kayalortho Podcast
I would like to take this opportunity to welcome you to another episode of the kayalortho Podcast. My name is Dr. Robert A. Kayal, and I am a board-certified Orthopaedic Surgeon and Founder, President & CEO of the Kayal Orthopaedic Center. We are a large multi-specialty and multi-disciplinary musculoskeletal medical center in Northern NJ and NY, specializing in orthopaedic surgery, interventional pain management, rheumatology, podiatry, chiropractics, physical therapy, massage therapy, acupuncture and high-resolution, cross-sectional medical imaging. For additional information or to schedule an appointment with one of our health care providers, you can contact us at 844-777-0910 or at kayalortho.com.
kayalortho Podcast
Navigating Hip Health: Dr. Victor Ortiz on Joint Anatomy, Innovative Treatments, and Preservation Techniques
Unlock the secrets of hip health with Dr. Victor Ortiz as we navigate the complexities of hip anatomy and the innovative treatments that are shifting the landscape of patient care. The hip joint is more than a ball and socket point—it's a marvel of engineering that Dr. Ortiz decodes for us, shedding light on the labrum's pivotal role in joint stability and how its dysfunction can lead to debilitating conditions like FAI and labral tears. Suffering from hip pain or know someone who is? Get ready to arm yourself with knowledge that could change the course of treatment.
This episode is a deep dive into how experts like Dr. Ortiz diagnose hip joint pathologies. Through a detailed exploration of examination techniques such as the FADIR and FABER tests, we reveal how specialists pinpoint the exact nature of hip discomfort. Discover the puzzle pieces that contribute to these conditions and how early detection can keep invasive surgeries at bay. Athletes, the hypermobile, and the young active demographic - this conversation is especially relevant to you as we uncover why these issues are so important.
For those weighing the options between surgery and non-invasive treatment, Dr. Ortiz illuminates the path to recovery. We investigate the role of physical therapy in strengthening core muscles and how diagnostic injections can be game-changers in managing hip pain. Delving into the realm of hip preservation procedures, we look at when surgery becomes the right choice and the breakthroughs in minimally invasive techniques like hip arthroscopy. Join us for this episode and take a significant step towards understanding and potentially overcoming hip pain.
Hello and welcome back to another edition of the KL Ortho podcast. Today is January 3, 2024, and we're so privileged to welcome back our very own Dr Victor Ortiz to the KL Ortho podcast. Today's topic is Acetabular Labral Tears and Hip Arthroscopy and a Disease Entity we describe as Femoral Acetabular Impingement. Welcome back to the podcast, dr Ortiz.
Victor Ortiz, MD:Thank you, Dr KL, for having me and looking forward to having a good discussion about hypertroscopy.
Robert A. Kayal, MD:Yeah, it's great having you back, and happy new year everyone. Well, we're first going to start out by having Dr Ortiz just describe the anatomy of the hip joint, and then we'll delve into what a labral tear is and what Femoral Acetabular Impingement is, how we diagnose it and how we treat it as well.
Victor Ortiz, MD:Perfect. So I think everything is important to start with how the anatomy of any joint in the body is, and it's especially the hip. I think it's one thing that I'm passionate about and the hip is a ball and socket joint and I always try to explain to the patients which is showing my hands is like a ball and a socket. So those are the bony parts of the joint that create that motion, that create that bony stability. But in addition to the bone, there's other soft tissues around the hip that are very important and that we have learned through time that treating them helps patients with recovery and symptoms.
Victor Ortiz, MD:And that entails the labrum, which is that extension of that acetabular rim that provides stability to the hip. We also have some ligaments, or the capsule is like that bag that covers the joint. That also provides a lot of stability and keeping that fluid in the joint. And that fluid that the joint has is very important because it provides nutrients to the cartilage and lubrication to the area. So there's a lot of roles for the soft tissues that are important, as same as the bony anatomy.
Robert A. Kayal, MD:Yeah, the hip joints, the ball and socket joint, as you described, very much like the shoulder joint right, which is a ball and socket joint. You know, the ball and socket joints are joints that basically have a lot of mobility typically, and because of the mobility, it potentially can be unstable Like we describe. In the shoulder you have a golf ball that potentially can fall off that golf teeth. But in the hip it's a little different. Right the ball is quite large but the socket is quite large as well. But just like in the ball and socket joint of the hip, there's static and dynamic stabilizers. Right, some of the static stabilizers include the bone and the labrum, but in the hip joint and in the shoulder joint we have dynamic stabilizers as well, the muscles right. So one of the static stabilizers we talked about was the labrum. What is the labrum?
Victor Ortiz, MD:So the labrum is an extension of the rim and I think that you know, if we look at the hip, at the socket of the hip, so that rim has an extension that could be four, 10 millimeters in length. The labrum is made of cartilage, it's collagen, it's an extension of that socket that increases surface area.
Robert A. Kayal, MD:It also helps to contain the fluid inside that joint. Right Describe that fluid. For me it's called synovial fluid. What function does the synovial fluid play in the hip joint?
Victor Ortiz, MD:So the synovial fluid is very important. It contains some of the proteins of the cartilage and you know they work with the lubrication of the joint and giving that nutrition to the cartilage that is so important to preserve the hip. You know, when you start losing those characteristics of the fluid or you're losing fluid from the joint, those are the things that can lead to our tritis of the hip.
Robert A. Kayal, MD:Right, the fluid is, like you know, largely made up of hyaluronic acid as well. Right, the lubrication. They have a lot of properties mechanical properties, load absorption, but predominantly nutrition and lubrication to the joint. Right, the analogy I often give patients is like the gasket on a car engine. Right, you have the pistons going up and down these cylinders and the oil provides that lubrication so that the engine doesn't fail. But if that gasket leaks you can literally blow your engine. Right, same thing in the hip joint or any other joint that contains synovial fluid.
Robert A. Kayal, MD:Synovial fluid is so vital for the lubrication function, mechanical properties of the joint, but also for nutritional purposes as well. And so that labrum around that bone socket joint plays such a vital role in maintaining the mechanical properties of that bone socket joint, cushioning it and preserving it to preserve it so it stays vital and healthy and does not deteriorate and become degenerative. Now we talked about some of the static stabilizers, ie the labrum, which you said is mainly fibro cartilage. But the ball and socket joint is also a static stabilizer of that construct. Right, so you have a ball on one side, like you described, and a socket on the other side that you described. Can there be changes that can occur not only to the labrum but to the ball and the socket. That can be detrimental to the hip joint.
Victor Ortiz, MD:Absolutely, and I think that's where we can talk about impingement of the hip. So there are two types of impingements in the hip that are very common, and the first one would be that the head is not completely rounded. So when the patient is flexing or rotating the hip, the ball is not completely rounded, so you're rubbing against the labrum. The second type of impingement would be in the socket part, so we have over coverage or the socket is more proud. So when we have a socket that is more proud I always try to make this analogy right Usually the normal coverage should be like this, but a lot of times there are places that are over covered. So when you're over covered, that distance between pinch or make the ball hit the socket is smaller and that creates that pair of the labrum.
Robert A. Kayal, MD:Right, and that often occurs in a condition we call acetabular retroversion right Correct. So why don't we describe the version of the acetabular and what is a normal version of the acetabular, so our viewing audience can get an understanding?
Victor Ortiz, MD:So if we're looking at the socket, I always tell the patient the socket is always looking towards us, where it's looking to the front. But there are different patients, have different morphologies, they're born different ways and one of the things that can happen is that the cup, instead of being looking to the front or the socket, it starts looking backwards, and that's what Dr Kale just mentioned about retroversion. So when the cup is looking backwards and you can identify that just from x-rays in the office the patient, the distance again to impingement is less. So the patients are at risk of these type of pairs or injuries and it's very important to be able to identify them because we have not only treat the pair but we also have to treat any anatomic, the morphology or deformity that the patient has.
Robert A. Kayal, MD:Right that acetabular retroversion can result in that femoral acetabular impingement that we described. And, by the way, this condition is called FAI or femoral acetabular impingement, and we call it that because the femur is the thigh bone, the acetabulum is the cup and you can get that mechanical impingement for the reasons that Dr Ortiz already outlined, between the femur and the acetabulum and that's why we call it FAI or femoral acetabular impingement. And this FAI, femoral acetabular impingement, may or may not result in acetabular labral tears and when those labral tears occur it ultimately often can lead to degenerative changes in the hip and hip arthritis ultimately as well. And by the way, I failed to mention earlier that Dr Ortiz, dr Victor Ortiz, is our hip specialist. He's the chief of the hip service at the Kale Orthopedic Center. Dr Ortiz is double fellowship trained. By the way, he's fellowship trained in hip arthroscopy and hip preservation as well as sports medicine and arthroscopy. He did a one year fellowship in Chicago in the area of sports medicine and arthroscopy and then stayed in Chicago to do a second fellowship at the American Hip Institute, also in Chicago, with a world renowned hip arthroscopy specialist. So he did that second year of training in this relatively new field of orthopedics called hip preservation. So he was hired specifically many years ago and joined the Kale Orthopedic Center, primarily to spearhead this cutting edge field in the area of orthopedics called hip preservation, where we're trying now to save patients' hips at a younger age and prevent them, hopefully, from ultimately requiring a hip replacement. So it's really been an amazing addition to our practice having Dr Ortiz with us.
Robert A. Kayal, MD:So, that being said, we talked about these forms of mechanical impingement, ultimately causing labral tears. Another way of describing this in layman's terms is to basically say that between the femur and the acetabulum you can get these spurs. Sometimes we'll call them spurs. On the femoral side we call those gross, bone-gross cam lesions and on the acetabular side we call that a pincer lesion. So you may hear your doctor talk about a cam lesion or a pincer lesion, but essentially we're discussing this condition called femoral acetabular impingement, and so at this point we should really talk about how the patients will typically present with these conditions. Dr Ortiz, how does a patient typically present to the office when you're suspicious of this condition?
Victor Ortiz, MD:So the most common complaint would be pain and a lot of the patients will grab their hand like a letter C and it's called like a C sign. They'll grab the hand like a letter C, they'll put it around the hip joint area and that's where my pain is and that's the main complaint. When they come to the office they are saying I have this pain usually worse with running, prolonged standing or any type of activity that requires cutting, twisting, pivoting or deep squatting. And I always tell the patients extreme range of motion, especially when you flex the hip or you rotate internally like what you're cutting. That's usually the most common complaint of patients.
Robert A. Kayal, MD:Hip pain definitely, and I can't overemphasize enough that complaint of what we call the C sign. It's almost universal, it's almost pathodontic for this condition. When patients, when you're assessing patients, and you ask them specifically where their pain is, they almost universally all go like this they grab their hip, just like Dr Ortiz described and we call that the C sign, and they grab their hip sort of just like this. They go like this it's here, it's here. You know they're describing the pain deep and it's not in the front, it's not in the back, it's sort of between where your thumb and your fingers meet, deep in the middle. That's the hip joint. A lot of patients come into our office and they think that this is the hip. They say, dr Kale, my hip hurts over here or this is my hip over here. It can be, but it's more often than not Pain in that location tends to be stemming primarily from the back.
Robert A. Kayal, MD:But the hip, to the orthopedic surgeon, is the groin. So when patients complain of pain in the groin, it's almost always secondary to what we call intraarticular hip joint pathology, a problem stemming from within the hip joint itself. It could be a labral tear, it could be water in the joint, it could be hip arthritis, we don't know. But typically groin pain more often than not is stemming from the hip joint itself, and nowhere else Would you agree with that, totally agree. Okay, so they come, complain of pain. But we described also that the labrum is associated with stability of the hip right. It keeps the joint together. We talked about the static stabilizers. So it's a stabilizer of the hip and it helps to stabilize. So if that labrum is torn, that hip's also going to feel unstable, a little bit right Correct, so mechanically the patients may complain that their hip is what Buckling?
Victor Ortiz, MD:or buckling or clicking. They can even hear like a pop or say like isn't that can create this pop, and that can be a case.
Robert A. Kayal, MD:Yeah, and they feel unstable, like when they navigate stairs. Sometimes they have to hold on to the side rail right, so that can be another complaint. So pain, and again that classical location that we described, that C sign, but also instability, anything else?
Victor Ortiz, MD:I think those are the main main presentation. You know, I think the 95% of our patients will show up with those type of history. There's another 5% that might have a different history and that's where you know we have to be a little bit more like aggressive, just include all the type of diagnostic tests that we might discuss down the road, but absolutely that would be the most common presentation.
Robert A. Kayal, MD:I agree. And then once you're suspicious of that, we can do a bunch of things on physical examination to confirm that diagnosis right Totally. What are some of those things, dr Ortiz?
Victor Ortiz, MD:So I think the first thing that I would do in a physical examination is inspect the hip. You know, I think a lot of times patients will be able to show you what's going on just from a simple inspection. Then you have to touch the area, and there are a lot of areas in the hip joint that you can touch, going down the way to the front, all the way to the back. You know, you can touch the hip flexors, you can touch the trochanteric bursa, you can touch the deep gluteal muscles. There's a lot of areas in the hip that can give you an idea of what's going on.
Victor Ortiz, MD:And then the next step will be to examine the range of motion. You know, just feeling the range of motion of the patients can give you a lot of information, especially of that bony anatomy or that bony morphology when are you rotating that hip, when do you get a block, when do you get a stop? And that gives you an idea of what's going on inside. So examining the range of motion is very important. And then this we have this classic exam. It's called a Fader, a flexion adduction, internal rotation. But what that means is that we are really recreating that position of impingement. We're flexing the hip, bringing it against the socket and creating some rotation, and that triggers the pain in the spasms. If the labrum is the symptom that is causing the pain.
Robert A. Kayal, MD:Right and for the most part this is an anterior sided hip problem right.
Robert A. Kayal, MD:It's almost always occurring in the front of the hip joint, so in the front of your body as opposed to the back of your body, and so you know it's a condition that occurs very often in deep flexion combined with rotation that he's describing.
Robert A. Kayal, MD:And because of that we do this classic quote, unquote impingement test and that's what he was describing where we take the patient lying down and we flex their hip beyond 90 degrees and combine that with what we call adduction and internal rotation.
Robert A. Kayal, MD:So just to demonstrate, I'll take this hip of mine and we'd flex it into deep flexion, adduct it and internally rotate at the same time, and that very often will create that mechanical impingement syndrome resulting in exacerbation of the patient's symptoms. That will hurt because when you're impinging you're irritating the torn labrum or further displacing the torn labrum, and that is a fairly classic test. So combine the history of pain in the front of the hip primarily, where the patient say that the pain is exacerbated by squatting, for instance, or sitting in a low chair for a prolonged period of time, and then corroborating that with their physical examination, where you flex them, you bring their knees together and you internally rotate that hip where it will trigger or exacerbate, elicit that painful response. That's fairly classic for an acetabular labral tear or the condition we described as femoral acetabular impingement. So that's really important. And, by the way, the patients that get these labral tears are typically in what age group population?
Victor Ortiz, MD:I would say anywhere in their late teens to the 40s and 50s, you know, anywhere around that range we can see these double tears Right, but in general, what the point I was trying to make is we're dealing with a younger age group population.
Robert A. Kayal, MD:We're not diagnosing labral tears and patients in their mid to late 60s, 70s and 80s. That's typically a different source of hip pain in that age group population and more often than that that would be a degenerative arthritic condition more often than not. So we're classically diagnosing femoral acetabular impingement and labral tears in patients in this younger age group population. So now that we may have a differential diagnosis and for the most part it's way up there we're thinking that this patient has a labral tear, femoral acetabular impingement. And, by the way, before I get to the next point, does everyone with femoral acetabular impingement get a labral tear and does everyone with a labral tear have femoral acetabular impingement? What's your opinion on that?
Victor Ortiz, MD:No, not everyone gets that If I think we can have patients only with impingement and we do imaging and we do the procedure and they don't have a torn labrum and the problem is impingement which might lead to that down the road. But I think that with the technology that we have today, we have been able to identify a lot of things before they happen. But they can happen one without the other.
Robert A. Kayal, MD:Yeah, and are certain patients at risk for developing these femoral acetabular impingement conditions or labral tears?
Victor Ortiz, MD:Absolutely. I think that if you know, I think, looking at the technology, as I mentioned, all the improvements that we have and innovations, and when you look at professional players, all the studies that they have done with these combines, when they go to the draft and all the x-rays that they take, you know you look at hockey players like goldies for hockey, 90% of them will have femoral acetabular impingement. And if you look at all those soccer players, basketball players, football players, there's a high incidence in some positions and high impact. Things that require a lot of cutting and twisting and a lot of pressure in the growth place when you were growing up are patients that are at risk of having these deformities.
Robert A. Kayal, MD:Is there a genetic component? Is there a genetic component to this condition? What?
Victor Ortiz, MD:do you think? I don't think I haven't seen anything identified to a genetic component, but there's absolutely a correlation between families. You know there's people that they have it and they have it on both sides. So there's absolutely something in the genetic part, but nothing that I can tell that is.
Robert A. Kayal, MD:I mean, certainly there is an arthritis, so you would think you would deduce that there probably is or will be ultimately discovered down the road. This is a relatively new diagnosis in the field of orthopedic surgery. Right, you know, prior to this diagnosis of femoral acetabular impingement, patients just ended up getting arthritis and we told them that they had arthritis. But this may be indeed a very significant risk factor for those patients and if we can identify that early, you may be able to save a lot of patients from needing a hip replacement down the road. That's our hope. That's the concept of this fellowship training that Dr Ortiz did for that added year in the field of hip preservation Trying to preserve patients own hips as opposed to replacing them with implants. That's the goal of making this diagnosis at an early age, and we'll talk about how we can intervene in effort to do that. What about patients that have ligamentous laxity, for instance? So young girls that are hypermobile, ligamentous lax? Are those patients at risk for any problems?
Victor Ortiz, MD:Absolutely. I think that. Thank you for the question, because I think that's something that I emphasize a lot, especially when I'm talking to other orthopedic surgeons or colleagues in the field. I think that young female with hypermobility we have this baton score where we're always checking the patients do they hyper extend the elbows, do they hyper extend the fingers?
Victor Ortiz, MD:That patient is at risk of having a torn labrum because they have instability or joint laxity. So that's a patient that whenever if we decide to do a surgical treatment, we have to treat the cause of the tear and that's the instability. So we have to make sure that when we're doing that procedure tension in the soft tissues we have physical therapy making sure that they work on tension in the soft tissues because you're protecting that repair. I think that sometimes I have heard that people said oh no, this patient is a young female with just a small labral tear. I think that's the most challenging case because you have to fix the labrum but you have to make sure you tension everything around that If you go in there and you don't do that, you're making the problem worse.
Robert A. Kayal, MD:Yeah, I'm with you. We deal with the same issues in the area of knee replacement surgery, when patients are ligamentously lax, dealing with those patients with hypermobile joints that tend to go into recurvotum or hyperextension of their knee. That's a scary thing. So I'm with you on that. So now that we've made that diagnosis, how do we confirm it? What type of imaging studies can we do to confirm the diagnosis?
Victor Ortiz, MD:So there's multiple imaging in our office. The first thing, and the thing that gives me more information, is x-rays, plain x-rays, where you can see all these. First look at the space how much space this patient has. Then look at this bone hemophilia, look at the socket, look at the ball, look if they have any type of impingement that we discussed and then you can see how the acetabular socket is looking. It's looking to the back, it's looking backwards. So that gives you an idea of what to expect when you get MRIs or CT scans.
Victor Ortiz, MD:I think the MRI is probably going to confirm our suspicion from our physical examination and our plain x-rays and it's probably the most this is the most specific testing to identify how the labrum is. I think that MRI also has a lot of utility in that patient to make sure that we don't have more advanced damage, more advanced arthritis. So sometimes these MRIs will show patients that have a full defect of a full hole in the cartilage or a demined bone. Those are signs that there's more advanced damage in the hip joint and that patient might not be a candidate for a hip precipitation procedure. I think that all the imaging is important for us to really identify who's a good candidate if they have to have any surgical procedure down the road with respect to imaging and X-rays in general.
Robert A. Kayal, MD:Are you just getting routine x-rays in the office of the hip or the pelvis or are you getting special views, and why is that important?
Victor Ortiz, MD:We have a very specific protocol and it has special views. You know, we get the plane, the normal x-rays, we get a standing Because we want to make sure that when the patient put weight on it, how the hip is behaving, we have other views. That really allows us to see. You know, x-rays only charges two dimensions, so we try to bring different views, to get other dimensions of how the hip is, to make sure that we have a socket that is covering enough the ball or you have enough coverage at the ball so we can measure that in different angles to make sure that we're making you know the right planning and right decision, yeah, or what the patient needs are you typically getting weight-bearing images in the office or supine images?
Robert A. Kayal, MD:We get both. We get a weight-bearing and a supine. Great, and then how about on MRI? What, what kinds of things are you looking for on MRI?
Victor Ortiz, MD:So in MRIs we we want to confirm, we want to make sure that the patient has a torn labrum. So we can see the labrum in the MRI in different views and you can see either a line going through it, you can see some blunting, you can see some intra substance fluid, you can see some cyst. Sometimes, when you have a tear, the labrum, the fluid, the fluid from the joint will start leaking to that here and so you can see signs in the MRI that confirm that that's the problem that's going on.
Victor Ortiz, MD:I also think the MRI for me is more important in that patient you know might be borderline between having a Hebertroscopy or a replacement, because you can never. You see subcontracted email whenever you see any cyst in the MRI. Those are findings that are telling you they are. There's more damage. And when you go in there there might be more damage. And it's important for me to have a good discussion with the patient about Expectations, about what the outcomes are gonna be if we decide to go ahead when and when the MRI is showing more Damage than what we see in the x-rays and primarily you, you're looking primarily for just disease Isolated to that one area of the hip, right, that anterior superior area on MRI.
Robert A. Kayal, MD:So if you start to see changes that are more diffusing nature, like you're describing the subconjural cysts and Marodema everywhere, different things like that, or label tearing, extensive label tearing outside of where you get that femoral acetatecaryl impingement, maybe you'd be thinking more along the lines no longer of hip preservation but maybe hip replacement, right, correct? So yeah, the anterior superior aspect on the MRI, that's where you're looking for your tear, that's where you're looking for your impingement, that's where you're looking for that early cartilage delamination, and I emphasize early, because if it's more advanced then maybe we're talking about that. The hip is no longer salvageable but rather needs to be replaced. And so what is the difference between the labral cartilage and the hyaline articular cartilage and the changes we described? The labral tear on the Label side, but on the acid, but on the Femoral head side, sometimes we see cartilage delamination. What's occurring there?
Victor Ortiz, MD:So I think that there are different type of collagen. You know one. You get the articular cartilage or hyaline cartilage, which is a collagen type 2, which is sulfur, and that's what you can see, some, some fraying delamination, and then you have the Labrum, which is a harder, is more like a like rubber, and instead that extension of the socket, which is harder, you know, tolerates a little bit more pressure and controls really that load bearing and creates a strong suction seal, the hip joint. And they're different, you know they. They is very important to really be able to identify them and in the MRI and treat in the right way, because that's, you know, that's the success of the procedure.
Robert A. Kayal, MD:All right, so it's just like the knee. I always go back to the knee and the knee we're talking about the meniscus, which would be analogous to the labrum in the shoulder and the hip, that type 1 fiber cartilage. And then we have the cartilage that coats the end of the knee joint, called hyaline articular cartilage, which is a type 2 collagen, that softer cushion that Dr Ortiz was describing, and so the key here is to identify changes on the MRI that are consistent with our diagnosis, but not advanced changes. We don't want advanced changes.
Robert A. Kayal, MD:Once we start seeing degenerative changes from a chronic Condition, it may not be a hip that's amenable to salvage anymore, but rather replacement. So we the key is when you're, if you're suffering from any of these conditions, you have to get in to see Dr Ortiz sooner rather than later so he can employ his skill set in the area of hip preservation in effort to try to save your hip, as opposed to Utilize his skill set in the area of robotic direct anterior hip replacement to replace your hip. We're trying to save your hip here, so that's what we're at with respect to that. So we talked about x-rays, special views, we talked about MRI and the things we're looking for. But also there's this 3d cross-sectional high resolution imaging modality called a CT scan, and just like there are protocols with x-rays, there's also protocol specific for this condition femoral acid tabular impingement, where dr Ortiz is ordering a cat scan for very, very specific reasons. Can you elaborate on that regard?
Victor Ortiz, MD:Absolutely, I think. I think cat scan is a very important part of diagnosing and what is the theology, what is the reason why we're having these stairs? The amount of information that we get from the scan is amazing. You know we can get exactly how much overgrowth you have in the ball, how much overgrowth you have in the socket In out. On a clockwise we always like to look at the hip in the socket as a clockwise right 12 to 3 o'clock is usually the area where you see those stairs. So we can correlate that to the cat scan and see is there's an overgrowth in the ball, in the socket, is this an overgrowth in this ball that colorates with that, and how much we have.
Victor Ortiz, MD:Also, I think it's very important what dr Kale mentioned initially about acid tabular retroversion. We can get some landmarks from the cat scan and we can calculate exactly where, what is the version, where is the acid tabulum looking at. But also, more importantly, there's a component of rotation also in the femur. Sometimes there are patients that the femur will be looking a lot to the front, so they will call and the version or increase femurotorchine that can translate to pay people that in tow or out tow. So those things we can measure and are important, because that might be the reason why the patient is having a tear in the labor and you might not need to treat that and you might need to just take care of those things.
Robert A. Kayal, MD:Yeah, that was very helpful. Thanks so much, dr Ortiz. You know, just to reemphasize, the MRI is very, very good at looking at the soft tissues. So when we're looking for a labral tear and we want to assess the articular cartilage or the fibro cartilage of the labrum, mri is the tool of choice. But when we're looking at the, the 3d reconstruction of the bony anatomy, nothing is better than a cat scan. A cat scan Literally reproduces the 3d anatomy of the bony part of this condition femurot, tabular impingement Whereas the MRI very nicely looks at the soft tissue component of this condition the bone marrow, the labrum, the articular cartilage and the soft tissue surrounding the hip joint as well. So both are vital in making a proper diagnosis of this condition, condition and also planning treatment. So now that we're talking about treatment, how do we first intervene when you make the diagnosis?
Victor Ortiz, MD:So every patient that we make the diagnosis or we have the suspicion we always want to start with, they come with pain. So we try to control the pain and we like to use any anti-inflammatory medication. You know, we want to have the patient modify the activities they are doing. As we mentioned, this is something that happens with extreme, some motions. So we try to tell the patient, you know, stay away from things that require a lot of fleshen, a lot of internal rotation. Then we like to do physical therapy.
Victor Ortiz, MD:I think supervised physical therapy is very important. It's a standard of care of any type of joint pain or back pain or neck pain in the in the orthopedic world Is something that we are big on and we emphasize that every patient needs to be in physical therapy. Working there's 17 muscles going to the hip joint. There's a lot of them that we don't use routinely and that's where a good physical therapist start working with you working with the core, we can with the gluteus working, and a lot of these patients come back and the pain is gone after six weeks of physical therapy.
Robert A. Kayal, MD:Yeah, so usually that's that's the first line of treatment for us in our practice and it's been a very successful yeah, because you did mention over and over again that the labrum is a key player in stability of the hip joint, right? So if we, if we've lost some of the static stabilizers, we focus on those dynamic stabilizers, the muscles we can control. We call those dynamic stabilizers. We can control the muscles and provide stability around joints by strengthening muscles and physical therapy. We can't control the static stabilizers, the bone, the cartilage, the labrum, etc. With physical therapy. Those are things that would have to ultimately be addressed Surgery, surgically, if we can't get the stability or the alleviation of pain or achieve our goals with physical therapy alone. So that's why it's important to distinguish between static stabilizers and dynamic stabilizers. Most joints, in fact I would say all joints, have both static and dynamic stabilizers. So we first try non operative care, physical therapy focusing on the dynamic stabilizers, to not only provide stability but also try to restore motion.
Robert A. Kayal, MD:This is a condition it's called femoroacetabular impingement. There's a mechanical impingement Going on around this hip joint that's restricting patients range of motion. That's one of their complaints They've lost motion, they have pain from the impingement or the tears, and we get them into physical therapy, try to restore motion but also to Achieve that stability that we talked about by strengthening the muscles as well, and so that's one of the reasons we start with conservative, non operative care physical therapy. We can also give a man time inflammatory, right. Sometimes they have pain associated with it, so sometimes we'll give a man time inflammatory as well. Sometimes you may not be a hundred percent sure that the pain is coming from the FAI or the labor tear. Is there a diagnostic procedure that you can do to help give you some feedback Whether or not we're treating the right condition? Because we don't like to treat x-rays, we don't like to treat MRIs, we like to treat the patient and make sure we make them better. So what is a tool that we can employ to try to get some feedback?
Victor Ortiz, MD:So I think that the that that's where diagnostic hip injection is the way to go. I think that is probably one of the most powerful tools that we have in that knows, in the hip as a source of the pain. I think all first for the patient, for acting patients sometimes come to us and they say no, I think the back is the problem. I think the I said you know this other thing, and I we tell them this let me give you the hip joint injection, let's see what you get, and they come back and they're surprised, like the pain is completely gone.
Victor Ortiz, MD:I think it's very powerful also for us as a provider because it can differentiate Is this is a backflip area problem? Is this a hip related problem? Is this an overlap where we maybe the hip is 60% and 40%? So it allows us to quantify what's going on to be able to, you know, first, improve the. I think that those injections are really allowed them to have less pain and be able to go to physical therapy and work better. I think that I have incorporated that to my practice because when they come in pain and they go back to the physical therapy, sometimes they come back in three or four days. I don't tolerate the exercises. But you get in the injection, they are able to do those exercises, they come back stronger and they come in a better way. But I think that the power, how powerful it is, in diagnosing the hip as a source of the pain is probably the best test that we have.
Robert A. Kayal, MD:That's great. I couldn't agree with you more, dr Ortiz. But this brings us back to what we talked about earlier, and that is the anatomical location of the hip joint. So it's not a superficial joint. The hip joint is not on the side of your hip, it's a deep joint, it's in the center of your body, between the front of your hip and the back of your hip, and it's in the groin, which is not a superficial joint. And it's important to know that, because you can't easily undergo a hip injection in the office without tools that will help you see that deep joint, and those tools can either be the usage of an ultrasound or the usage of a fluoroscopic X-ray machine that we have in the office that helps you see that deep joint.
Robert A. Kayal, MD:There are certain joints in the body that are very easy to inject, for instance the shoulder, the knee joint, for instance, but the hip joint is one that requires the assistance of imaging in order to get that medicine into the joint, and one way we do that is with the usage of that ultrasound or what's called C-arm fluoroscopy assistance, and sometimes even with that you're not 100% sure you're in the joint. So what we do is what's called an arthrogram. An arthrogram is when we take this contrast material and we first put the contrast material into the joint and perform that arthrogram, then we'll see under C-arm fluoroscopy or ultrasound that the joint is distended because, like Dr Ortiz mentioned earlier, it's like a balloon. The joint is a balloon and so we're filling up that joint with this contrast material and we'll see that contrast material contained within that joint. Once we know we're in the joint, we'll also look to see if there's an extension of that contrast material between the labrum and the bone, and that is that line he was describing on MRI. Sometimes you'll see that line fill in the space between the labrum and the bone, further confirming our suspicion for an acetabular labral tear.
Robert A. Kayal, MD:But then, once he's in the joint and we've confirmed that on ultrasound or C-arm fluoroscopy and, by the way, we have procedure rooms at the K Lord orthopedic center where we do this in these procedure rooms and once we confirm we're in the joint, then he'll add the corticosteroid or the local anesthetic and more often than not patients will get off that table completely relieved of their symptoms right then, and there Immediate relief of their symptoms they feel markedly different, they're able to get off the table, they're able to walk up and down, rotate their hip and for the most part their pain is gone. And that gives the doctor feedback that we're not only treating a study but we're treating the patient for the presumed diagnosis and we're accurate in our diagnosis and our impression of what's going on. So now you've done that and you got that feedback, you'll get the patient for physical therapy like we talked about and you'll see the patient back If the patient's better. You're done right.
Robert A. Kayal, MD:For the most part you don't just treat the patient because there's a labral tear or femoral acetabular impinge, but if there's enough of a pincer lesion or if there's enough of a cam lesion, you're probably going to keep a close eye on that patient because you don't want that to ultimately number one, result in significant loss of motion to that patient.
Robert A. Kayal, MD:Right, because that pincer can get bigger, that cam could get bigger and they can lose motion and we need to preserve motion to put on our socks and shoes and get in and out of cars, all those things. But also that mechanical impingement can cause the changes not only to the labrum but to that highland articular carlos, that delamination which ultimately leads to arthritis. So now that you've made the diagnosis and you're looking at the patient's MRI, cat scan and X-ray. What are the changes on X-ray that would suggest to you that maybe, if this patient fails physical therapy, you can undergo a definitive surgical hip preservation procedure, versus X-ray changes that may ultimately say look, if you fail conservative management, you're going to need a hip replacement? What are those changes you're looking for?
Victor Ortiz, MD:So there are a couple of criteria that we take in consideration when examining X-rays that really allow us to know if the patient would be a good candidate to undergo a hip preservation procedure. But the first one is how much space the patient has left. There's been multiple studies that have shown that if you have less than 2mm of joint space, that's a patient that would Wouldn't do well with a hip precipitation procedure will not do well.
Robert A. Kayal, MD:Right, well, needs a hip replacement.
Victor Ortiz, MD:It would be a reason so that's the first thing that you can see, this a classification of Colettonic classification, where patients zero and one are the good candidates, and the way you classify. That is when you look at the space, you look at this. This bone spurs as clear roses, all those findings. So just from the extra standpoint you get that classification. You have to make sure that you have enough space and you don't have Changes that are consistent with more advanced arthritis, right.
Robert A. Kayal, MD:So what he's talking about is that ball and socket join that first x-ray. You're looking at the ball in the socket and that space that we see on x-ray is not really a space. It's filled with cartilage normally. Well, you want it to be filled with cartilage and if that x-ray is showing that there's less than two millimeters of space Between that ball and socket, you can't save that patient's hip anymore. Ultimately, if that patient fails not operative care, that patient's getting a hip replacement. But if that patient that you're suspicious of has a labral tear, has an x-ray that looks like this and they're still healthy cartilage in or surrounding that ball of the bone socket joint, that patient if that patient fails not operative care, is getting a hip arthroscopy by dr Ortiz to save that patient's hip. That's that hip preservation. So that patient's gonna get well, let's talk about it. It let's talk about that patient.
Robert A. Kayal, MD:That patient now went to physical therapy for how long? How long would you treat them Nonoperatively? You give them a couple cortisone injections. They've they got significant relief. You put them in for physical therapy. Maybe ever, once in a while, they're taking some Tylenol or an anti-inflammatory, but they come back to you. When are you gonna see them back when you're gonna make a decision to pull the trigger, to take the next step.
Victor Ortiz, MD:I should like to wait like around six weeks. You know we can go anywhere from six to twelve, but I think six weeks for me is enough time for the patient to, you know, try all the conservative management, all the, all the non-surgical or non interventional procedures, including the injections, including the medication, including a supervised physical therapy. If they have done that, then like for good six weeks and the symptoms are worse or not getting better, I think that's a patient that would be a good surgical candidate.
Robert A. Kayal, MD:Yeah, and you know you're also listening to them if they're complaining of constant instability, constant pain, constant loss of motion, buckling giving way, they can't navigate stairs. You know every patient's different so you know this is not like a textbook Cookie cutter type of approach. We evaluate each patient, listen to their symptoms and see, see how it's affecting their quality of life. These labral tears, we know will never heal by themselves right.
Robert A. Kayal, MD:This problem is not going to go away by itself. You can manage the symptoms With physical therapy and things like that, but it's never going to heal. So what is your approach to the patient that doesn't want any surgical intervention? Are there any biological therapies or generative medicine techniques that you can employ to To maybe inject into that joint that will give some biology that potentially can alleviate the patient's symptoms and Plus or minus promote some biological healing?
Victor Ortiz, MD:Absolutely, and we have a good amount of patients that they don't have and you know they are maybe Later in age and they say, like you know what, I don't want to have a natuoscopic procedure, I don't want to go to the process. And we always have discussions with about platelet-rich plasma or bone marrow aspirated injections. I think they have a great role. They they are good To decrease the inflammation. I think that it's, uh, the evidence-based medicine out there. You know it's not going to be strong enough to say that it's going to heal the tear, but I think it brings all these cells, all these components that decrease inflammation and it will help with pain.
Victor Ortiz, MD:And so far we, I think in my hands I have had a great success of Of outcomes with those patients. You know, one of the things that I did in my training of herperecivation was within the case series, although in those patients a little bit different there was. Those were patients that Were not a surgical candidate because of that x-ray less than two millimeters, or an MRI that showed Moral arthritis, and but they were not completely bone-on-bone, it was not like a bone-on-bone patient. So we injected them with prp, we filed them for a year and all those patients have improvement in their patient reported outcomes. Um so I think is something that is a an absolutely a great option for those patients that don't want to go undergo a procedure.
Robert A. Kayal, MD:Yeah, I mean certainly the prp, or the platelet-rich plasma, has some Anti-inflammatory properties associated with it. It's something we offer routinely to our patients and perform routinely at the Kaila orthopedic center. A little bit of a disclaimer it is not FDA approved. It is considered by most insurance companies to be experimental, but a lot of patients believe in it and certainly that's where Medicine is heading and orthopedics in general is heading in the era of regenerative medicine, repairing as opposed to replacing. We do offer those technologies and anecdotally we both can tell you that it's helped a ton of patients in our practice for sure. And so if, if patients are adamantly opposed to fixing the problem and they're willing to try Maybe some future experimental orthobiological therapies for regenerative medical Therapies and interventions, we would be happy to oblige and offer you those services because we offer them routinely at the Kaila orthopedic center. So now You've indicated the patient for hip arthroscopy, let's talk about your approach to hip arthroscopy and what your goals are and how you achieve those goals.
Victor Ortiz, MD:It is also once we identify the, the label, there is what is causing the symptoms in the patients, and we would run all these imaging studies, physical examination, conservative management we have to be able to identify what are the sources of the pain, what is causing the problem, and I think that we have to. A lot of the times Maybe 90, 99 percent of the times we have a torn labrum, but I always ask myself why did the patient had a torn labrum? Was this because they have an impeachment? Was this because they are having hypermobility, as we discussed earlier? So we have to come with the plan and to offer the patient how can we fix this, but also how can we avoid this from happening in the future. And I think that's the most important thing in the decision-making process, in my conversation with the patients about what are we going to be doing, how are we? We attacking this? Um, the goal, and I think that when we're offering this procedure to the patient, the goal and only goal for surgery should be to improve pain and Functionality and that that's the main thing. You don't have pain, you don't need surgery, but if there's pain, we want to make the better, there's a highly high chance if you fail, everything we have done that we can make you better. And there's always a secondary goal that if we are preserved, we are fixing these problems, that we can preserve this, if that we can win time and give you More time down the road before the need of a replacement or the idea to try to avoid it in the future. Um, so I think that that once we have that, then we decide and we made the decision, the informed decision of going ahead with the procedure. Uh, this is a minimally invasive procedure that we do it through same as a shoulder and need a simple scope.
Victor Ortiz, MD:We go in there, we confirm the problem with the camera, we put the camera in there, we can take pictures, we can see the label and we can see the cartridges, we can see everything in the in the joint, uh, and then we go ahead and we fix it. And usually the first thing that I always like to do is go To that acetabular rim and we expose that rim where we're going to be reattaching that labrum. We trim whatever Impingement we have in that area, guided with all the pre-op planning that we did because we got a CAT scan, we got all this imaging that is telling me, letting me know Dr, this. This is where we're going to go. This is what, how much bone we're going to remove. Once we remove the bone, then we can put multiple anchors and as many anchors as we need. We can go as as as low as two, we can go all the way to six, seven anchors, whatever is needed to really restore that labrum, to be able to create that functional, that suction seal or that increased surface area, to restore the mechanics of the hip.
Victor Ortiz, MD:And after we we fix the joint, we clean everything that needs to be clean. Then we pull the traction off. You know, we when we go to the joint, we have to open it up, pulling on the leg. So once we close that, we can really see how we restore that seal mechanism. And we can now go to the ball and look at that area that is causing pinchment, trim all the bone down, increase that offset, increase that distance before the patient has any type of Impingement. And we do that guided by x-ray. We do x-ray guidance to the procedure To make sure that we get to that angle that we need to get, and also guided by the pre-op planning that we did from the, from the CT scan um, and once we fix everything, then we we go ahead, and something that I emphasize a lot is that we, when we get to the joint, we have to open the back.
Victor Ortiz, MD:It really the back open. That's going to create problems and the we have to close that back and that's called a capsule. So once we're done with the procedure, we have to close the capsule. I think that's something that has to be done routinely, um, and sometimes in patients we have to not only close it but do something called a capsule application when you put the sutures in a different orientation to tension that more to protect that repair, because we want to really Tighten the hip joint to protect the repair that we did.
Robert A. Kayal, MD:Wow, so you've achieved a lot of goals Arthroscopically. You've not only reattached the labrum which was the source of pain, um, you took down the bone spur on the acetabular side, the cup side. You took down the bone spur or the cannulise on the femur or the femoral side and by doing so, eliminating that source of impingement, your goal is to restore range of motion to that patient as well. And so now you've repaired the labrum, you've restored that watertight closure, that seal. The synovial fluid is now nourishing the joint, providing its mechanical properties of lubrication and shock absorption and nutrition To the articular cartilage. Uh, so you've achieved a lot of goals, doing this through a very minimally invasive, arthroscopic, arthroscopic approach, typically through two or three puncture, typically three puncture, yes, three little punctures around the hip joint. This is very cutting-edge technology.
Robert A. Kayal, MD:I I must emphasize to you the the lion's share of orthopedic surgeons In this in the world, not just this country, have never, ever done a hip arthroscopy. Uh, this is a procedure that should only be performed by very, very highly trained and experienced orthopedic surgeons like Dr Ortiz. Most orthopedic surgeons would never dare to attempt a hip arthroscopy. It's very different than a shoulder arthroscopy and a knee arthroscopy. That most orthopedic surgeons that do sports medicine do so.
Robert A. Kayal, MD:You definitely definitely need a highly experienced, trained and seasoned orthopedic surgeon, like Dr Ortiz, who does probably anywhere from five to 10 a week. He's a very, very highly experienced orthopedic surgeon in the area of hip arthroscopy, and so I do need to emphasize that, because most orthopedic surgeons that are dabbling in the field of hip arthroscopy may be, in fact, just doing that dabbling, and you certainly don't want to be a guinea pig. So you want to make sure that you go to a seasoned, experienced orthopedic surgeon that has done a high volume of these Okay, so I do want to emphasize that and, specifically, has done a hip preservation fellowship as well, because it is not as easy as most other joints that we routinely scope. So I do want to emphasize that, just to protect you. So we've done the surgery outpatient surgery, patients going home the same day. It's important that they protect your repair, right? What's your post op protocol?
Victor Ortiz, MD:So every patient the first two weeks is only put the foot on the floor. So that means they're going to wear crutches. So only the foot on the floor. We don't want to put any pressure in the area to not to damage the repair. The only thing that we use routinely is a hip brace. The brace will allow you to go from zero to 90 degrees so you're going to be able to sit in the chair comfortable. But we don't want to open the leg, we don't want to create any rotation in the leg for the first two weeks. But you start physical therapy right away. You know next day we have a very specific protocol for every patient Next day during physical therapy, then at two weeks, we get rid of the brace, we get rid of the crutches, then you go back to full weight bearing and then we progress you for multiple phases with the idea in four to five months for you to be able to go back to do everything that you want.
Robert A. Kayal, MD:That's great. And what have you found in your experience incidents of bilaterality? Do you find that a lot of these patients will have a tear on the other side too, or develop a tear on the other side as well?
Victor Ortiz, MD:It's very common. I always tell the patients that the other hip gets jealous and it's very common and not always we have to treat them. But I have done patients that I have done one week apart. I do one side and we go to the week we do the other side and it's very common.
Robert A. Kayal, MD:Yeah, wow, this has been very helpful, especially a subject like this that not a lot of people know about, right, femoral acetateblur impingement. You know, I think it's important to get the word out about this condition, even to non-orthopedic surgeons. First of all, a lot of orthopedic surgeons aren't familiar with this condition and maybe they're not 100% sure what the source of that patient's hip pain is. What is femoral acetateblur impingement? Again, as I mentioned, it's a relatively new disease condition that we've identified. But it's very important also to get the word out to chiropractors and medical doctors, primary care physicians, when patients are complaining of that classic groin pain and stability buckling, mechanical properties, pain with deep flexion and squatting, and the x-ray is normal think about femoral acetateblur impingement, think about labral tears the pain, where we described it to be, is coming from the hip joint and there's not too many things that can cause that pain in the hip joint. So when there's no arthritis, you know you have to be thinking about this condition femoral acetateblur impingement and if you're not routinely looking at hip x-rays and specifically the very specific views that we order to assess for this condition, you may be missing the diagnosis and we're not doing any justice to our patients. So it behooves us to think about this condition and send them to an expert like Dr Ortiz to get this condition assessed, so our patients can be treated and maybe you might even be saving them from a hip replacement down the road. So it's very important to be aware of this condition.
Robert A. Kayal, MD:So I hope that you found this podcast to be beneficial and helpful, and Dr Ortiz is readily accepting new patient visits and follow appointments as well, second opinions, injury cases and workman's compensation cases as well, so feel free to reach out, okay. So thanks so much for your time, dr Ortiz. Thank you for having me. It was a pleasure having you here again. Welcome back, thank you, have a great day. Bye-bye everyone.
