Hip Arthroscopy Presentation

Transcript Below:

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Dr. Urse: Lattice Collins’s chart and I did hip scope honor with knee arthroscopy equipment for set of eyes and a little flap of labor, which I don’t even remember how I did the surgery, except it was an old Bratcher table. So in the late 90s.

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Dr. Urse: And I the atrocity Association North America start offering hip arthroscopy labs and I started going to those where we had better equipment and longer instrumentation that allowed us to see in the hip and get a long enough.

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Dr. Urse: Set of calculus to to actually see where we were going and what we were doing.

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Dr. Urse: And then in the the 2000 year

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Dr. Urse: The hip impingement concept started with Dr ganz because they were doing these hip us to me. So I’m going to talk a little bit about that.

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Dr. Urse: And then it was a matter of hip impingement. Everybody’s got hip impingement. But we found out there are a lot of other things in the hip. So our goal.

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Dr. Urse: Is if we’re going to get into a hip is to get in without leaving a bunch of marks that said you were there. So if you look at the history of hip arthroscopy even goes back further to the early 30s.

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Dr. Urse: Some of the first published literature, but really it was the 80s, a guy named Jim Glick came up with some of these switching sticks that gradually enlarge the opening for you to get into a joint

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Dr. Urse: And then some of the calculus and scope options that were then adapted from knees and other joints were then started on hips. The problem is you can see they weren’t very long.

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Dr. Urse: So when we figured out, we had better equipment we decided, can we figure out where the problem is is coming from the hip joint is that are particular or is it from some other location and

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Dr. Urse: When we talk to people, we want to ask them what bothers you, can you reach your socks and shoes, is it we’re sitting or standing, you know, the usual things we ask people,

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Dr. Urse: Will help us, but to a degree, may not even tell you that we’re going to talk about this hip impingement or cam, which is

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Dr. Urse: A type of bump on the hip and it’s really a conflict between the hip moving and the socket accepting the hip movement. It’s a dance between this head, neck junction

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Dr. Urse: Between the femoral head and it’s recipient so tantalum. So this buzzword. We’re going to go with his condo label dilemma nation that is the new

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Dr. Urse: Name for that as a tabular Cartlidge to get sheared off. We have a bump, and we’re going to talk about why these bumps develop these

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Dr. Urse: Quote unquote cam lesions. And if you guys are anything in the car business, which I’m not a cam is in the engine to help push a piston. I think I don’t even know what it does. So

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Dr. Urse: Obviously these are abnormal shapes to the Federal head that may be developmental some of these they’ve shown and even soccer players as they go through years of soccer. They actually developed some

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Dr. Urse: morphologic changes in their head, neck junction, much like a Bunyan would be on a foot and I tell people, you know, is this a stress reaction. Is it a shoe problem is it

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Dr. Urse: Just something abnormal if you if you look in cavemen femurs, and these bones. They pulled out of these are anthropology journals. You see cam lesions on the on the femoral had some of these are out of round shaped

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Dr. Urse: femoral heads and they always tell my patients to square peg in a round socket, it’s going to lead to abnormal where we’ve all seen the car mechanics shoving that square another round socket.

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Dr. Urse: So what we want to do is say, look, does someone have a good look and hip. How do we tell. Well, we get a good x ray to start with.

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Dr. Urse: An X ray that’s centered. You’ll see both femoral had you’ll see the operator for him and below, and you’ll, you’ll be able to get a good view of why somebody has hip pain. We don’t want the you know the end of the COC six at the end of the sacred to not be above the

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Dr. Urse: The pubic synthesis. Otherwise, it throws off the wall geometry is show throws off your

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Dr. Urse: Hip and what’s called the ass to have a retro version, or how the hip is looking so if you don’t have accurate data. Look at your operator frame in or off, then everything else gets killed it rotated and you start making

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Dr. Urse: judgments on what you’re seeing because you started with a bad x ray. So I always get a good AP weight bearing, I get a

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Dr. Urse: What’s called a false profile and I get a done lateral or a frog leg that some doesn’t have the troll can are in the way so you can see the

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Dr. Urse: A cam lesion on the arrow is visible because the troll canner is in the way on a true frog lateral to actually hide the neck.

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Dr. Urse: So when we look at that we start looking at abnormal shapes that we see in different views we always look at the socket and see if it’s well formed or does somebody have

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Dr. Urse: A dis plastic hip or a shallow center edge angles so that anterior center edge angle should be over 25 degrees and if it isn’t, they have a shallow socket and they end up with a

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Dr. Urse: Under coverage, so to speak, which

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Dr. Urse: You know, a little Cindy didn’t get put in an abduction brace when she was young, her hip didn’t deepen and she’s got a shallow socket. Those are

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Dr. Urse: A whole nother set of talk. So we’re not going to talk a lot about hip dysplasia, but you definitely start

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Dr. Urse: Measuring that’s first thing I look at my AP is I look at this angle. And if I go back a little.

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Dr. Urse: To the true AP I just take a line down the middle of the femoral head goes straight up and then align off to the edge of the acid tablets that answers internet jangle should be between 25 and 40

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Dr. Urse: If it’s not, you’ve got a disc plastic hip and he got other problems that you may not want to deal with with arthroscopy

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Dr. Urse: Shallow socket has a narrow less than 20. Some people call 20 to 25 a borderline hip dysplasia. But either way, there’s a lot of lines we draw on these hips and

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Dr. Urse: The way I get my predictable done view is, I have this little phone thing they put the leg in and the x ray person usually gets a pretty good x ray each time.

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Dr. Urse: And then when Dr. Joe and I do our hip scopes, we can actually see that that impingement has been fixed with this with the lower picture and we can try to reproduce reproduce some of these views in the O. R. With our flow.

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Dr. Urse: This dizzying slide is some of the things we measure. We’re trying to see as the hips is the hip got a deep socket called a Coxon funder does it head protrude through the Elio issue line which is

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Dr. Urse: You know, another one, these vertical lines. Is there is there signs of a prominent it’s your spine sign those little arrows in the middle with the

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Dr. Urse: white lines and then how is the you know the center edge angle is the s have them flat is there overhang. Is there a pincer impingement because the impingement can come from the socket or from the femoral head, or both. Most commonly

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Dr. Urse: And then this is what we call an alpha angle we’re measuring on a good lateral and usually the MRI, give you a great views on the axial views we just draw a circle around the head like you would with a protractor

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Dr. Urse: And you measure where the circle meets the neck and on the bottom left, you can see 37 degrees means you got a pretty Roundhead that spherical

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Dr. Urse: But if you look where the circle deviates from the neck on the one on the one on the right, 79 degrees. There’s a big bump there. And clearly, and that’s a cam lesion so

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Dr. Urse: The numbers are usually over 50 would be abnormal, but a lot of this will also depend on your pelvic

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Dr. Urse: Inclination and tilt, just like a impingement of a chromium on the shoulders, depending on how the scapula is rolled forward or not. So if we can improve people’s posture and bring that

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Dr. Urse: femoral head back or bring the S tattling back with better

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Dr. Urse: Therapy exercises which will kind of go over later that’s going to help us with an impingement.

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Dr. Urse: There’s also what’s called an anterior offset I show some of these things because that’s it kind of dizzying calculation. I don’t like to do, is I’m an ortho pod and I went in to orthopedics because I wouldn’t need to do math.

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Dr. Urse: But what happens with a bump. So this pump on the left when they have duck their leg to do their hockey save

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Dr. Urse: Then there bang in that ass tab, along with this bump and you get this condo label dilemma nation. And that’s cartilage. That’s just getting sheared off.

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Dr. Urse: On the socket and that’s not we want to see. We do a hip scope, because once you see that dilemma nation.

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Dr. Urse: If you can find it on an MR. You know, you want to be sure you’re not working on hips, that are badly arthritic and this is the trend of hip arthroscopy in the last 15 years, you can see we’re doing a whole lot more of these.

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Dr. Urse: And why do we do them well there are labeled tears. There are Loose Bodies hip impingement called femoral has to have an impingement.

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Dr. Urse: Cartilage problem. Loose Bodies snowmobile problems, things that go snap and pop. We’ll talk a little bit about that infections.

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Dr. Urse: So here’s a Charlie near, who is the father of modern day shoulder surgery and you know you write this article and clinic Orthopedics and 72 and he goes, everybody’s got had been shoulder impingement.

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Dr. Urse: That’s what the problem is it see a Chrome, Ian. And then we realized away there’s AC joint there’s biceps. There’s labeled terrorists was people shoulder popping out

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Dr. Urse: You know, maybe the chromium is not responsible for his shoulder instability. So then we found other things in the shoulder. So if you fast forward to 1999 here’s Dr guns going hey you know if you’ve got a shallow hip. I’m going to crack your pelvis and do a

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Dr. Urse: Pelvic Ostia autumn, you called a PA O. And what they do is they crack the pelvis and they really shape it to form a roof over the hip.

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Dr. Urse: And then they found if they overcorrected people they got this hip impingement and about a deflection. They couldn’t bend their hips. They go, well, it causes hip impingement.

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Dr. Urse: Well, then they found people with the same symptoms and same impingement problems with didn’t have us the automation. They said, well, maybe hip impingement can be from an abnormal shape.

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Dr. Urse: So everybody needs a femoral pasty. Well, that’s what we did. And in the in the labs in 2000 at the arthroscopy Association meetings.

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Dr. Urse: And we went in and started shaving bone. And we did a lousy job. Trust me, we can open them and look at it and we were really crappy

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Dr. Urse: And I think that took a while to figure out why they open the hip in Europe and reshape it because they did a better job than we did initially

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Dr. Urse: We also found their things like label tears hip instability snapping tendons.

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Dr. Urse: Trunk terek pain patterns with rotator cuff problems. So the hip was just like the shoulder, except it’s a weight bearing joints.

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Dr. Urse: And what we wanted to find is, you know, we’re these things all complications of this osteoporotic problem.

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Dr. Urse: Or is impingement just means something’s rubbing against something which is what it is. You have three types of impingement. We see in orthopedics

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Dr. Urse: We see shoulder sub a chromium Benjamin, we just talked about hip impingement. The third type, you’ll see is anterior to tailor impingement. When you have a bone spur on your ankle and you can’t dorsal flex and

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Dr. Urse: Anything that rubs against anything is going to be impingement so

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Dr. Urse: You see these hatch Mark areas on the femoral head. This is a cam lesion. And what happens is, you know, we get these abnormal shaped femoral heads and they

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Dr. Urse: They, they get these athletes who just are beating the crap out of the established and they’re just playing they hurt the rest

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Dr. Urse: They go back and play more and they’re beat the crap out of their hit their beat their labor mop and they’re beaten, there has to have your cartilage up

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Dr. Urse: So unless we can reshape their head. That’s why we’re getting all these hip replacements and people in their 40s, because they’ve got

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Dr. Urse: Abnormal X rays. They’ve got advanced arthritis and all sudden you’ve got Coach K on Duke and Mike Ditka all getting hip replacements in their 40s, because they have crappy hips and they probably had some misshapen

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Dr. Urse: You know, hip anatomy. So what is our, our, our, our focus is find what’s wrong. So if you look at my cup.

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Dr. Urse: This is what your patients are doing. They’re looking at their Google and they’re saying, Gee, what’s wrong with me. I looked on Google and I think I’ve this well. Maybe you do. Maybe you don’t

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Dr. Urse: Let’s find out what’s wrong, and let’s find out if it’s in the hip at all. And how do we do that. Well, we do a history.

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Dr. Urse: You try to think in your mind is this coming from the inside of the hip medial is it anterior lateral as opposed to your

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Dr. Urse: Maybe you say is it related to menstrual cycles, is it when you squat stupid sitting. Some people can’t sit and I’m going to show you pictures of a hamstring tear

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Dr. Urse: These people’s been sitting off the edge of the chair because they feel like they got a lot of tape under there, but where their hamstrings torn

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Dr. Urse: Also, you can also think of it as a circles, you can think is this problem in the bone. Is it like a bathroom necrosis of the bone.

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Dr. Urse: And Mr. I might show that. Is that a Cartlidge problem is it in the fluid of the joint. Is it a loose body, is it a snowmobile problems and OBO control mitosis is it in the

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Dr. Urse: The area around the hip. Is that an overhang from the socket. Is it the hip. Is it, is it the biggest muscle have a

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Dr. Urse: Lymphoma in it. So is there some tumor that I’m missing in the pelvis, or is this from a large and large uterus. I mean, so when I do MRIs. I’m doing it to look at all that other stuff.

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Dr. Urse: Is this the SI joint is is a nerve issue from a higher lumbar spine problem, our problems have to be sorted out by our history.

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Dr. Urse: We watch them walk. We do a gate exam I watch my patients walk. I try to see how they’re moving, are they using assistive devices.

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Dr. Urse: And I’m looking at how they rotate their hips, there’s certain amount of rotation when you walk that occur in the hip. Some of them have this happens in the pelvis.

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Dr. Urse: And if you look how people stand dumb people have torsion of the tibia is girls right tibia has turned in.

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Dr. Urse: It affects their foot. Some people have a sense of retro version and version will determine how much the hip will rotate and we can check out the hip rotates in both collection and extension, Josh.

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Dr. Urse: Hi john. This is a homework here. So let’s hold this this watch, and then. So we have the NEO pain when we come up and she has SI joint goes right there at 85 degrees can set that down.

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Dr. Urse: Now we will even before then we recreate the pain and growing right it’s in the growing, but we also have the pain and yes I do.

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Dr. Urse: Yes. So when we looked at several versions as isn’t this two degrees. And when we turn it out. Let me just happy when we come out. Now we can come all the way up and we don’t have that.

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Dr. Urse: On your side.

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Dr. Urse: So her so far, this angle is still 90 but an extra rotation shows on Pinterest. Let’s remember we’re all and then I’ll show you one more thing to write you up.

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Dr. Urse: assesses the hip inflection and

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Dr. Urse: So here we are an extension for the spine. There’s where her spine is already starting to move here and if i x currently rotator to put her version normal, then we can come all the way back. And that, in contrast to the other side.

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Dr. Urse: And then when we have this we can come

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Dr. Urse: Back with

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Dr. Urse: No pelvis motion. So that’s positive. If that was collection that pulse extension for the left side you to decrease from origin, probably the same reason she has a stress fracture. We’re going to talk some more about it. Oh my goodness. OK.

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Dr. Urse: So again, this, this stuff is really

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Dr. Urse: Complicated. When you look again how Martin is like a genius. When you look at version. He’s got the biomechanics lab. He analyzes hip flexors and extension and whether they can

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Dr. Urse: With a neat rotation or not. So if you’ve got a retro vertigo femoral head which you have to measure from the CT scans of the hip and knee.

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Dr. Urse: Then what happens is that that hip is wearing abnormally and you’re getting a relative impingement in the hip. Some of these people require us to dummies. But again, excess femoral version can lead to problems with

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Dr. Urse: hip impingement. And you can assess those with with your exam. And again, I talked a little bit about before we started.

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Dr. Urse: How’s actually got this biomechanics lab where they put pressure transducers in the displaces and they’ve actually moved the hip back and forth.

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Dr. Urse: And they’ve shown how this linkage between just like a bicycle chain link will lead to pain in the hip and back.

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Dr. Urse: All coming from mostly hip impingement. So a lot of these people have back surgeries, they have

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Dr. Urse: fusions and they have you know a bunch of instrumentation in their back and their problem is still probably coming from their hips so

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Dr. Urse: You’re going to see some of this from pelvic obliquity we talked about whether or not you’re just like your shoulder blades when they’re back, you get less shoulder impingement.

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Dr. Urse: You can see this pelvic incidence when the pelvis is rolled forward that leads to more

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Dr. Urse: Risk for impingement. It also has some things to do with peak loads that you see across the lumbar for sets. And you can see that as you are getting those little red bars there higher with impingement. And they’re there for that linkage and pressure that’s

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Dr. Urse: Transmitted is worse this case they’re looking at if i which is called issue femoral impingement which is a kind of a cause of post your hip pain and we’ll talk a little bit about it, but I’m just showing me how actually complicated

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Dr. Urse: All this is and how hard it is for us to really figure out what’s going on in there. Okay, so we we kind of start our physical exam and I’m showing you some of the things how Martin does and I actually invited. Dr. Martin on this call, but I think he’s in clinic this morning but

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Dr. Urse: You can see that what you’re trying to do with an exam is find out where people hurt.

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Dr. Urse: You’re trying to put on your detective hat and not miss anything that might be a problem. So we’re going to put the full range of motion. We’re going to listen for clicking, we’re going to ask the patient they hear or feel a click.

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Dr. Urse: 5% of people will have a hip that makes a popping or clicking noise. The first thing I asked them, Is does your other hip. Do the same thing. And if they say yes.

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Dr. Urse: It might just be loose jointed and that’s normal. And I tell people just show people at parties how your hip makes noise and move on. Okay, you hit makes noise. I don’t care.

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Dr. Urse: If it does make noise, then you’re trying to decide is this what’s called internal or external snapping or impingement. And that can be from the SOS or your IT band over your troll canner

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Dr. Urse: I’m going to show you a bunch of these tests and to your post your label test taking the hip from flex and extension, looking at the disparity. We’re trying to push on the pubic synthesis and clearly there are athletic

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Dr. Urse: Injuries called sports hernia as they’re all put in a garbage bag that have to do with usually adductor tears. They can be from hip flexors. They can be from hernias.

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Dr. Urse: You pal paint. I tell people look I’m going to pop in the front of your hip. It’s a little

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Dr. Urse: Of a sensitive area to some people. So you tell my have to paint this region, I put gloves on. I’m feeling their abductors go into their pubic area.

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Dr. Urse: You have to make sure you tell them what you’re doing when you go into that area, but that’s how you find some of the medial quadrant problems. So we talked about medial

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Dr. Urse: anterior posterior lateral, those are those are the ways you examine those and I check them supine, then I put them on their side. I checked for pressure

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Dr. Urse: This this maneuver makes everything hurt. I think it doesn’t help you. It’s called a lateral compression tests we checked for reflection look at their tightness with external rotation, we all

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Dr. Urse: Have some hip, hip flexor tightness. You guys see it in therapy people spend their lives in cars and sitting at desks and our hip flexors are just part of the problem. We know that

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Dr. Urse: A person that feels that anterior pain and they get a snapping sensation used to call it.

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Dr. Urse: Into our particular snapping, but the alias OS 10 and as you know is extra particular so the term. Now that’s more properties internal snapping, we can see that on an ultrasound or MRI and it can be tested diagnostically I know Brad, you do a lot of injections on the other side. Yes, yes.

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Bradley Jelen: Yes, quite a few.

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Dr. Urse: And I think this is the reason this tenant is coming across the front of the hip across the pubic to vehicle. It makes a noise at about 30 reflection as it said it’s a symptomatic and

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Dr. Urse: 5% of people. We’re going to see a lot more of these with our anterior hip patients. I don’t know if you have Brad. If you’re seeing an awful lot of those

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Dr. Urse: Some, some pictures of that later. But we want to know if that’s their source of pain. We can selectively inject that obviously it’s gonna be different than the self. I never open these things. I think it’s much easier to do to a scope. I’m sure you’d agree.

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Bradley Jelen: So,

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Dr. Urse: Here’s your typical hamstring patient or someone with sitting syndrome.

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Dr. Urse: Them Deep Blue do pain they set off the edge of the chair. Sometimes they’ve been waterskiing and the engine stops, then it starts up and they get that pole in the back.

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Dr. Urse: But these things, these people go from doctor to doctor to doctor. They go from orthopedic surgeon orthopedic surgeon. A lot of these are Partial tears in the hamstring, you should be able to see a bone marrow edema on the MRI and

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Dr. Urse: Fixing the hamstring is going to make these people pretty happy if they need it. Some of these do have Sciatic Nerve involvement.

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Dr. Urse: Our last hip lab and at Anna was on deep glue to pain. We’re scoping nerve areas and I was waiting for how Martin since he was there to show us how to do it. That is where the sun doesn’t shine a brad

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Dr. Urse: Absolutely. But you know, I always told these guys, the beginning of this that I used to sweat bullets and 32 I learned my anatomy.

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Dr. Urse: So here’s an MRI this an actual view it showing you the issue them and they’re showing some hamstring edema there. And again, if they’ve got a hamstring injury that is symptomatic, you can fix those that’s a whole nother

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Dr. Urse: You know topic we’re not going to go into all of that. So, and I can tell you, sorting out the poster hip problems is dizzying at best. Some of these are from the back. Some of these are from SI joint somewhere in the pelvic

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Dr. Urse: Or extra pelvic areas. Some of these are worse reflection some words with extension.

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Dr. Urse: And again, I think what we know about this, we’re just scratching the surface. And I think these biomechanical labs are going to

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Dr. Urse: Really help us understand more where people’s pain is from

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Dr. Urse: The old term pure form of center has been replaced with deep blue do pain syndrome. Now that encompasses sciatic nerve entrapment 20% of people said it nervous right through the pure form is muscle.

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Dr. Urse: There are issues femoral impingement problems. I’m going to show you that Mr. And some of those things that that can help us diagnose that

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Dr. Urse: And then also some of the hamstring issues and other things in the back.

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Dr. Urse: Again, if you’re if you’re putting anything that makes the lesser troll can or get closer to the issue is going to make them more symptomatic. So he’s a extension and a deduction with instrumentation is going to move that and cause more symptoms post early

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Dr. Urse: You can pop eight the area. There are great exercises therapy can help people with this that hopefully avoid surgery in most cases.

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Dr. Urse: You can do a selective injection if they have this deep post your pain and this issue femoral problem is really an entrapment in that quadrant as feminists region between the lesser token, the issue.

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Dr. Urse: It’s a newer newer problem. And if we’re missing a lot of them. That’s because we probably don’t know what it is. I’ll have my

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Dr. Urse: Neuromuscular radiologists actually do an injection in that issue a femoral space, the space should be over a centimeter. But anything that narrows the distance between the issue.

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Dr. Urse: And the lesser trope is causing this deep issue femoral impingement problem. So another thing we look at, we do or anterior hip or total hips, is we look at our offset in our

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Dr. Urse: Offset on our femoral stems can be varied based on the type of implant. We place and that helps us recreate what’s normal

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Dr. Urse: By the way, this girl on the left has a pretty display nasty Kip, see how shallow that looks

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Dr. Urse: Very narrow center edge angle to draw a line straight up the middle of the femoral head there isn’t much roof on this person. So I kind of shy away from these people

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Dr. Urse: You can go in and take away some of the prominence from the lesser trope. Again, these si patterns of pain or dizzying at best.

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Dr. Urse: The SI joint can make the backer the lateral fly all the way down to the outside of the ankle.

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Dr. Urse: So again, when we’re testing we’re testing, you know, medial anterior lateral and then we’re testing abductor strength.

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Dr. Urse: We’re looking for snapping tendons. These are what patients. They are dislocated. They say watch my hip dislocate and it’s really the noise you hear the outpatient have a visible snapping

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Dr. Urse: It’s the IT band over the TRO canner and we’ve got a couple of my office girls here who have this issue and they’ll just

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Dr. Urse: Watch their hip move and snap in front of my students, I’ll show it to them, and none of them have paying me to show people at parties. You give a shot. Sometimes we actually released the IT band on these people

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Dr. Urse: You do a few of these right brand every year.

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Bradley Jelen: Yeah, probably doesn’t maybe it doesn’t.

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Dr. Urse: Yeah, I don’t know if I get quite that many, but it does solve the problem.

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Dr. Urse: Then enter particular problems are really is this in the joint or not. And we’re doing a reflection, a deduction and rotation tests.

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Dr. Urse: So look at all these tests and this is the quality of the tests and on the right you can see the overall scores poor moderate good crappy. And the bottom line is,

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Dr. Urse: The studies stink. Okay, you know, they don’t really solve the problem. It’s like the shoulders, a million of them.

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Dr. Urse: And why are they terrible because none of them really are accurate for everything. The evidence for their accuracy is lousy. But, you know, if you wanna get your name and an article

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Dr. Urse: Published one of these, you get some level five evidence which is which is lame.

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Dr. Urse: So I think what I do is I say, look, if you’re going to take a picture of one of my slides today. Take a picture of this slide.

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Dr. Urse: Because this is why we’re confused if you said look on the bottom there it says pain location with some of the classic femoral establish impingement. And I say, where are they going to cause

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Dr. Urse: Their symptoms to come to you in the office and say, where’s the problem. Well, I’m going to tell you that lateral hip pain.

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Dr. Urse: That you say is hip or situs 67% of the time it’s from inside the joint, okay. It’s not the bursa you want give me a shot in the bursa. Go ahead. I usually put a shot the joint.

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Dr. Urse: Though classically be growing pain 80% plus have growing pain, but look how many people have answered by paying 35% the pain only lateral fi post your thyroid buttock low back. Hit pain is all over the place. And why is that, well the reason

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Dr. Urse: Is that you’re focusing on the hip and it could be something else. So any good lecture as an old article review or a guy with a white beard. It looks like the cough drop Smith brothers guy so Hilton’s law basically says every

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Dr. Urse: Muscle the cross the nurse and the century branch to that joint. So if you think of all the muscles across the hip. The

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Dr. Urse: Pain patterns are all over the place. And this is just an example. So this is what I do 10 to 15 times a day in the office I inject their hip.

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Dr. Urse: Nobody’s put a shot in their hip everybody’s head shots in their side in there, but their pain management guys done this and that. I said, Anybody put a shot in your hip.

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Dr. Urse: And you can see the needle going right and the joint. This is stupid simple I do a bunch of these. And when their pain goes away with an office injection

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Dr. Urse: These people are your happiest people there they’re dancing to Jagan 10 psi go if you’re paying goes way in 20 seconds. Would you be happy and these people are just they can’t believe someone’s found their pain there but pains gone or whatever. So we’re aiming for this, this

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Dr. Urse: Left Arrow here the open arrow. There’s a big soft spot there at the neck, the capsule comes all the way down to the entertainment area, area.

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Dr. Urse: We’re not aiming for that yellow spot and the joint. You don’t need to be in the joint just need to be in the

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Dr. Urse: inside the capsule. So hip injections, really simple. THE ONLY WAY YOU’RE NOT GOING TO GET IN THERE AS IF YOU MISSED THE NECK medial or lateral or if you don’t use a long enough needle so look at your large Marge, get a larger need or longer needle, if you need it.

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Dr. Urse: In conclusion, your history and physical is trying to make sense out of chaos. How do you do that.

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Dr. Urse: You just say the door squeaking. It’s one of those three hinges, is that the hip. The SI joint or the back. I want to start spraying WD 40 on one of them.

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Dr. Urse: And I’m a hip guy. So I’m doing the hip. And if it’s not in the hip. Then I’m getting over to the back, guys. And then I don’t have to worry about you anymore, but my job to be sure it’s not your hip, Brad. You do quite a few hip injections every day.

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Bradley Jelen: I guess. Yeah.

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Bradley Jelen: Probably similar to you.

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Dr. Urse: You know, there’s an old saying from Vincent Bugliosi who prosecuted Charles Manson. He said, I never asked a question, I don’t already know the answer to.

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Dr. Urse: It is what the journey to hear the answers sequence. If I know you do a bunch of these. If you see on this page. These patients, you’re doing this because this is what non operative treatment is

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Dr. Urse: Everybody I send a therapy airway. I give shots. And then there are other types of shots besides steroids or cortisone.

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Dr. Urse: You can do prp we’ll talk a little bit about regenerative cells and bone marrow concentrations and some of the ortho biologics, I use those. I’m sure Brad you’re doing some of those also

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Dr. Urse: But let’s get into what we’ve came to do which is OK. We finally found out, it’s in their hip. We’ve looked at their X rays. It’s not too bad. It’s not beat up.

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Dr. Urse: We think it’s in the hip. They got a classic see sign la rooms torn. I got a sampling hip. You know, I’ve got, I’ve got this MRI that says, I think there’s a label tear may or may not have had been done with contrast. You gotta remember 40% of your hip.

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Dr. Urse: Mr eyes are going to be a false negative. They’re not going to show the problem. The test is going to be read as normal and then you give them a shot in the hip and their pain goes away. You know what

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Dr. Urse: That’s an over 95% chance. There’s something wrong there. So an article or injection is diagnostic

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Dr. Urse: Conversely, some of the dye tests they gadolinium enhance or die enhance them ours have a 20% false positive rate. So your MRI is

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Dr. Urse: Is helpful but not helpful in a way, it isn’t your only answer. I use it to look at all the things around the hip. As much as I do. What’s in the hip. As we get better.

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Dr. Urse: Magnets and some of the higher Tesla magnets, we’re going to be able to see cartilage better and I think it’s going to help us avoid some of these

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Dr. Urse: contraindications, which is going to be advanced arthritis and things that aren’t going to get better with the scope. There’s other things you would never scope, you’re not going to

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Dr. Urse: Scope somebody with a covert virus, you’re not going to scope someone with soft tissue swelling and redness, you’re not going to open wounds. The only thing that’s not on this is probably a recent

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Dr. Urse: fractured his location of the hip rest to have them, you’d probably wait at least three months to go after a loose body and make sure the fractures of field so

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Dr. Urse: All right, now we’ve looked at our X rays. This is called the source seals. So here’s your French word of the day source seal is French for what word

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Bradley Jelen: Eyebrow

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Dr. Urse: So the eyebrow. Is this area and there’s there’s three areas we look at, we look lateral we look medial and we look at the phobia and those areas have to have a space of at least a couple millimeters

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Dr. Urse: That means they don’t have a lot of arthritis. That tells us. Okay, we’re going to go into the hip. I’m going to either fix the labor or I’m going to shave it

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Dr. Urse: And, you know, obviously, we’re going to go through that if they don’t have a lot of arthritis. They’re going to have a pretty good tenure result with just fixing the label problem and addressing any bony impingement.

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Dr. Urse: And you can see the age group that we do the surgeries on now is getting older.

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Dr. Urse: Unfortunately, the insurance companies are are actually lowering the age they allow you to do the cases. So now, some of them are not even let you scope, a hip overreach 50 which is just ridiculous because

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Dr. Urse: People are living longer. There’s a study out of Israel doing hip impingement surgery on people in their 70s. Everybody in the studies in their 70s.

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Dr. Urse: And they had great outcomes that they didn’t have arthritis and we’re going to talk a little bit about that. But here’s what I try to show the insurance companies things

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Dr. Urse: That show pain improvement and the number of cases get better. If you don’t have arthritis. So here’s the two caveats. If you’re not read green colorblind, the success is based on joint space being greater than two millimeters and not having See I had cartilage defects.

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Dr. Urse: And this is really where patient satisfaction and avoidance of conversion to a total hip come into play.

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Dr. Urse: So these three things and really a fourth thing on whether the person’s age, I think, is relative at the top.

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Dr. Urse: You want to know is this hip got a lot of wear and tear. Is there a bony problem. Am I going to be able to address it from the hip socket or the femoral head and

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Dr. Urse: Or is it from the lesser stroke on a deep blue to pain problem and am I gonna be able to fix the labor and we’re shave it

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Dr. Urse: Because if I do the right thing. I’m going to see a significant improvement in Harris hip score, which is a pain and function score.

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Dr. Urse: And if I show this, the insurance companies and I say, look, these are these are

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Dr. Urse: older patients over 50 match with younger patients 30 and on and younger and they both benefit both the red and the blue show improvement. So let me fix people’s problems.

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Dr. Urse: That that are bad, just like you’d scope and need with a meniscus problem at age 60 just because they’re 60 doesn’t mean they can’t have a nice scope, you just don’t want to scope, a crappy need

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Dr. Urse: So again, when we’re doing our assessment. We’re looking for what’s called as tablet retro version we’re looking for changes in

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Dr. Urse: The thickness of that source seal and whether it’s as tablet, where if you get into and see a hint that looks like this.

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Dr. Urse: These are not good hips. OK, now we’re doing micro fractures and we talk later about our rehab. These are the people I protect their weight bearing

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Dr. Urse: The good news is micro fractures in the hip. I think do really well compared to the knee, and I do a fair number of these I protect them. I tell them, it might be 16 weeks for to heal. They actually feel better sooner. In my experience, you do some of this Brad.

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Bradley Jelen: Yes, and I would, I would agree.

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Bradley Jelen: Some of these look terrible. You do a microfracture especially the male patient with a big cam lesion. They do quite well.

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Yeah.

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Dr. Urse: So again, when we look at our entries. We’re using a ton of grading system.

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Dr. Urse: The take home point is grade two or three Thomas means there’s too much arthritis. So if you’re smart in your dictation. You always say there’s Thomas one or less.

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Dr. Urse: Otherwise, if it’s two or more, they don’t let your scope the hip.

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Dr. Urse: And you got to be honest with your patient. You got to know that some of these people in their late 30s, maybe have a little more arthritis than you’d like

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Dr. Urse: But the answer is a total hip otherwise. So if I get a patient with some narrowing. But they’ve got a big cam lesion understand this is a

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Dr. Urse: Time buying procedure. We’re going to scope your hip.

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Dr. Urse: I don’t like to do people that have narrowing on any of the views this person on this false profile on the far right as a pretty narrow joint space probably going to get a crappy outcome with a hip scope, unless they know that it’s, it’s just a

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Dr. Urse: Maybe a stepping stone to a total someday.

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Dr. Urse: We’re trying to preserve hips just like we wouldn’t need or any other joint. We’re trying to relieve pain, improve function.

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Dr. Urse: Delay joint replacement. So how do you sort through all the crap out there. Well, the answer is try to find the ideal patient for surgery. It’s just like any joint

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Dr. Urse: Like talked about less than great, great to

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Dr. Urse: Thomas changes, less than joint space dickering they’ve got a mechanical problem, like a label here they have hip impingement they’ve gotten better with a shot.

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Dr. Urse: you’ve ruled out other problems and then how are they going to do well, they’re going to do pretty well. And if you look at Diego Maradona study

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Dr. Urse: On Cartlidge he’s going to tell you to put PRP and there after that because they’re going to get less pain better function and more range of motion earlier with that.

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Dr. Urse: And take less anti inflammatories and less medications for pain. So this is really adding the ortho biologics, and we’ll talk a little bit about you know how that helps people

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Dr. Urse: We want to make sure we’re not picking crappy hips just like we don’t go crappy knees don’t forget. You always can do a total joint, you can always send these people somewhere children. It’s a great surgery.

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Dr. Urse: I always tell them, look, this is our job to get you to a JD with your body parts. We can always replace it. And you’re going to see

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Dr. Urse: A successful hip scope is someone who doesn’t need a total hip within two years of their hip surgery.

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Dr. Urse: I think if they get more than a couple years. It’s kind of like scoping crappy knees if you have a boat payment, you’re going to scope crappy nice Telmo your, your needs. Really bad you to total me it’s like why do I get a scope.

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Dr. Urse: If it was such a crappy knee. Same thing with hips don’t scope crappy hips, you want to convert them to totals very soon.

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Dr. Urse: So what do we want to do now, are we going to fix these labor. And while we think it makes sense to do that in Europe than they open the hip and reshaped it

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Dr. Urse: If they repaired the labor those people did better than people that had their labor them shaved. So we know that want to do is is work on things that preserve the labor them and they balance the

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Dr. Urse: initial symptoms with too much were over time and arthroscopy can only do so much you get the 35 year old kid who’s had a cam lesion in a torn labrum for 10 years

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Dr. Urse: You’re going to have a lot more Connor labeled elimination on the right and that person on the left. So in general.

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Dr. Urse: Let’s talk a little bit about how we do hip scopes and I’m going to run through this pretty quickly. It’s a big surgery, you need a lot of things.

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Dr. Urse: You can use a fracture table. I use a hand a table, more commonly unless I’m in my surgery center and they don’t have a Hannah table that I’m using this one.

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Dr. Urse: There are a few people that do lateral arthroscopy, I just show this picture to show you a lateral setup, but the majority of us do a supine, and you can see where the pressure is the pressures on the upper lateral thigh.

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Dr. Urse: I’m sorry, the upper media side to get lateral displacement, not against the issue. We’re not trying to push against the lady or the screw them.

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Dr. Urse: I call it a Michael Jackson sign if I get a glove between the post and the growing I tell them I’m not going to smash there you know what’s when I’m doing the case. And then I’m not going to get through dental nerve problem or a purple screw them.

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Dr. Urse: Again traction is the key to surgery it let you open the joint and get views that you need a little bit of reflection also relaxes the capsule. So if you look at this

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Dr. Urse: You’re getting slight abduction and a little bit of reflection. Some people use a little trend Schellenberg also

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Dr. Urse: We pad the feet we pad this it’s a lateral arm to get it out of the way and

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Dr. Urse: If you don’t get enough traction, you’re not going to get the joint. You’re going to scratch everything getting in there. You’re gonna ruin your instruments and your patients hip.

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Dr. Urse: So, first thing we do is we pull longitudinally. This is Brian white. Great guy out in Denver. I’ll see if his video comes through on the next one. But the sequence is longitudinal traction at direction and interpretation and you have your CRM there so

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Dr. Urse: Tracking traction

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Dr. Urse: Get a little crank there, Brian.

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Dr. Urse: There you go.

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Dr. Urse: Brian’s a mark philippon fellow he does only these big label reconstructions good ad duct.

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Dr. Urse: I’ve stolen a lot of people’s PowerPoint. So I give them credit when I can. But remember, if you steal one guy’s ideas. It’s plagiarism still 10 guys ideas. It’s research so

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Dr. Urse: That’s traction and that lets you get the hip. So when we get ready to start, holy cow is a lot of crap in a row, you got CRM. You got a couple X rays. You got your, your camera for your arthroscopy

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Dr. Urse: And you got all your instruments down here. So now how do we miss gators and things that go bang in the night. Well, those things that are yellow, red and blue are bad and things that are away from them are good. So we always mark the si es with a circle.

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Dr. Urse: You can almost take a Domino’s Pizza pie area of safe areas to work and we mark the troll canner on the on the side, you’re working portals are your answer. Angela lateral and your answer portal.

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Dr. Urse: And then there’s a lot of accessory portals. Again, a lot of safe zones for this. A lot of other accessories zones. We’re going to go into a few of these.

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Dr. Urse: The main thing is we’re going to miss yellow things that are nerves. The most common nerves get injured is going to be a branch of the lateral femoral cutaneous nerve it arises laterally and gets closer as we get more anterior

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Dr. Urse: The working portals, the answer a lateral and the anterior portal a modified answer portal is the one I use more commonly, and then there’s some distal portals for anchor insertion will talk to you about

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Dr. Urse: You shouldn’t be anywhere near the site at nervous. You’re overly internally rotate the hip to use that poster lateral portal. That’s the bottom red dot

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Dr. Urse: And our hip scopes are basically going in and you know we really shouldn’t be near any of these nerves.

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Dr. Urse: There are a couple things that you will get post-operatively. So when you see patients with complaints of numbness after surgery. It’s usually one of three areas and I’ll say actually for

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Dr. Urse: The lateral five and lateral femoral cutaneous nerve if you if you pushed on their growing, they can have some

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Dr. Urse: Media Fi or potential nerve irritation sided nerve would be pretty unusual and occasionally the foot will get some irritation from the traction pushing on the scanners and the foot. Most of these are transient, they’re not

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Dr. Urse: Obviously cut nerves in our practices that can get better over time.

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Dr. Urse: How we get into the hip is really

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Dr. Urse: Something that takes practice and time our annual lateral portals always first. You always want to go into the joint. This is a blind portal.

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Dr. Urse: And your poster lateral portals for Loose Bodies or four poster structures. Fortunately 80% of the things in hips are above the equator in the interior part of the hip.

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Dr. Urse: These accessory portals with the little stars are for inserting anchors and tying knots and those are called the dollar, the distal lateral anterior portal.

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Dr. Urse: And all these different red dots are accessory portals that you can use to get get in the hip and as a pretty safe area.

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Dr. Urse: To work in. So the first portals blind as the one that has the most risk for injury. You want to try to come in so that that needle is going to go directly into the phobia. We use a switching stick and a guide wire. You can use it with or without some fluid.

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Dr. Urse: And you know if your access isn’t correct your traction may not be good. The access you’re coming in, may be incorrect.

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Dr. Urse: So again, this needles actually kind of Hi, I’m wondering why that pictures there might be through the labor room there’s no way to see that until you’re in

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Dr. Urse: We put a switching stick. We put her scoping you are going to have issues with big people. I don’t know if you know any of these patients of mine, but

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Dr. Urse: You have to move your portals, a little more medial if you have bigger patients and use longer instruments.

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Dr. Urse: What you don’t want to do is go through the labor them. Okay, so if you’re if you’re in your answer lateral portal and now you’re making your second portal and clearly, you have to be a Nimrod to put a

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Dr. Urse: Probe or something through that if you’re looking at clearly you’ve gone through the label now you’ve got to fix that. If that’s your first portal. Because here’s the

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Dr. Urse: Thing is to have them on the left, that’s the labor on the right and you’re right through the labor with your candela. So don’t do that. If you have your cameras out you can YouTube it and I always tell people, doctors aren’t any smarter than anybody else. We know how to look it up faster.

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Dr. Urse: So what can you see when you look in the hip. Well, you should go see the femoral head as to have them the phobia. Some of the enter and post your wall structures and the and the L for the labor.

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Dr. Urse: Again, if you’ve got your first portal in and you want to bring in a needle for your second portal, you should be able to look right at where you’re bringing the needle. Therefore, if you hit the labor with your second portal, you’re really a Nimrod.

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Dr. Urse: So don’t do that. I mean, you just position your needle differently. So you missed that. Put your guide wire in and now you’re coming in through that answer lateral portal.

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Dr. Urse: And then you can look at the asked our wallet thermal had prob labor and do what you need to do start looking at how your seal looks look for what’s called Condor labeled examination, we call it a wave sign

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Dr. Urse: We can see the leg amount of Terry’s some of our ligaments. The lacs patients have Liam. Liam Terry’s laxity again.

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Dr. Urse: You then want to say, well, what am I looking at I’m looking at the tablet.

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Dr. Urse: And if you look at the as tab them. You can take it like a goalpost and do vertical lines and then a horizontal line and break the establishments info medial super medial

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Dr. Urse: Super central super lateral info lateral and when you’re saying, Where is the condor Malaysia.

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Dr. Urse: You can actually put this in your op record by using the proper zones zone six is where the ligament and Terry’s is in the phobia. So there’s soft tissue there.

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Dr. Urse: Same thing on the femoral head, you’ve got

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Dr. Urse: You’ve got a antara lateral super lateral super central and for me to infer lateral zones. So when we talk about where the wear and tear is

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Dr. Urse: We not only want to mark mark that area on our OB records. We also want to match impingement. And the problem that’s causing the contemplation. So the nice thing about hips is

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Dr. Urse: Their dynamic procedures, you can move the leg. You can watch that camp lesion bang against the establishment go, boy, it looks like it’s Robin there.

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Dr. Urse: And again,

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Dr. Urse: You know, given the, the, the area that you need to see you then need access to the hip.

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Dr. Urse: Different ways. Open the capsule is is really certain dependent. A lot of people don’t do enter portal capsule armies, we want to preserve as much capital as we can at least repair it later.

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Dr. Urse: So we want to make some people use traction sutures. Other people just expose that they need to to do the work that they have to. And I don’t use beaver blades. I’ve had one break I use the long striker samurai

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Dr. Urse: Your head of blade break off bread.

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Bradley Jelen: All thankfully now.

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Dr. Urse: Well, I have. And trust me, you don’t want to ever go looking for one I have had a few residents break a few guide wires those you want to do either.

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Dr. Urse: To see how you remember that stuff.

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Dr. Urse: But you have to be able to see what you’re doing. You have to be able to get in. Again, the labor is on the left, when you do your capsule autonomy.

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Dr. Urse: What you want to do is leave enough on the tablet side that you’d get a suture in it to repairs. You don’t wanna be cutting right next to the labor me see we’re diverging a little bit of way. This is Brian Weiss technique and

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Dr. Urse: Brian likes to use the beaver blades, but you can seal, some of the leaders as you go and you can actually improve your capsule army by coming outside the capsule and then getting more exposure to your

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Dr. Urse: We’re plastic and and some of your access to purple compartment. So we’re going to go through a little bit of what we do with the

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Dr. Urse: Exposure in the capsule lot of me. But again, the key is to be able to get in, get around and see your

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Dr. Urse: Tablet. Look at your label structures. Make sure you can get to the peripheral compartment. A lot of us do some of us do T capsule items I don’t do a lot of those, because unless I have to get way down on the neck.

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Dr. Urse: A lot of times my sutures could do that for me. Once you have your portals established. If you have a curved instrument or a larger instrument than normal, like a pic. You can use a half fibrous switching thing called a sled.

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Dr. Urse: And then that lets you see this condo label area and we’re looking at the tablet. We’re seeing if it forms a good seal around the femoral head.

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Dr. Urse: We’re looking at this junction and this condo label junction, again, is where that labor is going to get ripped off the SSL or rim and if there was a pincer Legion. We can take down that pincer behind the

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Dr. Urse: The labor. I don’t routinely detach the labor them to get to the pincer it just lifted capsule up. I don’t know if you do the same thing, Brad.

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Bradley Jelen: Absolutely. I

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Bradley Jelen: Don’t like cutting into that area. I think it’s good to leave it intact. I think for your section seal, things like that. And I’m just telling a sharp blade or whatever method to do that as towards making me nervous.

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Dr. Urse: Yeah, I agree. So again, here we are. We’re just looking at why do we need a labor and when you take a

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Dr. Urse: Cat of Eric study of a hip and cut the labor mount the hip. Just pull straight out and doesn’t have a suction effect if the labors intact. There’s a much greater seal and suction effect on the hip.

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Dr. Urse: And conversely, if we don’t fix the labor. I’m sorry if we don’t fix the labor or we don’t repair the capsule, then those people feel micro instability or micro

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Dr. Urse: laxity and they don’t feel right. The hip doesn’t feel right. It pops. I think they’re getting some of that feedback to you about how their hip doesn’t feel right.

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Dr. Urse: Again, we’re looking at the cartilage. We’re looking at the labor and we’re looking at things that

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Dr. Urse: Are causing impingement is our Legion and then all these things are what we see, sometimes you’ll see assist in the area of the ass to have them are the head

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Dr. Urse: Again, you can microfracture these areas some little bone graft in

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Dr. Urse: If you don’t have arthritis and you’ve got a labor miss hanging down like moss on a tree branch. These your happiest people you’re going to shave that thing.

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Dr. Urse: Know, arthritis. It’s like getting a rocket of your shoe. Most people walk right away. They have 10 year results are over 80% range.

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Dr. Urse: And they’re pretty happy people, you’re not gonna be able to really fix a flat tire like this. So we don’t try to fix those.

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Dr. Urse: But if you’re going to start fixing labouring GDS calculus because you’re going to pass sutures.

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Dr. Urse: And therefore, you want to put in anchors. If you’ve got a way to do that. The way to put in anchors is to get the correct angle. Get your

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Dr. Urse: Anchors and so they’re not going into the ass tab on you want to have a view of the ass to have them so that you know you’re not going to drill into it and that you have the proper angle to put in

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Dr. Urse: Your instruments. Again, use your portals use the correct one. To give you the right angles, use the

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Dr. Urse: Larger instrumentation. You can use your x ray where there’s a Carlos Guan say x ray of a hip labor and repair and you can see that that that

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Dr. Urse: That anchor is not going to go into the ass tablet on this view, you got a great view you can put your anchors in the proper angle and then once you do that,

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Dr. Urse: This is an atlas anchor he’s already got the feature in the labor.

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Dr. Urse: Music There’s your whole for that.

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Dr. Urse: Tap into the tagline.

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Dr. Urse: Then, this has a little twist and as you twist it, you can tension, your, your label repair not over tight knit or under tight knit. I don’t use a lot of novelists anchors. I do more on the

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Dr. Urse: On the ones with as tabular remember sections where I’ve got a nice view of that established so

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Dr. Urse: This is a, this is why we want a good labor and it gives you a great seal. That’s a happy looking hip.

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Dr. Urse: Hopefully you’ve refits the anchor the labor. And I think there’s an emptiness now to measure the label thickness in different areas. And if you don’t have a thick enough labor and sometimes we need label graphs.

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Dr. Urse: We’re not going to talk a lot about label grafting today, but that’s segmental graphs or complete label reconstructions is a whole nother topic.

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Dr. Urse: And then there. Then there’s the outside part of the hip called the periphery. So there’s a central compartment. There’s a peripheral compartment. When you get the hip periphery. We can see the snow vocal folds what’s called the zone orbicularis which is a kind of a longitudinal

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Dr. Urse: Circular reflection of the

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Dr. Urse: Hip capsule and then we can also see our calculation so loose bodies will be there. We always

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Dr. Urse: Know that that’s going to be a dynamic repositioning, then we’re going to release our traction. We’re going to flex, they have to take the capsule.

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Dr. Urse: Tension off and that’s going to allow us to get into the peripheral compartment and assess where we have it. So there’s a cam lesion. He’s lifting the capsule up here and

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Dr. Urse: Making sure that he can get exposure for his instrumentation to begin in his

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Dr. Urse: Peripheral compartment. The hip is flexed at this point transactions off that’s good for nerves. And that’s always good for whatever I always record my traction time on my opera record, Brad. If you do the same thing or not.

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My girls shirt cuff.

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Dr. Urse: But here again you can see and get all the way, medial, and you know that gives us exposure, it gets your room to get in the hip periphery and again

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Dr. Urse: The central compartment. You see attractions off on the x ray and now you’re looking at a labor and that’s already been fixed, but you got this big cam lesion. So how do we address the cam lesion. Well, Mark philippon teaches a goal line view, which is the view from the

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Dr. Urse: contralateral portal and then he comes down and makes a goal line and then kind of like cutting your grass. He makes a

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Dr. Urse: You know, a rectangular view. This is what they do in Europe, they open the hip. They dislocated and they surgically.

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Dr. Urse: Remove that cam impingement. But in when we’re done. If we can do the same thing through a scope, we’re accomplishing what they’re accomplishing

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Dr. Urse: When they do it open. They take these little c shaped half moons and they just say, Hey, that’s the impingement area and they make sure they reproduce that

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Dr. Urse: So when we get in there. We’re trying to do the mark philippon ski slope. Not only does he work in Vail, but he gets to use their slopes to ski.

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Dr. Urse: And you want this to look like a green slope like a bunny slope. That’s the easiest for your little daughter to ski. You don’t want to hit moguls or bumps on the way down. So we gently cascade that

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Dr. Urse: And we sculpt the hip to get a gentle smooth easy

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Dr. Urse: Read contouring. And that’s what this procedure is it’s a recon touring again, there’s the kind of the goal line view some people

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Dr. Urse: Will Tell You That is your scope is not moving a static view doesn’t give you the ability to move with the hip. So on the left is a static. I’m not moving my scope.

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Dr. Urse: And on the right, this is where the scope is moving as this as the bird is moving, and it’s more of a dynamic

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Dr. Urse: Arthritis arthroscopy to reshape that femoral head and you have to get way down. That’s why we have to open the capsule and some of these people.

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Dr. Urse: And you’re just gently making that a bunny slope.

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Dr. Urse: So when you’re done that labor’s repaired the cam lesions gone. You’ve got you, you know, almost started at the head, neck junction to get more proximal we keep the hip and extension.

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Dr. Urse: To get more distal we Flex up a little more that gets us further down the neck and if you think of Sergei

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Dr. Urse: dobrowski and a hockey goalie. You know, when they abduct you know 90 degrees or more that lower part of that neck is hitting the ass to have them. So you got to think of soccer goalies hockey goalies

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Dr. Urse: gymnastics patients people that are doing things and what you don’t want to do is end up with an apple logo on the femoral neck resection, you’re not cutting in with a huge resection of bone.

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Dr. Urse: Your favorite class. He has a learning curve. The tendency is to have under section because over a section is bad, so

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Dr. Urse: If you leave cam on the top left, that’s probably better than doing what the bottom right is and that is just not the extra you want to show people. Okay. It’s called

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Dr. Urse: Listening to too much music in the O R and burn away like, holy cow. So if you do that, I would pay this person to you know move to Bali Bali.

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Dr. Urse: They’re going to end up with a fracture. And then Dr. Jones gonna be doing some fracture work on them. So that’s not good.

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Dr. Urse: Excessive neck resection, how much neck. Do you have to cut in order to fracture it well again.

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Dr. Urse: A Maradona study and he was a male Fellow at this point, but he said 30% of the neck. If you cut that much you’re going to end up with a fracture so

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Dr. Urse: Holy cow. It’s a lot of bone. If you actually load with a instrument machine. You’ll see that’s the magic number. So again, pencil resection is what you do.

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Dr. Urse: We look at it as a clock face analysis. We’re trying to see our pre op films and our cameraman Benjamin. We’re trying to look at these different views crystal arsons really

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Dr. Urse: Good about showing the ways you can flourish Scott quickly assess your hip in the O. R. So different amounts of reflection extension internationalisation whatever you do to see that area posted early on the hip.

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Dr. Urse: And then can you see that your conflict has been removed, as you know, so if you have to turn that the

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Dr. Urse: Hip to get that false profile view. You’ve got flow there you’ve got your camera there between those that should help you is the

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Dr. Urse: Plan to get more science in this. I hope it is someday we’re going to be mapping these with

390
00:57:30.030 –> 00:57:48.120
Dr. Urse: Things called the plan, which is already out of those from cities, but this is a 3D way to map how much resection, we’re doing, we’re doing 3D mapping now for total hip replacements no conformists has this I went out to Pittsburgh to a company called a blue belt that had a

391
00:57:49.230 –> 00:58:08.070
Dr. Urse: Program where they were using mapping on the establishment famer to show what part of that to respect maybe robotics are going to help us or some of these CAD CAM designs. I think right now it’s optical navigation, which means that JOHN AND I ARE USING rivals instead of a robot.

392
00:58:09.960 –> 00:58:10.800
Dr. Urse: What do you think, Brad.

393
00:58:12.300 –> 00:58:12.660
Bradley Jelen: Great.

394
00:58:13.980 –> 00:58:22.410
Bradley Jelen: It’s and that’s why they experience the learning curve is so high or steep kind of once you get the feel.

395
00:58:23.760 –> 00:58:26.910
Bradley Jelen: You become much more discerning what you’re looking at.

396
00:58:28.800 –> 00:58:45.570
Dr. Urse: This is just aluminum Terry’s tear. This is a crazy surgery to fix this. There are guys that run a drill through the femoral head with it with a graft and then they swivel a button, an endo button on the inside of the US to have them on even think Dr. Jones doing those, but you can actually

397
00:58:46.830 –> 00:58:50.130
Dr. Urse: Do those philippon vendome do those things. Holy cow.

398
00:58:51.150 –> 00:59:03.600
Dr. Urse: So are we affecting the natural history of the hip. That’s the key. Our job is to get a JD maybe 90 again, we’re trying to fix lay rooms. We’re trying to show that isn’t good.

399
00:59:06.150 –> 00:59:09.660
Dr. Urse: What happened there boys stop sharing

400
00:59:12.030 –> 00:59:13.290
Dr. Urse: See if we can get this back

401
00:59:16.590 –> 00:59:17.520
Dr. Urse: Is it you or me.

402
00:59:22.500 –> 00:59:23.700
Dominic DiMarino: Well, I don’t think that’s me.

403
00:59:26.550 –> 00:59:33.000
Dr. Urse: Well, I think this couple a potty break time. Let’s see if we can get this working

404
00:59:36.630 –> 00:59:37.680
Dr. Urse: Back up.

405
00:59:46.470 –> 00:59:47.700
Dr. Urse: You guys see in the pictures.

406
00:59:50.010 –> 00:59:50.430
Dominic DiMarino: Now,

407
00:59:55.530 –> 00:59:59.070
Dr. Urse: Well, I am so let’s see if I can share this screen.

408
01:00:05.100 –> 01:00:05.880
Dominic DiMarino: There you go.

409
01:00:07.050 –> 01:00:08.220
Dr. Urse: All right, let me get back to work.

410
01:00:19.980 –> 01:00:21.360
Dr. Urse: Guys still seeing it.

411
01:00:22.800 –> 01:00:23.790
Dr. Urse: You’ll see the screen.

412
01:00:24.300 –> 01:00:26.730
Dr. Urse: Yeah, I gotta get down to where I was.

413
01:00:30.810 –> 01:00:33.360
Dr. Urse: And I could go to the sorter but i’d be I’d be a mess.

414
01:00:34.680 –> 01:00:36.720
Dr. Urse: So let me get down there real fast.

415
01:00:40.170 –> 01:00:43.230
Dr. Urse: Fix it, fix it, fix it, fix it, fix it, fix it.

416
01:00:46.500 –> 01:00:51.960
Dr. Urse: There’s more going to get to some therapy things and some of those extra ticklers so

417
01:00:55.560 –> 01:00:55.920
Dr. Urse: All right.

418
01:00:58.680 –> 01:00:59.700
Dr. Urse: Know why it’s doing

419
01:01:09.690 –> 01:01:11.640
Dr. Urse: Seems like we get to one slide.

420
01:01:21.330 –> 01:01:24.000
Dr. Urse: Alright, I think we’re, we’re almost where I want to be on

421
01:01:30.930 –> 01:01:32.580
Dr. Urse: Sports on rehab and definitely want to do

422
01:01:42.870 –> 01:01:46.080
Dr. Urse: Alright, so again, let’s let’s see if this where she got that picture, Don.

423
01:01:47.790 –> 01:01:50.250
Dr. Urse: Are you seeing the joint presentation slide.

424
01:01:50.400 –> 01:01:52.410
Dominic DiMarino: Yeah, can you just go to the presentation view.

425
01:01:55.290 –> 01:02:00.840
Dominic DiMarino: Your little bottom button there looks like a presentation.

426
01:02:03.390 –> 01:02:04.230
Dominic DiMarino: projector screen.

427
01:02:05.550 –> 01:02:06.660
Dominic DiMarino: Just below your mouse there.

428
01:02:10.650 –> 01:02:12.870
Dr. Urse: It’s not, it’s not open

429
01:02:15.120 –> 01:02:16.800
Dr. Urse: Is it just a small one, though.

430
01:02:18.390 –> 01:02:18.900
Dr. Urse: Are you saying

431
01:02:18.990 –> 01:02:24.450
Dominic DiMarino: Like it’s like the edit view like you are going to change it. That’s the one you want, right there.

432
01:02:26.190 –> 01:02:31.620
Dr. Urse: Well, I’m hitting that but it’s not opening to stand on the other screen size.

433
01:02:35.490 –> 01:02:40.980
Dr. Urse: I mean, I can just make this a little bigger, kind of just do that. Sure. Well, change to see that.

434
01:02:41.940 –> 01:02:45.930
Dr. Urse: All right, well, this is this is working, like this one, then we can see the next slide, you can cheat like me.

435
01:02:46.260 –> 01:02:53.970
Dr. Urse: So anyway, if you if you have a lot of arthritis, you’re going to end up with people with totals. And that’s what the bird study showed with that cartilage were problem.

436
01:02:54.300 –> 01:03:01.020
Dr. Urse: So again, fix what you can try to make sure they don’t have arthritis that read things has no way and

437
01:03:01.770 –> 01:03:05.370
Dr. Urse: You know, make sure someone has a disc plastic cap, you send them to someone with a

438
01:03:06.120 –> 01:03:17.520
Dr. Urse: Potential do what’s called a periodic table rusty autonomy for their hip dysplasia, and if they’re under 48 the age groups probably getting a little lower on those because almost a year of rehab to crack your pelvis.

439
01:03:18.630 –> 01:03:29.010
Dr. Urse: We talked about the increase in hip scopes complications. There’s a lot of things that go wrong and hips and so I’m going to run through a couple of real quickly. Some of them have do a fluid extrapolation.

440
01:03:30.720 –> 01:03:37.920
Dr. Urse: Header topic ossification. I give all my patients Celebrex after surgery or naps and we watch fluid.

441
01:03:38.580 –> 01:03:56.130
Dr. Urse: We make sure we don’t cut too much femoral head or take away too much bone en este have long to get a hip instability issue dr john does talk to you about the learning curve. And as you do the first 30 I think you really see improvements in not only

442
01:03:57.570 –> 01:04:06.990
Dr. Urse: Success. But in in this table, you’ll see three groups and this these are fellowship trained hip surgeons and in their first group was their first

443
01:04:07.380 –> 01:04:13.590
Dr. Urse: 10 patients, their second 10 there were actually not even that it was like 70 patients when they took

444
01:04:13.950 –> 01:04:23.760
Dr. Urse: A look at how long they took in the central compartment to do their surgery, you can see how that went from 7237 minutes. How long does the peripheral compartment to do the femoral pasty

445
01:04:24.420 –> 01:04:32.820
Dr. Urse: How many re operations. What were their hair scores, look at the different 6986 so as we do more of these were all going to get better.

446
01:04:33.960 –> 01:04:51.030
Dr. Urse: Header topic ossification can come from bone trimming, you’re doing a lot of bone work if you use prophylactic nonsteroidal that definitely decreases patients who got another topic ossification. You can also use PRP. I use PRP on all the patients that will pay for it.

447
01:04:52.800 –> 01:04:56.250
Dr. Urse: Fluid extrapolation is catastrophic. It can be life threatening.

448
01:04:57.270 –> 01:05:04.500
Dr. Urse: The average weight gain. After hip scopes almost six pounds. It’s actually seven verse shoulder, but there’s two places, you’ll see

449
01:05:04.890 –> 01:05:17.670
Dr. Urse: fluid accumulation in the thigh, which accommodates a lot of fluid, but the place that doesn’t accommodate is a retro peritoneal space. And if you get if you start to open the capsule either an alias solace release or a

450
01:05:18.780 –> 01:05:24.120
Dr. Urse: Significant capsule army, you can get fluid extrapolation or spiritual space that can affect

451
01:05:24.600 –> 01:05:33.990
Dr. Urse: Vital Signs gaveled extension, you definitely lower your pump pressure on that I always tell my anesthesia. People that part of the surgery starting or a moment in the capsule.

452
01:05:34.890 –> 01:05:43.140
Dr. Urse: And my retrograde Neil space gets fluid only at the end of the case if I’m doing another. So as I do that last and you can always, you know,

453
01:05:43.560 –> 01:05:53.940
Dr. Urse: Obviously, turn off your pump turn them on their side in fluid management. We don’t want to break instruments we talked about that. We don’t want to cut too much head away or disrupt the blood flow.

454
01:05:54.900 –> 01:06:03.630
Dr. Urse: Neuro practices. We talked a little bit about those. And, you know, we get now to what is my therapist need to know. I’m going to send you

455
01:06:04.710 –> 01:06:09.720
Dr. Urse: The therapy for the surgery. We just did that john and I did a great job on your hip and

456
01:06:10.350 –> 01:06:13.620
Dr. Urse: We’re gonna hook or therapist is going to help you. Where are you going to therapy and they go

457
01:06:13.860 –> 01:06:27.660
Dr. Urse: Well, I’m going to Dubuque, Iowa. It’s like, holy cow. Does the surface know anything about what I did. So you have to tell them exactly what you did. What did I find and then say, how can we make your rehab simpler and and

458
01:06:28.530 –> 01:06:36.750
Dr. Urse: move it along faster without damaging or injuring any of the problems that we’ve fixed during the procedure so

459
01:06:39.210 –> 01:06:48.540
Dr. Urse: This is what I tell people is their post op ladder of rehabilitation and when people say, well, when am I gonna be able to do

460
01:06:48.960 –> 01:06:57.360
Dr. Urse: basketball, volleyball, this that golf. I tell people you’re going to go in with a certain amount of pre operative misery.

461
01:06:57.720 –> 01:07:03.600
Dr. Urse: And you’re going to have the surgery. The next rung of the ladder is getting your movement back and starting on strengthening

462
01:07:03.930 –> 01:07:13.590
Dr. Urse: And so until you do that you don’t go to the next ladder. So if DOM sees you progressing well with this phase, then you go to the next phase stand on one leg.

463
01:07:13.950 –> 01:07:23.640
Dr. Urse: Okay, hop up and down on one leg hop through these tires, you know, run on a treadmill. As you get more and more advanced you get further up the ladder.

464
01:07:23.970 –> 01:07:36.630
Dr. Urse: To get your sports specific rehab goals accomplished and therefore if someone is progressing faster therapy is going to move them along faster, but nobody goes from the bottom of the top of the ladder, just like a baby doesn’t go

465
01:07:37.170 –> 01:07:44.070
Dr. Urse: out of the womb and start walking. They crawl, then they get up on all fours. Then they you know limp, a little bit and then they get going. So

466
01:07:44.340 –> 01:07:54.300
Dr. Urse: Again, this is a really good thing where the patient then has to achieve the next level, instead of blaming on the therapist or the doctor or their problem. So,

467
01:07:54.960 –> 01:08:00.060
Dr. Urse: What am I going to do to help you. I’m going to do multi modal pain control. I’m going to give them nonsteroidal

468
01:08:00.960 –> 01:08:06.750
Dr. Urse: Before and after the surgery. I’m going to use, you know, PRP. If I can to cut down squad scarring and pain.

469
01:08:07.260 –> 01:08:18.090
Dr. Urse: We’re going to try to use blocks, if we needed. I think there’s pretty good evidence that some arcane around the hip in the capsule in the ass to have them works about as well as some of these family acre blocks so

470
01:08:18.600 –> 01:08:28.560
Dr. Urse: You know, we’re going to give antibiotics to prevent an infection, but I tell my patients, you could be honest stationary bike. The night of surgery, you know, I want you moving I want motion we are

471
01:08:29.580 –> 01:08:44.070
Dr. Urse: Very aggressive, at least in the way we do it. We try to incorporate our crew because that helps us plan prepare and perform I use braces on all my patients on hip repairs on my label repairs and obviously all my glute repairs.

472
01:08:45.660 –> 01:08:52.200
Dr. Urse: It depends whether we’ve divided or repair the labor room, whether I braced the patients, but if you want to

473
01:08:53.040 –> 01:09:02.190
Dr. Urse: If you want to give them the ability to protect the labor and repair, you’ve got a limit collection past not more than 90 exploitation of less than

474
01:09:02.580 –> 01:09:12.090
Dr. Urse: 30 and you want to try to keep them in that safe zone and I am where the brace when they’re, when they’re standing. I don’t care if they have it on when they’re in bed or in a in a chair.

475
01:09:13.260 –> 01:09:19.680
Dr. Urse: Same thing with my glute repairs. They can put a pillow between their legs, either in bed or in a chair.

476
01:09:20.640 –> 01:09:28.950
Dr. Urse: I do protect weight bearing on my condo defects that I’ve done micro fractures on and certainly on the glute repairs. I keep them partial weight bearing for six weeks.

477
01:09:29.790 –> 01:09:41.790
Dr. Urse: I think you have to use your own psychology on how patients progress and you have to realize they have financial constraints. Their, their co pays maybe hi male be able to see him once a week.

478
01:09:42.720 –> 01:09:48.960
Dr. Urse: You got to know what their ages are there. Are they able to even get in. Do we have to put a mask on and finish.

479
01:09:49.680 –> 01:09:59.280
Dr. Urse: My lecture with one of these, because you know they’re afraid even come to the office to do therapy. So there’s a lot of things that have changed and how they’re going to

480
01:10:00.150 –> 01:10:13.320
Dr. Urse: Allow you to do things you may want to see them once in the first part, once a week for the first few weeks and then say, See me back in six weeks we’re going to change the weight bearing status or we’re going to progress you more 12 week mark and work on strengthening

481
01:10:14.700 –> 01:10:23.880
Dr. Urse: But the team has to help obviously the evidence on this level five is pretty crappy, that means that we really aren’t sure what to do.

482
01:10:24.540 –> 01:10:37.680
Dr. Urse: I always talk about flat foot weight bearing not toe touch. So I want flat foot touchdown. I went there, he’ll flat on the ground. I do not want him to get a flexor contractually hip. I don’t want it to get alias so is tightening

483
01:10:38.520 –> 01:10:52.860
Dr. Urse: I tell them it is really important that the feel the heel down flat, they’re going to self regulate weight bearing. It’s just like a sore tooth at the dentist. If you’ve had your tooth worked on it and I can meet you and steak that night and people will self regulate some of their

484
01:10:55.050 –> 01:11:00.060
Dr. Urse: weight bearing if they’ve had a microfracture or or if they’ve had pain from a femoral plastic, etc.

485
01:11:00.870 –> 01:11:09.420
Dr. Urse: I like CPS on so my big hip cases. I won’t chart. I won’t tell the patient to spend any money on them, though, if the insurance covers them. I’ll use them for two, three weeks.

486
01:11:09.690 –> 01:11:16.740
Dr. Urse: I think it helps to keep the hit move. And if they’re not motivated to get on a bike, but obviously a stationary bike as what a CPM does. If you have a motivated patient

487
01:11:17.250 –> 01:11:24.900
Dr. Urse: I start therapy immediately. This says, week to week paints controlled. This is already a slide that’s outdated in my book.

488
01:11:25.260 –> 01:11:39.030
Dr. Urse: I told you we use cell Bexar NAF person I try to communicate with my therapist, I give them a detailed note of what I want. And I, and I tell people not to go not to go crazy. But I want you to advance things at a rate that you think

489
01:11:40.470 –> 01:11:42.720
Dr. Urse: They can, they can see improvements in their

490
01:11:45.630 –> 01:11:53.040
Dr. Urse: In their in their therapy progress. What am I therapist want to say at this point because I’m going to go into a couple things on the glute after this

491
01:11:56.940 –> 01:11:58.350
Dr. Urse: Any questions in the crowd.

492
01:12:03.090 –> 01:12:03.630
Dr. Urse: Keep going.

493
01:12:05.070 –> 01:12:11.580
Dr. Urse: All right. Now let me ask you this. Are you guys missing the rotator cuff tear. The answer is you probably are.

494
01:12:11.940 –> 01:12:22.710
Dr. Urse: So this, this lady I guess her video isn’t working. But this lady is one of my fat ladies walking down the hall with an intelligent gate and a limb get kind of some quirky look and legs.

495
01:12:24.150 –> 01:12:31.410
Dr. Urse: And you go, Well, you’ve got a you’ve got a bad hip lady, the answer’s no. It’s already been replaced my surgeon said, and there’s nothing wrong with me.

496
01:12:31.770 –> 01:12:36.060
Dr. Urse: I might, in fact, he said, is X rays look great. It’s like, well, that sounds like a surgeon

497
01:12:36.630 –> 01:12:46.800
Dr. Urse: So what do you do well, you’ve got a painful total and you got a person who can’t walk so you want to make sure it’s not infected or loose so we do bone scans. We ask very tip.

498
01:12:47.070 –> 01:12:53.130
Dr. Urse: We may find out whether it’s in the joint or not. But the bottom line is, you know, if it’s not in the joint.

499
01:12:53.460 –> 01:13:02.790
Dr. Urse: It could be a snapping hip. It could be an abductor problem, we may be able do an MRI with artifact removal called a Mars, but we may not. So you may have to stick with

500
01:13:03.360 –> 01:13:13.740
Dr. Urse: Ultrasound on these patients because ultrasound can show you a glute problem. It can also help guide an injection for hip impingement. And again, we talked about some of these totals.

501
01:13:14.880 –> 01:13:23.430
Dr. Urse: Where we are now if you just look at this lateral view anterior is on the, on the right on the top, posters, the SEM on the left.

502
01:13:24.870 –> 01:13:26.490
Dr. Urse: We’re doing more anterior hips now.

503
01:13:27.600 –> 01:13:33.180
Dr. Urse: So I’m going to tell you as a guy who did post your hips for 31 years and I’ll do an anterior. So the last two or three

504
01:13:34.710 –> 01:13:44.640
Dr. Urse: None of us want the hip to dislocate interior Lee. So if this was a poster approach. I would actually and avert my cup a lot more it would be turned

505
01:13:45.750 –> 01:13:49.830
Dr. Urse: To be more animated to prevent it from dislocating posted early

506
01:13:50.340 –> 01:13:57.570
Dr. Urse: For an anterior hip. We actually don’t want it to come out the front. So if you oversized the hip or if you tilt it to keep it from going out the front.

507
01:13:57.900 –> 01:14:05.250
Dr. Urse: Your idea. So as tendon is going right at the tip of that arrow and all of a sudden you’ve got hip impingement. So we’ll take a needle.

508
01:14:06.090 –> 01:14:17.670
Dr. Urse: Inject that either ultrasound and if that relieves or pain will scope. Some of these totals. And here’s what the snow be and looks like pretty angry looking. That’s the femoral head on the right, you get a glimpse of the plastic socket.

509
01:14:18.120 –> 01:14:26.940
Dr. Urse: And here’s the alias SOS tendon. It is screaming. Okay, it’s that Ruby thing. You can see it’s it’s playing and right against the edge of the cup.

510
01:14:27.330 –> 01:14:38.850
Dr. Urse: And we go in and release these in the O. R. And these people are just stupid happy. You can see the opening there on the left has now been relieved with a thermal one. There’s your femoral head. There’s your cup.

511
01:14:40.260 –> 01:14:48.630
Dr. Urse: And you know this correlates to where that impingement is sometimes there’s two heads to the bicep or the LSO is tendon. You gotta make sure you get both of those.

512
01:14:49.590 –> 01:15:00.030
Dr. Urse: But if you can see what the hair scores have done. They’ve gone from 32 to 79 some of these outcomes scores on the activity, living or much improved so again this is a slide from

513
01:15:00.900 –> 01:15:09.120
Dr. Urse: Jovan was kosky one of my buddies, the Cleveland Clinic, so you know tendon apathy can also be a cause in the outside part of the hip.

514
01:15:09.870 –> 01:15:16.440
Dr. Urse: So lateral hip pain is really the stroke Derek pain syndrome issue. It’s not the only of solace and you think it’s lateral

515
01:15:16.770 –> 01:15:26.910
Dr. Urse: Than what’s out there. There’s only three things. There’s a drunk Derek bursa there’s a bunch of glute tendons and it could be a snapping hip and we talked about that, you know, if we had an MRI that showed this detached.

516
01:15:27.990 –> 01:15:33.180
Dr. Urse: Gluteus media’s tended, you know, we would just fix it. But in this patient.

517
01:15:34.200 –> 01:15:45.990
Dr. Urse: You know, somehow orthopedic surgeons don’t think those need to be fixed if you turn it on their side and say it’s a rotator cuff tendon. They’re like, oh, let’s fix it. So I think we should fix these things, whether they’re in total joint patients or not.

518
01:15:47.070 –> 01:15:51.270
Dr. Urse: They do help lift the leg and there are conservative measures that help

519
01:15:52.410 –> 01:15:58.470
Dr. Urse: Re Coulson recalcitrant cases you can do with either injections of Partial tears with PRP.

520
01:15:59.490 –> 01:16:04.770
Dr. Urse: They work better than cortisone. Or you can do repairs for partial or full thickness tears.

521
01:16:06.930 –> 01:16:14.100
Dr. Urse: If you, if you look at this slide, if you want to take two slides and take pictures. This would be the second one I would tell you is that the MRI.

522
01:16:15.330 –> 01:16:21.930
Dr. Urse: Of some of the trunk Derek hip pain is going to show isolated trope or situs less than

523
01:16:22.620 –> 01:16:30.750
Dr. Urse: 10% of the time. So the thing your, your, your orthopedic surgeon or PA is injecting which is the hip bursa for that lateral hip pain.

524
01:16:31.110 –> 01:16:41.280
Dr. Urse: Is not the problem over 90% of the time 45% of these people have complete glute tears and probably in the 60% range. Partial tears. So the glute tendons are the

525
01:16:42.420 –> 01:16:44.610
Dr. Urse: The problem in the trunk Derek space and

526
01:16:45.810 –> 01:16:49.980
Dr. Urse: If you decide you want to address these you’re going to be able to find a lot of these patients.

527
01:16:50.310 –> 01:16:56.730
Dr. Urse: So everything runs in threes. That’s why you have a rabbi a Presbyterian minister and a Catholic priest go into a convenience store.

528
01:16:57.060 –> 01:17:05.790
Dr. Urse: So, just like that. There’s three in this physical exam findings of a Gluteus triad. So a single leg squat test. This is a

529
01:17:06.420 –> 01:17:16.260
Dr. Urse: Thing out of the American Journal of sports medicine from Crossley and you can see as she does a single stance on one leg. Look at her right knee on the bottom right you can see she’s got glue do

530
01:17:17.790 –> 01:17:30.690
Dr. Urse: Hip function is weakness and actually a lot of your knee patients with ACL tears and core muscle weakness will have glute weakness and a single stance squat test is good to find that you should be able to keep that leg straight

531
01:17:31.890 –> 01:17:38.190
Dr. Urse: You can do a bridge test. You can have them lift their took us off the table and do that’s called a bridge test.

532
01:17:38.730 –> 01:17:43.440
Dr. Urse: Not many of my people can stand on one leg for 30 seconds for a trend dalembert but that’s the third part of it.

533
01:17:43.980 –> 01:17:56.700
Dr. Urse: Again, you’re lifting two to five times the force your body weight with a hip abductor. So again, if that’s torn either get a Mars study or get a one of your neuromuscular radiologist help you read an ultrasound.

534
01:17:58.020 –> 01:18:08.820
Dr. Urse: And if you don’t know what you’re doing and all sound is basically you’re looking for the bone down below, there’s a greater tro canner and you just go above that and find the area to tear. If you aren’t sure how to do it.

535
01:18:09.090 –> 01:18:13.050
Dr. Urse: You know, take a picture of this and go read about it or pull a YouTube video out

536
01:18:15.090 –> 01:18:20.250
Dr. Urse: your glutes are pretty important hip abductors this big purple thing is one of your fan shaped

537
01:18:20.670 –> 01:18:31.410
Dr. Urse: Pictures of the glute you when you do an ultrasound of the hip. It’s just like looking at the roof line of a house. So just think about whether own find a steep or gradual the

538
01:18:32.160 –> 01:18:40.020
Dr. Urse: The cassettes of the hip or where the glute muscles attach the interviewer said is the green thing that’s very steep. That’s for the minimalists this

539
01:18:40.440 –> 01:18:48.900
Dr. Urse: Super a poster and lateral for set is where the media attaches it’s more more horizontal and that yellow thing that loot.

540
01:18:49.800 –> 01:18:56.190
Dr. Urse: poster for sad is where the bursa is so you can see how far away. Hit per site is really as compared to where a lieutenant problem would be

541
01:18:56.970 –> 01:19:10.020
Dr. Urse: You can use your old sound to see the glue tendons. The minimises one. So just start looking at at steep and shallow roof lines and you’ll be able to figure out that a immediate tendon is

542
01:19:11.670 –> 01:19:22.890
Dr. Urse: Is more horizontal. You can see both sides of this almost looks like a shoulder. If you do oh sounds on shoulders and it looks like a superstar that has tended, you can see a bottom, top of the tendon and

543
01:19:23.370 –> 01:19:31.080
Dr. Urse: You can see how it is just to go over that again this more steep angle. Number one is the minimis horizontal is the media’s

544
01:19:33.360 –> 01:19:38.940
Dr. Urse: And what do you do if you got a torn tendon. Well, if it’s been a total joint patient like that lady I showed you

545
01:19:39.300 –> 01:19:48.510
Dr. Urse: This is the only study in the world literature on fixing glue media’s tears after total hips and this was out of France and they opened up 13 of these people and

546
01:19:48.840 –> 01:19:57.840
Dr. Urse: Well, they open up 11 they found 13 of them and 90 you know 90 plus percent were happy after got fixed and said, Hey, thanks for fixing it. So,

547
01:19:58.950 –> 01:20:12.870
Dr. Urse: I don’t really do these open. I do sort of scope. A lot of people do this with a central government arthroscopy, that’s what you’ll see on view, Matty. I think if you know it’s in the trunk Derek apartment, why not just do it. Some people do at supine I do mine in the lateral position.

548
01:20:14.010 –> 01:20:23.130
Dr. Urse: I use two portals a superhero anterior and super opposed to your portal Dr euless Cassie, and a couple of people probably use vertical portals to do, there’s

549
01:20:24.120 –> 01:20:38.910
Dr. Urse: Either way you get in there and find a torn tendon. Some of these retail and you can see suture from an old repair and they need a graph, but you can see this for set of a of a troll canner and this flat area where the media is attaches is pretty easy to put a couple anchors in

550
01:20:40.140 –> 01:20:56.580
Dr. Urse: We put the anchors in a suture put him through the tendon, pull it down and do a double row repair. That’s a fiber tape repair that I did on someone I embrace all these people afterwards, the California brace are pretty heavy. I used I have you seen the, oh, sir.

551
01:20:58.530 –> 01:21:10.860
Dr. Urse: It’s called a hip abduction brace and it’s it’s called a reaction. It’s pretty nice. It has less than weighs about 18 ounces and it’s a nice abduction brace that Oh sir, makes OSS you are

552
01:21:12.600 –> 01:21:19.260
Dr. Urse: A little more and more compliant for people I protect weight bearing for six weeks I let them partial Wait, Bear.

553
01:21:20.250 –> 01:21:29.610
Dr. Urse: Obviously, you want to get this thing to heal in the 68 week period of them take their brace off, but I do encourage them to use it so they don’t fall if they want to use a walker crutches, that’s fine.

554
01:21:30.360 –> 01:21:36.960
Dr. Urse: And it does take a long time. If you say, What is my patient going to feel better because I’m their therapist. I’m tired of hearing a bitch and moan.

555
01:21:37.260 –> 01:21:46.470
Dr. Urse: The answer is, it may be three months, they may be when. Am I satisfied, we look at the green that’s 12 to 18 weeks their pain is going to be better with their functions are crappy

556
01:21:46.800 –> 01:21:57.750
Dr. Urse: And a lot of these people retire. I’m going to do a study at some point, I’ll just read tears of people that fell after six weeks after having their boot repair because they didn’t have strength and they didn’t have any function.

557
01:21:58.260 –> 01:22:10.140
Dr. Urse: To avoid a fall. So the strength phase, really, is that four to 18 month period. We’re going to try to get some information on glue abductor strength with some of the biotics things we’re going to do with DOM and the other therapists.

558
01:22:12.210 –> 01:22:18.630
Dr. Urse: returned a sport and activities is sport activity related. So if you’re going to golf, you’re probably gonna do that a lot sooner than play volleyball.

559
01:22:18.900 –> 01:22:26.130
Dr. Urse: So I tell people if it’s nine months to put a heavy box on the shelf for a shoulder after a cuff repair is probably going to be six, you know,

560
01:22:26.580 –> 01:22:35.400
Dr. Urse: You know 12 to 18 months for a glute repair. But again, some people feel better, you know, whatever we do in medicine, we should look at our dirty laundry.

561
01:22:36.090 –> 01:22:47.460
Dr. Urse: We looked at this, this was a award winning poster nine years ago. So my residents and we basically saw these glued tears and my first patient. I did this on was a

562
01:22:47.910 –> 01:22:53.460
Dr. Urse: Piece. I didn’t even know how to glued to where they were a bursa removal, it’s taking a burst out of scope, I saw this whole and I got

563
01:22:53.910 –> 01:23:02.880
Dr. Urse: To fix that looks like a clear rotator cuff tear. I go if I was going to fix that. How would I fix the shoulder, I’d probably like put an anchor in, grab the tendon and

564
01:23:03.900 –> 01:23:08.460
Dr. Urse: Just put it back like when I do that. And then I thought, well, I better open this up and I’m thinking,

565
01:23:08.850 –> 01:23:21.030
Dr. Urse: I don’t open up my shoulders. Why can’t I do this to a scope. So the first one I did to the scope. I’m a little incision for my finger in the field repair and I thought, that’s pretty good. I don’t think I need open these. So in the first

566
01:23:22.050 –> 01:23:28.200
Dr. Urse: Part of this misery of what I did with glutes. This was back in 2010 out of my first

567
01:23:28.650 –> 01:23:34.950
Dr. Urse: 95 cases you know 10 of these people had total hips and those are the ones that I’ve gotten rejected in my

568
01:23:35.280 –> 01:23:43.980
Dr. Urse: Journal publications, because they said we can’t believe people did better with endoscopy glute repair. We don’t believe the results. So they rejected my paper which I may resubmit

569
01:23:44.490 –> 01:23:53.880
Dr. Urse: But basically double repairs do pretty well. We’ve done some biotech studies. That’s my buddy viet when and we took instruction machines that we pulled on these

570
01:23:55.380 –> 01:24:03.510
Dr. Urse: With single and double row repairs at a single row on one side, double role and the other and we looked at the pullout strength. We’re talking about Newton’s of strength and

571
01:24:03.990 –> 01:24:11.550
Dr. Urse: If you look at the single row Newtons. And the double row Newton’s you know we had probably 25 cadavers vendome did some of these and I did some I

572
01:24:11.820 –> 01:24:20.850
Dr. Urse: Submitted another paper on this saying here’s the pullout strength. Unfortunately, I didn’t know the data because our Thrax gave us the lab to do the studies.

573
01:24:21.150 –> 01:24:31.860
Dr. Urse: And they said, well, you don’t have enough data to do a study there. And I said, well, I’ve got 25 hips and it sure looks like the double rows are stronger than single rose, even though some of them pulled out.

574
01:24:32.730 –> 01:24:37.440
Dr. Urse: And I never published it because I didn’t own the data because I don’t wanna spend 50 grand on the lab.

575
01:24:37.860 –> 01:24:48.900
Dr. Urse: And then this this exact study came out last year, someone looked at, single, double, repairs and said, double rows are stronger. We can’t statistically say that, but that’s what we found. I’m like, great already did that could do anything with it.

576
01:24:49.980 –> 01:24:57.510
Dr. Urse: So total hip patients if we can submit this to another journal and get it submitted, we will be able to show that endoscopic repairs glutes.

577
01:24:57.840 –> 01:25:08.910
Dr. Urse: Can improve and these are Harris scores on total hip. Some of them were homies and look at their pre and post op Harris scores I. Hello. I think these people feel better. All I did is fixed. They’re torn tendon.

578
01:25:09.390 –> 01:25:16.980
Dr. Urse: And we imaged like 80% of the people with the same neuromuscular radiologists, who did the pre op ultrasound.

579
01:25:17.250 –> 01:25:24.630
Dr. Urse: And showed that they repaired and they said, well, you didn’t image all the people I go, Well, some of these are 92 year old people with, you know, I couldn’t get them back for

580
01:25:24.870 –> 01:25:35.220
Dr. Urse: Follow up imaging. It’s like, so that was another reason they didn’t accept that paper. So what do we do with hips. We try to find out what’s wrong. If it’s in the glute, why not fix it. It’s pretty simple.

581
01:25:36.300 –> 01:25:51.120
Dr. Urse: I’m going to take 10 MINUTES TO JUST FINISHED some quirky stuff that you don’t see very often that hurt hips and they may have any questions on glute things before I hit a couple things around the app that you just need to see, and then they’re going to fall off the wall like custard.

582
01:25:51.900 –> 01:26:07.320
Amy Harris: Yeah, I have. I have a quick question. So the patients that you are seeing with with me tears, how are they getting or what do you think is causing it. Is it like a degenerative. Is it a fall like what do you typically find is your reasoning like to even check that.

583
01:26:07.800 –> 01:26:15.480
Dr. Urse: That’s a great question. Amy. So there’s four reasons people get glued tears. One is wear and tear degeneration, just like a shoulder on a rotator cuff.

584
01:26:16.380 –> 01:26:29.310
Dr. Urse: The second is trauma. They go, I fell off a horse April 16 TWO YEARS AGO I’VE HAD THREE kippers injections and I can’t walk it’s like looking for your glue just like the one falling off during the rookie

585
01:26:30.540 –> 01:26:44.310
Dr. Urse: The other two are in arthroplasty patients. So if we do like every year on call and we get a hip fracture and we go to open the hip to put a half a half a hip and like having arthroplasty 20% of those people

586
01:26:44.400 –> 01:26:45.000
Dr. Urse: Who have a blue

587
01:26:46.410 –> 01:26:53.010
Dr. Urse: Will just find it, incidentally, that it was torn and maybe they were limping and every thought it was arthritis or or whatever.

588
01:26:54.060 –> 01:26:57.480
Dr. Urse: And they see him on a on a person with a femoral neck fracture.

589
01:26:57.810 –> 01:27:08.940
Dr. Urse: Than the other ones occur with our hip exposure, particularly the intro lateral approach. So we talked about anterior and posterior approaches, but the intro lateral you actually just rip off the abductor and you do your total

590
01:27:09.270 –> 01:27:17.760
Dr. Urse: And then if you don’t put it back on that thing called the Harding approach you actually create an abductor lurch and a

591
01:27:18.180 –> 01:27:26.730
Dr. Urse: glute tear. So two of them come from arthroplasty patients. Two of them are either degeneration or trauma and you know it’s a little bit like

592
01:27:27.480 –> 01:27:33.300
Dr. Urse: And I didn’t show this. I’ve made a slide yet, but I have a, an idea of an iceberg with the Titanic.

593
01:27:33.660 –> 01:27:44.850
Dr. Urse: And the tip of the iceberg is a label tear and they say, when you see the tip of the iceberg, you need to say why the labor tear or underneath the water line is hip impingement instability snapping tendons.

594
01:27:45.930 –> 01:27:50.610
Dr. Urse: Trauma whatever the reason for the label tear is just like what are the reasons for the week tear

595
01:27:51.960 –> 01:27:57.900
Dr. Urse: What i factorial, but the answer is, you know, you may not always know but sometimes you do

596
01:27:59.160 –> 01:27:59.760
Dr. Urse: That answer.

597
01:28:00.390 –> 01:28:08.580
Amy Harris: Yeah, and I just had one other question I have a lot of patients that come in for their like two week you know after surgical like surgical follow up.

598
01:28:09.240 –> 01:28:18.090
Amy Harris: To start PT in there, half the time. They’re full weight bearing on a walker. And so what’s the likelihood of them retiring from weight bearing because I like to

599
01:28:18.390 –> 01:28:26.880
Amy Harris: You know, give them all the facts and I’m always like, trying to correct their, their weight bearing, but it’s very frustrating because a lot of them are not being partial

600
01:28:28.110 –> 01:28:44.970
Dr. Urse: Again, I can tell you the experience we have is anecdotal, at best, it’s from a TRO canner of origin, where we would partial weight bearing. So the bone didn’t pull off in these cases are repairs. I think are pretty strong, but where we don’t even have a base.

601
01:28:46.020 –> 01:28:51.510
Dr. Urse: That doctor can exert until we get the study with DOM on the

602
01:28:51.570 –> 01:29:01.680
Dr. Urse: I got so my guess is within the six weeks i i don’t know that the weight bearing is their biggest problem as much as falling

603
01:29:01.950 –> 01:29:02.550
Off.

604
01:29:05.100 –> 01:29:07.500
Dr. Urse: On Brad. You got any comment on that.

605
01:29:08.760 –> 01:29:15.300
Bradley Jelen: The i agree i do this pretty much the same protocols, you do I protect our weight bearing

606
01:29:16.500 –> 01:29:25.920
Bradley Jelen: Maybe not as long, but I require them to use a walker or crutches for at least six weeks because i think i think the repair is strong.

607
01:29:26.760 –> 01:29:45.900
Bradley Jelen: But they end up stumbling maybe not a complete fall, but where they come down on that leg, because they’re just most these people obviously are really weak and have nor know core strength to begin with. So I encourage them to use an assistive device for quite a while.

608
01:29:47.700 –> 01:29:53.430
Dr. Urse: Yeah, I agree. I think our dogma for this and the evidence based medicine is very lacking.

609
01:29:55.050 –> 01:29:58.440
Dr. Urse: I see more retires from falls than anything.

610
01:29:59.460 –> 01:30:07.800
Dr. Urse: To like really try to protect them. It’s a lot like my Achilles tendon repairs. It was that six to 12 week period where people retire their Achilles.

611
01:30:08.220 –> 01:30:17.760
Dr. Urse: They spent a ton of time before surgery, telling them, don’t retire don’t retire. It’s really hard for me to fix it a second time, or I gotta put a patch on right got to do more extensive search

612
01:30:18.750 –> 01:30:26.400
Dr. Urse: Knock on wood, I’ve had no retailers have my Achilles, because I spent a lot of times when people why one of the reject and I’ve definitely have

613
01:30:27.570 –> 01:30:36.870
Dr. Urse: A pocket full of people that have their goods are great stories people fall down step they fall to coffee tables that people follow

614
01:30:37.320 –> 01:30:50.190
Dr. Urse: Your mail. I mean, I had a lady get mugged getting gas. One day I mean there’s all sorts of stories and some of these are just going to retire from the know crappy tissue or worse or

615
01:30:53.670 –> 01:31:00.750
Dr. Urse: Right, let’s take a couple things that are really outside the joint extra particular hip problems and I’m going to hit these real quickly.

616
01:31:01.530 –> 01:31:07.440
Dr. Urse: We’ve already talked about earlier sauce and Benjamin. The one thing about the SOS. And I’ll go back to the other ones in a minute.

617
01:31:07.920 –> 01:31:18.390
Dr. Urse: Is that you want to make sure you know that they will not be able to lift their leg for six weeks and I tell them I’m cutting a hip flexor we’re cutting a tendon part or leaving the muscle part

618
01:31:18.900 –> 01:31:25.860
Dr. Urse: You’re going to have to take your hands to lift your leg in and out of a car for six weeks just know it’s going to be weak and then it’s going to be okay.

619
01:31:26.130 –> 01:31:37.200
Dr. Urse: But if they don’t know that they freak out because they can’t lift their hip up their pains gone. You’re snapping is gone, but they will freak out. You just hit him 50 times over the head with that they know that

620
01:31:38.550 –> 01:31:45.570
Dr. Urse: A is impingement is the answer. Inferior ILLIAC spine. I’ma show you a couple pictures of that.

621
01:31:46.710 –> 01:31:51.570
Dr. Urse: If you have these old hip flexor injuries where you have those. The erectus.

622
01:31:53.070 –> 01:31:58.410
Dr. Urse: You get a bone. The overgrowth. You see these in ballet dancers. We’re going to talk. We talked about glutes.

623
01:31:58.800 –> 01:32:04.560
Dr. Urse: Little about a show femoral impingement. And we’ll hit a couple other things like the sciatic nerve and some other things. So

624
01:32:04.950 –> 01:32:23.550
Dr. Urse: A is or sub spying impingement is really, there’s a couple of different types. All you need to know is that the the the area that A is hangs lower and it can impinge this a 3D CT showing this sub spine impingement. And, you know, it can it can cause a tear in the labor.

625
01:32:24.660 –> 01:32:36.330
Dr. Urse: And this bony overgrowth, you can take a bird to it and you can actually just get rid of that this again this is I want a job endless galaxy slides. Thanks, Joanne for that. But it’s a

626
01:32:37.620 –> 01:32:42.210
Dr. Urse: You know, something that, you know, if you can’t see what you’re doing, you’re going to get problems.

627
01:32:44.010 –> 01:32:54.210
Dr. Urse: I want you to know that all these things we do are a bit of a crapshoot. You know, I don’t want to say it’s as mystical as what the guy looks like on the right.

628
01:32:54.660 –> 01:33:02.550
Dr. Urse: But we’re trying to pick problems that we think we can help. We’re trying to avoid arthritic problems we’re trying to fix things that

629
01:33:03.810 –> 01:33:04.680
Dr. Urse: You know, are

630
01:33:06.270 –> 01:33:14.640
Dr. Urse: You know, torn a labor and Repairs always preferable over a debrief trying to get the bony abnormalities out of the way, trying to deal with.

631
01:33:15.570 –> 01:33:21.690
Dr. Urse: Where their pain patterns from whether it’s linked to their back or the hip and Spine Center ME. JUST HAVE TO prompts and are people that have both.

632
01:33:22.050 –> 01:33:27.120
Dr. Urse: You know, and they lost motion and those people I don’t repair their capsule and so my older patients.

633
01:33:27.390 –> 01:33:37.800
Dr. Urse: You know when you cut their capsule to do your hip surgery. They actually say I’m a hip moves better. Well, they’re not going to have instability third 58 with a big can lesion. So I don’t fix those people in my brand feels about that.

634
01:33:39.120 –> 01:33:41.520
Dr. Urse: You don’t do fix capsules on older people read

635
01:33:42.630 –> 01:33:43.230
Bradley Jelen: I

636
01:33:44.400 –> 01:33:52.170
Bradley Jelen: Over the last couple of years gotten more aggressive, you know, closing capsules. I think there are certain patients. I don’t think need it.

637
01:33:52.830 –> 01:34:05.640
Bradley Jelen: I think a male patient with a bad Kim deformity with a thick really scarred capsule probably doesn’t need to be closed. And what I’ll do is I’ll, I’ll be approximated and but

638
01:34:06.690 –> 01:34:19.500
Bradley Jelen: Which is the opposite of if I’m dealing with a female patient that’s pincer impingement or kind of borderline dysplasia, I’ll close their capsule pretty tight because I think they are the ones that are going to have some micro instability.

639
01:34:20.730 –> 01:34:29.070
Bradley Jelen: So again, you got to look at the pathology present and I think I rarely treat everybody the same.

640
01:34:30.570 –> 01:34:31.620
Bradley Jelen: You know, across the board.

641
01:34:33.120 –> 01:34:40.260
Dr. Urse: And I think that’s what it is. The next line after abduction and range of motion is caution with dysplasia borderline dysplasia, first of all,

642
01:34:40.650 –> 01:34:51.870
Dr. Urse: You know, make sure you can even help those people. There is some evidence that we can actually placate the capsule and help them. But if it’s a bony deficiency, they really need a roof procedure called a PA to

643
01:34:54.000 –> 01:34:59.040
Dr. Urse: Again, look at your Mrs. Try to do pre op therapy to calm down their

644
01:35:01.110 –> 01:35:14.040
Dr. Urse: Misery ahead of time. We don’t operate on ACL is after they get hurt. We try to get the range of motion. First, and if you have a Stephanie going into an ACL reconstruction and up with the ACL fix me with a stiff outcome. So we want to really

645
01:35:15.270 –> 01:35:23.940
Dr. Urse: Push the therapy and do some pre have also, we want to take some of the mysticism out, you know, has the several Camille decompression of the hip.

646
01:35:24.360 –> 01:35:31.710
Dr. Urse: Been. The only thing there. I don’t think that’s the only thing wrong with hips. We know there’s a lot more. And we’ve seen that over the last 20 years where

647
01:35:32.070 –> 01:35:49.680
Dr. Urse: More than hip impingement is the problem and the hip it’s snapping tenants. It’s muscle tears, it’s labeled pathology. It’s instability. It’s Loose Bodies it’s it’s it’s sub spine extra particular problems like issue a femoral impingement or the Google pain problems.

648
01:35:50.790 –> 01:35:54.810
Dr. Urse: adductor injuries to the pubic synthesis area.

649
01:35:55.950 –> 01:36:01.860
Dr. Urse: sports hernia, so to speak, all this stuff that we just didn’t know much about if you pick the right person and do the right

650
01:36:02.250 –> 01:36:17.460
Dr. Urse: Surgery, you’re going to get a good outcome you gotta be able to see what you’re doing. You got to get label repair that gives you a good seal and I think you have to have a nice smooth bony resection. Try to be critical of what we do. I think we’re our own best

651
01:36:19.980 –> 01:36:29.520
Dr. Urse: Laundry basket. We got to check out how we’re doing. And if you are only doing what everybody else says, and not doing anything on your own that you see is maybe an improvement.

652
01:36:29.820 –> 01:36:37.950
Dr. Urse: Then maybe you need to pause and reflect and say, you know, maybe I should change a little what I’m doing. So with that, I will leave you with the

653
01:36:38.970 –> 01:36:41.610
Dr. Urse: Mecca grant do view.

654
01:36:43.440 –> 01:36:43.770
Dr. Urse: This

655
01:36:44.850 –> 01:36:56.850
Dr. Urse: New Era of medicine with masks and people wearing. I guess you can go into Meyer on Monday off devil mask on. So I’ll finish with a half mask view. Anybody have any other questions.

656
01:36:59.190 –> 01:37:17.010
andrearowland: I do. Dr. So if you find somebody with a glue lead tear, but they also have a crappy hip. So what you called a crappy hip. Would you do one procedure. First, or would you fix repair the hip and then also meet at the same time. Do you have like a hierarchy of what you try first

657
01:37:17.310 –> 01:37:20.940
Dr. Urse: That’s a great question. Andrea, I do. Well, there’s two, there’s two of those.

658
01:37:22.410 –> 01:37:29.100
Dr. Urse: And I’ll let Brad address it. One is the partial table and the other is the full glute tear and the Partial tears are hard sometimes.

659
01:37:29.370 –> 01:37:41.430
Dr. Urse: To know whether a shot alone is going to help them with BRB or where they needed actually repaired. So I kind of base, whether it needs repaired versus a PRP injection on how much weakness. They have and how what their what their

660
01:37:42.480 –> 01:37:50.610
Dr. Urse: MRI looks like. Is it an 80% tear the tendon and they had it for a while. Can they go up a flight of steps and they do a single standard squat test, blah, blah, blah.

661
01:37:51.090 –> 01:38:04.380
Dr. Urse: If they have a intro tricolor problem that’s repairable then I’ll scope their hip and then I’ll usually just inject PRP and their glute tended at the same time. And those people usually do really well if they have Partial tears.

662
01:38:05.670 –> 01:38:17.220
Dr. Urse: If they have a crappy hip that needs replaced. Well, then I’ll just do a post your approach to their hip, so I can fix their glute while I’m doing their hip replacement. So there may be

663
01:38:18.360 –> 01:38:21.990
Dr. Urse: I mean, I think you can do a natural. I don’t really do annual agile approaches.

664
01:38:23.280 –> 01:38:29.730
Dr. Urse: So my partners do but I’m pretty comfortable post your approaches. So I’ll do that and just fix them like you do those heavy hip fractures.

665
01:38:30.030 –> 01:38:41.730
Dr. Urse: Where you’re just nip and you’re looking right at the glute tear. When you do the total hip. So you just fix them both. While you’re there, that is a reason to do more imaging on some of the arthritic hip because it

666
01:38:42.960 –> 01:38:43.830
Dr. Urse: Or not.

667
01:38:44.970 –> 01:38:56.010
Dr. Urse: Then you sometimes they’re going to miss glute tears. If you don’t image. Those people ahead of time. You think they’re living their arthritis. If you do an answer, hip, you’re not going to see the glute tears all i mean you know we’re near those

668
01:38:57.030 –> 01:39:00.090
andrearowland: It seems to me that the meat tears can lead to

669
01:39:01.170 –> 01:39:10.350
andrearowland: You know shearing forces and hip and create then that art supply the need for arthroplasty, I don’t know, I just feel like one leads to the other, like you said, maybe the tip of the iceberg.

670
01:39:12.480 –> 01:39:17.610
Dr. Urse: Well, I’m not sure I have an answer for that. I’m not sure the glue tears lead to hip issues.

671
01:39:19.530 –> 01:39:23.460
Dr. Urse: I just think error so commonly missed. I think the average

672
01:39:24.270 –> 01:39:32.970
Dr. Urse: Person’s not imaging them. They’re injecting the wrong place. I think they’re injecting the burst over and over and I mean how many times on his shoulder, you tell someone

673
01:39:33.750 –> 01:39:41.250
Dr. Urse: Hey you got weakness and pain in your shoulder. I’m gonna give you a shot. It’s a versus shot doesn’t help. Once you to come back in three months and my pa give you another versus shot.

674
01:39:41.580 –> 01:39:44.040
Dr. Urse: That isn’t working, once you come back three months from that get another versus

675
01:39:44.670 –> 01:39:54.990
Dr. Urse: Not going to an MRI and look for a rotator cuff tear that can’t be the reason your shoulders week and painful. It has to be the bird. Well, that’s what we do with hip. So we just leave these hips and keep giving them shots.

676
01:39:55.230 –> 01:39:56.580
Dr. Urse: We don’t fit the tendon.

677
01:39:56.880 –> 01:40:09.960
Dr. Urse: Or address the tendon or we don’t see if the pain and the outside of the episodes coming from inside the hip and that can be from, you know, any particular problem. I think the arthritis part I think we see pretty well on imaging studies.

678
01:40:14.730 –> 01:40:15.480
Dominic DiMarino: Doctors

679
01:40:16.980 –> 01:40:19.410
Dominic DiMarino: From a rehab perspective with these gluten needs.

680
01:40:20.580 –> 01:40:25.050
Dominic DiMarino: You know we like to gradually low tissue and with this being like the rotator cuff of the hip.

681
01:40:26.100 –> 01:40:32.730
Dominic DiMarino: We get them out of that brace at six weeks, one can they handle the way to the body which know because of the muscles, probably not firing.

682
01:40:33.270 –> 01:40:43.470
Dominic DiMarino: But to, at what point are you okay with us maybe doing some ice and metrics with these glue needs, just to kind of start promoting more more tense how strengthening that repair.

683
01:40:43.890 –> 01:40:49.350
Dr. Urse: Into 12 weeks because I know the Sharpie fiber attachments of the 10 into the month of the bone are good.

684
01:40:50.460 –> 01:40:56.550
Dr. Urse: But I think that you’re doubling everything on weakness and strength recovery on a glute media’s versus a cuff.

685
01:40:57.810 –> 01:41:02.460
Dr. Urse: And that’s why if they’ll use I’m out here to get other breaking six weeks as long as you use a cane or pledge.

686
01:41:03.480 –> 01:41:12.150
Dr. Urse: I tell them it’s in Churchill had a you know a walking stick. We’ll call it even if they get a staff like Gandalf on Lord of the Rings with somebody, don’t fall.

687
01:41:12.720 –> 01:41:21.510
Dr. Urse: But I think if you can get those muscles firing me maybe we find some other ways to speed up the recovery, but like Brad said a lot of these people are willing

688
01:41:22.980 –> 01:41:28.230
Dr. Urse: To begin with, or they’ve had the tears for a while. Some of them atrophy. We haven’t even talked about the

689
01:41:29.310 –> 01:41:36.150
Dr. Urse: Classification of hip tears with atrophy or not just like the shoulder gets some muscle atrophy also and fatty infiltration.

690
01:41:38.040 –> 01:41:41.790
Dr. Urse: Rather you doing some PRP injections for Partial tears on your glutes.

691
01:41:42.240 –> 01:41:42.960
Bradley Jelen: Here and there.

692
01:41:44.940 –> 01:41:50.040
Bradley Jelen: It’s bad more payment issue. A lot of people don’t want to spend the money.

693
01:41:51.390 –> 01:41:55.080
Bradley Jelen: And getting insurance locally here to pay for it pretty tough.

694
01:41:55.380 –> 01:41:57.750
Dr. Urse: And I tell you what I’ve done. And I’ll just

695
01:41:57.780 –> 01:42:14.700
Dr. Urse: throw this out at you. I tell people that I’m going to do a nice anatomy near have taken the outpatient thing. And I’ll say, Look, I can do it. That’d be a great study if you want to do it with me and take Partial tears, where they don’t have significant weakness.

696
01:42:15.930 –> 01:42:23.610
Dr. Urse: And half the people get a pretty tedious tonight me the long tip topaz use an old sound to place it accurately and put your needle into that.

697
01:42:24.240 –> 01:42:33.990
Dr. Urse: Half the people get red dye. Number two, and the other half get looks I rich PRP whether the anatomy and the irritation of the actual tissue.

698
01:42:34.470 –> 01:42:41.760
Dr. Urse: Helps healing. Like it would on a tennis elbow injection or whether it’s the PRP. I mean, and I and I take my patient. I tell them, look, I’m going to do a

699
01:42:42.090 –> 01:42:52.920
Dr. Urse: Tonight I’m either tendon and I’m going to see if that’ll help the healing. If you don’t want to pay for the PRP don’t pay for it. And I just do a prettiness and anatomy and a lot of them actually get better with just that.

700
01:42:54.090 –> 01:43:03.930
Dr. Urse: And it’s a minimally invasive procedure you avoid all this rehab and repair protocol and bracing and I tell them it’s going to be, you know, two to 10 weeks to feel better.

701
01:43:04.170 –> 01:43:05.100
Dr. Urse: But if it works.

702
01:43:05.340 –> 01:43:12.090
Dr. Urse: I mean especially some of my fat or patients who get them and I’ll do both sides which pertains to automate and these people feel better. It’s

703
01:43:12.450 –> 01:43:13.080
Bradley Jelen: Thanks. Now,

704
01:43:13.500 –> 01:43:14.970
Dr. Urse: And even without the PRP so

705
01:43:14.970 –> 01:43:15.030
Dr. Urse: I’d

706
01:43:15.360 –> 01:43:23.400
Dr. Urse: Like to know if that helps. And then I let the insurance fight it out with the hospital on the PRP and we’ve got some carriers that cover some of it.

707
01:43:24.570 –> 01:43:32.640
Dr. Urse: And then our office has a baseline charge if I do it, and if they pay that and we find out the hospital. I don’t get a lot of complaints on my PRP.

708
01:43:34.050 –> 01:43:38.820
Dr. Urse: littles but somehow it’s getting worked out. I don’t know what it is. I don’t do

709
01:43:40.500 –> 01:43:41.220
Bradley Jelen: Like that and

710
01:43:42.450 –> 01:43:46.710
Bradley Jelen: I would say a handful of fun inspiration is just right in the office.

711
01:43:47.910 –> 01:43:51.510
Bradley Jelen: Under ultrasound with pretty good results surprisingly good

712
01:43:53.370 –> 01:43:58.140
Bradley Jelen: I think what’s his name Jacobson radiologist up in Michigan.

713
01:43:58.170 –> 01:44:09.780
Bradley Jelen: Uber has shown some pretty good results with that people hurt a lot. I’m pretty aggressive with what I do, but trying to kind of insight that reaction.

714
01:44:11.280 –> 01:44:15.600
Bradley Jelen: And I do think I call it, I tell my patients. It’s the poor man’s PRP.

715
01:44:16.800 –> 01:44:19.320
Bradley Jelen: Because I think you’re you’re trying to do the same thing.

716
01:44:20.460 –> 01:44:29.670
Dr. Urse: Yeah, I think there’s got to be some credence to that. I think the thing I do if I do it at the surgery centers that get some law juice and it doesn’t hurt as much

717
01:44:30.480 –> 01:44:42.150
Dr. Urse: But it’s a procedure and it’s usually covered, you know, and there’s what I do is I call it a perfect. I tell I tell the insurance company. It’s a PR cutaneous anatomy of attendance.

718
01:44:43.050 –> 01:44:48.510
Dr. Urse: We have a code for add doctors like when they trying the doctors and cerebral palsy up yet. There’s a code for

719
01:44:49.380 –> 01:44:58.860
Dr. Urse: Me, I say, it’s like an ad. Dr. Tonight me through the skin, or maybe later. So it’s like this cup. It’s actually 29999 or

720
01:44:59.280 –> 01:45:08.490
Dr. Urse: Whatever you want to use. And then the insurance is have an idea of what you’re doing and they will approve it. And then the patient’s pretty happy. They don’t have that misery in the office.

721
01:45:09.570 –> 01:45:19.620
Dr. Urse: That being said, my partners who are that elbow and hand, we need a lot of them when they do tennis elbow injections. They’re not even putting steroids and they’re just bang and the

722
01:45:19.650 –> 01:45:26.790
Dr. Urse: pecan dial wasn’t needle and put wholesaling in doing the same thing. So I think that what you’re doing, make sense.

723
01:45:27.510 –> 01:45:38.820
Dr. Urse: I think it’s just like that. It’s like that cartoon or the Bulldog has the little bird digging its claws and they’re back and how much pain is that person going to put up with as you have into their

724
01:45:39.690 –> 01:45:54.690
Dr. Urse: Into their your glue it doesn’t. I think it makes sense. I mean, I really do. I think your, your idea is good. I like doing it under a little more control, but then they got to drop any, you know, the blood draws little easier in your

725
01:45:56.850 –> 01:45:58.620
Dr. Urse: You need for looks a rich

726
01:46:02.790 –> 01:46:10.470
Amy Harris: Doctor, so I was just gonna say earlier and you were talking about the muscles that cross the joint, you know, bring a sensory nerve into that joint

727
01:46:10.800 –> 01:46:20.460
Amy Harris: I’ve noticed clinically a lot with doing the dry needling that some of those patients as releasing those muscles and trigger points in the glute meat and the movement and

728
01:46:21.810 –> 01:46:37.020
Amy Harris: The CFL they’re actually having, you know, a lot of relief of their pain. Some of them even like you know needle that Leo. So as and they’re getting some relief of what they would describe as, like, you know, the femoral as the tabular impingement types and you know symptom so

729
01:46:37.260 –> 01:46:37.920
Amy Harris: Just cleaning

730
01:46:38.220 –> 01:46:38.550
Amy Harris: And really

731
01:46:39.060 –> 01:46:40.530
Dr. Urse: Smooth SO AS TENANTS.

732
01:46:41.430 –> 01:46:44.310
Dr. Urse: What you dry needling the associate oh

733
01:46:44.850 –> 01:46:46.530
Dr. Urse: Yeah, well,

734
01:46:47.070 –> 01:46:55.740
Amy Harris: Like them I’m utilizing. I mean, more so than muscle as it’s coming down like I’m not going all the way down to the tendon itself. But yeah, we need all in

735
01:46:58.050 –> 01:47:01.920
Dr. Urse: One one another, getting some more abductors than the other. So it’s, it’s a pretty deep muscle.

736
01:47:03.570 –> 01:47:10.530
Dr. Urse: Well, I know dry needling helps. I’ve had it done on my hamstrings. I keep entering a baseball. So I’m a big proponent of it so

737
01:47:11.340 –> 01:47:25.770
Amy Harris: Yeah, definitely. And really good for. I mean, when people are having, like the snapping hips syndrome, like the the tightness in the CFL we I’ve had patients where we’ve gotten that released with the kneeling, and they’ve gotten relief of just snapping up or somewhat or completely

738
01:47:26.730 –> 01:47:33.720
Dr. Urse: Yeah, I will leave you. One more thing that it’s worth doing is there’s a YouTube video called How to Fix frontal hip pain.

739
01:47:34.440 –> 01:47:49.410
Dr. Urse: And you guys probably do this in therapy already, but they take those big their bands in the upper thigh and put them on a pole and then that helps pull the femur back so that you get less impingement. So it’s a it’s more of a dynamic

740
01:47:50.910 –> 01:47:56.790
Dr. Urse: Method to stretch the hip flexors even, even the yoga stretches called proud warrior where you open up that

741
01:47:57.180 –> 01:48:15.690
Dr. Urse: front hip and stretch with your hip extending is, you know, a useful thing. I put a lot of my patients in either yoga or polities or try to keep them from sitting all day and desks or cars, you know, these adjustable desk heights are also good for the people who can stand if they can

742
01:48:17.430 –> 01:48:26.490
Dr. Urse: Well, I want to thank you everybody for this a kind of went over a little on time. But I did want to cover a lot of different areas on the hip. That’s my

743
01:48:27.570 –> 01:48:32.040
Dr. Urse: Hip for Tata talk. So thanks for listening.

744
01:48:34.080 –> 01:48:35.430
Bradley Jelen: Job, Job enjoy it.

745
01:48:35.910 –> 01:48:37.080
Dr. Urse: Then on Brad.

746
01:48:38.160 –> 01:48:38.670
Bradley Jelen: Thanks.

747
01:48:38.910 –> 01:48:39.420
Dominic DiMarino: Thank you.

748
01:48:40.710 –> 01:48:41.490
Wike Family: Thank you.

749
01:48:42.600 –> 01:48:44.130
Dr. Urse: Know if you want another topic you

750
01:48:44.550 –> 01:48:45.750
Dr. Urse: Put some slides together.

751
01:48:48.060 –> 01:48:48.630
Dominic DiMarino: Will do.

752
01:48:49.980 –> 01:48:50.700
Dominic DiMarino: Thanks again.

753
01:48:51.780 –> 01:48:52.230
Dr. Urse: See you later.