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Melanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Cole. And today I hope you'll join us, as we explore hip arthroscopy, a new frontier in treating hip pain. Joining me is Dr. Aaron Casp. He's an Assistant Professor, an Orthopedic Surgeon, and an Orthopedic Sports Medicine Specialist at UAB Medicine. Dr. Casp, thank you for joining us as a repeat guest today. I'd like you to start by telling us about hip arthroscopy, as it's relatively new and expanding field to treat hip impingement and groin pain in young active individuals. What had been the options for treatment? How has it evolved now?

Aaron Casp, MD (Guest): Sure. Previously, in years past, people had just attributed people with groin pain or hip pain as, oh, you strained a hip flexer or something along those lines and sort of didn't think of it as anything that needed to be intervened upon. More recently, as we've learned a little bit more about hip anatomy and hip biomechanics, we've realized that people are actually having some signs of impingement and you can actually tear a structure around your hip called the labrum, and then, that labrul tear can lead to small mechanical changes in your hip and can actually lead to early arthritis and early degenerative changes.

So, when people were initially sort of brushed off a little bit about what their hip was doing, it could have been doing some long term damage to their hip. And more recently as technology and techniques have evolved a little bit, people are actually able to intervene upon these labrul tears and this hip impingement.

In early years, it was open surgery where it was called a open surgical hip dislocation, which is about as morbid as it sounds, you make a big incision and dislocate the hip and have a long, massive painful recovery from this big open incision. But now we're able to do almost everything arthroscopically.

Host: So for other providers that may not see hip labrum tears very often or may not recognize as you say things we learn, right? How does that happen in younger people that can cause significant pinching pain with deep flexion, prolonged running, sitting, tell us a little bit about the most common causes that would necessitate the need for arthroscopy in the hip.

Dr. Casp: Yeah. So, labral tear can happen in a few different ways. I sort of split them up in my head in kind of two main ways. One is a hyperflexible patient that has a labrum tear. And that could be someone like a dancer or a cheerleader or someone who uses a lot of high hip flexion angles as part of their activities and that usually creates a labral tear that is a little more acute in nature. By that I mean, they did it and then they started having hip pain afterwards. The other one is a little bit more of an overuse type labral tear, and that's runners or sort of more endurance athletes.

And while they still have pain with high hip flexion angles or deep squatting, it was more of a sort of prolonged wear and tear type injury for them. And so I get a lot of questions like how did this happen? Well, there are a number of ways it can happen and a number of different mechanisms. Some of them being either sort of more acute, like I talked about, or sort of more wear and tear, and sometimes they're a little bit of a combination of both.

Host: So then tell us the goal as far as intervening before, especially for young people, dr. Casp before degenerative changes in hip, arthritis begin to set in, prolonging the health of the joint is really essential. So what are the clinical indications for the procedure we're talking about today?

Dr. Casp: The main clinical indications are what we call a symptomatic labral tear. What does that mean? Well, there are a lot of people that if you got an MRI or imaged their hip, with no symptoms, they would have some evidence of a small labral tear. Those are the people that don't need surgery or need intervention. But there are a subset of people who have a labral tear that is quite symptomatic. And what do they look like? Oftentimes they look like they have deep seated groin pain, kind of in the front of their hip. Sometimes it radiates almost through their hip and oftentimes people sort of grab the side of their hip in a, in a C shape with their hand and say the pain is in there.

It mainly bothers people, like I said, with some deep squatting activities or prolonged running and oftentimes people get very sore when going from sitting to standing or after they've been in a car for a long period of time. And so the people that do the best are, you know, healthy, active individuals who have this labrum tear on imaging, but also don't have any current arthritis. By that I mean, their cartilage is still in good enough shape that if you repair the labrum, you're preserving an otherwise healthy joint. And the goal is to prolong the health of the joint and reestablish the labral suction seal that it creates and stabilize the hip and give people back their activities that they want to do.

Host: So speak about patient selection for whom this procedure is indicated. As we said at the beginning, it's relatively new. Tell us a little bit about the procedure itself for other providers that are looking to refer their patients to you. Tell us are you using robotics? What's the procedure itself like.

Dr. Casp: So the procedure sort of starts before we even get into the operating room, looking at the imaging. I have a very particular set of x-rays and MRI that I get to evaluate the entire anatomy of the hip. So there's a reason that this labrum tore, and it's usually because the head of the femur has impinged on the acetabulum or the socket and in between those two is the labrum.

So it's gotten pinched and torn. So if you can look at the bony anatomy, you can see whether or not somebody has a little bit of a bony deformity on their hip that would put them at risk for this labrum tear. And then the MRI confirms any cartilage or labrum damage. And then the procedure itself, is mainly for people who have these symptomatic labral tears in otherwise healthy joint and want to get back to their painfreeactivities.

The procedure is all outpatient. So it's a come in and go home same day kind of procedure. The procedure itself, uses two or three small poke holes in the skin using all arthroscopic techniques. By that I mean, small four or five millimeter camera and some four or five millimeter instruments. And the labrum is then reattached or repaired back up onto the socket to where it should be. And then any bony impinging lesions or bony deformity that caused the issue to begin with are sort of shaved down according to the imaging and the template from the preoperative imaging. So the overall goal is to make this a very thorough one and done surgery. So not only does the labrum get repaired, but any cause of the labral tear, any cause of the impingement is then shaved away back to a more sort of normal bony anatomy.

Host: Dr. Casp we've been doing knee arthroscopies for a long time. Why is this new?

Dr. Casp: The hip is particularly difficult to get access to for a number of reasons. Number one, there's a lot of soft tissue around the hip joint itself. Even in the skinniest person, you have all of your gluteal muscles, you have your hip flexor muscles and your thigh muscles that sort of get in the way. The other reason is that the hip is a very deep ball and socket joint. So in order to get access to the joint, you have to have a specific traction type table to distract the hip joint, to get in and work in that area. So, both the improvement of arthroscopic tools, as well as the improvement in techniques and ability and specialized OR tables in order to access the hip have made this a little bit slower on the playing field as far as an option goes to treat hip pain.

Host: And how have been your outcomes? Does the repair hold? What have you seen with your patients?

Dr. Casp: I think it's mainly because of very sort of strict selection criteria, but a lot of my patients are back and doing some of the things that they really enjoy doing, hiking, playing sports, and running. And so, the overall outcomes are very good, but even though I repair the labrum back, that's using some small anchors and some stitches, the labrum still has to heal there. So overall it heals very well, and reliably, so, but you have to allow it to heal. So the recovery, is just very slow initially, cuz you have to allow that labrum to heal there if you want the most optimal outcome.

Host: And do you have any final thoughts for other providers that are looking to add this to their armamentarium of available therapies, or to refer to the specialists at UAB Medicine? What would you like to tell them about hip arthroscopy, the new frontier in treating hip pain.

Dr. Casp: I think that hip arthroscopy is definitely an emerging field. And I think we'll see a lot more hip preservation and surgeries to prevent hip arthritis going forward. As far as adding this to their armamentarium, there's a fairly steep learning curve to learning hip arthroscopy. Again, it's a little bit different than a knee arthroscopy. But I think getting exposed to hip arthroscopy and of being able to evaluate your patient's hips, doing a good hip exam is very important, for understanding what's going on with your patients. So I think listen to them and then if you are not quite sure, I'm always happy to discuss with any provider in the area or any provider across the country that has any questions.

Host: Thank you so much, Dr. Casp for joining us, telling us about this procedure, the learning curve, technical considerations, everything you've shared with us today. A physician can refer a patient to UAB Medicine by calling the mist line at 1-800-UAB-MIST, or you can visit our website at UABmedicine.org/physician.

That concludes this episode of UAB Med Cast. For more updates on the latest medical advancements, breakthroughs and research, follow us on your social channels. I'm Melanie Cole.