tic P Puba ubalgi gia (“sp “sports he s hernia”)
Perf rfect Storm t Storm • Coexis oexistent nt D Disea ease – Pelvi vic f floor oor di disor sorde ders? s?
Arthroscopy, 2014;30(1):42-46. Ultrasound-Guided Hip Injections: A Comparative Study with Fluoroscopy-Guided Injections J. W. Thomas Byrd, MD, Elizabeth A. Potts, MSN, APN, ACNP-BC, Rachel K. Allison, RT, Kay S. Jones, MSN, RN
U/S G U/ S Gui uide ded Inj njection on • Most ost use useful l diag agnos ostic ic adju junct to ct to H&P • Most hi ost hip j joi oint p t prob oblems not not isola solated ed ( ( coe oexi xiste stent/ nt/comp ompens nsator tory y ders ) di disor sorde • Muc uch b bett tter er tol toler erated ed b by y patie ient nts tha than f n fluo uoro g gui uided ed i inje nject ctio ions ns • Real eal ti time a e ass ssessmen ent • Use seful f l for or c clin linic icia ian & & patie ient nt( ! )
U/S G U/ S Gui uide ded Inj njection on • Tru True fo for h r hip & ip & extra-arti articul ular ar diso sorders a as s well ell
Perf rfect Storm t Storm • Fa Faile iled p prev eviou ous a arth throscop opic c proced cedure w with r h recu ecurren ent or t or residual p al pain? ain? – La Laye yers sta s stack up up
Raining Cats and Dogs
Raining ng Cats ts & D & Dogs ogs • Pa Pain in w with th h/o h/o of of prev evio ious us l labral l debri bride deme ment – Doe oesn’t sn’t uni unifor orml mly y me mean tha n that t se seque quela of of labr bral r rese secti tion i on is s cause use pa pain
Raining ng Cats ts & D & Dogs ogs • Reas easons ns f for or Fa Failu ilure: R Revisio ion n surge gery ry – Capsul psulol olabr bral a adhe dhesions ons – Inc Incomp omplete c cor orrecti tion of on of FA FAI
Raining ng Cats ts & D & Dogs ogs • Reas easons ns f for or Fa Failu ilure: R Revisio ion n surge gery ry – If If c caps psul ulol olabr bral a adhe dhesions a ons are unifor uni orml mly y pr present i nt in n revi visi sion on arthr thros oscop opy: y: How How ma many ny pe peopl ople not not requi quiring ng revi visi sion on likely y ha have ve sa same me f findi ndings? ngs? – If If close osely y sc scruti utini nize zed, how how ma many ny pe peopl ople doi doing w ng well mi might ght ha have ve findi ndings ngs of of inc ncompl omplete te c cor orrection on of i of impi mpinge ngeme ment? nt?
Raining ng Cats ts & D & Dogs ogs • Reas easons ns f for or Fa Failu ilure: R Revisio ion n surge gery ry – Failu ilure re of f la labra ral l re repair, air, in a n abse bsenc nce of of inc ncompl omplete te bony bony cor orrection, on, rarely y a cause use for or repe peat t arthr thros oscop opy • Exc Excel elle lent h healin ealing c cap apacit ity of labrum • Rehab ab precau cautions t to p protect tect r repai air r proba obabl bly t too c o conse onserva vative ve • Just t don’t want nt to fin ind point nt wher ere e repai air failur ilures escal calat ate
Raining ng Cats ts & D & Dogs ogs • Reas easons ns f for or Fa Failu ilure: R Revisio ion n surge gery ry – Tr Try not to y not to me mess ss with th iliopsoa opsoas s te tendon ndon • Sp Specif ecific ic rea easons to to consider er fracti ctional al lengt ngthening ng • Si Simp mply ly failu ilure re to to recog ogni nize o obviou ous F FAI c AI cause se o of pain in/patholo logy i insuffic fficien ient r rea eason
Raining ng Cats ts & D & Dogs ogs • Reas easons ns f for or Fa Failu ilure: R Revisio ion n surge gery ry – Tr Try not to y not to me mess ss with th iliopsoa opsoas s te tendon ndon • In absen ence of clea lear r reason oning, g, peop ople don’t on’t like e hav avin ing th their eir iliopsoas as v violated ated • Can an make f make for r a diffic ficult lt ti time g get ettin ing ove over sur surgery • Don’t on’t need d mor ore s surge gery, j , just n need d more a e atten ttenti tion g getti tting o over i r index ex proced cedure re
Preaching to the Choir
Preachi Pr hing ng to the to the C Cho hoir • Aver verage op e oper eration ion w will ll b be oka kay wit with go good P d PT T • Best op oper erat atio ion d n doom oomed ed to to fail il with th i inad nadeq equate or e or poor oor PT PT • 80/1 /10/1 0/10 R 0 Rule
Preachi Pr hing ng to the to the C Cho hoir • 80% of of posto ostop p prob oble lems addre dresse ssed t d through gh a adjust stme ments s in R in Rehab – Too muc Too much, h, too l too littl ttle, , too too wrong ong • Postop Postop g gui uidelin ines es/proto toco cols ls just ust guideli eline nes – Ti Titr trate ted to to indi ndivi vidua dual hi hip p toleranc tol nces • Le Less ss “ “coo ookbook ok” tha than othe other joi oints ts
Preachi Pr hing ng to the to the C Cho hoir • Pa Patien ients ts ha havin ing prob oble lems see P PT T fir first – Adj djustme ustments nts/st strate tegy a y already y outl outline ned w d whe hen I se n I see the them
Preachi Pr hing ng to the to the C Cho hoir • Most ost patien ients ts will ill develo lop a glit itch ch at som t some p e poi oint nt – Mor ore you you tr try y to to convi onvinc nce the them m tha that thi t things ngs are ok okay; y; mor more convi onvinc nced the d they y are tha that t some somethi thing’ ng’s w s wrong ong – Re Reoper erat atio ion ra rate e lo low; w; likelihood hood it’s t’s ok okay hi y high gh
Preachi Pr hing ng to the to the C Cho hoir • No one o one com omes es to se to see e sur surgeon on d desir iring ng PT PT – The Therapists sw sts swimmi mming ng upstr upstream – Not Not enough to nough to be be a abl ble to to de deciph pher pr probl oblem( m( s ) – Ha Have ve to to ge get t pa pati tient nt to to buy-in buy in
Preachi Pr hing ng to the to the C Cho hoir • Compe pensa satory ry probl blems ms can ob obscu scure c cont ontrib ibution ion of of und under erlyin ing j joi oint p t path tholog logy – Tim ime-consumi nsuming i ng in n of office to to atte ttemp mpt t to decip ipher a er all ll diffe ifferen ent fe t featu tures es – The Therapists a sts ade dept a t at t isol solati ting ng va various ous contr ontributi buting ng compone omponents nts • Ahe head d of cur urve ve com ompa pared d to orth thopaed aedic s c surgeo eons
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