Intro: This is Weekly Dose of Wellness, brought to you by MemoralCare Health System. Here's Deborah Howell.

Deborah Howell (Host): Many people who have chronic hip pain are still not aware that they might not have to have a big joint replacement surgery. Hip arthroscopy, a minimally invasive hip treatment option, is becoming more and more popular. Today, our guest, Dr. Prem Ramkumar, an orthopedic surgeon at MemorialCare Long Beach Medical Center, will talk to us about hip arthroscopy in depth, detailing the procedure, its benefits, the conditions it treats, who qualifies, preoperative preparations, the recovery process, and expected outcomes. Welcome, Dr. Ramkumar.

Prem Ramkumar, MD: Thank you so much for having me excited to be here.

Host: Excited to have you. So what is hip arthroscopy? Can you just describe it for us?

Prem Ramkumar, MD: Absolutely. It's hard to understand what hip arthroscopy is without actually understanding what the diagnosis it treats is. And the main diagnosis that hip arthroscopy is used for is called hip impingement, which is a short way of describing what we commonly refer to as femoroacetabular impingement. Femoro meaning the top of the femur, the ; and the acetabular, meaning the socket. And oftentimes, patients with hip impingement are suffering in silence. They have been told for many years that, you know, their hip tightness and hip stiffness and groin pain is normal, or they maybe just pulled a muscle and they should just stretch it out. You shouldn't really be 20, 25 years old and be doing activities like hiking or sports and have any kind of hip pain. And what makes the picture even more complicated is that hip pain can be pretty hard to recognize because oftentimes it starts off as back pain or sometimes knee pain, but hip pain, most people don't even know that it starts usually in the front of the top of the thigh or sometimes the side of the thigh, and rarely in the buttock. So, a lot of people spend a lot of time wondering what is happening. But it's not like an explosive ACL injury where you hear a pop or you hear a swelling. It's just this generalized achiness, a dull toothache pain that just gnaws at you. And it's a very big problem. It's an epidemic

Host: I bet people just pop the Tylenol afterwards thinking, "Oh, I hiked too far."

Prem Ramkumar, MD: Absolutely. And it's a very interesting condition that we're starting to understand a little bit more because the way it happens, it preferentially affects athletes. The way that happens is typically between the ages of 15 to 22 years old. When we're young, we have these things called growth plates and they're open. And when we're using our bodies a lot, it's commonly lacrosse, soccer, hockey, basketball, those growth plates, the only thing the body knows how to do by responding to this extreme stress at a young age is put down more bone to protect our hips. It puts down bone on the pelvis near the socket, and it puts down bone on the proximal femur near the head of the hip. And what that does is that it causes a lot of limited range of motion to strengthen the bone, or if so, the body thinks. But over time, this abnormal bone causes the hip to lose its range of motion. And what makes it very interesting is that, you know, when five, 10 years go by, that's when people start to recognize that there's a problem, sometimes even longer. Because that abnormal bone then articulates or moves into the joint and first hits the cartilage, which doesn't have any pain receptors. So, no one really knows they're starting this early arthritic process, but only when that bone then tears the labrum second is when people start to recognize that there's a problem

Host: Interesting.

Prem Ramkumar, MD: And only after they recognize that there's a problem, that's when the maze of the healthcare system takes over and people are often lost. It takes about, on average, four to five different healthcare providers before they can actually see a hip specialist. And on average, one in six patients gets a sham procedure because, again, it's hard to diagnose this condition. Some people get inguinal hernia operations, some people get gynecologic examinations when the whole time it's probably their hip impingement.

Host: Wow, that's fascinating. So, what makes hip arthroscopy unique? And why do so few people do it?

Prem Ramkumar, MD: Well, it's unique because of its history. It was done a long time ago, 50 to 60 years ago, but it wasn't necessarily done on the correctly selected patients and using modern techniques that we now know actually preserve the joint and help the patient and provide long-term durable relief. So yes, in the past we used to make small incisions in patients and look inside the hip joint with a camera after pulling on the leg. And oftentimes, people would remove the labrum and now we know you have to save the labrum as much as possible. Historically, people would also just ignore the giant bony bump, what we call the CAM lesion. And now, we of course shave that down, because we recognize that hip impingement is a bony problem, and the labrum is just the innocent bystander that gets hurt in the process. The real crux of the operation comes down to shaving down that bone and repairing the labrum.

And then, finally, and most importantly, is closing the capsule, which is the piece of soft tissue we cut that provides stability to the hip joint and lets people return back faster. All three of those things are very, very technically demanding. And many surgeons I just view hip arthroscopy as probably the most difficult elective orthopedic operation because of the amount of learning that's required to do this.

Many people spend an additional year just trying to get facile at this operation. And it makes sense because it's a hard operation to do. It takes two and a half to three hours. It seems minimally invasive because the incisions are so small, but it's a long operation and it requires a lot of meticulousness.

Host: Wow. And what kind of a tool do you use to do the shaving?

Prem Ramkumar, MD: Yeah. So, we typically use a burr to shave down the bone. It's almost like re-sculpting the hip to get back to what we think the normal anatomy. And the big question in Orthopedics is what is normal anatomy? And so, it's a bit of a judgment call, but the important thing is the hip needs to have normal range of motion when you're done with the surgery.

Host: Got it. Now, what conditions can hip arthroscopy treat and why might someone need this procedure as opposed to other types of hip surgeries?

Prem Ramkumar, MD: The most common hip surgery is a hip replacement, and that's for people who already have severe arthritis. Hip arthroscopy is not typically meant for people with any arthritis. In fact, it's a contraindication in most cases for people who already have that arthritic process starting, because we don't have a reliable means of regrowing cartilage or putting it back. The main purpose of hip arthroscopy is addressing that hip impingement, which we just talked about, that generalized achy stiffness and tightness in the hip that can cause pain. That femoroacetabular impingement or hip impingement typically affects people who can't stand sitting in long car rides and have difficulty getting up and out of a chair. And usually, standing feels better. So, imagine having the pain and difficulty of just trying to relax when you're sitting down, but you can't do that. You can recognize these people across the room, they're the ones that are always getting up and out of a chair, trying to stand and walk it out. And they're typically well-built athletes who've used their body a lot and developed that hip impingement. But hip arthroscopy can also be used for other things such as benign tumor excisions where patients don't need a large open incision to recover.

Host: Got it. Now, how does hip arthroscopy allow you to see inside the hip joint and perform your necessary repairs?

Prem Ramkumar, MD: So, it comes down to the technology. We use a camera, also known as an arthroscope, where we put inside the hip joint after pulling traction on the leg. And it's what we call a 70--degree scope where you can spherically look around the hip joint. And that allows us to examine and inspect the hip. And then, we use other long, small instruments to basically do our work from repairing the labrum to shaving down the bone. And you already asked about the burr. There's a lot of great technology from Stryker, which really allows us to basically thread the needle around the labrum and fasten that labrum back to the bone.

Host: So interesting. What are the main benefits of choosing hip arthroscopy over traditional hip surgeries?

Prem Ramkumar, MD: Hip arthroscopy is reserved for, again, just those select patients who have that hip impingement and who would benefit because they don't have arthritis. So, the main benefit of this is that you have the potential to reset the life of a hip if you catch it early. There's increasing research coming out that's showing that if you address hip impingement at a young age, there's a pretty good chance you may actually be able to delay arthritic changes on x-rays, almost 25% chance. So, if you have this diagnosis, and if you're lucky enough to have heard of it and gotten through the maze of the healthcare system and found the correct hip specialist, and you're a candidate, then it's an excellent operation with amazing results that range from 92-98% success rate when chosen correctly.

Host: And when you say young, can you be a little bit more specific?

Prem Ramkumar, MD: Yeah, typically I would say anywhere from the ages of 17 to 45 is probably the average range.

Host: Okay. Okay. And what are the key symptoms indicating a need for hip arthroscopy?

Prem Ramkumar, MD: Yes, it's a lot of these people who are suffering in silence. It's these people who, especially in Southern California where we're stuck in our car, sitting in a car for a long time, that can just cause this dull ache in the front of your thigh or sometimes the side. And so, sitting pain is probably one of the most common signs of hip impingement, as well as pain with squatting and lunging, not being able to get back to these higher demand activities.

Additionally, people really have difficulty when they're bringing their knee close to their chest, and turning it inwards is very difficult, but that's getting more into a physical exam that a hip specialist should evaluate.

Host: Sure. You covered this a bit earlier, but I want to make sure you've said everything about this you want to. Who's a good candidate for hip arthroscopy?

Prem Ramkumar, MD: Yes. So, a great candidate for hip arthroscopy is someone who has that hip tightness, achiness, and stiffness, on history as well as someone who on x-rays and advanced imaging has abnormal bone that explains why they're having their symptoms. And they must pretty much have no severe or major arthritic changes in the process. So, it's a lot of people who are typically younger athletic individuals that want to get back to sports and get back to the amazing outdoor activities we have in Southern California.

Host: Yeah. And do you start with an x-ray?

Prem Ramkumar, MD: Yep. We start with an x-ray, but it's not a typical x-ray. It's a special view x-ray that allows us to bring the bony impingement or source of abnormal bone into a view. We call that the Dunn lateral or the long neck view. There are many different names of describing it, but it does require a special x-ray. So if you show up to the ER with a hip impingement, that's just gone too far, most people are going to take an AP pelvis x-ray. And they're going to say nothing's wrong with you, because you're actually missing that diagnosis so many times. So, if you have this generalized achiness and you feel like something's not right, there's probably something wrong and you may not have gotten the correct x-ray.

And most people come in to my office only after getting an MRI that says, "Hey, you have a labral tear." And even then, some patients who already have heard of hip impingement, the radiologist might have missed the diagnosis of labral tear, because it's actually quite subtle to detect a labral tear on MRI. So really, these people have to go through so many leaps and bounds and efforts to just get to the correct diagnosis and then get to the correct specialist, but it affects so many people.

Host: For the lucky ones who do get through the whole system, what should patients expect in terms of preparation before undergoing hip arthroscopy?

Prem Ramkumar, MD: Yep. So although it's minimally invasive, you still have to put in work on the backend after surgery. It requires limiting your weight-bearing for at least two weeks. You have to wear a brace for those two weeks and you're restricted in your range of motion. But restricted range of motion doesn't mean you're not being active. You need to get back on the stationary bike and use your hip. And oftentimes, I have patients that bike five to ten miles in the first few days after a hip arthroscopy.

Host: Wow. That's great.

Prem Ramkumar, MD: And then after two weeks, you're done with the crutches and done with the brace and you're walking normally from weeks two to four. And by week four, I expect my patients to be having a completely normal gait and walking normally. And then, from weeks four to month three, that's when you're really learning how to stretch and strengthen in a safe manner that still protects the repair. And then, after three months, we really turn you loose and you can get back to strengthening your muscles, because the hip is a very core foundational joint. And this is the only operation in Orthopedics that increases the range of motion of a joint. But at the same time, the hip has 17 plus muscles that attach to it. And they're all used to being tight and stiff. And now, all of a sudden, at the time of surgery, we're giving that hip the ability to breathe again. So, those 17 plus muscles need to learn what a normal length-tension relationship is. And that requires sometimes months of rehab to feel good again.

Host: Sure. And people will always ask, I'm sure, "When can I drive?"

Prem Ramkumar, MD: Yep. They typically can drive when they're done with narcotics and they have the ability to react from their foot. I can't give a perfect example. But oftentimes, it's usually about two weeks.

Host: Okay. That's good enough. I have a final question for you, doctor. How does practicing at MemorialCare Long Beach Medical Center enhance your ability to perform advanced procedures like hip arthroscopy and really ensure the best outcomes for your patients?

Prem Ramkumar, MD: It starts with the team Everyone here is really putting the patient first and I've seen that firsthand and it's where I would send my own family members to. I'm very proud of all the people that I work with on a daily basis. And quite honestly, the commitment to staying at the forefront of technology. So, for example, hip arthroscopy, the gold standard of treatment is, in my opinion, the Stryker Guardian Table and the Stryker Pivot Equipment that one of the key pioneers, Brian Kelly, helped establish. And it really set us forward in terms of how we do this operation. So in brief, I would say it's the quality of people that assist me in the operating room, as well as the commitment to the technology and always being at the forefront.

Host: Your passion is shining through. This has been incredibly interesting. Thank you so much for being with us today, Dr. Ramkumar.

Prem Ramkumar, MD: Thank you so much for taking the time and giving me the opportunity to speak about this.

Host: That's all for this time. For more info, you can call 562-933-4014 or visit memorialcare.org/lbjointreplacement, or you can listen to a podcast of this show at memorialcare.org. I'm Deborah Howell. Have yourself a terrific day.