Unlock the secrets of hip health with Dr. Victor Ortiz as we navigate the complexities of hip anatomy and the innovative treatments that are shifting the landscape of patient care. The hip joint is more than a ball and socket point—it's a marvel of engineering that Dr. Ortiz decodes for us, shedding light on the labrum's pivotal role in joint stability and how its dysfunction can lead to debilitating conditions like FAI and labral tears. Suffering from hip pain or know someone who is? Get ready to arm yourself with knowledge that could change the course of treatment.
This episode is a deep dive into how experts like Dr. Ortiz diagnose hip joint pathologies. Through a detailed exploration of examination techniques such as the FADIR and FABER tests, we reveal how specialists pinpoint the exact nature of hip discomfort. Discover the puzzle pieces that contribute to these conditions and how early detection can keep invasive surgeries at bay. Athletes, the hypermobile, and the young active demographic - this conversation is especially relevant to you as we uncover why these issues are so important.
For those weighing the options between surgery and non-invasive treatment, Dr. Ortiz illuminates the path to recovery. We investigate the role of physical therapy in strengthening core muscles and how diagnostic injections can be game-changers in managing hip pain. Delving into the realm of hip preservation procedures, we look at when surgery becomes the right choice and the breakthroughs in minimally invasive techniques like hip arthroscopy. Join us for this episode and take a significant step towards understanding and potentially overcoming hip pain.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Robert A. Kayal, MD (00:00):
Hello and welcome back to another edition
of the KL Ortho podcast.
Today is January 3, 2024, andwe're so privileged to welcome
back our very own Dr VictorOrtiz to the KL Ortho podcast.
Today's topic is AcetabularLabral Tears and Hip Arthroscopy
and a Disease Entity wedescribe as Femoral Acetabular
(00:21):
Impingement.
Welcome back to the podcast, drOrtiz.
Victor Ortiz, MD (00:24):
Thank you, Dr KL, for having me and looking
forward to having a gooddiscussion about hypertroscopy.
Robert A. Kayal, MD (00:29):
Yeah, it's great having you back, and happy
new year everyone.
Well, we're first going tostart out by having Dr Ortiz
just describe the anatomy of thehip joint, and then we'll delve
into what a labral tear is andwhat Femoral Acetabular
Impingement is, how we diagnoseit and how we treat it as well.
Victor Ortiz, MD (00:46):
Perfect.
So I think everything isimportant to start with how the
anatomy of any joint in the bodyis, and it's especially the hip
.
I think it's one thing that I'mpassionate about and the hip is
a ball and socket joint and Ialways try to explain to the
patients which is showing myhands is like a ball and a
socket.
So those are the bony parts ofthe joint that create that
(01:10):
motion, that create that bonystability.
But in addition to the bone,there's other soft tissues
around the hip that are veryimportant and that we have
learned through time thattreating them helps patients
with recovery and symptoms.
And that entails the labrum,which is that extension of that
acetabular rim that providesstability to the hip.
We also have some ligaments, orthe capsule is like that bag
(01:33):
that covers the joint.
That also provides a lot ofstability and keeping that fluid
in the joint.
And that fluid that the jointhas is very important because it
provides nutrients to thecartilage and lubrication to the
area.
So there's a lot of roles forthe soft tissues that are
important, as same as the bonyanatomy.
Robert A. Kayal, MD (01:54):
Yeah, the hip joints, the ball and socket
joint, as you described, verymuch like the shoulder joint
right, which is a ball andsocket joint.
You know, the ball and socketjoints are joints that basically
have a lot of mobilitytypically, and because of the
mobility, it potentially can beunstable Like we describe.
In the shoulder you have a golfball that potentially can fall
off that golf teeth.
(02:14):
But in the hip it's a littledifferent.
Right the ball is quite largebut the socket is quite large as
well.
But just like in the ball andsocket joint of the hip, there's
static and dynamic stabilizers.
Right, some of the staticstabilizers include the bone and
the labrum, but in the hipjoint and in the shoulder joint
we have dynamic stabilizers aswell, the muscles right.
(02:36):
So one of the staticstabilizers we talked about was
the labrum.
What is the labrum?
Victor Ortiz, MD (02:43):
So the labrum is an extension of the rim and I
think that you know, if we lookat the hip, at the socket of
the hip, so that rim has anextension that could be four, 10
millimeters in length.
The labrum is made of cartilage, it's collagen, it's an
extension of that socket thatincreases surface area.
Robert A. Kayal, MD (03:03):
It also helps to contain the fluid
inside that joint.
Right Describe that fluid.
For me it's called synovialfluid.
What function does the synovialfluid play in the hip joint?
Victor Ortiz, MD (03:13):
So the synovial fluid is very important
.
It contains some of theproteins of the cartilage and
you know they work with thelubrication of the joint and
giving that nutrition to thecartilage that is so important
to preserve the hip.
You know, when you start losingthose characteristics of the
fluid or you're losing fluidfrom the joint, those are the
things that can lead to ourtritis of the hip.
Robert A. Kayal, MD (03:34):
Right, the fluid is, like you know, largely
made up of hyaluronic acid aswell.
Right, the lubrication.
They have a lot of propertiesmechanical properties, load
absorption, but predominantlynutrition and lubrication to the
joint.
Right, the analogy I often givepatients is like the gasket on
a car engine.
Right, you have the pistonsgoing up and down these
(03:55):
cylinders and the oil providesthat lubrication so that the
engine doesn't fail.
But if that gasket leaks youcan literally blow your engine.
Right, same thing in the hipjoint or any other joint that
contains synovial fluid.
Synovial fluid is so vital forthe lubrication function,
mechanical properties of thejoint, but also for nutritional
(04:16):
purposes as well.
And so that labrum around thatbone socket joint plays such a
vital role in maintaining themechanical properties of that
bone socket joint, cushioning itand preserving it to preserve
it so it stays vital and healthyand does not deteriorate and
become degenerative.
Now we talked about some of thestatic stabilizers, ie the
(04:39):
labrum, which you said is mainlyfibro cartilage.
But the ball and socket jointis also a static stabilizer of
that construct.
Right, so you have a ball onone side, like you described,
and a socket on the other sidethat you described.
Can there be changes that canoccur not only to the labrum but
to the ball and the socket.
That can be detrimental to thehip joint.
Victor Ortiz, MD (05:02):
Absolutely, and I think that's where we can
talk about impingement of thehip.
So there are two types ofimpingements in the hip that are
very common, and the first onewould be that the head is not
completely rounded.
So when the patient is flexingor rotating the hip, the ball is
not completely rounded, soyou're rubbing against the
labrum.
The second type of impingementwould be in the socket part, so
(05:24):
we have over coverage or thesocket is more proud.
So when we have a socket thatis more proud I always try to
make this analogy right Usuallythe normal coverage should be
like this, but a lot of timesthere are places that are over
covered.
So when you're over covered,that distance between pinch or
make the ball hit the socket issmaller and that creates that
(05:45):
pair of the labrum.
Robert A. Kayal, MD (05:47):
Right, and that often occurs in a condition
we call acetabular retroversionright Correct.
So why don't we describe theversion of the acetabular and
what is a normal version of theacetabular, so our viewing
audience can get anunderstanding?
Victor Ortiz, MD (06:00):
So if we're looking at the socket, I always
tell the patient the socket isalways looking towards us, where
it's looking to the front.
But there are differentpatients, have different
morphologies, they're borndifferent ways and one of the
things that can happen is thatthe cup, instead of being
looking to the front or thesocket, it starts looking
backwards, and that's what DrKale just mentioned about
(06:21):
retroversion.
So when the cup is lookingbackwards and you can identify
that just from x-rays in theoffice the patient, the distance
again to impingement is less.
So the patients are at risk ofthese type of pairs or injuries
and it's very important to beable to identify them because we
have not only treat the pairbut we also have to treat any
anatomic, the morphology ordeformity that the patient has.
Robert A. Kayal, MD (06:45):
Right that acetabular retroversion can
result in that femoralacetabular impingement that we
described.
And, by the way, this conditionis called FAI or femoral
acetabular impingement, and wecall it that because the femur
is the thigh bone, theacetabulum is the cup and you
can get that mechanicalimpingement for the reasons that
(07:09):
Dr Ortiz already outlined,between the femur and the
acetabulum and that's why wecall it FAI or femoral
acetabular impingement.
And this FAI, femoralacetabular impingement, may or
may not result in acetabularlabral tears and when those
labral tears occur it ultimatelyoften can lead to degenerative
(07:32):
changes in the hip and hiparthritis ultimately as well.
And by the way, I failed tomention earlier that Dr Ortiz,
dr Victor Ortiz, is our hipspecialist.
He's the chief of the hipservice at the Kale Orthopedic
Center.
Dr Ortiz is double fellowshiptrained.
By the way, he's fellowshiptrained in hip arthroscopy and
(07:55):
hip preservation as well assports medicine and arthroscopy.
He did a one year fellowship inChicago in the area of sports
medicine and arthroscopy andthen stayed in Chicago to do a
second fellowship at theAmerican Hip Institute, also in
Chicago, with a world renownedhip arthroscopy specialist.
(08:15):
So he did that second year oftraining in this relatively new
field of orthopedics called hippreservation.
So he was hired specificallymany years ago and joined the
Kale Orthopedic Center,primarily to spearhead this
cutting edge field in the areaof orthopedics called hip
preservation, where we're tryingnow to save patients' hips at a
(08:39):
younger age and prevent them,hopefully, from ultimately
requiring a hip replacement.
So it's really been an amazingaddition to our practice having
Dr Ortiz with us.
So, that being said, we talkedabout these forms of mechanical
impingement, ultimately causinglabral tears.
(09:00):
Another way of describing thisin layman's terms is to
basically say that between thefemur and the acetabulum you can
get these spurs.
Sometimes we'll call them spurs.
On the femoral side we callthose gross, bone-gross cam
lesions and on the acetabularside we call that a pincer
(09:21):
lesion.
So you may hear your doctortalk about a cam lesion or a
pincer lesion, but essentiallywe're discussing this condition
called femoral acetabularimpingement, and so at this
point we should really talkabout how the patients will
typically present with theseconditions.
Dr Ortiz, how does a patienttypically present to the office
(09:42):
when you're suspicious of thiscondition?
Victor Ortiz, MD (09:44):
So the most common complaint would be pain
and a lot of the patients willgrab their hand like a letter C
and it's called like a C sign.
They'll grab the hand like aletter C, they'll put it around
the hip joint area and that'swhere my pain is and that's the
main complaint.
When they come to the officethey are saying I have this pain
usually worse with running,prolonged standing or any type
of activity that requirescutting, twisting, pivoting or
(10:08):
deep squatting.
And I always tell the patientsextreme range of motion,
especially when you flex the hipor you rotate internally like
what you're cutting.
That's usually the most commoncomplaint of patients.
Robert A. Kayal, MD (10:20):
Hip pain definitely, and I can't
overemphasize enough thatcomplaint of what we call the C
sign.
It's almost universal, it'salmost pathodontic for this
condition.
When patients, when you'reassessing patients, and you ask
them specifically where theirpain is, they almost universally
all go like this they grabtheir hip, just like Dr Ortiz
(10:41):
described and we call that the Csign, and they grab their hip
sort of just like this.
They go like this it's here,it's here.
You know they're describing thepain deep and it's not in the
front, it's not in the back,it's sort of between where your
thumb and your fingers meet,deep in the middle.
That's the hip joint.
A lot of patients come into ouroffice and they think that this
(11:05):
is the hip.
They say, dr Kale, my hip hurtsover here or this is my hip
over here.
It can be, but it's more oftenthan not Pain in that location
tends to be stemming primarilyfrom the back.
But the hip, to the orthopedicsurgeon, is the groin.
So when patients complain ofpain in the groin, it's almost
(11:26):
always secondary to what we callintraarticular hip joint
pathology, a problem stemmingfrom within the hip joint itself
.
It could be a labral tear, itcould be water in the joint, it
could be hip arthritis, we don'tknow.
But typically groin pain moreoften than not is stemming from
(11:47):
the hip joint itself, andnowhere else Would you agree
with that, totally agree.
Okay, so they come, complain ofpain.
But we described also that thelabrum is associated with
stability of the hip right.
It keeps the joint together.
We talked about the staticstabilizers.
So it's a stabilizer of the hipand it helps to stabilize.
(12:09):
So if that labrum is torn, thathip's also going to feel
unstable, a little bit rightCorrect, so mechanically the
patients may complain that theirhip is what Buckling?
Victor Ortiz, MD (12:19):
or buckling or clicking.
They can even hear like a popor say like isn't that can
create this pop, and that can bea case.
Robert A. Kayal, MD (12:26):
Yeah, and they feel unstable, like when
they navigate stairs.
Sometimes they have to hold onto the side rail right, so that
can be another complaint.
So pain, and again thatclassical location that we
described, that C sign, but alsoinstability, anything else?
Victor Ortiz, MD (12:44):
I think those are the main main presentation.
You know, I think the 95% ofour patients will show up with
those type of history.
There's another 5% that mighthave a different history and
that's where you know we have tobe a little bit more like
aggressive, just include all thetype of diagnostic tests that
we might discuss down the road,but absolutely that would be the
most common presentation.
Robert A. Kayal, MD (13:04):
I agree.
And then once you're suspiciousof that, we can do a bunch of
things on physical examinationto confirm that diagnosis right
Totally.
What are some of those things,dr Ortiz?
Victor Ortiz, MD (13:15):
So I think the first thing that I would do in
a physical examination isinspect the hip.
You know, I think a lot oftimes patients will be able to
show you what's going on justfrom a simple inspection.
Then you have to touch the area, and there are a lot of areas
in the hip joint that you cantouch, going down the way to the
front, all the way to the back.
You know, you can touch the hipflexors, you can touch the
trochanteric bursa, you cantouch the deep gluteal muscles.
(13:37):
There's a lot of areas in thehip that can give you an idea of
what's going on.
And then the next step will beto examine the range of motion.
You know, just feeling therange of motion of the patients
can give you a lot ofinformation, especially of that
bony anatomy or that bonymorphology when are you rotating
that hip, when do you get ablock, when do you get a stop?
And that gives you an idea ofwhat's going on inside.
(13:58):
So examining the range ofmotion is very important.
And then this we have thisclassic exam.
It's called a Fader, a flexionadduction, internal rotation.
But what that means is that weare really recreating that
position of impingement.
We're flexing the hip, bringingit against the socket and
creating some rotation, and thattriggers the pain in the spasms
(14:21):
.
If the labrum is the symptomthat is causing the pain.
Robert A. Kayal, MD (14:24):
Right and for the most part this is an
anterior sided hip problem right.
It's almost always occurring inthe front of the hip joint, so
in the front of your body asopposed to the back of your body
, and so you know it's acondition that occurs very often
in deep flexion combined withrotation that he's describing.
And because of that we do thisclassic quote, unquote
(14:47):
impingement test and that's whathe was describing where we take
the patient lying down and weflex their hip beyond 90 degrees
and combine that with what wecall adduction and internal
rotation.
So just to demonstrate, I'lltake this hip of mine and we'd
flex it into deep flexion,adduct it and internally rotate
(15:07):
at the same time, and that veryoften will create that
mechanical impingement syndromeresulting in exacerbation of the
patient's symptoms.
That will hurt because whenyou're impinging you're
irritating the torn labrum orfurther displacing the torn
labrum, and that is a fairlyclassic test.
(15:28):
So combine the history of painin the front of the hip
primarily, where the patient saythat the pain is exacerbated by
squatting, for instance, orsitting in a low chair for a
prolonged period of time, andthen corroborating that with
their physical examination,where you flex them, you bring
(15:48):
their knees together and youinternally rotate that hip where
it will trigger or exacerbate,elicit that painful response.
That's fairly classic for anacetabular labral tear or the
condition we described asfemoral acetabular impingement.
So that's really important.
And, by the way, the patientsthat get these labral tears are
(16:09):
typically in what age grouppopulation?
Victor Ortiz, MD (16:11):
I would say anywhere in their late teens to
the 40s and 50s, you know,anywhere around that range we
can see these double tears Right, but in general, what the point
I was trying to make is we'redealing with a younger age group
population.
Robert A. Kayal, MD (16:25):
We're not diagnosing labral tears and
patients in their mid to late60s, 70s and 80s.
That's typically a differentsource of hip pain in that age
group population and more oftenthan that that would be a
degenerative arthritic conditionmore often than not.
So we're classically diagnosingfemoral acetabular impingement
(16:46):
and labral tears in patients inthis younger age group
population.
So now that we may have adifferential diagnosis and for
the most part it's way up therewe're thinking that this patient
has a labral tear, femoralacetabular impingement.
And, by the way, before I getto the next point, does everyone
with femoral acetabularimpingement get a labral tear
and does everyone with a labraltear have femoral acetabular
(17:08):
impingement?
What's your opinion on that?
Victor Ortiz, MD (17:11):
No, not everyone gets that If I think we
can have patients only withimpingement and we do imaging
and we do the procedure and theydon't have a torn labrum and
the problem is impingement whichmight lead to that down the
road.
But I think that with thetechnology that we have today,
we have been able to identify alot of things before they happen
.
But they can happen one withoutthe other.
Robert A. Kayal, MD (17:31):
Yeah, and are certain patients at risk for
developing these femoralacetabular impingement
conditions or labral tears?
Victor Ortiz, MD (17:41):
Absolutely.
I think that if you know, Ithink, looking at the technology
, as I mentioned, all theimprovements that we have and
innovations, and when you lookat professional players, all the
studies that they have donewith these combines, when they
go to the draft and all thex-rays that they take, you know
you look at hockey players likegoldies for hockey, 90% of them
will have femoral acetabularimpingement.
And if you look at all thosesoccer players, basketball
(18:03):
players, football players,there's a high incidence in some
positions and high impact.
Things that require a lot ofcutting and twisting and a lot
of pressure in the growth placewhen you were growing up are
patients that are at risk ofhaving these deformities.
Robert A. Kayal, MD (18:16):
Is there a genetic component?
Is there a genetic component tothis condition?
What?
Victor Ortiz, MD (18:21):
do you think?
I don't think I haven't seenanything identified to a genetic
component, but there'sabsolutely a correlation between
families.
You know there's people thatthey have it and they have it on
both sides.
So there's absolutely somethingin the genetic part, but
nothing that I can tell that is.
Robert A. Kayal, MD (18:36):
I mean, certainly there is an arthritis,
so you would think you woulddeduce that there probably is or
will be ultimately discovereddown the road.
This is a relatively newdiagnosis in the field of
orthopedic surgery.
Right, you know, prior to thisdiagnosis of femoral acetabular
impingement, patients just endedup getting arthritis and we
(18:56):
told them that they hadarthritis.
But this may be indeed a verysignificant risk factor for
those patients and if we canidentify that early, you may be
able to save a lot of patientsfrom needing a hip replacement
down the road.
That's our hope.
That's the concept of thisfellowship training that Dr
Ortiz did for that added year inthe field of hip preservation
(19:18):
Trying to preserve patients ownhips as opposed to replacing
them with implants.
That's the goal of making thisdiagnosis at an early age, and
we'll talk about how we canintervene in effort to do that.
What about patients that haveligamentous laxity, for instance
?
So young girls that arehypermobile, ligamentous lax?
(19:39):
Are those patients at risk forany problems?
Victor Ortiz, MD (19:42):
Absolutely.
I think that.
Thank you for the question,because I think that's something
that I emphasize a lot,especially when I'm talking to
other orthopedic surgeons orcolleagues in the field.
I think that young female withhypermobility we have this baton
score where we're alwayschecking the patients do they
hyper extend the elbows, do theyhyper extend the fingers?
That patient is at risk ofhaving a torn labrum because
(20:03):
they have instability or jointlaxity.
So that's a patient thatwhenever if we decide to do a
surgical treatment, we have totreat the cause of the tear and
that's the instability.
So we have to make sure thatwhen we're doing that procedure
tension in the soft tissues wehave physical therapy making
sure that they work on tensionin the soft tissues because
you're protecting that repair.
I think that sometimes I haveheard that people said oh no,
(20:26):
this patient is a young femalewith just a small labral tear.
I think that's the mostchallenging case because you
have to fix the labrum but youhave to make sure you tension
everything around that If you goin there and you don't do that,
you're making the problem worse.
Robert A. Kayal, MD (20:38):
Yeah, I'm with you.
We deal with the same issues inthe area of knee replacement
surgery, when patients areligamentously lax, dealing with
those patients with hypermobilejoints that tend to go into
recurvotum or hyperextension oftheir knee.
That's a scary thing.
So I'm with you on that.
So now that we've made thatdiagnosis, how do we confirm it?
What type of imaging studiescan we do to confirm the
(21:00):
diagnosis?
Victor Ortiz, MD (21:01):
So there's multiple imaging in our office.
The first thing, and the thingthat gives me more information,
is x-rays, plain x-rays, whereyou can see all these.
First look at the space howmuch space this patient has.
Then look at this bonehemophilia, look at the socket,
look at the ball, look if theyhave any type of impingement
that we discussed and then youcan see how the acetabular
(21:25):
socket is looking.
It's looking to the back, it'slooking backwards.
So that gives you an idea ofwhat to expect when you get MRIs
or CT scans.
I think the MRI is probablygoing to confirm our suspicion
from our physical examinationand our plain x-rays and it's
probably the most this is themost specific testing to
identify how the labrum is.
(21:45):
I think that MRI also has a lotof utility in that patient to
make sure that we don't havemore advanced damage, more
advanced arthritis.
So sometimes these MRIs willshow patients that have a full
defect of a full hole in thecartilage or a demined bone.
Those are signs that there'smore advanced damage in the hip
joint and that patient might notbe a candidate for a hip
(22:08):
precipitation procedure.
I think that all the imaging isimportant for us to really
identify who's a good candidateif they have to have any
surgical procedure down the roadwith respect to imaging and
X-rays in general.
Robert A. Kayal, MD (22:23):
Are you just getting routine x-rays in
the office of the hip or thepelvis or are you getting
special views, and why is thatimportant?
Victor Ortiz, MD (22:31):
We have a very specific protocol and it has
special views.
You know, we get the plane, thenormal x-rays, we get a
standing Because we want to makesure that when the patient put
weight on it, how the hip isbehaving, we have other views.
That really allows us to see.
You know, x-rays only chargestwo dimensions, so we try to
bring different views, to getother dimensions of how the hip
is, to make sure that we have asocket that is covering enough
(22:55):
the ball or you have enoughcoverage at the ball so we can
measure that in different anglesto make sure that we're making
you know the right planning andright decision, yeah, or what
the patient needs are youtypically getting weight-bearing
images in the office or supineimages?
Robert A. Kayal, MD (23:07):
We get both .
We get a weight-bearing and asupine.
Great, and then how about onMRI?
What, what kinds of things areyou looking for on MRI?
Victor Ortiz, MD (23:15):
So in MRIs we we want to confirm, we want to
make sure that the patient has atorn labrum.
So we can see the labrum in theMRI in different views and you
can see either a line goingthrough it, you can see some
blunting, you can see some intrasubstance fluid, you can see
some cyst.
Sometimes, when you have a tear, the labrum, the fluid, the
fluid from the joint will startleaking to that here and so you
(23:36):
can see signs in the MRI thatconfirm that that's the problem
that's going on.
I also think the MRI for me ismore important in that patient
you know might be borderlinebetween having a Hebertroscopy
or a replacement, because youcan never.
You see subcontracted emailwhenever you see any cyst in the
MRI.
Those are findings that aretelling you they are.
(23:57):
There's more damage.
And when you go in there theremight be more damage.
And it's important for me tohave a good discussion with the
patient about Expectations,about what the outcomes are
gonna be if we decide to goahead when and when the MRI is
showing more Damage than what wesee in the x-rays and primarily
you, you're looking primarilyfor just disease Isolated to
that one area of the hip, right,that anterior superior area on
(24:21):
MRI.
Robert A. Kayal, MD (24:21):
So if you start to see changes that are
more diffusing nature, likeyou're describing the
subconjural cysts and Marodemaeverywhere, different things
like that, or label tearing,extensive label tearing outside
of where you get that femoralacetatecaryl impingement, maybe
you'd be thinking more along thelines no longer of hip
preservation but maybe hipreplacement, right, correct?
(24:42):
So yeah, the anterior superioraspect on the MRI, that's where
you're looking for your tear,that's where you're looking for
your impingement, that's whereyou're looking for that early
cartilage delamination, and Iemphasize early, because if it's
more advanced then maybe we'retalking about that.
The hip is no longersalvageable but rather needs to
(25:03):
be replaced.
And so what is the differencebetween the labral cartilage and
the hyaline articular cartilageand the changes we described?
The labral tear on the Labelside, but on the acid, but on
the Femoral head side, sometimeswe see cartilage delamination.
What's occurring there?
Victor Ortiz, MD (25:21):
So I think that there are different type of
collagen.
You know one.
You get the articular cartilageor hyaline cartilage, which is
a collagen type 2, which issulfur, and that's what you can
see, some, some frayingdelamination, and then you have
the Labrum, which is a harder,is more like a like rubber, and
(25:41):
instead that extension of thesocket, which is harder, you
know, tolerates a little bitmore pressure and controls
really that load bearing andcreates a strong suction seal,
the hip joint.
And they're different, you knowthey.
They is very important toreally be able to identify them
and in the MRI and treat in theright way, because that's, you
know, that's the success of theprocedure.
Robert A. Kayal, MD (26:01):
All right, so it's just like the knee.
I always go back to the kneeand the knee we're talking about
the meniscus, which would beanalogous to the labrum in the
shoulder and the hip, that type1 fiber cartilage.
And then we have the cartilagethat coats the end of the knee
joint, called hyaline articularcartilage, which is a type 2
collagen, that softer cushionthat Dr Ortiz was describing,
(26:22):
and so the key here is toidentify changes on the MRI that
are consistent with ourdiagnosis, but not advanced
changes.
We don't want advanced changes.
Once we start seeingdegenerative changes from a
chronic Condition, it may not bea hip that's amenable to
salvage anymore, but ratherreplacement.
(26:42):
So we the key is when you're,if you're suffering from any of
these conditions, you have toget in to see Dr Ortiz sooner
rather than later so he canemploy his skill set in the area
of hip preservation in effortto try to save your hip, as
opposed to Utilize his skill setin the area of robotic direct
anterior hip replacement toreplace your hip.
(27:04):
We're trying to save your hiphere, so that's what we're at
with respect to that.
So we talked about x-rays,special views, we talked about
MRI and the things we're lookingfor.
But also there's this 3dcross-sectional high resolution
imaging modality called a CTscan, and just like there are
protocols with x-rays, there'salso protocol specific for this
(27:28):
condition femoral acid tabularimpingement, where dr Ortiz is
ordering a cat scan for very,very specific reasons.
Can you elaborate on thatregard?
Victor Ortiz, MD (27:37):
Absolutely, I think.
I think cat scan is a veryimportant part of diagnosing and
what is the theology, what isthe reason why we're having
these stairs?
The amount of information thatwe get from the scan is amazing.
You know we can get exactly howmuch overgrowth you have in the
ball, how much overgrowth youhave in the socket In out.
(27:58):
On a clockwise we always liketo look at the hip in the socket
as a clockwise right 12 to 3o'clock is usually the area
where you see those stairs.
So we can correlate that to thecat scan and see is there's an
overgrowth in the ball, in thesocket, is this an overgrowth in
this ball that colorates withthat, and how much we have.
Also, I think it's veryimportant what dr Kale mentioned
initially about acid tabularretroversion.
(28:19):
We can get some landmarks fromthe cat scan and we can
calculate exactly where, what isthe version, where is the acid
tabulum looking at.
But also, more importantly,there's a component of rotation
also in the femur.
Sometimes there are patientsthat the femur will be looking a
lot to the front, so they willcall and the version or increase
femurotorchine that cantranslate to pay people that in
(28:39):
tow or out tow.
So those things we can measureand are important, because that
might be the reason why thepatient is having a tear in the
labor and you might not need totreat that and you might need to
just take care of those things.
Robert A. Kayal, MD (28:50):
Yeah, that was very helpful.
Thanks so much, dr Ortiz.
You know, just to reemphasize,the MRI is very, very good at
looking at the soft tissues.
So when we're looking for alabral tear and we want to
assess the articular cartilageor the fibro cartilage of the
labrum, mri is the tool ofchoice.
But when we're looking at the,the 3d reconstruction of the
bony anatomy, nothing is betterthan a cat scan.
(29:12):
A cat scan Literally reproducesthe 3d anatomy of the bony part
of this condition femurot,tabular impingement Whereas the
MRI very nicely looks at thesoft tissue component of this
condition the bone marrow, thelabrum, the articular cartilage
and the soft tissue surroundingthe hip joint as well.
(29:32):
So both are vital in making aproper diagnosis of this
condition, condition and alsoplanning treatment.
So now that we're talking abouttreatment, how do we first
intervene when you make thediagnosis?
Victor Ortiz, MD (29:46):
So every patient that we make the
diagnosis or we have thesuspicion we always want to
start with, they come with pain.
So we try to control the painand we like to use any
anti-inflammatory medication.
You know, we want to have thepatient modify the activities
they are doing.
As we mentioned, this issomething that happens with
extreme, some motions.
So we try to tell the patient,you know, stay away from things
that require a lot of fleshen, alot of internal rotation.
(30:08):
Then we like to do physicaltherapy.
I think supervised physicaltherapy is very important.
It's a standard of care of anytype of joint pain or back pain
or neck pain in the in theorthopedic world Is something
that we are big on and weemphasize that every patient
needs to be in physical therapy.
Working there's 17 musclesgoing to the hip joint.
(30:29):
There's a lot of them that wedon't use routinely and that's
where a good physical therapiststart working with you working
with the core, we can with thegluteus working, and a lot of
these patients come back and thepain is gone after six weeks of
physical therapy.
Robert A. Kayal, MD (30:39):
Yeah, so usually that's that's the first
line of treatment for us in ourpractice and it's been a very
successful yeah, because you didmention over and over again
that the labrum is a key playerin stability of the hip joint,
right?
So if we, if we've lost some ofthe static stabilizers, we
focus on those dynamicstabilizers, the muscles we can
control.
We call those dynamicstabilizers.
(30:59):
We can control the muscles andprovide stability around joints
by strengthening muscles andphysical therapy.
We can't control the staticstabilizers, the bone, the
cartilage, the labrum, etc.
With physical therapy.
Those are things that wouldhave to ultimately be addressed
Surgery, surgically, if we can'tget the stability or the
(31:20):
alleviation of pain or achieveour goals with physical therapy
alone.
So that's why it's important todistinguish between static
stabilizers and dynamicstabilizers.
Most joints, in fact I wouldsay all joints, have both static
and dynamic stabilizers.
So we first try non operativecare, physical therapy focusing
on the dynamic stabilizers, tonot only provide stability but
(31:44):
also try to restore motion.
This is a condition it's calledfemoroacetabular impingement.
There's a mechanicalimpingement Going on around this
hip joint that's restrictingpatients range of motion.
That's one of their complaintsThey've lost motion, they have
pain from the impingement or thetears, and we get them into
(32:04):
physical therapy, try to restoremotion but also to Achieve that
stability that we talked aboutby strengthening the muscles as
well, and so that's one of thereasons we start with
conservative, non operative carephysical therapy.
We can also give a man timeinflammatory, right.
Sometimes they have painassociated with it, so sometimes
we'll give a man timeinflammatory as well.
(32:24):
Sometimes you may not be ahundred percent sure that the
pain is coming from the FAI orthe labor tear.
Is there a diagnostic procedurethat you can do to help give
you some feedback Whether or notwe're treating the right
condition?
Because we don't like to treatx-rays, we don't like to treat
MRIs, we like to treat thepatient and make sure we make
them better.
(32:45):
So what is a tool that we canemploy to try to get some
feedback?
Victor Ortiz, MD (32:49):
So I think that the that that's where
diagnostic hip injection is theway to go.
I think that is probably one ofthe most powerful tools that we
have in that knows, in the hipas a source of the pain.
I think all first for thepatient, for acting patients
sometimes come to us and theysay no, I think the back is the
problem.
I think the I said you knowthis other thing, and I we tell
(33:09):
them this let me give you thehip joint injection, let's see
what you get, and they come backand they're surprised, like the
pain is completely gone.
I think it's very powerful alsofor us as a provider because it
can differentiate Is this is abackflip area problem?
Is this a hip related problem?
Is this an overlap where wemaybe the hip is 60% and 40%?
So it allows us to quantifywhat's going on to be able to,
(33:31):
you know, first, improve the.
I think that those injectionsare really allowed them to have
less pain and be able to go tophysical therapy and work better
.
I think that I haveincorporated that to my practice
because when they come in painand they go back to the physical
therapy, sometimes they comeback in three or four days.
I don't tolerate the exercises.
But you get in the injection,they are able to do those
exercises, they come backstronger and they come in a
(33:52):
better way.
But I think that the power, howpowerful it is, in diagnosing
the hip as a source of the painis probably the best test that
we have.
Robert A. Kayal, MD (34:02):
That's great.
I couldn't agree with you more,dr Ortiz.
But this brings us back to whatwe talked about earlier, and
that is the anatomical locationof the hip joint.
So it's not a superficial joint.
The hip joint is not on theside of your hip, it's a deep
joint, it's in the center ofyour body, between the front of
(34:22):
your hip and the back of yourhip, and it's in the groin,
which is not a superficial joint.
And it's important to know that, because you can't easily
undergo a hip injection in theoffice without tools that will
help you see that deep joint,and those tools can either be
the usage of an ultrasound orthe usage of a fluoroscopic
(34:46):
X-ray machine that we have inthe office that helps you see
that deep joint.
There are certain joints in thebody that are very easy to
inject, for instance theshoulder, the knee joint, for
instance, but the hip joint isone that requires the assistance
of imaging in order to get thatmedicine into the joint, and
(35:09):
one way we do that is with theusage of that ultrasound or
what's called C-arm fluoroscopyassistance, and sometimes even
with that you're not 100% sureyou're in the joint.
So what we do is what's calledan arthrogram.
An arthrogram is when we takethis contrast material and we
first put the contrast materialinto the joint and perform that
(35:31):
arthrogram, then we'll see underC-arm fluoroscopy or ultrasound
that the joint is distendedbecause, like Dr Ortiz mentioned
earlier, it's like a balloon.
The joint is a balloon and sowe're filling up that joint with
this contrast material andwe'll see that contrast material
contained within that joint.
Once we know we're in the joint, we'll also look to see if
(35:55):
there's an extension of thatcontrast material between the
labrum and the bone, and that isthat line he was describing on
MRI.
Sometimes you'll see that linefill in the space between the
labrum and the bone, furtherconfirming our suspicion for an
acetabular labral tear.
But then, once he's in the jointand we've confirmed that on
(36:17):
ultrasound or C-arm fluoroscopyand, by the way, we have
procedure rooms at the K Lordorthopedic center where we do
this in these procedure roomsand once we confirm we're in the
joint, then he'll add thecorticosteroid or the local
anesthetic and more often thannot patients will get off that
table completely relieved oftheir symptoms right then, and
(36:40):
there Immediate relief of theirsymptoms they feel markedly
different, they're able to getoff the table, they're able to
walk up and down, rotate theirhip and for the most part their
pain is gone.
And that gives the doctorfeedback that we're not only
treating a study but we'retreating the patient for the
presumed diagnosis and we'reaccurate in our diagnosis and
(37:02):
our impression of what's goingon.
So now you've done that and yougot that feedback, you'll get
the patient for physical therapylike we talked about and you'll
see the patient back If thepatient's better.
You're done right.
For the most part you don't justtreat the patient because
there's a labral tear or femoralacetabular impinge, but if
there's enough of a pincerlesion or if there's enough of a
(37:24):
cam lesion, you're probablygoing to keep a close eye on
that patient because you don'twant that to ultimately number
one, result in significant lossof motion to that patient.
Right, because that pincer canget bigger, that cam could get
bigger and they can lose motionand we need to preserve motion
to put on our socks and shoesand get in and out of cars, all
those things.
But also that mechanicalimpingement can cause the
(37:49):
changes not only to the labrumbut to that highland articular
carlos, that delamination whichultimately leads to arthritis.
So now that you've made thediagnosis and you're looking at
the patient's MRI, cat scan andX-ray.
What are the changes on X-raythat would suggest to you that
maybe, if this patient failsphysical therapy, you can
(38:09):
undergo a definitive surgicalhip preservation procedure,
versus X-ray changes that mayultimately say look, if you fail
conservative management, you'regoing to need a hip replacement
?
What are those changes you'relooking for?
Victor Ortiz, MD (38:23):
So there are a couple of criteria that we take
in consideration when examiningX-rays that really allow us to
know if the patient would be agood candidate to undergo a hip
preservation procedure.
But the first one is how muchspace the patient has left.
There's been multiple studiesthat have shown that if you have
less than 2mm of joint space,that's a patient that would
(38:43):
Wouldn't do well with a hipprecipitation procedure will not
do well.
Robert A. Kayal, MD (38:46):
Right, well , needs a hip replacement.
Victor Ortiz, MD (38:48):
It would be a reason so that's the first thing
that you can see, this aclassification of Colettonic
classification, where patientszero and one are the good
candidates, and the way youclassify.
That is when you look at thespace, you look at this.
This bone spurs as clear roses,all those findings.
So just from the extrastandpoint you get that
classification.
You have to make sure that youhave enough space and you don't
(39:08):
have Changes that are consistentwith more advanced arthritis,
right.
Robert A. Kayal, MD (39:13):
So what he's talking about is that ball
and socket join that first x-ray.
You're looking at the ball inthe socket and that space that
we see on x-ray is not really aspace.
It's filled with cartilagenormally.
Well, you want it to be filledwith cartilage and if that x-ray
is showing that there's lessthan two millimeters of space
Between that ball and socket,you can't save that patient's
hip anymore.
(39:33):
Ultimately, if that patientfails not operative care, that
patient's getting a hipreplacement.
But if that patient that you'resuspicious of has a labral tear
, has an x-ray that looks likethis and they're still healthy
cartilage in or surrounding thatball of the bone socket joint,
that patient if that patientfails not operative care, is
getting a hip arthroscopy by drOrtiz to save that patient's hip
(39:55):
.
That's that hip preservation.
So that patient's gonna getwell, let's talk about it.
It let's talk about thatpatient.
That patient now went tophysical therapy for how long?
How long would you treat themNonoperatively?
You give them a couplecortisone injections.
They've they got significantrelief.
You put them in for physicaltherapy.
Maybe ever, once in a while,they're taking some Tylenol or
(40:16):
an anti-inflammatory, but theycome back to you.
When are you gonna see themback when you're gonna make a
decision to pull the trigger, totake the next step.
Victor Ortiz, MD (40:24):
I should like to wait like around six weeks.
You know we can go anywherefrom six to twelve, but I think
six weeks for me is enough timefor the patient to, you know,
try all the conservativemanagement, all the, all the
non-surgical or noninterventional procedures,
including the injections,including the medication,
including a supervised physicaltherapy.
If they have done that, thenlike for good six weeks and the
symptoms are worse or notgetting better, I think that's a
(40:45):
patient that would be a goodsurgical candidate.
Robert A. Kayal, MD (40:48):
Yeah, and you know you're also listening
to them if they're complainingof constant instability,
constant pain, constant loss ofmotion, buckling giving way,
they can't navigate stairs.
You know every patient'sdifferent so you know this is
not like a textbook Cookiecutter type of approach.
We evaluate each patient,listen to their symptoms and see
(41:08):
, see how it's affecting theirquality of life.
These labral tears, we knowwill never heal by themselves
right.
This problem is not going to goaway by itself.
You can manage the symptomsWith physical therapy and things
like that, but it's never goingto heal.
So what is your approach to thepatient that doesn't want any
surgical intervention?
Are there any biologicaltherapies or generative medicine
(41:31):
techniques that you can employto To maybe inject into that
joint that will give somebiology that potentially can
alleviate the patient's symptomsand Plus or minus promote some
biological healing?
Victor Ortiz, MD (41:44):
Absolutely, and we have a good amount of
patients that they don't haveand you know they are maybe
Later in age and they say, likeyou know what, I don't want to
have a natuoscopic procedure, Idon't want to go to the process.
And we always have discussionswith about platelet-rich plasma
or bone marrow aspiratedinjections.
I think they have a great role.
They they are good To decreasethe inflammation.
(42:04):
I think that it's, uh, theevidence-based medicine out
there.
You know it's not going to bestrong enough to say that it's
going to heal the tear, but Ithink it brings all these cells,
all these components thatdecrease inflammation and it
will help with pain.
And so far we, I think in myhands I have had a great success
of Of outcomes with thosepatients.
You know, one of the thingsthat I did in my training of
(42:26):
herperecivation was within thecase series, although in those
patients a little bit differentthere was.
Those were patients that Werenot a surgical candidate because
of that x-ray less than twomillimeters, or an MRI that
showed Moral arthritis, and butthey were not completely
bone-on-bone, it was not like abone-on-bone patient.
So we injected them with prp,we filed them for a year and all
those patients have improvementin their patient reported
(42:48):
outcomes.
Um so I think is something thatis a an absolutely a great
option for those patients thatdon't want to go undergo a
procedure.
Robert A. Kayal, MD (42:55):
Yeah, I mean certainly the prp, or the
platelet-rich plasma, has someAnti-inflammatory properties
associated with it.
It's something we offerroutinely to our patients and
perform routinely at the Kailaorthopedic center.
A little bit of a disclaimer itis not FDA approved.
It is considered by mostinsurance companies to be
experimental, but a lot ofpatients believe in it and
(43:16):
certainly that's where Medicineis heading and orthopedics in
general is heading in the era ofregenerative medicine,
repairing as opposed toreplacing.
We do offer those technologiesand anecdotally we both can tell
you that it's helped a ton ofpatients in our practice for
sure.
And so if, if patients areadamantly opposed to fixing the
(43:37):
problem and they're willing totry Maybe some future
experimental orthobiologicaltherapies for regenerative
medical Therapies andinterventions, we would be happy
to oblige and offer you thoseservices because we offer them
routinely at the Kailaorthopedic center.
So now You've indicated thepatient for hip arthroscopy,
(43:58):
let's talk about your approachto hip arthroscopy and what your
goals are and how you achievethose goals.
Victor Ortiz, MD (44:05):
It is also once we identify the, the label,
there is what is causing thesymptoms in the patients, and we
would run all these imagingstudies, physical examination,
conservative management we haveto be able to identify what are
the sources of the pain, what iscausing the problem, and I
think that we have to.
A lot of the times Maybe 90, 99percent of the times we have a
(44:26):
torn labrum, but I always askmyself why did the patient had a
torn labrum?
Was this because they have animpeachment?
Was this because they arehaving hypermobility, as we
discussed earlier?
So we have to come with theplan and to offer the patient
how can we fix this, but alsohow can we avoid this from
happening in the future.
And I think that's the mostimportant thing in the
decision-making process, in myconversation with the patients
(44:50):
about what are we going to bedoing, how are we?
We attacking this?
Um, the goal, and I think thatwhen we're offering this
procedure to the patient, thegoal and only goal for surgery
should be to improve pain andFunctionality and that that's
the main thing.
You don't have pain, you don'tneed surgery, but if there's
pain, we want to make the better, there's a highly high chance
if you fail, everything we havedone that we can make you better
(45:11):
.
And there's always a secondarygoal that if we are preserved,
we are fixing these problems,that we can preserve this, if
that we can win time and giveyou More time down the road
before the need of a replacementor the idea to try to avoid it
in the future.
Um, so I think that that oncewe have that, then we decide and
we made the decision, theinformed decision of going ahead
with the procedure.
(45:31):
Uh, this is a minimallyinvasive procedure that we do it
through same as a shoulder andneed a simple scope.
We go in there, we confirm theproblem with the camera, we put
the camera in there, we can takepictures, we can see the label
and we can see the cartridges,we can see everything in the in
the joint, uh, and then we goahead and we fix it.
And usually the first thingthat I always like to do is go
(45:51):
To that acetabular rim and weexpose that rim where we're
going to be reattaching thatlabrum.
We trim whatever Impingement wehave in that area, guided with
all the pre-op planning that wedid because we got a CAT scan,
we got all this imaging that istelling me, letting me know Dr,
this.
This is where we're going to go.
This is what, how much bonewe're going to remove.
Once we remove the bone, thenwe can put multiple anchors and
(46:13):
as many anchors as we need.
We can go as as as low as two,we can go all the way to six,
seven anchors, whatever isneeded to really restore that
labrum, to be able to createthat functional, that suction
seal or that increased surfacearea, to restore the mechanics
of the hip.
And after we we fix the joint,we clean everything that needs
(46:34):
to be clean.
Then we pull the traction off.
You know, we when we go to thejoint, we have to open it up,
pulling on the leg.
So once we close that, we canreally see how we restore that
seal mechanism.
And we can now go to the balland look at that area that is
causing pinchment, trim all thebone down, increase that offset,
increase that distance beforethe patient has any type of
(46:54):
Impingement.
And we do that guided by x-ray.
We do x-ray guidance to theprocedure To make sure that we
get to that angle that we needto get, and also guided by the
pre-op planning that we did fromthe, from the CT scan um, and
once we fix everything, then wewe go ahead, and something that
I emphasize a lot is that we,when we get to the joint, we
(47:15):
have to open the back.
It really the back open.
That's going to create problemsand the we have to close that
back and that's called a capsule.
So once we're done with theprocedure, we have to close the
capsule.
I think that's something thathas to be done routinely, um,
and sometimes in patients wehave to not only close it but do
something called a capsuleapplication when you put the
sutures in a differentorientation to tension that more
(47:37):
to protect that repair, becausewe want to really Tighten the
hip joint to protect the repairthat we did.
Robert A. Kayal, MD (47:45):
Wow, so you've achieved a lot of goals
Arthroscopically.
You've not only reattached thelabrum which was the source of
pain, um, you took down the bonespur on the acetabular side,
the cup side.
You took down the bone spur orthe cannulise on the femur or
the femoral side and by doing so, eliminating that source of
impingement, your goal is torestore range of motion to that
(48:07):
patient as well.
And so now you've repaired thelabrum, you've restored that
watertight closure, that seal.
The synovial fluid is nownourishing the joint, providing
its mechanical properties oflubrication and shock absorption
and nutrition To the articularcartilage.
Uh, so you've achieved a lot ofgoals, doing this through a
very minimally invasive,arthroscopic, arthroscopic
(48:31):
approach, typically through twoor three puncture, typically
three puncture, yes, threelittle punctures around the hip
joint.
This is very cutting-edgetechnology.
I I must emphasize to you thethe lion's share of orthopedic
surgeons In this in the world,not just this country, have
never, ever done a hiparthroscopy.
Uh, this is a procedure thatshould only be performed by very
(48:56):
, very highly trained andexperienced orthopedic surgeons
like Dr Ortiz.
Most orthopedic surgeons wouldnever dare to attempt a hip
arthroscopy.
It's very different than ashoulder arthroscopy and a knee
arthroscopy.
That most orthopedic surgeonsthat do sports medicine do so.
You definitely definitely need ahighly experienced, trained and
(49:21):
seasoned orthopedic surgeon,like Dr Ortiz, who does probably
anywhere from five to 10 a week.
He's a very, very highlyexperienced orthopedic surgeon
in the area of hip arthroscopy,and so I do need to emphasize
that, because most orthopedicsurgeons that are dabbling in
(49:45):
the field of hip arthroscopy maybe, in fact, just doing that
dabbling, and you certainlydon't want to be a guinea pig.
So you want to make sure thatyou go to a seasoned,
experienced orthopedic surgeonthat has done a high volume of
these Okay, so I do want toemphasize that and, specifically
, has done a hip preservationfellowship as well, because it
(50:09):
is not as easy as most otherjoints that we routinely scope.
So I do want to emphasize that,just to protect you.
So we've done the surgeryoutpatient surgery, patients
going home the same day.
It's important that theyprotect your repair, right?
What's your post op protocol?
Victor Ortiz, MD (50:28):
So every patient the first two weeks is
only put the foot on the floor.
So that means they're going towear crutches.
So only the foot on the floor.
We don't want to put anypressure in the area to not to
damage the repair.
The only thing that we useroutinely is a hip brace.
The brace will allow you to gofrom zero to 90 degrees so
you're going to be able to sitin the chair comfortable.
But we don't want to open theleg, we don't want to create any
(50:50):
rotation in the leg for thefirst two weeks.
But you start physical therapyright away.
You know next day we have avery specific protocol for every
patient Next day duringphysical therapy, then at two
weeks, we get rid of the brace,we get rid of the crutches, then
you go back to full weightbearing and then we progress you
for multiple phases with theidea in four to five months for
you to be able to go back to doeverything that you want.
Robert A. Kayal, MD (51:12):
That's great.
And what have you found in yourexperience incidents of
bilaterality?
Do you find that a lot of thesepatients will have a tear on
the other side too, or develop atear on the other side as well?
Victor Ortiz, MD (51:21):
It's very common.
I always tell the patients thatthe other hip gets jealous and
it's very common and not alwayswe have to treat them.
But I have done patients that Ihave done one week apart.
I do one side and we go to theweek we do the other side and
it's very common.
Robert A. Kayal, MD (51:39):
Yeah, wow, this has been very helpful,
especially a subject like thisthat not a lot of people know
about, right, femoralacetateblur impingement.
You know, I think it'simportant to get the word out
about this condition, even tonon-orthopedic surgeons.
First of all, a lot oforthopedic surgeons aren't
familiar with this condition andmaybe they're not 100% sure
(52:01):
what the source of thatpatient's hip pain is.
What is femoral acetateblurimpingement?
Again, as I mentioned, it's arelatively new disease condition
that we've identified.
But it's very important also toget the word out to
chiropractors and medicaldoctors, primary care physicians
, when patients are complainingof that classic groin pain and
(52:25):
stability buckling, mechanicalproperties, pain with deep
flexion and squatting, and thex-ray is normal think about
femoral acetateblur impingement,think about labral tears the
pain, where we described it tobe, is coming from the hip joint
and there's not too many thingsthat can cause that pain in the
hip joint.
(52:46):
So when there's no arthritis,you know you have to be thinking
about this condition femoralacetateblur impingement and if
you're not routinely looking athip x-rays and specifically the
very specific views that weorder to assess for this
condition, you may be missingthe diagnosis and we're not
doing any justice to ourpatients.
(53:06):
So it behooves us to thinkabout this condition and send
them to an expert like Dr Ortizto get this condition assessed,
so our patients can be treatedand maybe you might even be
saving them from a hipreplacement down the road.
So it's very important to beaware of this condition.
So I hope that you found thispodcast to be beneficial and
(53:26):
helpful, and Dr Ortiz is readilyaccepting new patient visits
and follow appointments as well,second opinions, injury cases
and workman's compensation casesas well, so feel free to reach
out, okay.
So thanks so much for your time, dr Ortiz.
Thank you for having me.
It was a pleasure having youhere again.
Welcome back, thank you, have agreat day.
Bye-bye everyone.
Hello and welcome back to another edition
of the KL Ortho podcast.
Today is January 3, 2024, andwe're so privileged to welcome
back our very own Dr VictorOrtiz to the KL Ortho podcast.
Today's topic is AcetabularLabral Tears and Hip Arthroscopy
and a Disease Entity wedescribe as Femoral Acetabular
(00:21):
Impingement.
Welcome back to the podcast, drOrtiz.
Victor Ortiz, MD (00:24):
Thank you, Dr KL, for having me and looking
forward to having a gooddiscussion about hypertroscopy.
Robert A. Kayal, MD (00:29):
Yeah, it's great having you back, and happy
new year everyone.
Well, we're first going tostart out by having Dr Ortiz
just describe the anatomy of thehip joint, and then we'll delve
into what a labral tear is andwhat Femoral Acetabular
Impingement is, how we diagnoseit and how we treat it as well.
Victor Ortiz, MD (00:46):
Perfect.
So I think everything isimportant to start with how the
anatomy of any joint in the bodyis, and it's especially the hip
.
I think it's one thing that I'mpassionate about and the hip is
a ball and socket joint and Ialways try to explain to the
patients which is showing myhands is like a ball and a
socket.
So those are the bony parts ofthe joint that create that
(01:10):
motion, that create that bonystability.
But in addition to the bone,there's other soft tissues
around the hip that are veryimportant and that we have
learned through time thattreating them helps patients
with recovery and symptoms.
And that entails the labrum,which is that extension of that
acetabular rim that providesstability to the hip.
We also have some ligaments, orthe capsule is like that bag
(01:33):
that covers the joint.
That also provides a lot ofstability and keeping that fluid
in the joint.
And that fluid that the jointhas is very important because it
provides nutrients to thecartilage and lubrication to the
area.
So there's a lot of roles forthe soft tissues that are
important, as same as the bonyanatomy.
Robert A. Kayal, MD (01:54):
Yeah, the hip joints, the ball and socket
joint, as you described, verymuch like the shoulder joint
right, which is a ball andsocket joint.
You know, the ball and socketjoints are joints that basically
have a lot of mobilitytypically, and because of the
mobility, it potentially can beunstable Like we describe.
In the shoulder you have a golfball that potentially can fall
off that golf teeth.
(02:14):
But in the hip it's a littledifferent.
Right the ball is quite largebut the socket is quite large as
well.
But just like in the ball andsocket joint of the hip, there's
static and dynamic stabilizers.
Right, some of the staticstabilizers include the bone and
the labrum, but in the hipjoint and in the shoulder joint
we have dynamic stabilizers aswell, the muscles right.
(02:36):
So one of the staticstabilizers we talked about was
the labrum.
What is the labrum?
Victor Ortiz, MD (02:43):
So the labrum is an extension of the rim and I
think that you know, if we lookat the hip, at the socket of
the hip, so that rim has anextension that could be four, 10
millimeters in length.
The labrum is made of cartilage, it's collagen, it's an
extension of that socket thatincreases surface area.
Robert A. Kayal, MD (03:03):
It also helps to contain the fluid
inside that joint.
Right Describe that fluid.
For me it's called synovialfluid.
What function does the synovialfluid play in the hip joint?
Victor Ortiz, MD (03:13):
So the synovial fluid is very important
.
It contains some of theproteins of the cartilage and
you know they work with thelubrication of the joint and
giving that nutrition to thecartilage that is so important
to preserve the hip.
You know, when you start losingthose characteristics of the
fluid or you're losing fluidfrom the joint, those are the
things that can lead to ourtritis of the hip.
Robert A. Kayal, MD (03:34):
Right, the fluid is, like you know, largely
made up of hyaluronic acid aswell.
Right, the lubrication.
They have a lot of propertiesmechanical properties, load
absorption, but predominantlynutrition and lubrication to the
joint.
Right, the analogy I often givepatients is like the gasket on
a car engine.
Right, you have the pistonsgoing up and down these
(03:55):
cylinders and the oil providesthat lubrication so that the
engine doesn't fail.
But if that gasket leaks youcan literally blow your engine.
Right, same thing in the hipjoint or any other joint that
contains synovial fluid.
Synovial fluid is so vital forthe lubrication function,
mechanical properties of thejoint, but also for nutritional
(04:16):
purposes as well.
And so that labrum around thatbone socket joint plays such a
vital role in maintaining themechanical properties of that
bone socket joint, cushioning itand preserving it to preserve
it so it stays vital and healthyand does not deteriorate and
become degenerative.
Now we talked about some of thestatic stabilizers, ie the
(04:39):
labrum, which you said is mainlyfibro cartilage.
But the ball and socket jointis also a static stabilizer of
that construct.
Right, so you have a ball onone side, like you described,
and a socket on the other sidethat you described.
Can there be changes that canoccur not only to the labrum but
to the ball and the socket.
That can be detrimental to thehip joint.
Victor Ortiz, MD (05:02):
Absolutely, and I think that's where we can
talk about impingement of thehip.
So there are two types ofimpingements in the hip that are
very common, and the first onewould be that the head is not
completely rounded.
So when the patient is flexingor rotating the hip, the ball is
not completely rounded, soyou're rubbing against the
labrum.
The second type of impingementwould be in the socket part, so
(05:24):
we have over coverage or thesocket is more proud.
So when we have a socket thatis more proud I always try to
make this analogy right Usuallythe normal coverage should be
like this, but a lot of timesthere are places that are over
covered.
So when you're over covered,that distance between pinch or
make the ball hit the socket issmaller and that creates that
(05:45):
pair of the labrum.
Robert A. Kayal, MD (05:47):
Right, and that often occurs in a condition
we call acetabular retroversionright Correct.
So why don't we describe theversion of the acetabular and
what is a normal version of theacetabular, so our viewing
audience can get anunderstanding?
Victor Ortiz, MD (06:00):
So if we're looking at the socket, I always
tell the patient the socket isalways looking towards us, where
it's looking to the front.
But there are differentpatients, have different
morphologies, they're borndifferent ways and one of the
things that can happen is thatthe cup, instead of being
looking to the front or thesocket, it starts looking
backwards, and that's what DrKale just mentioned about
(06:21):
retroversion.
So when the cup is lookingbackwards and you can identify
that just from x-rays in theoffice the patient, the distance
again to impingement is less.
So the patients are at risk ofthese type of pairs or injuries
and it's very important to beable to identify them because we
have not only treat the pairbut we also have to treat any
anatomic, the morphology ordeformity that the patient has.
Robert A. Kayal, MD (06:45):
Right that acetabular retroversion can
result in that femoralacetabular impingement that we
described.
And, by the way, this conditionis called FAI or femoral
acetabular impingement, and wecall it that because the femur
is the thigh bone, theacetabulum is the cup and you
can get that mechanicalimpingement for the reasons that
(07:09):
Dr Ortiz already outlined,between the femur and the
acetabulum and that's why wecall it FAI or femoral
acetabular impingement.
And this FAI, femoralacetabular impingement, may or
may not result in acetabularlabral tears and when those
labral tears occur it ultimatelyoften can lead to degenerative
(07:32):
changes in the hip and hiparthritis ultimately as well.
And by the way, I failed tomention earlier that Dr Ortiz,
dr Victor Ortiz, is our hipspecialist.
He's the chief of the hipservice at the Kale Orthopedic
Center.
Dr Ortiz is double fellowshiptrained.
By the way, he's fellowshiptrained in hip arthroscopy and
(07:55):
hip preservation as well assports medicine and arthroscopy.
He did a one year fellowship inChicago in the area of sports
medicine and arthroscopy andthen stayed in Chicago to do a
second fellowship at theAmerican Hip Institute, also in
Chicago, with a world renownedhip arthroscopy specialist.
(08:15):
So he did that second year oftraining in this relatively new
field of orthopedics called hippreservation.
So he was hired specificallymany years ago and joined the
Kale Orthopedic Center,primarily to spearhead this
cutting edge field in the areaof orthopedics called hip
preservation, where we're tryingnow to save patients' hips at a
(08:39):
younger age and prevent them,hopefully, from ultimately
requiring a hip replacement.
So it's really been an amazingaddition to our practice having
Dr Ortiz with us.
So, that being said, we talkedabout these forms of mechanical
impingement, ultimately causinglabral tears.
(09:00):
Another way of describing thisin layman's terms is to
basically say that between thefemur and the acetabulum you can
get these spurs.
Sometimes we'll call them spurs.
On the femoral side we callthose gross, bone-gross cam
lesions and on the acetabularside we call that a pincer
(09:21):
lesion.
So you may hear your doctortalk about a cam lesion or a
pincer lesion, but essentiallywe're discussing this condition
called femoral acetabularimpingement, and so at this
point we should really talkabout how the patients will
typically present with theseconditions.
Dr Ortiz, how does a patienttypically present to the office
(09:42):
when you're suspicious of thiscondition?
Victor Ortiz, MD (09:44):
So the most common complaint would be pain
and a lot of the patients willgrab their hand like a letter C
and it's called like a C sign.
They'll grab the hand like aletter C, they'll put it around
the hip joint area and that'swhere my pain is and that's the
main complaint.
When they come to the officethey are saying I have this pain
usually worse with running,prolonged standing or any type
of activity that requirescutting, twisting, pivoting or
(10:08):
deep squatting.
And I always tell the patientsextreme range of motion,
especially when you flex the hipor you rotate internally like
what you're cutting.
That's usually the most commoncomplaint of patients.
Robert A. Kayal, MD (10:20):
Hip pain definitely, and I can't
overemphasize enough thatcomplaint of what we call the C
sign.
It's almost universal, it'salmost pathodontic for this
condition.
When patients, when you'reassessing patients, and you ask
them specifically where theirpain is, they almost universally
all go like this they grabtheir hip, just like Dr Ortiz
(10:41):
described and we call that the Csign, and they grab their hip
sort of just like this.
They go like this it's here,it's here.
You know they're describing thepain deep and it's not in the
front, it's not in the back,it's sort of between where your
thumb and your fingers meet,deep in the middle.
That's the hip joint.
A lot of patients come into ouroffice and they think that this
(11:05):
is the hip.
They say, dr Kale, my hip hurtsover here or this is my hip
over here.
It can be, but it's more oftenthan not Pain in that location
tends to be stemming primarilyfrom the back.
But the hip, to the orthopedicsurgeon, is the groin.
So when patients complain ofpain in the groin, it's almost
(11:26):
always secondary to what we callintraarticular hip joint
pathology, a problem stemmingfrom within the hip joint itself
.
It could be a labral tear, itcould be water in the joint, it
could be hip arthritis, we don'tknow.
But typically groin pain moreoften than not is stemming from
(11:47):
the hip joint itself, andnowhere else Would you agree
with that, totally agree.
Okay, so they come, complain ofpain.
But we described also that thelabrum is associated with
stability of the hip right.
It keeps the joint together.
We talked about the staticstabilizers.
So it's a stabilizer of the hipand it helps to stabilize.
(12:09):
So if that labrum is torn, thathip's also going to feel
unstable, a little bit rightCorrect, so mechanically the
patients may complain that theirhip is what Buckling?
Victor Ortiz, MD (12:19):
or buckling or clicking.
They can even hear like a popor say like isn't that can
create this pop, and that can bea case.
Robert A. Kayal, MD (12:26):
Yeah, and they feel unstable, like when
they navigate stairs.
Sometimes they have to hold onto the side rail right, so that
can be another complaint.
So pain, and again thatclassical location that we
described, that C sign, but alsoinstability, anything else?
Victor Ortiz, MD (12:44):
I think those are the main main presentation.
You know, I think the 95% ofour patients will show up with
those type of history.
There's another 5% that mighthave a different history and
that's where you know we have tobe a little bit more like
aggressive, just include all thetype of diagnostic tests that
we might discuss down the road,but absolutely that would be the
most common presentation.
Robert A. Kayal, MD (13:04):
I agree.
And then once you're suspiciousof that, we can do a bunch of
things on physical examinationto confirm that diagnosis right
Totally.
What are some of those things,dr Ortiz?
Victor Ortiz, MD (13:15):
So I think the first thing that I would do in
a physical examination isinspect the hip.
You know, I think a lot oftimes patients will be able to
show you what's going on justfrom a simple inspection.
Then you have to touch the area, and there are a lot of areas
in the hip joint that you cantouch, going down the way to the
front, all the way to the back.
You know, you can touch the hipflexors, you can touch the
trochanteric bursa, you cantouch the deep gluteal muscles.
(13:37):
There's a lot of areas in thehip that can give you an idea of
what's going on.
And then the next step will beto examine the range of motion.
You know, just feeling therange of motion of the patients
can give you a lot ofinformation, especially of that
bony anatomy or that bonymorphology when are you rotating
that hip, when do you get ablock, when do you get a stop?
And that gives you an idea ofwhat's going on inside.
(13:58):
So examining the range ofmotion is very important.
And then this we have thisclassic exam.
It's called a Fader, a flexionadduction, internal rotation.
But what that means is that weare really recreating that
position of impingement.
We're flexing the hip, bringingit against the socket and
creating some rotation, and thattriggers the pain in the spasms
(14:21):
.
If the labrum is the symptomthat is causing the pain.
Robert A. Kayal, MD (14:24):
Right and for the most part this is an
anterior sided hip problem right.
It's almost always occurring inthe front of the hip joint, so
in the front of your body asopposed to the back of your body
, and so you know it's acondition that occurs very often
in deep flexion combined withrotation that he's describing.
And because of that we do thisclassic quote, unquote
(14:47):
impingement test and that's whathe was describing where we take
the patient lying down and weflex their hip beyond 90 degrees
and combine that with what wecall adduction and internal
rotation.
So just to demonstrate, I'lltake this hip of mine and we'd
flex it into deep flexion,adduct it and internally rotate
(15:07):
at the same time, and that veryoften will create that
mechanical impingement syndromeresulting in exacerbation of the
patient's symptoms.
That will hurt because whenyou're impinging you're
irritating the torn labrum orfurther displacing the torn
labrum, and that is a fairlyclassic test.
(15:28):
So combine the history of painin the front of the hip
primarily, where the patient saythat the pain is exacerbated by
squatting, for instance, orsitting in a low chair for a
prolonged period of time, andthen corroborating that with
their physical examination,where you flex them, you bring
(15:48):
their knees together and youinternally rotate that hip where
it will trigger or exacerbate,elicit that painful response.
That's fairly classic for anacetabular labral tear or the
condition we described asfemoral acetabular impingement.
So that's really important.
And, by the way, the patientsthat get these labral tears are
(16:09):
typically in what age grouppopulation?
Victor Ortiz, MD (16:11):
I would say anywhere in their late teens to
the 40s and 50s, you know,anywhere around that range we
can see these double tears Right, but in general, what the point
I was trying to make is we'redealing with a younger age group
population.
Robert A. Kayal, MD (16:25):
We're not diagnosing labral tears and
patients in their mid to late60s, 70s and 80s.
That's typically a differentsource of hip pain in that age
group population and more oftenthan that that would be a
degenerative arthritic conditionmore often than not.
So we're classically diagnosingfemoral acetabular impingement
(16:46):
and labral tears in patients inthis younger age group
population.
So now that we may have adifferential diagnosis and for
the most part it's way up therewe're thinking that this patient
has a labral tear, femoralacetabular impingement.
And, by the way, before I getto the next point, does everyone
with femoral acetabularimpingement get a labral tear
and does everyone with a labraltear have femoral acetabular
(17:08):
impingement?
What's your opinion on that?
Victor Ortiz, MD (17:11):
No, not everyone gets that If I think we
can have patients only withimpingement and we do imaging
and we do the procedure and theydon't have a torn labrum and
the problem is impingement whichmight lead to that down the
road.
But I think that with thetechnology that we have today,
we have been able to identify alot of things before they happen
.
But they can happen one withoutthe other.
Robert A. Kayal, MD (17:31):
Yeah, and are certain patients at risk for
developing these femoralacetabular impingement
conditions or labral tears?
Victor Ortiz, MD (17:41):
Absolutely.
I think that if you know, Ithink, looking at the technology
, as I mentioned, all theimprovements that we have and
innovations, and when you lookat professional players, all the
studies that they have donewith these combines, when they
go to the draft and all thex-rays that they take, you know
you look at hockey players likegoldies for hockey, 90% of them
will have femoral acetabularimpingement.
And if you look at all thosesoccer players, basketball
(18:03):
players, football players,there's a high incidence in some
positions and high impact.
Things that require a lot ofcutting and twisting and a lot
of pressure in the growth placewhen you were growing up are
patients that are at risk ofhaving these deformities.
Robert A. Kayal, MD (18:16):
Is there a genetic component?
Is there a genetic component tothis condition?
What?
Victor Ortiz, MD (18:21):
do you think?
I don't think I haven't seenanything identified to a genetic
component, but there'sabsolutely a correlation between
families.
You know there's people thatthey have it and they have it on
both sides.
So there's absolutely somethingin the genetic part, but
nothing that I can tell that is.
Robert A. Kayal, MD (18:36):
I mean, certainly there is an arthritis,
so you would think you woulddeduce that there probably is or
will be ultimately discovereddown the road.
This is a relatively newdiagnosis in the field of
orthopedic surgery.
Right, you know, prior to thisdiagnosis of femoral acetabular
impingement, patients just endedup getting arthritis and we
(18:56):
told them that they hadarthritis.
But this may be indeed a verysignificant risk factor for
those patients and if we canidentify that early, you may be
able to save a lot of patientsfrom needing a hip replacement
down the road.
That's our hope.
That's the concept of thisfellowship training that Dr
Ortiz did for that added year inthe field of hip preservation
(19:18):
Trying to preserve patients ownhips as opposed to replacing
them with implants.
That's the goal of making thisdiagnosis at an early age, and
we'll talk about how we canintervene in effort to do that.
What about patients that haveligamentous laxity, for instance
?
So young girls that arehypermobile, ligamentous lax?
(19:39):
Are those patients at risk forany problems?
Victor Ortiz, MD (19:42):
Absolutely.
I think that.
Thank you for the question,because I think that's something
that I emphasize a lot,especially when I'm talking to
other orthopedic surgeons orcolleagues in the field.
I think that young female withhypermobility we have this baton
score where we're alwayschecking the patients do they
hyper extend the elbows, do theyhyper extend the fingers?
That patient is at risk ofhaving a torn labrum because
(20:03):
they have instability or jointlaxity.
So that's a patient thatwhenever if we decide to do a
surgical treatment, we have totreat the cause of the tear and
that's the instability.
So we have to make sure thatwhen we're doing that procedure
tension in the soft tissues wehave physical therapy making
sure that they work on tensionin the soft tissues because
you're protecting that repair.
I think that sometimes I haveheard that people said oh no,
(20:26):
this patient is a young femalewith just a small labral tear.
I think that's the mostchallenging case because you
have to fix the labrum but youhave to make sure you tension
everything around that If you goin there and you don't do that,
you're making the problem worse.
Robert A. Kayal, MD (20:38):
Yeah, I'm with you.
We deal with the same issues inthe area of knee replacement
surgery, when patients areligamentously lax, dealing with
those patients with hypermobilejoints that tend to go into
recurvotum or hyperextension oftheir knee.
That's a scary thing.
So I'm with you on that.
So now that we've made thatdiagnosis, how do we confirm it?
What type of imaging studiescan we do to confirm the
(21:00):
diagnosis?
Victor Ortiz, MD (21:01):
So there's multiple imaging in our office.
The first thing, and the thingthat gives me more information,
is x-rays, plain x-rays, whereyou can see all these.
First look at the space howmuch space this patient has.
Then look at this bonehemophilia, look at the socket,
look at the ball, look if theyhave any type of impingement
that we discussed and then youcan see how the acetabular
(21:25):
socket is looking.
It's looking to the back, it'slooking backwards.
So that gives you an idea ofwhat to expect when you get MRIs
or CT scans.
I think the MRI is probablygoing to confirm our suspicion
from our physical examinationand our plain x-rays and it's
probably the most this is themost specific testing to
identify how the labrum is.
(21:45):
I think that MRI also has a lotof utility in that patient to
make sure that we don't havemore advanced damage, more
advanced arthritis.
So sometimes these MRIs willshow patients that have a full
defect of a full hole in thecartilage or a demined bone.
Those are signs that there'smore advanced damage in the hip
joint and that patient might notbe a candidate for a hip
(22:08):
precipitation procedure.
I think that all the imaging isimportant for us to really
identify who's a good candidateif they have to have any
surgical procedure down the roadwith respect to imaging and
X-rays in general.
Robert A. Kayal, MD (22:23):
Are you just getting routine x-rays in
the office of the hip or thepelvis or are you getting
special views, and why is thatimportant?
Victor Ortiz, MD (22:31):
We have a very specific protocol and it has
special views.
You know, we get the plane, thenormal x-rays, we get a
standing Because we want to makesure that when the patient put
weight on it, how the hip isbehaving, we have other views.
That really allows us to see.
You know, x-rays only chargestwo dimensions, so we try to
bring different views, to getother dimensions of how the hip
is, to make sure that we have asocket that is covering enough
(22:55):
the ball or you have enoughcoverage at the ball so we can
measure that in different anglesto make sure that we're making
you know the right planning andright decision, yeah, or what
the patient needs are youtypically getting weight-bearing
images in the office or supineimages?
Robert A. Kayal, MD (23:07):
We get both .
We get a weight-bearing and asupine.
Great, and then how about onMRI?
What, what kinds of things areyou looking for on MRI?
Victor Ortiz, MD (23:15):
So in MRIs we we want to confirm, we want to
make sure that the patient has atorn labrum.
So we can see the labrum in theMRI in different views and you
can see either a line goingthrough it, you can see some
blunting, you can see some intrasubstance fluid, you can see
some cyst.
Sometimes, when you have a tear, the labrum, the fluid, the
fluid from the joint will startleaking to that here and so you
(23:36):
can see signs in the MRI thatconfirm that that's the problem
that's going on.
I also think the MRI for me ismore important in that patient
you know might be borderlinebetween having a Hebertroscopy
or a replacement, because youcan never.
You see subcontracted emailwhenever you see any cyst in the
MRI.
Those are findings that aretelling you they are.
(23:57):
There's more damage.
And when you go in there theremight be more damage.
And it's important for me tohave a good discussion with the
patient about Expectations,about what the outcomes are
gonna be if we decide to goahead when and when the MRI is
showing more Damage than what wesee in the x-rays and primarily
you, you're looking primarilyfor just disease Isolated to
that one area of the hip, right,that anterior superior area on
(24:21):
MRI.
Robert A. Kayal, MD (24:21):
So if you start to see changes that are
more diffusing nature, likeyou're describing the
subconjural cysts and Marodemaeverywhere, different things
like that, or label tearing,extensive label tearing outside
of where you get that femoralacetatecaryl impingement, maybe
you'd be thinking more along thelines no longer of hip
preservation but maybe hipreplacement, right, correct?
(24:42):
So yeah, the anterior superioraspect on the MRI, that's where
you're looking for your tear,that's where you're looking for
your impingement, that's whereyou're looking for that early
cartilage delamination, and Iemphasize early, because if it's
more advanced then maybe we'retalking about that.
The hip is no longersalvageable but rather needs to
(25:03):
be replaced.
And so what is the differencebetween the labral cartilage and
the hyaline articular cartilageand the changes we described?
The labral tear on the Labelside, but on the acid, but on
the Femoral head side, sometimeswe see cartilage delamination.
What's occurring there?
Victor Ortiz, MD (25:21):
So I think that there are different type of
collagen.
You know one.
You get the articular cartilageor hyaline cartilage, which is
a collagen type 2, which issulfur, and that's what you can
see, some, some frayingdelamination, and then you have
the Labrum, which is a harder,is more like a like rubber, and
(25:41):
instead that extension of thesocket, which is harder, you
know, tolerates a little bitmore pressure and controls
really that load bearing andcreates a strong suction seal,
the hip joint.
And they're different, you knowthey.
They is very important toreally be able to identify them
and in the MRI and treat in theright way, because that's, you
know, that's the success of theprocedure.
Robert A. Kayal, MD (26:01):
All right, so it's just like the knee.
I always go back to the kneeand the knee we're talking about
the meniscus, which would beanalogous to the labrum in the
shoulder and the hip, that type1 fiber cartilage.
And then we have the cartilagethat coats the end of the knee
joint, called hyaline articularcartilage, which is a type 2
collagen, that softer cushionthat Dr Ortiz was describing,
(26:22):
and so the key here is toidentify changes on the MRI that
are consistent with ourdiagnosis, but not advanced
changes.
We don't want advanced changes.
Once we start seeingdegenerative changes from a
chronic Condition, it may not bea hip that's amenable to
salvage anymore, but ratherreplacement.
(26:42):
So we the key is when you're,if you're suffering from any of
these conditions, you have toget in to see Dr Ortiz sooner
rather than later so he canemploy his skill set in the area
of hip preservation in effortto try to save your hip, as
opposed to Utilize his skill setin the area of robotic direct
anterior hip replacement toreplace your hip.
(27:04):
We're trying to save your hiphere, so that's what we're at
with respect to that.
So we talked about x-rays,special views, we talked about
MRI and the things we're lookingfor.
But also there's this 3dcross-sectional high resolution
imaging modality called a CTscan, and just like there are
protocols with x-rays, there'salso protocol specific for this
(27:28):
condition femoral acid tabularimpingement, where dr Ortiz is
ordering a cat scan for very,very specific reasons.
Can you elaborate on thatregard?
Victor Ortiz, MD (27:37):
Absolutely, I think.
I think cat scan is a veryimportant part of diagnosing and
what is the theology, what isthe reason why we're having
these stairs?
The amount of information thatwe get from the scan is amazing.
You know we can get exactly howmuch overgrowth you have in the
ball, how much overgrowth youhave in the socket In out.
(27:58):
On a clockwise we always liketo look at the hip in the socket
as a clockwise right 12 to 3o'clock is usually the area
where you see those stairs.
So we can correlate that to thecat scan and see is there's an
overgrowth in the ball, in thesocket, is this an overgrowth in
this ball that colorates withthat, and how much we have.
Also, I think it's veryimportant what dr Kale mentioned
initially about acid tabularretroversion.
(28:19):
We can get some landmarks fromthe cat scan and we can
calculate exactly where, what isthe version, where is the acid
tabulum looking at.
But also, more importantly,there's a component of rotation
also in the femur.
Sometimes there are patientsthat the femur will be looking a
lot to the front, so they willcall and the version or increase
femurotorchine that cantranslate to pay people that in
(28:39):
tow or out tow.
So those things we can measureand are important, because that
might be the reason why thepatient is having a tear in the
labor and you might not need totreat that and you might need to
just take care of those things.
Robert A. Kayal, MD (28:50):
Yeah, that was very helpful.
Thanks so much, dr Ortiz.
You know, just to reemphasize,the MRI is very, very good at
looking at the soft tissues.
So when we're looking for alabral tear and we want to
assess the articular cartilageor the fibro cartilage of the
labrum, mri is the tool ofchoice.
But when we're looking at the,the 3d reconstruction of the
bony anatomy, nothing is betterthan a cat scan.
(29:12):
A cat scan Literally reproducesthe 3d anatomy of the bony part
of this condition femurot,tabular impingement Whereas the
MRI very nicely looks at thesoft tissue component of this
condition the bone marrow, thelabrum, the articular cartilage
and the soft tissue surroundingthe hip joint as well.
(29:32):
So both are vital in making aproper diagnosis of this
condition, condition and alsoplanning treatment.
So now that we're talking abouttreatment, how do we first
intervene when you make thediagnosis?
Victor Ortiz, MD (29:46):
So every patient that we make the
diagnosis or we have thesuspicion we always want to
start with, they come with pain.
So we try to control the painand we like to use any
anti-inflammatory medication.
You know, we want to have thepatient modify the activities
they are doing.
As we mentioned, this issomething that happens with
extreme, some motions.
So we try to tell the patient,you know, stay away from things
that require a lot of fleshen, alot of internal rotation.
(30:08):
Then we like to do physicaltherapy.
I think supervised physicaltherapy is very important.
It's a standard of care of anytype of joint pain or back pain
or neck pain in the in theorthopedic world Is something
that we are big on and weemphasize that every patient
needs to be in physical therapy.
Working there's 17 musclesgoing to the hip joint.
(30:29):
There's a lot of them that wedon't use routinely and that's
where a good physical therapiststart working with you working
with the core, we can with thegluteus working, and a lot of
these patients come back and thepain is gone after six weeks of
physical therapy.
Robert A. Kayal, MD (30:39):
Yeah, so usually that's that's the first
line of treatment for us in ourpractice and it's been a very
successful yeah, because you didmention over and over again
that the labrum is a key playerin stability of the hip joint,
right?
So if we, if we've lost some ofthe static stabilizers, we
focus on those dynamicstabilizers, the muscles we can
control.
We call those dynamicstabilizers.
(30:59):
We can control the muscles andprovide stability around joints
by strengthening muscles andphysical therapy.
We can't control the staticstabilizers, the bone, the
cartilage, the labrum, etc.
With physical therapy.
Those are things that wouldhave to ultimately be addressed
Surgery, surgically, if we can'tget the stability or the
(31:20):
alleviation of pain or achieveour goals with physical therapy
alone.
So that's why it's important todistinguish between static
stabilizers and dynamicstabilizers.
Most joints, in fact I wouldsay all joints, have both static
and dynamic stabilizers.
So we first try non operativecare, physical therapy focusing
on the dynamic stabilizers, tonot only provide stability but
(31:44):
also try to restore motion.
This is a condition it's calledfemoroacetabular impingement.
There's a mechanicalimpingement Going on around this
hip joint that's restrictingpatients range of motion.
That's one of their complaintsThey've lost motion, they have
pain from the impingement or thetears, and we get them into
(32:04):
physical therapy, try to restoremotion but also to Achieve that
stability that we talked aboutby strengthening the muscles as
well, and so that's one of thereasons we start with
conservative, non operative carephysical therapy.
We can also give a man timeinflammatory, right.
Sometimes they have painassociated with it, so sometimes
we'll give a man timeinflammatory as well.
(32:24):
Sometimes you may not be ahundred percent sure that the
pain is coming from the FAI orthe labor tear.
Is there a diagnostic procedurethat you can do to help give
you some feedback Whether or notwe're treating the right
condition?
Because we don't like to treatx-rays, we don't like to treat
MRIs, we like to treat thepatient and make sure we make
them better.
(32:45):
So what is a tool that we canemploy to try to get some
feedback?
Victor Ortiz, MD (32:49):
So I think that the that that's where
diagnostic hip injection is theway to go.
I think that is probably one ofthe most powerful tools that we
have in that knows, in the hipas a source of the pain.
I think all first for thepatient, for acting patients
sometimes come to us and theysay no, I think the back is the
problem.
I think the I said you knowthis other thing, and I we tell
(33:09):
them this let me give you thehip joint injection, let's see
what you get, and they come backand they're surprised, like the
pain is completely gone.
I think it's very powerful alsofor us as a provider because it
can differentiate Is this is abackflip area problem?
Is this a hip related problem?
Is this an overlap where wemaybe the hip is 60% and 40%?
So it allows us to quantifywhat's going on to be able to,
(33:31):
you know, first, improve the.
I think that those injectionsare really allowed them to have
less pain and be able to go tophysical therapy and work better
.
I think that I haveincorporated that to my practice
because when they come in painand they go back to the physical
therapy, sometimes they comeback in three or four days.
I don't tolerate the exercises.
But you get in the injection,they are able to do those
exercises, they come backstronger and they come in a
(33:52):
better way.
But I think that the power, howpowerful it is, in diagnosing
the hip as a source of the painis probably the best test that
we have.
Robert A. Kayal, MD (34:02):
That's great.
I couldn't agree with you more,dr Ortiz.
But this brings us back to whatwe talked about earlier, and
that is the anatomical locationof the hip joint.
So it's not a superficial joint.
The hip joint is not on theside of your hip, it's a deep
joint, it's in the center ofyour body, between the front of
(34:22):
your hip and the back of yourhip, and it's in the groin,
which is not a superficial joint.
And it's important to know that, because you can't easily
undergo a hip injection in theoffice without tools that will
help you see that deep joint,and those tools can either be
the usage of an ultrasound orthe usage of a fluoroscopic
(34:46):
X-ray machine that we have inthe office that helps you see
that deep joint.
There are certain joints in thebody that are very easy to
inject, for instance theshoulder, the knee joint, for
instance, but the hip joint isone that requires the assistance
of imaging in order to get thatmedicine into the joint, and
(35:09):
one way we do that is with theusage of that ultrasound or
what's called C-arm fluoroscopyassistance, and sometimes even
with that you're not 100% sureyou're in the joint.
So what we do is what's calledan arthrogram.
An arthrogram is when we takethis contrast material and we
first put the contrast materialinto the joint and perform that
(35:31):
arthrogram, then we'll see underC-arm fluoroscopy or ultrasound
that the joint is distendedbecause, like Dr Ortiz mentioned
earlier, it's like a balloon.
The joint is a balloon and sowe're filling up that joint with
this contrast material andwe'll see that contrast material
contained within that joint.
Once we know we're in the joint, we'll also look to see if
(35:55):
there's an extension of thatcontrast material between the
labrum and the bone, and that isthat line he was describing on
MRI.
Sometimes you'll see that linefill in the space between the
labrum and the bone, furtherconfirming our suspicion for an
acetabular labral tear.
But then, once he's in the jointand we've confirmed that on
(36:17):
ultrasound or C-arm fluoroscopyand, by the way, we have
procedure rooms at the K Lordorthopedic center where we do
this in these procedure roomsand once we confirm we're in the
joint, then he'll add thecorticosteroid or the local
anesthetic and more often thannot patients will get off that
table completely relieved oftheir symptoms right then, and
(36:40):
there Immediate relief of theirsymptoms they feel markedly
different, they're able to getoff the table, they're able to
walk up and down, rotate theirhip and for the most part their
pain is gone.
And that gives the doctorfeedback that we're not only
treating a study but we'retreating the patient for the
presumed diagnosis and we'reaccurate in our diagnosis and
(37:02):
our impression of what's goingon.
So now you've done that and yougot that feedback, you'll get
the patient for physical therapylike we talked about and you'll
see the patient back If thepatient's better.
You're done right.
For the most part you don't justtreat the patient because
there's a labral tear or femoralacetabular impinge, but if
there's enough of a pincerlesion or if there's enough of a
(37:24):
cam lesion, you're probablygoing to keep a close eye on
that patient because you don'twant that to ultimately number
one, result in significant lossof motion to that patient.
Right, because that pincer canget bigger, that cam could get
bigger and they can lose motionand we need to preserve motion
to put on our socks and shoesand get in and out of cars, all
those things.
But also that mechanicalimpingement can cause the
(37:49):
changes not only to the labrumbut to that highland articular
carlos, that delamination whichultimately leads to arthritis.
So now that you've made thediagnosis and you're looking at
the patient's MRI, cat scan andX-ray.
What are the changes on X-raythat would suggest to you that
maybe, if this patient failsphysical therapy, you can
(38:09):
undergo a definitive surgicalhip preservation procedure,
versus X-ray changes that mayultimately say look, if you fail
conservative management, you'regoing to need a hip replacement
?
What are those changes you'relooking for?
Victor Ortiz, MD (38:23):
So there are a couple of criteria that we take
in consideration when examiningX-rays that really allow us to
know if the patient would be agood candidate to undergo a hip
preservation procedure.
But the first one is how muchspace the patient has left.
There's been multiple studiesthat have shown that if you have
less than 2mm of joint space,that's a patient that would
(38:43):
Wouldn't do well with a hipprecipitation procedure will not
do well.
Robert A. Kayal, MD (38:46):
Right, well , needs a hip replacement.
Victor Ortiz, MD (38:48):
It would be a reason so that's the first thing
that you can see, this aclassification of Colettonic
classification, where patientszero and one are the good
candidates, and the way youclassify.
That is when you look at thespace, you look at this.
This bone spurs as clear roses,all those findings.
So just from the extrastandpoint you get that
classification.
You have to make sure that youhave enough space and you don't
(39:08):
have Changes that are consistentwith more advanced arthritis,
right.
Robert A. Kayal, MD (39:13):
So what he's talking about is that ball
and socket join that first x-ray.
You're looking at the ball inthe socket and that space that
we see on x-ray is not really aspace.
It's filled with cartilagenormally.
Well, you want it to be filledwith cartilage and if that x-ray
is showing that there's lessthan two millimeters of space
Between that ball and socket,you can't save that patient's
hip anymore.
(39:33):
Ultimately, if that patientfails not operative care, that
patient's getting a hipreplacement.
But if that patient that you'resuspicious of has a labral tear
, has an x-ray that looks likethis and they're still healthy
cartilage in or surrounding thatball of the bone socket joint,
that patient if that patientfails not operative care, is
getting a hip arthroscopy by drOrtiz to save that patient's hip
(39:55):
.
That's that hip preservation.
So that patient's gonna getwell, let's talk about it.
It let's talk about thatpatient.
That patient now went tophysical therapy for how long?
How long would you treat themNonoperatively?
You give them a couplecortisone injections.
They've they got significantrelief.
You put them in for physicaltherapy.
Maybe ever, once in a while,they're taking some Tylenol or
(40:16):
an anti-inflammatory, but theycome back to you.
When are you gonna see themback when you're gonna make a
decision to pull the trigger, totake the next step.
Victor Ortiz, MD (40:24):
I should like to wait like around six weeks.
You know we can go anywherefrom six to twelve, but I think
six weeks for me is enough timefor the patient to, you know,
try all the conservativemanagement, all the, all the
non-surgical or noninterventional procedures,
including the injections,including the medication,
including a supervised physicaltherapy.
If they have done that, thenlike for good six weeks and the
symptoms are worse or notgetting better, I think that's a
(40:45):
patient that would be a goodsurgical candidate.
Robert A. Kayal, MD (40:48):
Yeah, and you know you're also listening
to them if they're complainingof constant instability,
constant pain, constant loss ofmotion, buckling giving way,
they can't navigate stairs.
You know every patient'sdifferent so you know this is
not like a textbook Cookiecutter type of approach.
We evaluate each patient,listen to their symptoms and see
(41:08):
, see how it's affecting theirquality of life.
These labral tears, we knowwill never heal by themselves
right.
This problem is not going to goaway by itself.
You can manage the symptomsWith physical therapy and things
like that, but it's never goingto heal.
So what is your approach to thepatient that doesn't want any
surgical intervention?
Are there any biologicaltherapies or generative medicine
(41:31):
techniques that you can employto To maybe inject into that
joint that will give somebiology that potentially can
alleviate the patient's symptomsand Plus or minus promote some
biological healing?
Victor Ortiz, MD (41:44):
Absolutely, and we have a good amount of
patients that they don't haveand you know they are maybe
Later in age and they say, likeyou know what, I don't want to
have a natuoscopic procedure, Idon't want to go to the process.
And we always have discussionswith about platelet-rich plasma
or bone marrow aspiratedinjections.
I think they have a great role.
They they are good To decreasethe inflammation.
(42:04):
I think that it's, uh, theevidence-based medicine out
there.
You know it's not going to bestrong enough to say that it's
going to heal the tear, but Ithink it brings all these cells,
all these components thatdecrease inflammation and it
will help with pain.
And so far we, I think in myhands I have had a great success
of Of outcomes with thosepatients.
You know, one of the thingsthat I did in my training of
(42:26):
herperecivation was within thecase series, although in those
patients a little bit differentthere was.
Those were patients that Werenot a surgical candidate because
of that x-ray less than twomillimeters, or an MRI that
showed Moral arthritis, and butthey were not completely
bone-on-bone, it was not like abone-on-bone patient.
So we injected them with prp,we filed them for a year and all
those patients have improvementin their patient reported
(42:48):
outcomes.
Um so I think is something thatis a an absolutely a great
option for those patients thatdon't want to go undergo a
procedure.
Robert A. Kayal, MD (42:55):
Yeah, I mean certainly the prp, or the
platelet-rich plasma, has someAnti-inflammatory properties
associated with it.
It's something we offerroutinely to our patients and
perform routinely at the Kailaorthopedic center.
A little bit of a disclaimer itis not FDA approved.
It is considered by mostinsurance companies to be
experimental, but a lot ofpatients believe in it and
(43:16):
certainly that's where Medicineis heading and orthopedics in
general is heading in the era ofregenerative medicine,
repairing as opposed toreplacing.
We do offer those technologiesand anecdotally we both can tell
you that it's helped a ton ofpatients in our practice for
sure.
And so if, if patients areadamantly opposed to fixing the
(43:37):
problem and they're willing totry Maybe some future
experimental orthobiologicaltherapies for regenerative
medical Therapies andinterventions, we would be happy
to oblige and offer you thoseservices because we offer them
routinely at the Kailaorthopedic center.
So now You've indicated thepatient for hip arthroscopy,
(43:58):
let's talk about your approachto hip arthroscopy and what your
goals are and how you achievethose goals.
Victor Ortiz, MD (44:05):
It is also once we identify the, the label,
there is what is causing thesymptoms in the patients, and we
would run all these imagingstudies, physical examination,
conservative management we haveto be able to identify what are
the sources of the pain, what iscausing the problem, and I
think that we have to.
A lot of the times Maybe 90, 99percent of the times we have a
(44:26):
torn labrum, but I always askmyself why did the patient had a
torn labrum?
Was this because they have animpeachment?
Was this because they arehaving hypermobility, as we
discussed earlier?
So we have to come with theplan and to offer the patient
how can we fix this, but alsohow can we avoid this from
happening in the future.
And I think that's the mostimportant thing in the
decision-making process, in myconversation with the patients
(44:50):
about what are we going to bedoing, how are we?
We attacking this?
Um, the goal, and I think thatwhen we're offering this
procedure to the patient, thegoal and only goal for surgery
should be to improve pain andFunctionality and that that's
the main thing.
You don't have pain, you don'tneed surgery, but if there's
pain, we want to make the better, there's a highly high chance
if you fail, everything we havedone that we can make you better
(45:11):
.
And there's always a secondarygoal that if we are preserved,
we are fixing these problems,that we can preserve this, if
that we can win time and giveyou More time down the road
before the need of a replacementor the idea to try to avoid it
in the future.
Um, so I think that that oncewe have that, then we decide and
we made the decision, theinformed decision of going ahead
with the procedure.
(45:31):
Uh, this is a minimallyinvasive procedure that we do it
through same as a shoulder andneed a simple scope.
We go in there, we confirm theproblem with the camera, we put
the camera in there, we can takepictures, we can see the label
and we can see the cartridges,we can see everything in the in
the joint, uh, and then we goahead and we fix it.
And usually the first thingthat I always like to do is go
(45:51):
To that acetabular rim and weexpose that rim where we're
going to be reattaching thatlabrum.
We trim whatever Impingement wehave in that area, guided with
all the pre-op planning that wedid because we got a CAT scan,
we got all this imaging that istelling me, letting me know Dr,
this.
This is where we're going to go.
This is what, how much bonewe're going to remove.
Once we remove the bone, thenwe can put multiple anchors and
(46:13):
as many anchors as we need.
We can go as as as low as two,we can go all the way to six,
seven anchors, whatever isneeded to really restore that
labrum, to be able to createthat functional, that suction
seal or that increased surfacearea, to restore the mechanics
of the hip.
And after we we fix the joint,we clean everything that needs
(46:34):
to be clean.
Then we pull the traction off.
You know, we when we go to thejoint, we have to open it up,
pulling on the leg.
So once we close that, we canreally see how we restore that
seal mechanism.
And we can now go to the balland look at that area that is
causing pinchment, trim all thebone down, increase that offset,
increase that distance beforethe patient has any type of
(46:54):
Impingement.
And we do that guided by x-ray.
We do x-ray guidance to theprocedure To make sure that we
get to that angle that we needto get, and also guided by the
pre-op planning that we did fromthe, from the CT scan um, and
once we fix everything, then wewe go ahead, and something that
I emphasize a lot is that we,when we get to the joint, we
(47:15):
have to open the back.
It really the back open.
That's going to create problemsand the we have to close that
back and that's called a capsule.
So once we're done with theprocedure, we have to close the
capsule.
I think that's something thathas to be done routinely, um,
and sometimes in patients wehave to not only close it but do
something called a capsuleapplication when you put the
sutures in a differentorientation to tension that more
(47:37):
to protect that repair, becausewe want to really Tighten the
hip joint to protect the repairthat we did.
Robert A. Kayal, MD (47:45):
Wow, so you've achieved a lot of goals
Arthroscopically.
You've not only reattached thelabrum which was the source of
pain, um, you took down the bonespur on the acetabular side,
the cup side.
You took down the bone spur orthe cannulise on the femur or
the femoral side and by doing so, eliminating that source of
impingement, your goal is torestore range of motion to that
(48:07):
patient as well.
And so now you've repaired thelabrum, you've restored that
watertight closure, that seal.
The synovial fluid is nownourishing the joint, providing
its mechanical properties oflubrication and shock absorption
and nutrition To the articularcartilage.
Uh, so you've achieved a lot ofgoals, doing this through a
very minimally invasive,arthroscopic, arthroscopic
(48:31):
approach, typically through twoor three puncture, typically
three puncture, yes, threelittle punctures around the hip
joint.
This is very cutting-edgetechnology.
I I must emphasize to you thethe lion's share of orthopedic
surgeons In this in the world,not just this country, have
never, ever done a hiparthroscopy.
Uh, this is a procedure thatshould only be performed by very
(48:56):
, very highly trained andexperienced orthopedic surgeons
like Dr Ortiz.
Most orthopedic surgeons wouldnever dare to attempt a hip
arthroscopy.
It's very different than ashoulder arthroscopy and a knee
arthroscopy.
That most orthopedic surgeonsthat do sports medicine do so.
You definitely definitely need ahighly experienced, trained and
(49:21):
seasoned orthopedic surgeon,like Dr Ortiz, who does probably
anywhere from five to 10 a week.
He's a very, very highlyexperienced orthopedic surgeon
in the area of hip arthroscopy,and so I do need to emphasize
that, because most orthopedicsurgeons that are dabbling in
(49:45):
the field of hip arthroscopy maybe, in fact, just doing that
dabbling, and you certainlydon't want to be a guinea pig.
So you want to make sure thatyou go to a seasoned,
experienced orthopedic surgeonthat has done a high volume of
these Okay, so I do want toemphasize that and, specifically
, has done a hip preservationfellowship as well, because it
(50:09):
is not as easy as most otherjoints that we routinely scope.
So I do want to emphasize that,just to protect you.
So we've done the surgeryoutpatient surgery, patients
going home the same day.
It's important that theyprotect your repair, right?
What's your post op protocol?
Victor Ortiz, MD (50:28):
So every patient the first two weeks is
only put the foot on the floor.
So that means they're going towear crutches.
So only the foot on the floor.
We don't want to put anypressure in the area to not to
damage the repair.
The only thing that we useroutinely is a hip brace.
The brace will allow you to gofrom zero to 90 degrees so
you're going to be able to sitin the chair comfortable.
But we don't want to open theleg, we don't want to create any
(50:50):
rotation in the leg for thefirst two weeks.
But you start physical therapyright away.
You know next day we have avery specific protocol for every
patient Next day duringphysical therapy, then at two
weeks, we get rid of the brace,we get rid of the crutches, then
you go back to full weightbearing and then we progress you
for multiple phases with theidea in four to five months for
you to be able to go back to doeverything that you want.
Robert A. Kayal, MD (51:12):
That's great.
And what have you found in yourexperience incidents of
bilaterality?
Do you find that a lot of thesepatients will have a tear on
the other side too, or develop atear on the other side as well?
Victor Ortiz, MD (51:21):
It's very common.
I always tell the patients thatthe other hip gets jealous and
it's very common and not alwayswe have to treat them.
But I have done patients that Ihave done one week apart.
I do one side and we go to theweek we do the other side and
it's very common.
Robert A. Kayal, MD (51:39):
Yeah, wow, this has been very helpful,
especially a subject like thisthat not a lot of people know
about, right, femoralacetateblur impingement.
You know, I think it'simportant to get the word out
about this condition, even tonon-orthopedic surgeons.
First of all, a lot oforthopedic surgeons aren't
familiar with this condition andmaybe they're not 100% sure
(52:01):
what the source of thatpatient's hip pain is.
What is femoral acetateblurimpingement?
Again, as I mentioned, it's arelatively new disease condition
that we've identified.
But it's very important also toget the word out to
chiropractors and medicaldoctors, primary care physicians
, when patients are complainingof that classic groin pain and
(52:25):
stability buckling, mechanicalproperties, pain with deep
flexion and squatting, and thex-ray is normal think about
femoral acetateblur impingement,think about labral tears the
pain, where we described it tobe, is coming from the hip joint
and there's not too many thingsthat can cause that pain in the
hip joint.
(52:46):
So when there's no arthritis,you know you have to be thinking
about this condition femoralacetateblur impingement and if
you're not routinely looking athip x-rays and specifically the
very specific views that weorder to assess for this
condition, you may be missingthe diagnosis and we're not
doing any justice to ourpatients.
(53:06):
So it behooves us to thinkabout this condition and send
them to an expert like Dr Ortizto get this condition assessed,
so our patients can be treatedand maybe you might even be
saving them from a hipreplacement down the road.
So it's very important to beaware of this condition.
So I hope that you found thispodcast to be beneficial and
(53:26):
helpful, and Dr Ortiz is readilyaccepting new patient visits
and follow appointments as well,second opinions, injury cases
and workman's compensation casesas well, so feel free to reach
out, okay.
So thanks so much for your time, dr Ortiz.
Thank you for having me.
It was a pleasure having youhere again.
Welcome back, thank you, have agreat day.
Bye-bye everyone.
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