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Welcome to the Mayo Clinic Orthopedic Surgery podcast, a curated series of interviews and discussions highlighting the three shields of orthopedic surgery at Mayo Clinic-- clinical practice, research, and education.
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JON: Welcome back to the Mayo Clinic Orthopedic Surgery podcast. I'm really excited today to welcome Kelechi Okoroha. He's An Outstanding Sports Medicine surgeon who joins us. He did undergrad at Xavier and played basketball there, did Med school at Howard University, and then did his residency training at Henry Ford. He's a fellowship trained sports surgeon. He trained at Rush University, helps take care of the Minnesota Timberwolves with our sports medicine group, and we're really excited to have him join us today to tell us a little bit more about hip impingement. Thanks for joining KC.
KC: Thanks for having me on Jon.
JON: This is a topic that seems to just be continually changing and I think it was really new when I was a resident we started to talk about hip impingement. Maybe it was just new to me. But the field seems to continually slowly change. Can you talk to us about what the current thinking is about hip impingement? Is it congenital? Is it developmental? Where does it come from, and how does it fit into hip pain and young athletes?
KC: Yeah well I think the understanding of hip impingement has expanded quite a bit over the last 10 years. I think we know that hip impingement is defined as a normal contact between the femoral head and acetabulum, and that continues to be diagnosed at increasing rates. So I think as we learn more about hip impingement our treatment algorithms continue to evolve. So we first started with performing hip arthroscopy with labral debridements.
Then after we understand the importance of correcting the bony abnormalities and preserving the labrum, surgeons started performing osseous corrections, and then they started performing labral repairs. And now we're finding that whereas initially capsular closure was thought to be not so important, I think the current literature really demonstrates those patients that undergo hip arthroscopy without capsular closure have decreased outcomes. So I think it's important to perform capsular closure.
So I think currently we've evolved into the surgical treatment and performing a comprehensive management of all the structures, and that includes a labral repair, femoral neck osteochondroplasty, acetabuloplasty, and then [INAUDIBLE] closure whenever possible.
JON: That's great, and it sounds like it's really adapted a lot since I was really learning about it a lot. Is it thought that this is congenital, or is it thought it's developmental, or some combination of the two? How are these bumps and things forming?
KC: Yeah so that's a great question. I like to put the hips at risk of impingement into three categories. So you can have abnormal anatomy and normal use. That speaks to what you were talking about that can be the congenital, such as a SCFE. That could be hip dysplasia or even prior surgery. Then you can have normal anatomy and abnormal use where that use really exceeds the tolerance of the joint structures. Now that can be an acute injury in like a contact athlete, or that can be a chronic injury involving either occupational, or recreational use. And then that last category is a combination of abnormal anatomy and abnormal use, which is really common as well.
JON: Got it. And is the thought that once these changes develop or once you really start to use it in this way that this is actually rapidly-- or it's moving you toward arthritis, or is treatment geared at just symptomatic management?
KC: Yeah so I think we do believe that hip impingement can lead to arthritis. In fact, if you look at the studies, studies have shown that up to 70% to 90% of all hip arthritis is caused by either FIA or hip dysplasia.
JON: Got it. So it seems to be a growing number and I think the harder part that I also see is-- I see a lot of, let's say middle aged or slightly older, patients with hip pain. How do you sort of go about the workup and thinking about if they're a candidate for hip preservation or if they need to go down a different road, let's say, toward total hip replacement?
KC: Yes. I think the middle aged population is the most difficult population. I think the young patients are pretty straight forward. They have a labral tear. They have a huge cam. I think those middle aged patients are similar to the degenerative meniscus tear. So if you image everybody over 40 and get a hip MRI, you're going to find labral tears you're going to find cam deformities. The question is who needs treatment? All right, so I think in those set of patients it is important to exhaust your non operative management with physical therapy, your injections, and see who really needs surgery.
Now we've done some studies to really evaluate what patient factors lead to increased success after hip arthroscopy and some of those are lower BMI, younger age, especially under 45, decreased arthritis, and really getting to that treatment within six months. Those are the factors found to be most beneficial.
JON: That sounds great. So let's look at the younger population and let's say a more straightforward situation, maybe abnormal anatomy. I would guess maybe the abnormal anatomy and abnormal use patients fall out a little bit earlier in this category, but do you go through the process of physical therapy and go through the process of an MRI-- or sorry of an injection, or is this a situation where you say the anatomy is problematic enough that we're going to jump straight to surgery? How do you make that decision?
KC: Yeah that's a very great question because I actually treat patients differently by their age groups. So my younger patients are-- I still do a trial of physical therapy. I still get advanced imaging with MRI just to see what's going on. But in the younger patients when it's really telltale, I don't inject them just because I'm worried about steroid in the joint and their cartilage being preserved. So in those patients, after they fail physical therapy and they have labral tear in a huge cam, I'll go straight to surgery.
JON: That makes sense. And for the older patients even with very early arthritis or the patients that seem to fall into let's say lower BMI and a better candidate for hip arthroscopy, even in the middle age, is there is a role for hip arthroscopy, or is it just wait for a total hip replacement? How do you decide to finally indicate somebody for that?
KC: Yeah. There's definitely a role. Like you said, in those ideal patients or they have a low BMI, they're middle age but not too old and they don't have a lot of arthritis, what I'll do is I'll do an injection. OK? Like you said before, and that injection does two things-- it's diagnostic and it's therapeutic. So if I perform an injection in the hip and that patient gets pain relief, I know definitively then that pain is coming from the hip. OK? It's not coming from the back, the muscles, it's come from inside the joint. And then number two, it gives them some therapeutic effect. So it gives them some pain relief, allows them to really do physical therapy, and see if this is something we treat non operatively. In those patients, if they fail that, that's when I indicate them for a hip arthroscopy.
JON: That makes sense. In thoughts about time frame after injection to surgical management, do you have a cutoff that you like to go by?
KC: Yeah, usually three months. I think the hip and knee literature is similar.
JON: Yeah. The shoulder literature has gone that way even for shoulder arthroscopy, which is a pretty low risk operation just like hip arthroscopy. But it's interesting because I see a lot of patients who have almost a reflex injection into something let's say, and probably it's more common in your young patients, where they go in and somebody's given them an injection and now you've really lost three months of--
KC: Right.
JON: --retention time. But in the older patient obviously a little less critical, especially in terms of that decision making, that makes sense.
KC: Right. That is a hard number, but I'm less worried about infection in arthroscopy. So it's not a hard number.
JON: Can you talk a little bit more about the steps of the procedure? So I know that-- or my understanding is that there's portions of the procedure that you do on the acetabular side, portions on the femoral side. Do you do all of the procedures? And then you talked a little bit about labral repair versus debridement, capsular closure. Do you do all the procedures on every patient by and large, or is it really individualized based on what their deformity looks like and how they got the tear?
KC: Yeah so I really try to treat patients in an a la carte manner based on the pathology present. So if there's a labral repair I try to preserve labral tissue. So I'm trying to do a labral repair whenever possible. And then you start looking at the femoral cam or the pencil deformity. Now most patients have a combination of both, but I only treat what I see. So if they have a cam deformity, I'm going to do an osteochondroplasty and get that alpha angle under 55. If they have a large center edge angle and they have a large pencil deformity, then I'm doing the acetabuloplasty. And then all my patients get a capsular closure.
JON: That's great. And is that an intraoperative decision, most of those steps, or is it more based on the radiographs and the MRI scan about the femoral side and the acetabular side?
KC: I think for the most part you can see that on an MRI. I do get CT scans on some of my patients, especially patients that I'm concerned with some version issues of either the femur or the acetabulum. So that really allows you to assess that bony abnormality.
JON: Perfect. And one of the things I sometimes read about is the thought of labral reconstruction as opposed to labral repair. Thoughts about that in a current age?
KC: Yeah, so labral reconstruction is a great tool to have. Those are going to be the patients where they have a real diminutive labrum, or they've had previous procedures and don't have a lot of labrum . So the labral reconstruction is a procedure we can do where we take either an autograft or an allograft tissue and really form a new labrum for that patient. Now I think this kicked off 5 to 10 years ago, but we've done some recent research at Rush and evaluating augmentation versus reconstruction.
So augmentation is a little bit different in that you don't take down the whole labrum and put in new tissue. You really just augment your new labrum on top of that old tissue. And what we think is because the labrum provides a suction seal effect to the hip. So think about if you have a suction cup on something. If you do a 360 degree resection, and then fix it down by 8 points, you still have some space in between those repairs for [INAUDIBLE] air. Whereas if you augment, you're putting new tissue on top of that and you really don't lose as much of that suction seal. So I'm more of a fan of augmentation whenever I can than reconstruction.
JON: That makes a lot of sense. And going the opposite direction, do you think there's a role for debridements in any patients, or is that something that sort of has gone by the wayside for the most part?
KC: Yeah I think the debridements are going to be more in your older patients that have a degenerative labral tear, there's not really much tissue to repair. Those are still good candidates for debridement, but most in large we try to repair it whenever we can.
JON: Great. My understanding is that the learning curve for hip arthroscopy is fairly steep and obviously the costs are high if you don't get it quite right in terms of either cartilage defects or, heaven forbid, femoral neck fractures or otherwise. Can you talk about some of the key components and maybe talk a little bit about the learning curve about frequency of use or somebody-- thoughts about low volume hip arthroscopy surgeons?
KC: Yeah. So hip arthroscopy is not as common as shoulder any arthroscopy. So it requires some additional expertise or training. So one thing that's not as common as you use a 70 degree scope. So that is a little bit difficult, especially for residents and fellows and therefore they don't get as much practice and training. So a key to a really successful hip arthroscopy is performing the procedure in an atraumatic nature so you're not damaging any cartilage or any labrum on the way in. And so it's harder to teach that because coming in the hip is not easy.
And so as a resident or a fellow if you're doing that and you're damaging cartilage or the labrum, you're already setting yourself back. So I just think it's something that needs a little bit more practice and detail in the lab and a little more familiarity with that 70 degree scope.
JON: Got it. And it sure sounds-- Oh go ahead.
KC: Go ahead.
JON: I was going to say it sure sounds like with the indications the way that they are it's a sort of a complex indications game, but then also a complex surgical game. And probably seems like something best done by people who are doing a relatively high volume.
KC: Yeah. I'd agree it's best done by people that are doing a higher degree of volume. I think when we look at what's the most common reason for reoperation it's inadequate bony resection. So I think you have to have experience in really resecting that cam to the proper level. And then the second reason is probably capsular closure. So we know that the iliofemoral ligament is the strongest ligament in the body. It's a key hip stabilizer. And so back in the day, nobody used to repair the capsule a lot of the times just because it's too difficult to do. Your end of the procedure, you're two hours 30 minutes, three hours, some people just bailed.
What we're finding is that those patients that didn't have capsular closure are doing worse than patients that do. So capsular closure is a key component as well.
JON: That's interesting. And can you talk about the technique around that capsular closure and then tie into that any emerging technologies that you see over the next few months or years that will come out that you think will dramatically change this game again?
KC: Yeah. So just a little bit about the capsular closure. It depends on what you do. So some people just make a straight incision in the capsule and some people perform a T in the capsule. But what you really want to do is make sure that you have a suture knot every one to 2 centimeters of capsular closure you do to make sure you have a tight repair. I'm sure that's it about capsular closure and then emerging techniques, there's a lot of current technologies that are current coming out. There's one that's used to map the bony deformities preoperatively, and then you can correlate that interoperatively to check your resection. So these are techniques that are useful to really check your bony resection and they're really useful in surgeons that haven't done a lot of hip arthroscopies.
JON: That's super helpful. I'm going to try and summarize what this shoulder surgeon learned about hip arthroscopy, and then you can update what I got wrong and have any final comments for our listeners, who I'm sure are excited about continuing to move this ball forward. So it sounds like obviously hip arthroscopy is here to stay. And the early concerns about not exactly finding out who should have it or when should have it are dying down as the indications really tightened down. Sounds like there's sort of a combination of some congenital factors or abnormal growth patterns, but then there's clearly some use issues in association with this. That combination or overplay seems to be really important in terms of making decisions.
It sounds like we've gotten confident enough about the procedure that in young athletes with pretty clear anatomic deformities, going straight to surgery is a reasonable option as opposed to nursing things along with injections, which potentially could have some risk of complications. But in the older population where there's a few more pain generators that could be in play an injection for diagnostic and therapeutic reasons can be really helpful.
And then finally, it's a very technical operation it sounds like with a number of different steps that really need to be done to give the patient a best chance at a good outcome, particularly addressing the bony abnormality sufficiently, repairing or reconstructing the acetabular labrum, and then obviously capsular closure, which you mentioned a few times. Any other thoughts that you'd like to add for people who are either interested in hip impingement or surgeons who want to maybe add it to their game or residents who are interested in it?
KC: Yeah. That is a really great summary of hip impingement and where we are. I would just say if you want to do hip arthroscopy, make sure you go somewhere either a fellowship that has somebody doing it in high volume or make sure you get a lot of practice. But I don't think people should give up. I think if you want to do it there's plenty of opportunities to get it done right.
JON: Beautiful. Thanks so much for joining us.
KC: All right. Thanks for having me.
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