Non-Arthritic Hip Pain

[Host] Good afternoon, and welcome [Host] to our Orthopedic and Sports Medicine Lecture series. [Host] During this interactive presentation, [Host] you'll have the ability to ask questions [Host] via the chat box on your screen. [Host] Please post your questions directly to the moderator. [Host] This afternoon we have the distinct pleasure [Host] of introducing Dr. Lionel Lazaro. [Host] His presentation will be, Non-arthritic Hip Pain. [Host] Dr. Lazaro is an orthopedic surgeon [Host] and resear

cher specializing in sports medicine, [Host] hip preservation, hip arthroscopy during preservation [Host] and articular cartilage restoration [Host] at Baptist Health South Florida. [Host] Dr. Lazaro received his medical training [Host] at the Autonomous University [Host] of Guadalajara School of Medicine in Jalisco, Mexico. [Host] In New York Medical College, [Host] he also completed an orthopedic surgery residency [Host] at the Hospital for Specialty Surgeries in New York. [Host] His postdocto

ral training included a fellowship [Host] in orthopedic surgery, research of the hospital [Host] for a specialty surgery, and a fellowship [Host] in orthopedic sports medicine [Host] at Kerlan-Jobe Orthopedic Clinic [Host] at Cedars-Sinai Kerlan-Jobe Institute [Host] in Los Angeles, California. [Host] Dr. Lazaro is actively involved in clinical [Host] and laboratory-based research projects [Host] that aim to improve their understanding [Host] of the vascular contribution [Host] to bone and soft

tissue using qualitative-MRI [Host] and anatomical dissection. [Host] He has a keen interest [Host] in minimizing surgically-induced trauma [Host] and optimizing preservation of vascular anatomy. [Host] His interest in bone vascularity [Host] and the associated iatrogenic surgical vascular insult [Host] have extended to investigations to vascular impacts [Host] from not only surgical approaches, [Host] but also traumatic injuries [Host] and minimal invasive surgical interventions. [Host] He serv

es as an editorial reviewer [Host] for major orthopedic journals, [Host] and he is widely published in his field. [Host] He has actually peer-reviewed scientific publications [Host] and seven book chapters. [Host] He has about 45 different peer review activities [Host] already published. [Host] He has been an invited speaker [Host] at the national and international academic symposiums. [Host] And Dr. Lazaro has extensive experience [Host] providing medical coverage [Host] for high school and col

lege sports teams [Host] as well as athletes in the National Football League, [Host] Major League Baseball, and the National Hockey League. [Host] Dr. Lazaro is a member of several professional associations [Host] including the American Academy of Orthopedic Surgeons, [Host] the American Orthopedic Society for Sports Medicine, [Host] and the International Society [Host] for Hip Arthroscopy among others. [Host] He, of course, speaks English and Spanish. [Host] Please let's give a warm welcome to

Dr. Lazaro. [Host] Thank you so much for joining us, Dr. Lazaro [Dr. Lazaro] Hi, how are you everybody? [Dr. Lazaro] So let me just share my screen here. [Dr. Lazaro] Hi, good afternoon. [Dr. Lazaro] Thank you for joining us. [Dr. Lazaro] Thank you for that presentation. [Dr. Lazaro] I really appreciate it, [Dr. Lazaro] and I really  appreciate the opportunity [Dr. Lazaro] to present here today. [Dr. Lazaro] So I'm gonna be talking a little bit [Dr. Lazaro] about Non-arthritic Hip Pain, A Diagno

stic Dilemma. [Dr. Lazaro] So let's start. [Dr. Lazaro] Okay, I have no disclosures [Dr. Lazaro] So the non-arthritic hip pain. [Dr. Lazaro] So it's a complex  and diagnostic dilemma. [Dr. Lazaro] You have these patients with this pain around the hip joint. [Dr. Lazaro] You get an  X-ray, and it looks like this. [Dr. Lazaro] It looks pretty good. [Dr. Lazaro] And also, the location, the description of the location, [Dr. Lazaro] sometimes it's  a little bit in the front, [Dr. Lazaro] a little bit

  on the back, on the side, [Dr. Lazaro] it gets a little confusing. [Dr. Lazaro] And then, when you look into the causes of hip pain, [Dr. Lazaro] it can be from  the musculoskeletal system, [Dr. Lazaro] neurological, GI, GU, gynecological. [Dr. Lazaro] So it can be a complex problem. [Dr. Lazaro] I'm gonna talk today about the musculoskeletal system. [Dr. Lazaro] And only looking at that, if you look at this list here, [Dr. Lazaro] on the musculoskeletal hip pain, it's a lot diagnoses. [Dr. La

zaro] And usually, we've been trained [Dr. Lazaro] to think about the diagnosis [Dr. Lazaro] depending on where the location of the pain is. [Dr. Lazaro] But you can look in this diagram and this table, [Dr. Lazaro] with an anterior hip pain, you have different diagnoses. [Dr. Lazaro] And it's definitely complex, [Dr. Lazaro] and it's very difficult to really [Dr. Lazaro] get to the final diagnosis. [Dr. Lazaro] It's so many things that can give you anterior hip pain [Dr. Lazaro] or lateral hip

pain. [Dr. Lazaro] So it's a little problematic. [Dr. Lazaro] And that's been reported in the literature. [Dr. Lazaro] So we have papers telling us [Dr. Lazaro] that people have been misdiagnosed. [Dr. Lazaro] 60% of athletic people coming for hip arthroscopy, [Dr. Lazaro] it actually took them seven months to get to a diagnosis. [Dr. Lazaro] Imagine seven  months trying to figure out [Dr. Lazaro] what's happening with you. [Dr. Lazaro] And not only that, [Dr. Lazaro] 17% has been recommended su

rgery in the wrong side. [Dr. Lazaro] So this is a little concerning. [Dr. Lazaro] You cannot  define what is the problem, [Dr. Lazaro] and you're indicating surgeries that may be not fixing [Dr. Lazaro] that problem. [Dr. Lazaro] I think something that helped me [Dr. Lazaro] to understand the hip joint better, [Dr. Lazaro] was this layered, anatomical approach [Dr. Lazaro] popularized by Dr. Kelly from HSS in New York. [Dr. Lazaro] And I think it's extremely good to see the joint [Dr. Lazaro] i

n these layers, [Dr. Lazaro] because I think it helps to understand what's happening. [Dr. Lazaro] I'm gonna go through these layers, [Dr. Lazaro] go through the structures, the purpose, and the pathology, [Dr. Lazaro] because I think  it's extremely important [Dr. Lazaro] to look at it like this, the hip joint problems. [Dr. Lazaro] So in layer one, we have the osteochondral layer. [Dr. Lazaro] It's where the bones are, [Dr. Lazaro] the femur, the acetabulum, the innominate bone. [Dr. Lazaro] A

nd the purpose of this layer is [Dr. Lazaro] for joint congruency, arthro kinematical movement. [Dr. Lazaro] And the pathology that you can see, [Dr. Lazaro] it can be either  developmental or dynamic, [Dr. Lazaro] or it can  interrelate with both of them. [Dr. Lazaro] In the developmental side, [Dr. Lazaro] you have the dysplasia, the problem with version, [Dr. Lazaro] protrusio, femoral inclination. [Dr. Lazaro] Dynamic is where  you have the impingement. [Dr. Lazaro] You have CAM  impingement

, RIM impingement, [Dr. Lazaro] or trochanteric impingement, sub-spine impingement. [Dr. Lazaro] It's that problem on the layer one. [Dr. Lazaro] Then we move to layer 2. [Dr. Lazaro] Layer 2 is more the inner structures. [Dr. Lazaro] The structures here will be the labrum, the capsule, [Dr. Lazaro] the ligament complex, the ligamentum. [Dr. Lazaro] And the purpose here is for static stability [Dr. Lazaro] of the hip joint, okay. [Dr. Lazaro] The pathology that we can see is labral tears, [Dr. L

azaro] capsular instability, ligamentum teres tear, adhesive capsulitis. [Dr. Lazaro] Then we move to the third layer. [Dr. Lazaro] Third layer is the muscular layer, the dynamic layer. [Dr. Lazaro] So here we have the muscles crossing the hip joint. [Dr. Lazaro] Lumbosacral  muscles, the pelvic floor. [Dr. Lazaro] The purpose here, dynamic stability. [Dr. Lazaro] And the pathology that we can see, [Dr. Lazaro] we can see pubalgia, we can see enthesopathy. [Dr. Lazaro] And I think in this layer,

[Dr. Lazaro] when you're trying to define the problem on layer three, [Dr. Lazaro] I think we can go back at using the location [Dr. Lazaro] of the pain,  because I think it's helpful. [Dr. Lazaro] So with anterior pain, [Dr. Lazaro] and you're thinking about a muscle layer injury, [Dr. Lazaro] flexor strain, psoas impingement, rectus femoris. [Dr. Lazaro] The medial side,  adductor tendinopathies, [Dr. Lazaro] rectus abdominus tendinopathy, [Dr. Lazaro] more like the core muscle injury, [Dr. L

azaro] or another name is a sport hernia, type of thing. [Dr. Lazaro] We can also have the posterior enthesopathies, [Dr. Lazaro] proximal hamstring strain or tears. [Dr. Lazaro] Or, the lateral enthesopathy [Dr. Lazaro] with the peritrochanteric space, [Dr. Lazaro] a problem gluteus medius tear, [Dr. Lazaro] peritrochanteric bursitis, and all that stuff. [Dr. Lazaro] Then we move to the layer 4, the neural layer. [Dr. Lazaro] I think this one is, [Dr. Lazaro] the structure will be the thoroco-l

umbar mechanics, [Dr. Lazaro] the lower extremity mechanics, neuro-vascular structures, [Dr. Lazaro] regional mechanoreceptors. [Dr. Lazaro] The purpose here is important. [Dr. Lazaro] It's the communication and timing and sequencing [Dr. Lazaro] of the kinematic chain that is extremely important [Dr. Lazaro] for us to perform  in different activities. [Dr. Lazaro] I think this, the pathology, what we see here, [Dr. Lazaro] we can be having a nerve problem and nerve entrapment, [Dr. Lazaro] refe

rred pain  from the back or pathology, [Dr. Lazaro] neuromuscular  dysfunction, pain syndrome. [Dr. Lazaro] Or, it can be mechanical, foot structure and mechanics, [Dr. Lazaro] as related to  foot structures, scoliosis, [Dr. Lazaro] perfect posture over the femur, osteitis pubis, [Dr. Lazaro] pubic symphysis pathology. [Dr. Lazaro] I think this  layer, anatomical approach, [Dr. Lazaro] provides you a systematic means [Dr. Lazaro] to determine which structure of the hip is the source [Dr. Lazaro]

of the pathology and what structure are pain generators. [Dr. Lazaro] And I think that distinction is extremely important. [Dr. Lazaro] What is causing the pain? [Dr. Lazaro] What is causing the problem, and what is causing the pain? [Dr. Lazaro] Because you can have a problem on layer one, [Dr. Lazaro] it seems you ossify your bone, but you don't have symptoms, [Dr. Lazaro] or you don't have a pain generator [Dr. Lazaro] until you start disrupting layer two, [Dr. Lazaro] the labrum, the capsul

e, or maybe layer three. [Dr. Lazaro] You're stressing too much, [Dr. Lazaro] overloading  the muscles around your hip. [Dr. Lazaro] Or even layer four, disrupting the kinematic chain [Dr. Lazaro] and having  problems outside the hip joint. [Dr. Lazaro] So I think it's extremely important [Dr. Lazaro] to have that constant understanding. [Dr. Lazaro] Where is the source of the pain, [Dr. Lazaro] and who are the pain generators? [Dr. Lazaro] Because that can help us to implement a treatment, [Dr.

Lazaro] not only to solve the pain [Dr. Lazaro] and also to  prevent recurring of symptoms. [Dr. Lazaro] So let's talk about one of the issues [Dr. Lazaro] that we have in layer one, [Dr. Lazaro] that is creating a lot of problems [Dr. Lazaro] on layer two,  layer three, and layer four. [Dr. Lazaro] One of them is an osseous problem [Dr. Lazaro] and poor mechanics of the hip joint [Dr. Lazaro] that we call a hip impingement. [Dr. Lazaro] And this has  been reported since the 1920, [Dr. Lazaro]

when Dr. Jones relieved some pain in a house painter [Dr. Lazaro] when he performed a cheilectomy on the femoral head. [Dr. Lazaro] Then, Smith-Peterson, in 1936, [Dr. Lazaro] he started doing some acetabuloplasty [Dr. Lazaro] with open approach, [Dr. Lazaro] and he was able to address a femoral epiphysis, [Dr. Lazaro] taking pieces of the acetabulum and the femur. [Dr. Lazaro] But it's not similar, [Dr. Lazaro] but the same concept of trying to resolve that impingement. [Dr. Lazaro] And then, a

fter that, in '49, [Dr. Lazaro] Heyman did 42 acetabuloplasties with good outcomes. [Dr. Lazaro] In '65, we start talking about the anatomy of the pelvis [Dr. Lazaro] and pelvic tilt. [Dr. Lazaro] Then, Murray  and Duncan start observing, [Dr. Lazaro] in this distinguished outlet, [Dr. Lazaro] how they became degenerative disease of the hip [Dr. Lazaro] in the middle life. [Dr. Lazaro] So 50-year, young people, with prominent arthritis. [Dr. Lazaro] So they start reporting that problem. [Dr. Laz

aro] And then, Stulberg described this Pistol Grip anatomy [Dr. Lazaro] of the femoral  head or the femoral neck. [Dr. Lazaro] Solomon was  the first to early theories [Dr. Lazaro] of mechanical malalignment [Dr. Lazaro] as a part of etiology for hip osteoarthritis, [Dr. Lazaro] so even in '76. [Dr. Lazaro] Then, in '79, [Dr. Lazaro] Demarais and  Lequesne described hip pain [Dr. Lazaro] associated with  structural abnormalities [Dr. Lazaro] of the proximal femoral neck [Dr. Lazaro] in athletes

participating in hockey, football, soccer, [Dr. Lazaro] different athletes back in 1979. [Dr. Lazaro] Then, in 2001 Philippon described these triad [Dr. Lazaro] of findings common in athletes that participate in sport [Dr. Lazaro] with labral pathology, iliofemoral ligament elongation [Dr. Lazaro] and chondaral injury. [Dr. Lazaro] Then, McCarthy  reported similar things, [Dr. Lazaro] labral pathology, chondral pathology [Dr. Lazaro] in these elite  athletes, young people. [Dr. Lazaro] So for mo

re than 50 years, [Dr. Lazaro] observations have been suggesting structural deficiencies [Dr. Lazaro] and its relationship to early-onset osteoarthritis [Dr. Lazaro] of the hip joint. [Dr. Lazaro] However, these conclusions were mainly drawn [Dr. Lazaro] from childhood hip pathologists, ranging from SCFE or DDH. [Dr. Lazaro] But it has become clear [Dr. Lazaro] that an irregular-shaped ball housed [Dr. Lazaro] in an irregular-shaped socket [Dr. Lazaro] will create irregular mechanics [Dr. Lazaro

] and forces across the hip joint. [Dr. Lazaro] Then, in 2003, Professor Ganz popularized the term [Dr. Lazaro] of femoro acetabular impingement, [Dr. Lazaro] and he relayed that to the development of osteoarthritis [Dr. Lazaro] of the hip joint. [Dr. Lazaro] Here you can see, on this diagram, [Dr. Lazaro] where you can  see a normal hip anatomy. [Dr. Lazaro] But if you have a CAM morphology, [Dr. Lazaro] when you have  a bump on the femur side, [Dr. Lazaro] or a pincer morphology, [Dr. Lazaro]

when you have over coverage of the acetabulum, [Dr. Lazaro] even when mixed, [Dr. Lazaro] but you can see how a normal anatomy have full range [Dr. Lazaro] of motion with no conflict. [Dr. Lazaro] But when you  start having those bumps, [Dr. Lazaro] you can have conflict through that range of motion [Dr. Lazaro] that can lead  to injury to soft tissues. [Dr. Lazaro] And here's another cartoon presenting that. [Dr. Lazaro] When you have that bump on the femoral head [Dr. Lazaro] that is disruptin

g the connection between the labrum [Dr. Lazaro] and the acetabular cartilage. [Dr. Lazaro] And you can see it here better. [Dr. Lazaro] You get that damage [Dr. Lazaro] of the labral-chondral junction disruption. [Dr. Lazaro] And this is  how we see it when we go in [Dr. Lazaro] and look at the labrum. [Dr. Lazaro] This is the labrum, the disruption, [Dr. Lazaro] and that's articular cartilage. [Dr. Lazaro] And this how you see disruption on the articular cartilage. [Dr. Lazaro] Then, on the ot

her spectrum, [Dr. Lazaro] you have over coverage of the femoral head. [Dr. Lazaro] Here it's more like crush injury to the labrum. [Dr. Lazaro] You crush the labrum, and you create that damage. [Dr. Lazaro] With (indistinct) it gets calcified. [Dr. Lazaro] And this is how we see it in the operating room. [Dr. Lazaro] And after that, [Dr. Lazaro] a similar publication has come out expressing the concern [Dr. Lazaro] of poor anatomy and malalignment, [Dr. Lazaro] how it can lead to osteoarthritis

. [Dr. Lazaro] This paper talks to us about DDH [Dr. Lazaro] and how can that lead to osteoarthritis of the hip. [Dr. Lazaro] But this important paper, [Dr. Lazaro] The Prevalence  of Radiographic Criteria [Dr. Lazaro] of Femoral Acetabular Impingement [Dr. Lazaro] of Patients Undergoing Total Hip Arthroplasty. [Dr. Lazaro] So patients  undergoing hip arthroplasty [Dr. Lazaro] exhibit a high incidence [Dr. Lazaro] of radiographic abnormalities consistent with FAI. [Dr. Lazaro] The CAM-type morph

ology occurs more frequently [Dr. Lazaro] in younger  patient with advanced arthritis [Dr. Lazaro] requiring hip arthroscopy. [Dr. Lazaro] So this story supports the notion [Dr. Lazaro] that CAM-type  morphology is a risk factor [Dr. Lazaro] for earlier development of degenerative arthritis. [Dr. Lazaro] And the bigger the CAM, the faster that it degenerates. [Dr. Lazaro] And other papers coming out, [Dr. Lazaro] expressing that concern of poor anatomy, CAM morphology, [Dr. Lazaro] and impingeme

nt can lead to osteoarthritis. [Dr. Lazaro] This paper about the acetabular rim degeneration. [Dr. Lazaro] Acetabular rim degeneration is constant finding [Dr. Lazaro] in aged hip  which seems to be triggered [Dr. Lazaro] by femoro acetabular impingement. [Dr. Lazaro] And then, that labrum pathology is extremely important. [Dr. Lazaro] The suction seal that we create with the labrum is essential [Dr. Lazaro] to maintain a normal function of the hip joint. [Dr. Lazaro] Contact between the acetabu

lar labrum [Dr. Lazaro] and the articular cartilage [Dr. Lazaro] of the femoral head creates a ceiling effect [Dr. Lazaro] that controls the fluid flow in and out of the hip joint. [Dr. Lazaro] And that fluid seal [Dr. Lazaro] creates an intra-articular fluid pressurization [Dr. Lazaro] to protect the cartilage matrix, create suction effect, [Dr. Lazaro] and it gives  stability to the hip joint. [Dr. Lazaro] So not only protects the intra-articular cartilage, [Dr. Lazaro] but also gives  stabili

ty into the joint. [Dr. Lazaro] You can see in this video [Dr. Lazaro] how that suction seal really holds that ball in place. [Dr. Lazaro] But what happens when you have a deficient labrum? [Dr. Lazaro] So, for example, [Dr. Lazaro] you see they took out a piece of labrum there. [Dr. Lazaro] There's no suction seal. [Dr. Lazaro] You lose that stability. [Dr. Lazaro] But then, we  can reconstruct that defect, [Dr. Lazaro] and you see how we can reestablish that suction seal. [Dr. Lazaro] So that'

s the concept behind tuning that labrum. [Dr. Lazaro] And Professor Ganz described an excellent beautiful way [Dr. Lazaro] to access the joint, [Dr. Lazaro] making an  osteotomy, opening the joint, [Dr. Lazaro] and doing an anterior surgical hip dislocation. [Dr. Lazaro] You take out the entire femoral head, [Dr. Lazaro] you have great  access to the femoral head, [Dr. Lazaro] and you can see the CAM morphology. [Dr. Lazaro] You then can have a good resection of that CAM morphology. [Dr. Lazaro]

However, it's a big approach, [Dr. Lazaro] and it's a surgical dislocation. [Dr. Lazaro] So recovery  can be a little compromised. [Dr. Lazaro] Then, the push  from arthroscopic surgery, [Dr. Lazaro] and the people in the arthroscopic world start pushing for, [Dr. Lazaro] hey, can we do this through a scope? [Dr. Lazaro] And this group of people [Dr. Lazaro] from the International Society of Hip Arthroscopy, [Dr. Lazaro] they keep pushing and say, [Dr. Lazaro] "Hey, this can  be done through a

scope." [Dr. Lazaro] And then, several papers demonstrated that, [Dr. Lazaro] that you can perform the osteochondroplasty, [Dr. Lazaro] restore the femoral head-neck offset [Dr. Lazaro] in similar depth and height. [Dr. Lazaro] We can do it through a scope [Dr. Lazaro] instead of  doing a complete dislocation. [Dr. Lazaro] And then, a lot of papers trying [Dr. Lazaro] to investigate open versus arthroscopically. [Dr. Lazaro] But even cadaveric studies [Dr. Lazaro] [Dr. Lazaro] and  clinical stud

ies showing that, [Dr. Lazaro] it confirmed that it can be done through arthroscopic means, [Dr. Lazaro] also including this paper that demonstrates that even, [Dr. Lazaro] when you do this through a scope, [Dr. Lazaro] you maintain the vascular supply to the femoral head. [Dr. Lazaro] These diagram, it shows you different resection [Dr. Lazaro] on how much bone you can take out. [Dr. Lazaro] And the more that you go posterior, [Dr. Lazaro] you start hitting the vessel, the main blood supply [Dr

. Lazaro] to the femoral head comes from this posterior aspect [Dr. Lazaro] of the femoral head. [Dr. Lazaro] Usually, the CAM morphology and deformity are in the front. [Dr. Lazaro] So if you stay on the green area, [Dr. Lazaro] even though you hit a few vessels, [Dr. Lazaro] you can maintain blood supply to the femoral head, [Dr. Lazaro] confirming that  it's safe through a scope. [Dr. Lazaro] We demonstrated that the more posterior that you go, [Dr. Lazaro] then you can start disrupting the v

ascular supply [Dr. Lazaro] to the femoral head. [Dr. Lazaro] So it gives you a safe zone of where to do the work. [Dr. Lazaro] And then, another  paper compares outcomes [Dr. Lazaro] of open versus arthroscopy. [Dr. Lazaro] Open dislocation gives you a great visualization. [Dr. Lazaro] You can see everything. [Dr. Lazaro] But it's a major operation, soft tissue damage. [Dr. Lazaro] You can have risk of nonunion of the trochanteric osteotomy. [Dr. Lazaro] But it's a  powerful surgical approach,

[Dr. Lazaro] and it's extremely good. [Dr. Lazaro] And it has also demonstrated [Dr. Lazaro] that it maintains completely the blood supply [Dr. Lazaro] to the femoral head. [Dr. Lazaro] But arthroscopic means is minimally invasive. [Dr. Lazaro] You can access everything. [Dr. Lazaro] Sometimes, you can have some difficulties accessing [Dr. Lazaro] the ligamentum teres and some areas, [Dr. Lazaro] and it can lead  to traction complications, [Dr. Lazaro] neurapraxias and stuff like that. [Dr. Laza

ro] So some indications can be done with the arthroscope. [Dr. Lazaro] Some indication  needs to be done open. [Dr. Lazaro] And that's what it shows in several older papers saying, [Dr. Lazaro] "Hey, the outcomes are good, both open and closed, [Dr. Lazaro] "but the open one has a little more re-operation [Dr. Lazaro] "and complication compared to arthroscopy." [Dr. Lazaro] Also, both hip arthroscopy [Dr. Lazaro] and open surgery give you excellent results. [Dr. Lazaro] But maybe some  of the ou

tcome measures, [Dr. Lazaro] the people  with arthroscopy do better. [Dr. Lazaro] The routine treatment nowadays [Dr. Lazaro] for intra-articular work is done through a scope. [Dr. Lazaro] So everybody's moving more into doing these [Dr. Lazaro] through arthroscopic means. [Dr. Lazaro] However, the  open technique have a role, [Dr. Lazaro] and a very important role, [Dr. Lazaro] that needs to be open in some cases where it cannot be done, [Dr. Lazaro] or it's not safe to be done through arthrosc

opic means. [Dr. Lazaro] So arthroscopic techniques shows there are better outcomes [Dr. Lazaro] in short terms,  and higher return to play. [Dr. Lazaro] But in cases that are complex, [Dr. Lazaro] you need to do an open approach. [Dr. Lazaro] So it's good to have that technique in your (indistinct). [Dr. Lazaro] So arthroscopic treatment of femoro acetabular [Dr. Lazaro] results in significant improvement in pain function [Dr. Lazaro] with low complication rate. [Dr. Lazaro] And other papers su

pporting a hip arthroscopy [Dr. Lazaro] as a way to treat that. [Dr. Lazaro] But important, not having arthritis, [Dr. Lazaro] not having dysplasia is extremely important [Dr. Lazaro] to have a successful outcome. [Dr. Lazaro] How is the return to play? [Dr. Lazaro] 92.5% return to play in the NFL after arthroscopic FAI. [Dr. Lazaro] That's extremely  high, it's pretty good. [Dr. Lazaro] Usually, it takes them six months to come back [Dr. Lazaro] and be able to  start hitting each other. [Dr. La

zaro] And others, looking at the long-term, [Dr. Lazaro] what's happening, anatomical recovery [Dr. Lazaro] of the acetabular labrum on the labrum function [Dr. Lazaro] was associated with improved clinical symptoms. [Dr. Lazaro] So it maintains the improvement, and it lasts. [Dr. Lazaro] This other paper, looking at quantitative way [Dr. Lazaro] and a more objective way, in a quantitative way, [Dr. Lazaro] to see how the  articular cartilage change, [Dr. Lazaro] after you change the anatomy. [D

r. Lazaro] So they show the alteration [Dr. Lazaro] of the hip mechanic through a surgical intervention [Dr. Lazaro] improve the overall health of the hip joint. [Dr. Lazaro] So that prove that it can improve [Dr. Lazaro] the articular cartilage situation. [Dr. Lazaro] An important concept is this compensatory injury. [Dr. Lazaro] Because you have  a problem with layer one, [Dr. Lazaro] that can lead  to problems in layer two, [Dr. Lazaro] labral pathology, [Dr. Lazaro] but it also can lead to p

roblems on layer three [Dr. Lazaro] and layer four. [Dr. Lazaro] So individuals that have FAI, they have a reduced [Dr. Lazaro] punching arm range of motion that can lead to high impaction [Dr. Lazaro] and loads at terminal range. [Dr. Lazaro] That result in compensatory effect [Dr. Lazaro] in the bony and soft tissue structure [Dr. Lazaro] within the hip  and outside the hip joint. [Dr. Lazaro] And that's extremely important [Dr. Lazaro] because in this patient population in sports [Dr. Lazaro]

you start  having patients that present [Dr. Lazaro] with pathology or pain generators that are outside [Dr. Lazaro] of the site of  etiology, and you can lose, [Dr. Lazaro] the treatment you get recurrent (indistinct) tears [Dr. Lazaro] And, looking at the anatomy of the hip joint [Dr. Lazaro] and the  biomechanics of the hip joint. [Dr. Lazaro] So for example, femoral acetabular impingement, [Dr. Lazaro] and (indistinct) [Dr. Lazaro] 34% of patient  with chronic abductor pain [Dr. Lazaro] tha

t was resistant  to standard treatment, [Dr. Lazaro] they look into the x-ray, 94% have a radiographic FAI. [Dr. Lazaro] So that's an important concept [Dr. Lazaro] about the compensatory injury. [Dr. Lazaro] How about on this, on the NFL? [Dr. Lazaro] Evaluating association between labral tear, [Dr. Lazaro] rectus abdominus  tear and adductor strain. [Dr. Lazaro] The Sport Hit Triad. [Dr. Lazaro] We found that 90% of the NFL prospect have radiographic FAI. [Dr. Lazaro] That's interesting. [Dr.

Lazaro] How about the pictures? [Dr. Lazaro] So this story is talking more about the kinematic chain [Dr. Lazaro] and FAI. [Dr. Lazaro] So loss of hip motion, it sees as a plant foot close, [Dr. Lazaro] the poor pelvic alignment and pitcher throw across the body. [Dr. Lazaro] And they show that there is reduced transfer of power [Dr. Lazaro] from the lower body [Dr. Lazaro] to the upper body affecting that kinematic chain [Dr. Lazaro] that is extremely important to be able to perform like that.

[Dr. Lazaro] So they increased torque on the elbow [Dr. Lazaro] and shoulder increasing injuries of the elbow [Dr. Lazaro] Tommy John injuries, or shoulder injuries. [Dr. Lazaro] This other study, [Dr. Lazaro] looking at the  velocity of the pitchers. [Dr. Lazaro] So increase in hip internal rotation in the trail leg, [Dr. Lazaro] can increase the pitch velocity. [Dr. Lazaro] And so those patients with [Dr. Lazaro] non-arthritic hip pain ideal for hip arthroscopy cases, [Dr. Lazaro] are symptoma

tic less than a year, [Dr. Lazaro] inability to perform the sport and activity [Dr. Lazaro] based on subjective symptoms. [Dr. Lazaro] Well-defined FAI on x-rays, [Dr. Lazaro] and good articular cartilage, [Dr. Lazaro] good pre-surgical muscle strength. [Dr. Lazaro] In 2016, a group of experts got together and say, [Dr. Lazaro] "Hey it's all femoro acetabular impingement [Dr. Lazaro] "or why we don't define [Dr. Lazaro] "femoro acetabular  impingement syndrome." [Dr. Lazaro] I think this is impo

rtant because the syndrome [Dr. Lazaro] is emotional related clinical disorder of the hip [Dr. Lazaro] with a triad of symptoms, [Dr. Lazaro] clinical signs and imaging findings. [Dr. Lazaro] So you have to have that triad. [Dr. Lazaro] And it represents symptomatic premature contact [Dr. Lazaro] between the femoro acetabulum, and the acetabulum. [Dr. Lazaro] Because you can  have radiographic changes [Dr. Lazaro] but I'm not creating a problem, I'm not creating symptoms. [Dr. Lazaro] So it's no

t the syndrome. [Dr. Lazaro] Once you have that syndrome and you identified that patient [Dr. Lazaro] you have different treatment options. [Dr. Lazaro] You can treat  it with physical therapy [Dr. Lazaro] and conservative management that a lot of the time [Dr. Lazaro] you can get them  better by improving them. [Dr. Lazaro] it can make the hip joint. [Dr. Lazaro] But if that  doesn't work and that fails, [Dr. Lazaro] then you move  into surgical intervention. [Dr. Lazaro] Remove the impingement

, [Dr. Lazaro] repair the soft tissue layer one and layer two problems [Dr. Lazaro] to improve the mechanics [Dr. Lazaro] and improve the  function of the hip joint. [Dr. Lazaro] We use a lot  of radiographic measurement [Dr. Lazaro] to really understand what's happening with the hip. [Dr. Lazaro] And I can give you a complete lecture [Dr. Lazaro] on just looking at the x-ray. [Dr. Lazaro] That is extremely interesting [Dr. Lazaro] on how we can define that anatomy and that impingement. [Dr. Laz

aro] But the most important thing is to, [Dr. Lazaro] when you have a hip like this, it looks okay. [Dr. Lazaro] It's very concerning, [Dr. Lazaro] because you don't know exactly what the problem is [Dr. Lazaro] unless you get all these radiographic views [Dr. Lazaro] and do a measurement. [Dr. Lazaro] Because when you have one like this is easy, [Dr. Lazaro] and you have to do a hip replacement. [Dr. Lazaro] Or if you have one like this [Dr. Lazaro] that is completely this plastic [Dr. Lazaro]

then you know what you're do. [Dr. Lazaro] You need to do  a periacetabular osteotomy [Dr. Lazaro] to resolve the problem. [Dr. Lazaro] But the problem is when you're here, [Dr. Lazaro] between here, and here, and here, and here. [Dr. Lazaro] Is too arthritic  or it's too dysplastic, [Dr. Lazaro] that's where we have to define. [Dr. Lazaro] And those radiographic measurements help us to define [Dr. Lazaro] if it's too much arthritis, or is too dysplastic. [Dr. Lazaro] Is important to rule out ar

thritis [Dr. Lazaro] because we know that having arthritis and changes [Dr. Lazaro] is not good for the result of hip arthroscopy. [Dr. Lazaro] So the more advanced the arthritis, [Dr. Lazaro] you even have to try because it's not gonna work. [Dr. Lazaro] You have to have at least two millimeters of space [Dr. Lazaro] in these three  different areas to say, [Dr. Lazaro] "Hey, maybe we can try hip preservation procedure." [Dr. Lazaro] But less than two millimeters, don't even try. [Dr. Lazaro] Th

en tonnis  classification, zero to one. [Dr. Lazaro] More than that, you're just getting into trouble [Dr. Lazaro] and you're not helping the patient. [Dr. Lazaro] And then how much dysplasia. [Dr. Lazaro] A lot of people look at the lateral center edge angle [Dr. Lazaro] and this term  of borderline dysplasia, [Dr. Lazaro] only looking at the lateral center edge angle. [Dr. Lazaro] But I think it's extremely important to look at [Dr. Lazaro] all the stuff that is giving the the dysplasia, [Dr.

Lazaro] because they can have dysplasia, [Dr. Lazaro] they can have also impingement. [Dr. Lazaro] So we have all the measurements that we use [Dr. Lazaro] to try to define  that dysplasia and say, [Dr. Lazaro] "Hey, this patient is too dysplastic. [Dr. Lazaro] "We may need to  do an arthroscopic surgery [Dr. Lazaro] "to solve the  intra-articular problem, [Dr. Lazaro] "but then do  a periacetabular osteotomy [Dr. Lazaro] "and acetabular reorientation to give a better mechanics [Dr. Lazaro] "and

avoid issues with a dysplastic patient." [Dr. Lazaro] So we have more radiographic measurements to analyze that. [Dr. Lazaro] For me, they  have to have the syndrome. [Dr. Lazaro] They have to have [Dr. Lazaro] the femoro acetabular impingement syndrome. [Dr. Lazaro] Pain is coming from the hip joint. [Dr. Lazaro] History, physical exam imaging and a good response [Dr. Lazaro] to that diagnostic injection. [Dr. Lazaro] I use a lot of diagnostic injection. [Dr. Lazaro] Insidious onset of pain [D

r. Lazaro] in active  young and middle-aged adult. [Dr. Lazaro] The groin pain with the C-sign they show within the front [Dr. Lazaro] in the back and they pull the hand around the hip [Dr. Lazaro] in the C-sign type. [Dr. Lazaro] And it's associated with activities. [Dr. Lazaro] Not always, it comes and goes [Dr. Lazaro] and that's why  it's confusing for them. [Dr. Lazaro] But they feel this painful clicking, locking instability. [Dr. Lazaro] And they have reduced range of motion in femoral ab

duction, [Dr. Lazaro] internal rotation of previous tests. [Dr. Lazaro] And good response to the diagnosing injection [Dr. Lazaro] was extremely important. [Dr. Lazaro] Minimal the generation. [Dr. Lazaro] So Tonnis is less than zero to one, maybe zero better. [Dr. Lazaro] More than two millimeters of joint space, stable hip. [Dr. Lazaro] Lateral  center-edge angle, more than 20, [Dr. Lazaro] and all the measurement that are telling me [Dr. Lazaro] that they're not dysplastic. [Dr. Lazaro] And t

hey have to fail to respond to conservative treatment. [Dr. Lazaro] Like I say  before, some of them get better [Dr. Lazaro] just with conservative treatment. [Dr. Lazaro] The patient has to have appropriate expectation [Dr. Lazaro] and capacity to rehab. [Dr. Lazaro] The goals are to relieve the pain, [Dr. Lazaro] improve function  and return to activity. [Dr. Lazaro] And prevent the degeneration of the hip joint. [Dr. Lazaro] And then address all the contributory mechanical factors [Dr. Lazaro

] that are affecting that patient. [Dr. Lazaro] So in conclusion,  non-arthritic hip pain [Dr. Lazaro] is a diagnostic dilemma. [Dr. Lazaro] Systemic approach to a physical exam and imaging evaluation [Dr. Lazaro] can lead to the correct diagnosis. [Dr. Lazaro] We'll just use that layer approach to a hip, [Dr. Lazaro] I think is extremely helpful to understand what happening [Dr. Lazaro] with the hip joint. [Dr. Lazaro] Femoral acetabular impingement [Dr. Lazaro] is associated with the element o

f osteoarthritis, [Dr. Lazaro] especially those CAM type morphology, [Dr. Lazaro] the bigger  they CAM, the worse it gets. [Dr. Lazaro] FAI can be treated with arthroscopic means, [Dr. Lazaro] with excellent outcome. [Dr. Lazaro] Patients selection is key. [Dr. Lazaro] Open means extremely powerful and it's needed in some cases. [Dr. Lazaro] But we can now  address several pathologies [Dr. Lazaro] on layer one,  layer two, and layer three, [Dr. Lazaro] throughout arthroscopy. [Dr. Lazaro] Fixing

the pathology, addressing the pain generators, [Dr. Lazaro] and improving hip mechanics and pain outcome. [Dr. Lazaro] I wanna thank everybody for their attention, [Dr. Lazaro] and I'm looking  forward to some questions. [Host] Thank you so much, Dr. Lazaro. [Host] That was a brilliant synthesis [Host] of a great and very complex procedure [Host] that you guys performed at (indistinct) [Host] Yes, so we do have some questions [Host] and we will be waiting for some more in few seconds. [Host] Bu

t I wanted to point out at something that you mentioned [Host] which is extremely important. [Host] And it's obviously the fact that the patient [Host] can receive other types of treatment [Host] as they wait for this final step in the process [Host] and get and submit themselves to this type of surgery. [Host] What is a prudent time for a patient to actually [Host] undergo pain management and all the other modalities [Host] before you consider them to be candidates for the surgery? [Dr. Lazaro]

Yeah, so when  I see a patient like this, [Dr. Lazaro] I first of all, try to explain everything to them. [Dr. Lazaro] because I think  it's extremely important [Dr. Lazaro] for them to understand the problem. [Dr. Lazaro] The other thing is, [Dr. Lazaro] let's see if conservative treatment is gonna manage this. [Dr. Lazaro] I don't think pain management is a good option, [Dr. Lazaro] I don't like it. [Dr. Lazaro] What I like to do, [Dr. Lazaro] these patients get into a vicious cycle of pain [

Dr. Lazaro] that leads to weakness, [Dr. Lazaro] that weakness leads to more pain and more weakness. [Dr. Lazaro] And they fall in these vicious cycle [Dr. Lazaro] that then gets to injuries in the abductors [Dr. Lazaro] in the lumbar spine. [Dr. Lazaro] So we have to break that cycle. [Dr. Lazaro] So my goal always is, anti-inflammatory techniques [Dr. Lazaro] and medication, or even injections, to calm the pain, [Dr. Lazaro] relieve the pain, but it's a temporary, is a window. [Dr. Lazaro] So

they can participate in therapy, [Dr. Lazaro] improve the muscle strength, improve the muscle mechanics, [Dr. Lazaro] and they start doing more activity. [Dr. Lazaro] But you don't wanna be on anti-inflammatories [Dr. Lazaro] or pain control medication for a longer time, [Dr. Lazaro] because that  pain is actually telling you [Dr. Lazaro] you have a problem. [Dr. Lazaro] So you cannot mask the pain [Dr. Lazaro] because it's just gonna degenerate your hip. [Dr. Lazaro] But if we go into the menta

lity [Dr. Lazaro] that we have  to improve the mechanics, [Dr. Lazaro] we have to improve the strength, [Dr. Lazaro] I think that's where you win. [Dr. Lazaro] And I spend a lot of time talking to these patients [Dr. Lazaro] because a lot  of people get injections [Dr. Lazaro] and get medications and they have a short period of relief. [Dr. Lazaro] And then they say, "Oh, it last for a month [Dr. Lazaro] "and then it went away." [Dr. Lazaro] But you ask them, what they did. [Dr. Lazaro] What do

you do in that month? [Dr. Lazaro] They did the physical therapy. [Dr. Lazaro] You got stronger. [Dr. Lazaro] I know I didn't do anything. [Dr. Lazaro] So you lost your opportunity because all this is a window, [Dr. Lazaro] so you can improve your mechanics. [Dr. Lazaro] If not, you're  not doing the right thing. [Dr. Lazaro] If you participate in sport with anti-inflammatories [Dr. Lazaro] and you're doing all your stuff [Dr. Lazaro] always with an anti-inflammatory, you're masking your pain, [

Dr. Lazaro] you're creating a problem, that's not the way to go. [Dr. Lazaro] You mask your pain, so you can get stronger [Dr. Lazaro] for knowing that  you're having some damage [Dr. Lazaro] that it needs to be addressed. [Dr. Lazaro] But you should not be participating in stuff [Dr. Lazaro] with anti-inflammatories and pain medication. [Host] It defeats the purpose [Host] because really you're gonna have to submit the patient [Host] to the surgical procedure. [Host] Now, how long does this pro

cedure take typically? [Dr. Lazaro] So it depends [Dr. Lazaro] depending on the complexity of the hip joint. [Dr. Lazaro] It goes from  two hours up to six hours, [Dr. Lazaro] depending on what needs to be done. [Dr. Lazaro] You have to resect the bone, [Dr. Lazaro] you have to eliminate the problem, [Dr. Lazaro] the etiology, and then you have to solve the pain generators [Dr. Lazaro] the labral pathology, the articular cartilage. [Dr. Lazaro] If the labral  is completely destroyed, [Dr. Lazaro

] we know it's important to have that labral, [Dr. Lazaro] so we put a new labral, and we put a caloric tissue [Dr. Lazaro] to reconstruct the labral, [Dr. Lazaro] and to reconstruct the suction seal [Dr. Lazaro] that we're showing on the video that is extremely important [Dr. Lazaro] for stability  and health of the joint. [Dr. Lazaro] But it depends on how much where you have to do [Dr. Lazaro] but it can take from two hours up to six hours, [Dr. Lazaro] depending on what you need to do. [Host

] Fantastic. [Host] And this is a good subway for the question [Host] that Dino's posing. [Host] And it says, what's the actual role [Host] of orthobiologics and hip pathology, like a PRP, [Host] and this goes supplementation. [Dr. Lazaro] Yeah, definitely. [Dr. Lazaro] So I use the injection technique and biologic injections [Dr. Lazaro] into the hip joint to minimize those symptoms, [Dr. Lazaro] to give them that window to participate in therapy. [Dr. Lazaro] None of these biologics really, [D

r. Lazaro] it's gonna grow your cartilage is gonna heal-- [Dr. Lazaro] It's not true. [Dr. Lazaro] What it does, is give you an anti-inflammatory effect, [Dr. Lazaro] and it can bring  some cells into a system [Dr. Lazaro] to help you with that inflammation. [Dr. Lazaro] But again, it's a band-aid, so you can do a therapy. [Dr. Lazaro] If you don't do a therapy afterwards, [Dr. Lazaro] that's when you get there different complications [Dr. Lazaro] of PRP works, PRP doesn't work, [Dr. Lazaro] but

none of them are looking [Dr. Lazaro] at what the patient is doing after. [Dr. Lazaro] Also, PRP is different. [Dr. Lazaro] Your PRP is different than mine. [Dr. Lazaro] So it's a little difficult understand their stories, [Dr. Lazaro] but I use it a lot in those patients [Dr. Lazaro] that they don't wanna go to hip arthroscopy yet, [Dr. Lazaro] or they're not candidates. [Dr. Lazaro] They have too much arthritis [Dr. Lazaro] but they're not candidate for a hip replacement. [Dr. Lazaro] That's

when I  get into those injections [Dr. Lazaro] trying to minimize the symptoms so we can improve [Dr. Lazaro] the mechanics of the hip joint. [Dr. Lazaro] Once you improve the mechanics [Dr. Lazaro] of the hip joint and on the strength, [Dr. Lazaro] a lot of them get better, [Dr. Lazaro] at least diminish the pain symptoms and improve function. [Host] Carlos is wondering, [Host] which is the best image diagnostic tool. [Dr. Lazaro] So for me,  x-ray is extremely important. [Dr. Lazaro] You canno

t go to an MRI before understanding the x-ray. [Dr. Lazaro] MRI, I use it  to confirm my diagnosis. [Dr. Lazaro] Your physical exam and x-ray is the way to go, [Dr. Lazaro] MRI is to confirm. [Dr. Lazaro] Like, if you see in my talk, when I'm talking about [Dr. Lazaro] the femoral acetabular impingement syndrome, [Dr. Lazaro] MRI is not even there. [Dr. Lazaro] It's just to  confirm the labral pathology, [Dr. Lazaro] in the radiographic findings. [Dr. Lazaro] So there is specific views that you

have to take [Dr. Lazaro] to look at the anatomy of the femur. [Dr. Lazaro] The problem is, that we usually do AP pelvis, [Dr. Lazaro] AP hip for labral. [Dr. Lazaro] In those x-ray,  they're gonna be normal. [Dr. Lazaro] But you have to get an x-ray that shows you [Dr. Lazaro] the anterior-superior aspect [Dr. Lazaro] of the femoral head-neck junction, [Dr. Lazaro] that's where usually the bump is. [Dr. Lazaro] Some of the lateral views, like the front lateral [Dr. Lazaro] cross-table lateral,

[Dr. Lazaro] you can see on the anterior neck, [Dr. Lazaro] on the head and neck joints, [Dr. Lazaro] and you can see sclerosis or cystic formation, [Dr. Lazaro] that are indicative of an impingement process, [Dr. Lazaro] but I will get a complete, full set of x-rays [Dr. Lazaro] for me, all gets AP pelvis standing, [Dr. Lazaro] I like it standing because it's more physiological for me. [Dr. Lazaro] It's telling  me exactly what's happening. [Dr. Lazaro] When the laying down, they can change a l

ittle bit. [Dr. Lazaro] Then I do an AP of the hip, front leg lateral, [Dr. Lazaro] and then I do a modified (indistinct) [Dr. Lazaro] that that's the one that shows you [Dr. Lazaro] that anterior superior aspect. [Dr. Lazaro] And it gives  you it's a specific view. [Dr. Lazaro] And then the false profile [Dr. Lazaro] that it gives me the anatomy of the acetabulum in the front. [Dr. Lazaro] So I get those extra, I analyze them, [Dr. Lazaro] and I do a lot of measurements. [Dr. Lazaro] That paper

that I put up on the presentation, [Dr. Lazaro] extremely good to understand the different x-rays [Dr. Lazaro] for femoro acetabular impingement and problem in the hip. [Dr. Lazaro] I think you have to get more x-ray. [Dr. Lazaro] Regular x-ray, they don't show you. [Dr. Lazaro] And if you having a patient with hip pain and hip problem, [Dr. Lazaro] look more deep because the problem is there, [Dr. Lazaro] the thing is you not looking at it [Host] And this is one of the challenges. [Host] Somet

imes we have specially during the pandemic, [Host] where you guys are doing a lot of the tele consultation [Host] and using the records, the medical records, [Host] and the images from abroad [Host] where they are not necessarily appropriate [Host] or adequate enough for you to at least have a dialogue [Host] with the patient. [Host] So that is an extremely important point. [Dr. Lazaro] Another thing is, imaging, advanced images on MRI, [Dr. Lazaro] unfortunately, this concept of labral patholog

y [Dr. Lazaro] and all that, and FAI is young, you know, it's 15 years. [Dr. Lazaro] So there is a lot of people that are radiologists, [Dr. Lazaro] and people that are well-trained and pretty good, [Dr. Lazaro] but they're missing the pathology. [Dr. Lazaro] I get here, even here in Miami, [Dr. Lazaro] a lot of the  reports says no labral tear. [Dr. Lazaro] But I look at the MRI myself and the labral tear is there. [Dr. Lazaro] So you have to-- [Dr. Lazaro] I like to look at the images myself,

[Dr. Lazaro] I cannot trust any radiologist. [Dr. Lazaro] And it's important, [Dr. Lazaro] you know you have musculoskeletal radiology [Dr. Lazaro] saying that  there is no labral pathology [Dr. Lazaro] and the pathology is there. [Host] And that's why you're the expert that will answer. [Host] Demarqes Martinez has a question. [Host] It's a very good one. [Host] What is the protocol [Host] when a patient has a cognitive hip replacement [Host] and has the surgery, but then starts to have complic

ations [Host] during the recovery leading to rejections of the implant. [Dr. Lazaro] Yeah, so that's  a little difficult to-- [Dr. Lazaro] When you put a hip replacement in as a complete arthroplasty [Dr. Lazaro] of the hip, you know, you're putting foreign a material. [Dr. Lazaro] The thing is,  what is really the problem? [Dr. Lazaro] Because, is the patient reacting to the materials, [Dr. Lazaro] or is because we have an infection, [Dr. Lazaro] or is because we have deficiency and muscle stre

ngth [Dr. Lazaro] that is giving you pain? [Dr. Lazaro] And I think it's difficult to completely come prove [Dr. Lazaro] that is reaction on materials. [Dr. Lazaro] It is extremely rare that happens. [Dr. Lazaro] You know, usually they are separate, well the arthroplasty, [Dr. Lazaro] material that we use, [Dr. Lazaro] but I will look more into the-- [Dr. Lazaro] Make sure that  there is not an infection [Dr. Lazaro] that will be horrible [Dr. Lazaro] and it's also difficult to diagnose [Dr. Laz

aro] but there's a lot of things to do. [Dr. Lazaro] I will rule out infection. [Dr. Lazaro] Infection, infection, [Dr. Lazaro] Make sure there is not infection. [Dr. Lazaro] And then try to look at the anatomy. [Dr. Lazaro] Is the implant well placed? [Dr. Lazaro] Is the implant causing pain on the iliopsoas irritation? [Dr. Lazaro] Or the patient didn't rehab well [Dr. Lazaro] and doesn't have good mechanics. [Dr. Lazaro] Last, I would think about rejection. [Dr. Lazaro] That will be the last

thing I will start thinking about. [Host] Mm. [Host] Now, obviously the arthroscopic surgery, [Host] especially for hip has changed dramatically [Host] in the past 10 years. [Host] And we used to see patients stay in the hospital forever [Host] in the past, just because of a hip replacement or a surgery. [Host] What is the length of stay currently [Host] for your patients that receive this type of training? [Dr. Lazaro] They'll go home the same day. [Dr. Lazaro] They go home the same day. [Dr. L

azaro] Nobody stays,  we give pain medication. [Dr. Lazaro] We inject pain medication around the portals. [Dr. Lazaro] We make in three to four portals, little holes, [Dr. Lazaro] and accessing everything. [Dr. Lazaro] They go home the same day. [Host] And that's why I wanted to point that out. [Host] In the other question is, obviously, [Host] this patients will require some type of rehab [Host] to gain the range of motion and all that. [Host] Is it still recommended for them to go to rehab [Ho

st] and get intensive rehab? [Host] Or can they do it at home? [Dr. Lazaro] No, extremely important to have a good therapist. [Dr. Lazaro] This is not easy to do by yourself. [Dr. Lazaro] And, you know, we start rehab the next day after surgery. [Dr. Lazaro] You're in a stationary bike, [Dr. Lazaro] you using a CPM to move your hip up and down. [Dr. Lazaro] There is a very active rehab. [Dr. Lazaro] Every day you have something to do. [Dr. Lazaro] And I have a very detailed thing that we do by w

eek. [Dr. Lazaro] Every week, we  have something different. [Dr. Lazaro] Depending on how you're doing and you're reacting, [Dr. Lazaro] everything for me on the rehab is by phases. [Dr. Lazaro] I have four phases. [Dr. Lazaro] Phase one, you protect the repair, [Dr. Lazaro] phase two, you  start doing normal activity [Dr. Lazaro] like walking and all that, [Dr. Lazaro] phase three, we start doing more jogging, running [Dr. Lazaro] doing more sport related stuff, [Dr. Lazaro] phase four, then yo

u start with sport-related activity. [Dr. Lazaro] But for you to progress through those phases, [Dr. Lazaro] you need somebody to coach you, [Dr. Lazaro] and say, "Hey you're able to now go to the next phase [Dr. Lazaro] "because all these phases I have with hard stop. [Dr. Lazaro] "If you cannot do this, we don't go to the next place." [Dr. Lazaro] So I think extremely important for me, therapy, [Dr. Lazaro] is extremely important pre, before surgery, [Dr. Lazaro] and after surgery. [Dr. Lazaro

] I can do an excellent job, everything perfect. [Dr. Lazaro] But if they don't get a good therapy [Dr. Lazaro] and they don't put the effort on the therapy, we lost. [Dr. Lazaro] They're not gonna do well. [Dr. Lazaro] And that's one of my indications [Dr. Lazaro] when I'm doing surgery is that they have the mental capacity [Dr. Lazaro] and they have the motivation to do therapy. [Dr. Lazaro] If I see patients [Dr. Lazaro] that they don't like to go to therapy before, [Dr. Lazaro] why I'm gonna

  do therapy and all that, [Dr. Lazaro] then those I delay injection, [Dr. Lazaro] try not to operate on them [Dr. Lazaro] because I don't think they're gonna do well. [Host] Catalina Brenda asks, how likely is for a person [Host] with a bone hip deformity to have an FAI symptom? [Host] Or can good muscle strength and mobility prevent it? [Dr. Lazaro] Yes, so muscle strength and good mechanics [Dr. Lazaro] of your hip joint can solve a lot of problems. [Dr. Lazaro] But the issue is, is what do y

ou need from your hip? [Dr. Lazaro] That concept is extremely important. [Dr. Lazaro] Is what are  you asking your hip to do? [Dr. Lazaro] A lot of people  can modify the activity, [Dr. Lazaro] avoid the position of pain, do some physical therapy, [Dr. Lazaro] they're happy they're doing everything that they want to do. [Dr. Lazaro] We're happy with the same way. [Dr. Lazaro] The problem is in the active person [Dr. Lazaro] that wants to have sport, [Dr. Lazaro] or cannot avoid the position of p

ain [Dr. Lazaro] because it's what they do for the work, or whatever, [Dr. Lazaro] there is like, okay, so now we have to solve the problem [Dr. Lazaro] through surgical means. [Dr. Lazaro] A lot of people can get better modifying their activity, [Dr. Lazaro] but I always  tell them, are you happy? [Dr. Lazaro] Are you doing what you want to do? [Dr. Lazaro] Because if not, then let's look for, [Dr. Lazaro] to improve your quality of life. [Dr. Lazaro] And that's what  I like I will do, and this

[Dr. Lazaro] is all elective surgery, [Dr. Lazaro] and I'm trying to improve your quality of life. [Dr. Lazaro] A lot of people can walk with a cane or whatever, [Dr. Lazaro] and they avoid this and that, but if they're not happy [Dr. Lazaro] and I'm able to provide them a surgical intervention [Dr. Lazaro] that can improve their quality of life and their happiness, [Dr. Lazaro] that's where we are. [Host] By all means. [Host] And a lot of the questions that we do get [Host] especially for pati

ents that are interested on hip surgery, [Host] is, am I too old for this kind of surgery? [Host] When is too old for a patient to not be considered? [Dr. Lazaro] So very interesting and important questions. [Dr. Lazaro] Because, one  thing is physiological age, [Dr. Lazaro] one thing is chronological age. [Dr. Lazaro] We know that and it happens in different injuries. (indistinct) [Dr. Lazaro] More than 45, you have worse outcomes than less than 45. [Dr. Lazaro] So less than 45, people do very

well, [Dr. Lazaro] more than 45, they do better than non-operative treatment, [Dr. Lazaro] but it's a little more compromised [Dr. Lazaro] or a little more unpredictable. [Dr. Lazaro] So I think the age, [Dr. Lazaro] the problem is that when you start getting older, [Dr. Lazaro] you start having changes on the articular cartilage, [Dr. Lazaro] on the labral injury is not the same. [Dr. Lazaro] And then your muscle strength is not the same, [Dr. Lazaro] recovery is not gonna be the same, [Dr. Laz

aro] so it can compromise a little bit your activity. [Dr. Lazaro] So people that are more than 45, [Dr. Lazaro] I have good conversation, and analyze them, [Dr. Lazaro] and look at them more as a, where are you physically? [Dr. Lazaro] You know, you have 50 years old, 60 years old [Dr. Lazaro] that are in better shape than a 30 year old. [Dr. Lazaro] So those people you cannot say, okay, he's a 60 year old, [Dr. Lazaro] I'm not gonna do this. [Dr. Lazaro] No. [Dr. Lazaro] We have to look at the

ir activity, [Dr. Lazaro] we have to look at the images, [Dr. Lazaro] we get on the good MRI to analyze the articular cartilage. [Dr. Lazaro] So subchondral bone of (indistinct) is a no-no. [Dr. Lazaro] So you see subchondral bone of (indistinct) [Dr. Lazaro] you have to hold off, but if the bone looks good, [Dr. Lazaro] the articular cartilage looks good, [Dr. Lazaro] the guy is motivated, have good muscle mass, [Dr. Lazaro] then we go for it. [Dr. Lazaro] But I always tell them, and you know,

[Dr. Lazaro] while we have in the (indistinct) more than 45, [Dr. Lazaro] a little unpredictable, but I have a long conversation. [Dr. Lazaro] But we can do older. [Dr. Lazaro] The thing is  like, do you have arthritis? [Dr. Lazaro] Where is your muscle mass? [Dr. Lazaro] Where is your motivation? [Host] Hm. [Host] In order for you to make the determination [Host] which is extremely important. [Host] What a great conversation, what a phenomenal presentation, [Host] what a great surgeon you are.

[Host] We're so thrilled to have you, at most me, [Host] and we look forward to continuing hearing more [Host] of your expertise and the near future. [Host] Unfortunately, time is running out on us. [Host] We can keep you here forever, [Host] but we wanna be conscientious of your time as well. [Host] So I am going to go ahead [Host] and just thank you all for participating today, [Host] and to you Dr. Lazaro, for this incredible presentation. [Dr. Lazaro] Thank you for that. [Host] Thank you. [H

ost] If you have additional questions for Dr. Lazaro, [Host] please feel free to email them [Host] to International@BaptistHealth.net. [Host] We'll make sure to respond to them, [Host] and send them back to you. [Host] We look forward to seeing you at our next [Host] Orthopedic and Sports Medicine lecture series [Host] scheduled for March 3rd, 2021. [Host] Thank you again. [Host] Be safe, get vaccinated, and let's get back to life. [Host] Thank you, Doctor Lazaro. [Dr. Lazaro Thank you. Have a g

ood one. [Dr. Lazaro] Thank you for the invitation. [Host] Thank you.