Dr. Andrea Spiker:
Welcome everyone to the Arthroscopy Association's Arthroscopy Journal podcast. I'm Dr. Andrea Spiker from the University of Wisconsin. Today, I have the privilege of speaking with Dr. Winston Gwathmey, who practices sports medicine in hip arthroscopy as an associate professor at the University of Virginia, and is the residency program director and vice chair of education. Dr. Gwathmey was the author of the editorial commentary titled, "Repeat Revision Hip Arthroscopy: Unaddressed Femoroacetabular Impingement, Labral Damage, and Capsular Deficiency Are Commonly Encountered", which was published in the December 2021 edition of the Arthroscopy Journal. This commentary focused on the article titled, "Repeat Revision Hip Arthroscopy: Outcomes Match That Of Initial Revision, But Not That Of Primary Surgery For Femoroacetabular Impingement Syndrome", also published in the same issue. Welcome Dr. Gwathmey and thank you very much for joining me.
Dr. Winston Gwathmey:
Thank You, Andrea. I'm happy to be here. Thank you.
Dr. Andrea Spiker:
Winston, can you start our conversation by telling us a little bit about your practice and your experience with both primary and revision hip arthroscopy?
Dr. Winston Gwathmey:
Exactly. So I'm here at the University of Virginia, in Charlottesville, Virginia. This is my ninth year in practice and I'm the only hip arthroscopist here at this institution. Obviously, I've sort of built this practice from the ground up. Back in 2013, I came here to basically start a hip practice, and over the course of the past nine years, I've basically evolved with the primary and revision arthroscopists hear. Probably do about 200 to 250 hips per year. I'd say about 10% of those were revisions.
Dr. Andrea Spiker:
Great. In your editorial, you gave us a sense of your overall approach to revision hip arthroscopy specifically. So can you distill this down for the listeners and give us a few general rules that apply to revision hip orthoscopy in your practice?
Dr. Winston Gwathmey:
Yeah, so I think that the more hips you end up doing, the more you start seeing kind of modes of failure and modes of why these hips don't do as well as you'd like them to do. I guess, the value of being a revision hip arthroscopist is being able to see the errors that are probably made the first time. So I think over the course of nine years, I've learned a lot about primary hip arthroscopy by doing revision hip arthroscopy. My first rule, probably is trying to figure out what went wrong the first time, whether it be a bony problem or a soft tissue problem and see if I can address that in the second surgery, and make sure that I don't make the same mistake twice. If that makes sense. So I think that my general approach for revision hip arthroscopy is trying to figure out what went wrong first time. Then the second approach, obviously, would be to execute it well the second time. If that makes sense.
Dr. Andrea Spiker:
Are you using preoperative imaging then, for the most part a clinical exam, to figure out what went wrong? Or is that something that you're doing at the time of a revision hip arthroscopy?
Dr. Winston Gwathmey:
I think your evaluation of a patient in clinic ends up being pretty critical. I mean, obviously what you want to do is listen to the patient, hear what they're telling you. If a patient basically says that they didn't get any better after their surgery, you kind of wonder if the indications were accurate or if they actually had the right diagnosis going in. If they say they're worse after surgery, then you think that perhaps the first surgery might have done something to create that problem. If they're completely better after the surgery, then perhaps you can work with that. Maybe they have unaddressed FAI or perhaps they have adhesion, or something to that effect, that you can address at the second surgery. So I try to, with the first call with a patient, get a sense of kind of what they're experiencing. When did their symptoms occur or were they persistent after that surgery?
At that point, once you get a sense of what they're experiencing, then I think the secondary diagnostic evaluation is going to be imaging. So obviously x-rays are going to be where you start. An MRI arthrogram can be helpful here. I don't necessarily do MRI arthrograms in the primary setting, but getting a good sense of the capsule, getting a sense of the soft tissue, I think there's value there. Then CT scans, to make sure that you understand the bony morphology, both in the joint and outside the joint too, as well as version and those types of things.
Dr. Andrea Spiker:
That's great. Yeah. That's a very similar approach that I have as well. One point about those CT studies in the revision setting. I've found that in a primary setting, I use those 3D CT scans to measure things like femoral version and acetabular version, and I don't anticipate that those will change in the revision setting, but I still like to get that CT scan in order to really assess the bony morphology, the prior camera section and what the acetabular rim looks like. Especially if using that protocol, it seems like it's a study that's well worth it's while when you're doing a revision surgery.
Dr. Winston Gwathmey:
Yeah, of course. Again, you're just trying to... It's just such a huge investment for our patient. They've already been through one surgery, they've already rehabbed, they've spent the money on it. So the second time around, you just got to make sure that you understand exactly all the different variables that go into getting a good outcome.
Dr. Andrea Spiker:
In your editorial, you actually gave us a great analogy, using golf. So I was hoping you could also introduce that here, because I thought that was a nice way to put the overall approach to revision surgeries in perspective. Would you mind just talking us through that analogy?
Dr. Winston Gwathmey:
Yes. It's one of my favorite things about the arthroscopy journal or these editorial commentaries. Mainly because it actually... The way that these are written, it just kind of peaks your interest. So when I was asked to write this one, I wanted to make sure that the journal readers could at least be attracted to this article. I was sitting there thinking about... I read some comment about a golf shot one time, and how a hip arthroscopy is like a good golf shot. You get right down the fairway, you feel pretty good about your approach to the hole. Then when you have a bad outcome, perhaps you've hit your shot into the woods. So I sort of tried to expand on that with my commentary, because anybody can do a good job in golf if you hit the fairway and you hit the green every single time. It's that person who can get out of the woods commonly, is really the one who's going to be the golfer, and who's going to be able to come back and fight again another day.
Unfortunately in golf, I find myself in the woods pretty often. So the way I try to compare golf to hip arthroscopy is that, hitting a good first shot can make the rest of the hole much easier. Whereas hitting a bad first shot, the first thing you need to do is get your ball back in play in order to do a good job on the hole. So I think in comparing it to hip arthroscopy, if the first hip scope did not give the optimal outcome, the first thing you do when addressing the second hip scope would be to get the ball back into the fairway. If that makes sense.
Dr. Andrea Spiker:
Absolutely. It is something interesting about doing a revision hip arthroscopy that was primarily performed by another surgeon, because it is a little bit like entering the woods. You don't know what you're going to find, you don't know what technique they use, what kind of implants they used, sometimes. So it is very much a good analogy of what we're dealing with sometimes in these revision hips.
Dr. Winston Gwathmey:
Yeah.
Dr. Andrea Spiker:
Can you talk us through your evolution of this approach, to both first time revision hip arthroscopy and then those who are multiply revised in your own practice, and then how, if at all, this has changed over the years of practice?
Dr. Winston Gwathmey:
Yeah, of course. I mean, all of us started hip scopes at some point, and initially when you're starting hip scope practice, you're just happy to get into the joint, to correct the bony impingement, to getting a repair. I think that over the course of the evolution of my practice, understanding the nuance of hip arthroscopy has really defined my evolution as a surgeon. I think the first thing is just getting the bony correction right. Just getting a spherical femoral head, making sure you address any rim deformity, sub-spine. Getting that right the first time, I think really makes a huge difference in outcome. So I think that over the course of my evolution as a surgeon, it actually takes me longer to do femoroplasty now than it did five years ago, because I feel like I can get to all the different corners and I definitely want to make sure I get that right.
There's nothing worse than, you have a postoperative x-ray and you realize you haven't adequately addressed the femur. So that is something that's a consideration for me. Probably the most important thing for me is capsular management, at this point. I trained in the time where capsular management was sort of in the infancy of its understanding. When I was training, we rarely closed capsule. A lot of times, we'd actually take a big chunk of capsule out and I really feel like that's going to end up being, in some patients at least, a reason why they don't do as well. So I think that now, nine years in, I'm pretty obsessive about the capsular management. Making sure that I make the smallest possible capsulotomy to do the work and make sure I close it adequately, in order to assure the patient that I basically leave the hip the same way I found it.
With the closed capsule, except the impingement correction and the labral repair. So the reason why I bring that up, is I think that a lot of times when you're doing revision arthroscopy, what you realize are two things. One, sometimes a previous surgeon did not get all the way medial with their femoroplasty or they left a big ridge posterolaterally. Having seen a lot of these revision hip scopes, I start to realize that I need to make sure I get that in that primary setting. Secondly, in revision hip arthroscopy, you get in there and sometimes you see it exposed to something with so much tender, you'll see a giant capsule with a hole, and you realize that patient's probably not doing well, because the capsule was inadequately managed during the first surgery. So that actually kind of changed a lot of how I do things and I think that anybody doing a lot of hip scopes, you learn so much from going back into a hip and seeing kind of what the hip looks like after it has had a previous surgery.
Dr. Andrea Spiker:
I absolutely agree with you. I think every single revision I've done and the few of my own that I've done especially, I think you learn so much and progress so much as a surgeon every time you see one of those and get a patient feeling better.
Dr. Winston Gwathmey:
Yeah. I mean, I think you can utilize that knowledge to really improve your primary practice. That's the best part about being someone who does a lot of revisions, is that I think it really does improve your primary practice when you can understand why someone might not be doing well. Because you go in there and you actually can physically see it, inside the joint.
Dr. Andrea Spiker:
Absolutely. In this published study by Doctors Browning, Clapp, Krivicich, Nwachukwu, and Nho, the authors looked at results after repeat revision hip arthroscopy, meaning the second revision surgery after patients had already had a first revision surgery. They found that at a minimum of one year follow up, the repeat revision patients did actually achieve minimally clinically important differences or MCID postoperatively, at a similar rate to patients having a primary hip arthroscopy, which was approximately 90% of the time. However, only 30% achieved a patient acceptable symptomatic state or PASS. So a couple of questions based on this finding. First, what were your thoughts on this conclusion? Is this something that you've seen in your own practice? Then second, as you work with residents and fellows, how do you explain the differences in MCID and PASS using this study's findings as an example?
Dr. Winston Gwathmey:
Exactly. I really think that these kinds of studies are super important for us to understand what we can tell a patient before surgery, because a lot of times a patient wants to... I mean, setting expectations I think is really critical. So you're sitting in clinic with a patient who's had a previous hip scope and they're like, "If I have a second hip scope or a third hip scope, what can I expect?" I think you can tell them pretty reliably they can expect improvement. You're going to see a difference, this study would support that. I think the interesting thing about this study, is that a lot of the second hip arthroscopy or the repeat hip arthroscopy patients, started off at a much lower level than the other two groups. So these are pretty miserable people if you think about it. They're sitting there in clinic with a baseline score that's pretty low.
So I think you reliably tell them that yes, if we go back into your hip and we address the problems that were in there, you can expect an improvement. The question's going to be the magnitude of that improvement, and will you get to what you would consider an acceptable systematic state? So the MCID or the minimal clinically important difference, is basically a detectable difference through whatever scale you might use. iHOT 12 or Harris Hip Score. You can appreciate a difference, and some patients are just looking for that. "If I can just get a little bit better, I'll be happy". You know? So it's important to set that expectation. However, when you're trying to look at the patient acceptable symptomatic state, or basically taking into account all their activities like their living, their pain, their function, when you get to a point after surgery in which you find it to be acceptable... Only one in three patients really get that repeat revision.
So I think that, again, that's just to me a really important finding from the study. In order to be able to explain to patients who might be looking at another surgery, the cost of it, six or eight weeks on crutches possibly, three or four month recovery. Is it worth it? So in my own practice, yes, I've definitely seen that. You get a primary hip scope with the big cam, and you can pretty reliably tell them, you're going to be pretty happy when you're done. You get back to a lot of your activities. You see somebody who's had two previous failed surgeries and maybe you kind of tipper their enthusiasm that they're going through a third surgery.
As far as how I explain this to my residents and fellows, I think it's really important to understand this stuff, and I think I really do try to utilize this to help set patient expectations after surgery. MCID is going to be a relative value, it's basically a difference you can detect. Whereas a PASS score would be a more absolute value, that's been set in the literature by previous studies. So I try to explain that as how... And this study kind of helps me explain that to fellows and residents, as far as how that difference actually occurs.
Dr. Andrea Spiker:
Yeah. That's an excellent distillation of that, and I think it's a very important concept as you pointed out. Now, also in this specific study, the authors found that there was less bony work happening at the time of the repeat revision surgery, than at the initial revision surgery, and that labral reconstructions were occurring about 15% of the time in the repeat revision cases. Additionally, they noted that all repeat revision cases had some sort of comprehensive capsular management performed, at the time of surgery, with half actually requiring a capsular reconstruction. So how did you interpret these results, and is this what you're also seeing at Virginia?
Dr. Winston Gwathmey:
I think from the time someone's had a second revision surgery, hopefully the bony work has been done. However, a lot of times you have to sort of I'd say tinker with it, or there might be a medial ridge or something to that effect. But for the most part, somebody who has had two surgeries, a lot of times the issues could be soft tissue. There can be scar tissue that's formed, adhesions you take down, labral looks pretty junky when you're done with it. So I do think that going in there knowing that you're going to have soft tissue work to be done is important to your preoperative discussion with the patient, kind of your planning. Yeah. I'm seeing that in Virginia here too. If somebody has had two surgeries, perhaps, two labral... A lot of times a residual labrum is no longer going to be functional.
So doing a labral reconstruction, you have to be at least be planning for that. I think more importantly though, is as the capsular management picture of this. Half of these patients required capsular reconstruction. I think, as a surgeon going into a repeat revision, you have to be prepared to address the capsule. So all these patients in this study had some type of comprehensive capsule closure, and half required capsule reconstruction. So I think that going in, you have to at least have a graph prepared, have that conversation with the patient, prepare them for the postoperative rehab, which is going to be different, just so that you know that when they fully recovered from the second surgery, the capsule's not going to be your issue anymore.
Dr. Andrea Spiker:
Yeah. I agree. Also, in your editorial, you noted that after you read this study, you came away with two main conclusions. Can you discuss those two main conclusions from these authors' results with the listeners?
Dr. Winston Gwathmey:
Yeah. The two conclusions I really came with from the study is one, don't give up hope. A hip arthroscopy patient is a very fragile patient, especially someone who's had two failures. They're sitting in your clinic, they might have come from far away to see you, and from the results of the study, you can tell them there is hope. I think that's really important. Don't give up on the two time failure, because if you can identify the etiology of failure and execute a good second revision surgery, you can get them better. You know, you might not get them perfect, but you can get them better, so don't give up hope. But secondly, and perhaps more importantly, is get it right the first time. The whole thing is, if you can figure out how to avoid the first and second revision, then you really are helping your entire patient population. So I think that's, to me, the most valuable thing I learned from the study. It was all the different problems they found the second time around that could have been avoided possibly with a better primary surgery.
Dr. Andrea Spiker:
Yeah, that's an excellent point. I think, maybe one thing that we could add to this is, both you and I have very subspecialized hip arthroscopy practices, but if a patient shows up to someone's practice who doesn't do much hip arthroscopy and has had two prior surgeries, maybe phone a friend and somebody who would be prepared to do these additional procedures that may be required at the time of that revision.
Dr. Winston Gwathmey:
Exactly. Andrea, one of the best things about being a hip arthroscopist, is the network here. I mean, I think you and I can really speak to this, that the groups we have in our societies are so helpful. Here in Virginia, I have Andy Walker up the road, I've got Chad Mather down at Duke, I can call Andrea Spiker up at Wisconsin, Thomas Bird in Nashville, these people are all on my phone. Trust me, all of us are in this together and we're trying to figure out the best we can do for patients. I think your patients will benefit by you, or by me, or any surgeon just kind of swallowing your pride, understanding what you know and what you don't know and making sure that you do the best thing for your patients.
Dr. Andrea Spiker:
Yeah, that's an absolutely excellent point and I live by that as well. What questions do you think we still have to answer, related to revision hip arthroscopy procedures going forward?
Dr. Winston Gwathmey:
I think that, we talk a lot about the structural components, the bones, the soft tissue, there's just so much more out there in the world of hips. These patients have had multiple hip surgeries over the course of two or three years. The neural elements to this, the muscle balance dysfunction, you get muscle atrophy, the overall bio-mechanics of the hip are altered by this. Also, even prior to the first arthroscopy, they probably had some dysfunction. So I think we really have to understand the overall hip function, as it relates to a malfunctioning hip.
You know, it's easy to say that the labrum's torn, there's FAI, but what's harder for us to really distill, is the overall bio-mechanical dysfunction that occurs around a bad hip. As a surgeon, patients come in, "I have a labral tear, I need you to fix it." But the soft tissue, the muscle, the neural elements around that labor tear, I think are still things we don't understand completely. I don't know how to understand it, but I do know that there're some patients that you can do a perfect procedure on, yet they still have issues with it, because you don't understand what's outside the hip joint.
Dr. Andrea Spiker:
That's excellent. Well, thank you so much Dr. Gwathmey, for sharing your thoughts with us today. It's been a true pleasure speaking with you and I look forward to speaking with you again soon.
Dr. Winston Gwathmey:
Thank you so much, Andrea. I really enjoyed doing this. To all the hip arthroscopists out there, we're all in this together and we're all trying to do the best for our patients.
Dr. Andrea Spiker:
Dr. Gwathmey's editorial titled, "Repeat Revision Hip Arthroscopy: Unaddressed Femoroacetabular Impingement, Labral Damage, and Capsular Deficiency Are Commonly Encountered", can be found in the December 2021 issue of the arthroscopy journal or online at, www.arthroscopyjournal.org. This concludes our episode of the arthroscopy journal podcast. Thank you for joining us.
The views expressed in this podcast do not necessarily represent the views of the arthroscopy association or the arthroscopy journal.
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