The Failed Hip Arthroscopic Patient: Principles of Revision- How - - PowerPoint PPT Presentation

The Failed Hip Arthroscopic Patient: Principles of Revision-

How to Succeed: 5 Tips in 10 minutes

• J. W
• W. T

Thom homas as B Byr yrd, MD MD

Advan anced Pr Pract ctit itio ioner Su Summ mmit it – The he H Hip p

Orthop thopaed edic Summit t 2017 17 - Evol

• lving

ng Techn hniq iques es Las Vegas as, Nevad ada Decem ember er 8th

th, 2017

017

Through the Eye of the Beholder

Ey Eye of the

• f the B

Behol holder

• Vi

View the the case se thr through

• ugh the

the eye ye of

• f the

the pr previ vious sur

• us surge

geon

• n

– Wh What w was t s the di diagnosi sis a s and ho how w was i s it deriv erived ed? – Was i imagi ging g g good

• d/current

nt? – Wa Was t s the sur surgery don y done qui quickly? y? – Wa Was pa s patient i in n a hu hurry y for

• r sur

surgery? y? – Was th the p e pat atien ient c complia liant? – Wh What w was t s the st structure of

• f t

the po post st-op p rehab? b?

Perfect Storm

• Most hi
• st hip d

diso sorders a are m e mul ultif tifacto torial l ( ( “Perf

erfect ct s storm rm” ) – Ma May ne y neve ver i ide denti ntify y all factor tors – FA FAI l I logi

• gically

y expl xplains 2 ns 2º joi

• int

nt da dama mage

• But ho

how & & why hy are some e athle letes lifelo elong com

• mpe

pensa sators?

Perf rfect Storm t Storm

• FA

FAI

– Rega gardl dless ss of

• f sudde

suddenn nness ss of

• f symptom

symptom

• nse
• nset,

t, it i t is s cul ulmi mina nati tion

• n of
• f cumul

umulati tive ve effect of t of di disor sorde der pr prese sent nt si sinc nce chi hildhood dhood – Isol Isolate ted intr ntraarti ticul ular pr probl

• blem

m unc uncommon

• mmon
• Compensa

nsating ng long ng before F FAI b I becomes sym sympt ptomatic

• Com
• mpensatory pr

y problems m s may y be be f first st pr presenting sym sympt ptoms

Perf rfect Storm t Storm

• Gl

Gluts uts over

• ver-fir

irin ing & & painf nful ul

Perf rfect Storm t Storm

• Coexis
• existent

nt D Disea ease

– Hi Hip p & & Lumba Lumbar di dise sease

Perf rfect Storm t Storm

• Coexis
• existent

nt D Disea ease

– Athl thleti tic P Puba ubalgi gia (“sp

“sports he s hernia”)

Perf rfect Storm t Storm

• Coexis
• existent

nt D Disea ease

– Pelvi vic f floor

• or di

disor sorde ders? s?

Perf rfect Storm t Storm

Arthroscopy, 2014;30(1):42-46.

Ultrasound-Guided Hip Injections: A Comparative Study with Fluoroscopy-Guided Injections

• J. W. Thomas Byrd, MD, Elizabeth A. Potts, MSN, APN,

ACNP-BC, Rachel K. Allison, RT, Kay S. Jones, MSN, RN

• Most
• st use

useful l diag agnos

• stic

ic adju junct to ct to H&P

• Most hi
• st hip j

joi

• int p

t prob

• blems not

not isola solated ed ( (coe

• exi

xiste stent/ nt/comp

• mpens

nsator tory y di disor sorde ders)

• Muc

uch b bett tter er tol toler erated ed b by y patie ient nts tha than f n fluo uoro g gui uided ed i inje nject ctio ions ns

• Real

eal ti time a e ass ssessmen ent

• Use

seful f l for

• r c

clin linic icia ian & & patie ient nt(!)

U/ U/S G S Gui uide ded Inj njection

• n

• Tru

True fo for h r hip & ip & extra-arti articul ular ar diso sorders a as s well ell

U/ U/S G S Gui uide ded Inj njection

• n

• Fa

Faile iled p prev eviou

• us a

arth throscop

• pic

c proced cedure w with r h recu ecurren ent or t or residual p al pain? ain?

– La Laye yers sta s stack up up

Perf rfect Storm t Storm

Raining Cats and Dogs

• Pa

Pain in w with th h/o h/o of

• f prev

evio ious us l labral l debri bride deme ment

– Doe

• esn’t

sn’t uni unifor

• rml

mly y me mean tha n that t se seque quela of

• f labr

bral r rese secti tion i

• n is

s cause use pa pain

Raining ng Cats ts & D & Dogs

• gs

• Reas

easons ns f for

• r Fa

Failu ilure: R Revisio ion n surge gery ry

– Capsul psulol

• labr

bral a adhe dhesions

• ns

– Inc Incomp

• mplete c

cor

• rrecti

tion of

• n of FA

FAI

Raining ng Cats ts & D & Dogs

• gs

• Reas

easons ns f for

• r Fa

Failu ilure: R Revisio ion n surge gery ry

– If If c caps psul ulol

• labr

bral a adhe dhesions a

• ns are

uni unifor

• rml

mly y pr present i nt in n revi visi sion

• n

arthr thros

• scop
• py:

y: How How ma many ny pe peopl

• ple

not not requi quiring ng revi visi sion

• n likely

y ha have ve sa same me f findi ndings? ngs? – If If close

• sely

y sc scruti utini nize zed, how how ma many ny pe peopl

• ple doi

doing w ng well mi might ght ha have ve findi ndings ngs of

• f inc

ncompl

• mplete

te c cor

• rrection
• n
• f
• f i

impi mpinge ngeme ment? nt?

Raining ng Cats ts & D & Dogs

• gs

• Reas

easons ns f for

• r Fa

Failu ilure: R Revisio ion n surge gery ry

– Failu ilure re of f la labra ral l re repair, air, in a n abse bsenc nce of

• f inc

ncompl

• mplete

te bony bony cor

• rrection,
• n, rarely

y a cause use for

• r repe

peat t arthr thros

• scop
• py
• Exc

Excel elle lent h healin ealing c cap apacit ity of labrum

• Rehab

ab precau cautions t to p protect tect r repai air r proba

• babl

bly t too c

• conse
• nserva

vative ve

• Just

t don’t want nt to fin ind point nt wher ere e repai air failur ilures escal calat ate

Raining ng Cats ts & D & Dogs

• gs

• Reas

easons ns f for

• r Fa

Failu ilure: R Revisio ion n surge gery ry

– Tr Try not to y not to me mess ss with th iliopsoa

• psoas

s te tendon ndon

• Sp

Specif ecific ic rea easons to to consider er fracti ctional al lengt ngthening ng

• Si

Simp mply ly failu ilure re to to recog

• gni

nize o

• bviou
• us F

FAI c AI cause se o

• f

pain in/patholo logy i insuffic fficien ient r rea eason

Raining ng Cats ts & D & Dogs

• gs

• Reas

easons ns f for

• r Fa

Failu ilure: R Revisio ion n surge gery ry

– Tr Try not to y not to me mess ss with th iliopsoa

• psoas

s te tendon ndon

• In absen

ence of clea lear r reason

• ning,

g, peop

• ple don’t
• n’t

like e hav avin ing th their eir iliopsoas as v violated ated

• Can

an make f make for r a diffic ficult lt ti time g get ettin ing

• ve
• ver sur

surgery

• Don’t
• n’t need

d mor

• re s

surge gery, j , just n need d more a e atten ttenti tion g getti tting o

• ver i

r index ex proced cedure re

Raining ng Cats ts & D & Dogs

• gs

Preaching to the Choir

• Aver

verage op e oper eration ion w will ll b be

• ka

kay wit with go good P d PT T

• Best op
• per

erat atio ion d n doom

• omed

ed to to fail il with th i inad nadeq equate or e or poor

• or PT

PT

• 80/1

/10/1 0/10 R 0 Rule

Pr Preachi hing ng to the to the C Cho hoir

• 80% of
• f posto
• stop p

prob

• ble

lems addre dresse ssed t d through gh a adjust stme ments s in in R Rehab

– Too muc Too much, h, too l too littl ttle, , too too wrong

• ng
• Postop

Postop g gui uidelin ines es/proto toco cols ls just ust guideli eline nes

– Ti Titr trate ted to to indi ndivi vidua dual hi hip p tol toleranc nces

• Le

Less ss “ “coo

• okbook
• k” tha

than othe

• ther

joi

• ints

ts

Pr Preachi hing ng to the to the C Cho hoir

• Pa

Patien ients ts ha havin ing prob

• ble

lems see P PT T fir first

– Adj djustme ustments nts/st strate tegy a y already y

• utl
• utline

ned w d whe hen I se n I see the them

Pr Preachi hing ng to the to the C Cho hoir

• Most
• st patien

ients ts will ill develo lop a glit itch ch at som t some p e poi

• int

nt

– Mor

• re you

you tr try y to to convi

• nvinc

nce the them m tha that thi t things ngs are ok

• kay;

y; mor more convi

• nvinc

nced the d they y are tha that t some somethi thing’ ng’s w s wrong

• ng

– Re Reoper erat atio ion ra rate e lo low; w; likelihood hood it’s t’s ok

• kay hi

y high gh

Pr Preachi hing ng to the to the C Cho hoir

• No one
• one com
• mes

es to se to see e sur surgeon

• n d

desir iring ng PT PT

– The Therapists sw sts swimmi mming ng upstr upstream – Not Not enough to nough to be be a abl ble to to de deciph pher pr probl

• blem(

m(s) – Ha Have ve to to ge get t pa pati tient nt to to buy buy-in in

Pr Preachi hing ng to the to the C Cho hoir

• Compe

pensa satory ry probl blems ms can ob

• bscu

scure c cont

• ntrib

ibution ion of

• f

und under erlyin ing j joi

• int p

t path tholog logy

– Tim ime-consumi nsuming i ng in n of

• ffice to

to atte ttemp mpt t to decip ipher a er all ll diffe ifferen ent fe t featu tures es – The Therapists a sts ade dept a t at t isol solati ting ng va various

• us

contr

• ntributi

buting ng compone

• mponents

nts

• Ahe

head d of cur urve ve com

• mpa

pared d to

• rth

thopaed aedic s c surgeo eons

Pr Preachi hing ng to the to the C Cho hoir

• PT c

T can asse sess ss & & addre dress ss the these C e Com

• mpens

nsato tory p prob

• blems

– Ma May y rega gain n abi bility ty to to compe

• mpens

nsate – Bette tter posi positi tione

• ned f

d for

• r ge

getti tting ove ng over sur surge gery: Prehab

hab!

Pr Preachi hing ng to the to the C Cho hoir

• PT c

T can asse sess ss & & addre dress ss the these C e Com

• mpens

nsato tory p prob

• blems

– At t ve very y least ga st gain n se sense nse of

• f awarene

ness s for

• r clini

nician n & & pa pati tient nt tha that the t these se c can n be be ongoi

• ngoing

ng cha halleng nges i s in n recov

• vering

ng fro from s surg rgery ery

• Best to a
• add

ddress ss on f

• n front e

end, bu but som sometimes l s limits

Pr Preachi hing ng to the to the C Cho hoir

• PT c

T can asse sess ss & & addre dress ss the these C e Com

• mpens

nsato tory p prob

• blems

– Resi sidua dual compe

• mpens

nsator tory pr y probl

• blems not

ms not a contr

• ntraindi

ndicati tion to

• n to sur

surge gery; but but just ust ne need to d to be be inc ncor

• rpor

porated i d into nto ove

• verall

tre reat atmen ent s stra rateg egy

Pr Preachi hing ng to the to the C Cho hoir

What’s Going to be Different?

• What a

hat are you e you goi

• ing to

to do

• differ

erent ntly ly the the se seco cond nd ti time a e arou

• und

nd to to ha have e chan hance ce of

• f mor
• re succe

e successful l

• utc
• utcome?

e?

Different? t?

• If you

you cann annot

• t, w

with c h conf

• nfiden

ence, e, defin ine or e or env nvis ision

• n a

a poten

• tential

ially ly cor

• rrectab

able le i iss ssue, e, d do

• not

not do

• sur

surgery j just ust b beca caus use ne next sur xt surgeon n would

• uld

– “D “Don’t ma

• n’t make ne

next xt sur surge geon’

• n’s mi

mista stake fo for h r him im”

Different? t?

• Timing

ing i is e s ever veryth thin ing

– Sur urge gery i is s as muc s much h a que questi stion of

• n of

whe hen as s whe hethe ther to ope to operate te – Addr ddress ss non non-surg rgical ical aspects ects firs first whe hen possi n possibl ble – Ga Gain n se sense nse of

• f pa

pati tient nt’s c s commi

• mmitme

tment nt to to recove very

• “When

en you you find nd your yoursel elf in n a deep ep hol hole, e, the the first t thi thing ng to to do

• is stop

s stop d digging ng.”

Different? t?

Closing

• Advan

ancin ing DJD most

• st

com

• mmon
• n c

cause f e for

• r f

failu ailure

– Mor More l likely y conse

• nseque

uenc nces of s of poor poor pa pati tient nt se selecti tion r

• n rathe

ther tha than e n error

• rs

in te n techni hnique que

Clo Closin sing

• 83% succe

successful l outc

• utcom
• mes

with r h revis ision

• n a

arthr throscop copy

– Decisi sion

• n of
• fte

ten ba n base sed mor d more on

• n

insti nstinc nct – Subj ubjective ve pa paramete ters ma may be y be weighte ghted d mor more he heavi vily y tha than n obj

• bjecti

tive ve f findi ndings ngs

Clo Closin sing