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Jan 04, 2023

The Truth About Hip Arthroscopy

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Dr. Yoni Rosenblatt: Welcome back to the True Sports Physical Therapy Podcast. Dr. Callista Morris, super excited to have you, and you have been such a great support system to the True Sports family. So first of all, I wanna thank you for that.

Dr. Callista Morris: Thank you for having me, and thank you guys for your hard work.

Dr. Yoni Rosenblatt: Oh, please, and one of the great things is when I get to have surgeons on that know and love our model, it's usually because we know and love your model. So you have had some outstanding outcomes up there in the York and Lebanon areas of Pennsylvania. And then I got the chance to spend some time with you at Mesa. So with some of the best surgeons in the world. So obviously we know and love your work. Tell us our audience of sports PTs. What is it that makes you an outstanding surgeon?

Dr. Callista Morris: Well, I appreciate that. I do think the big thing really is our support system. So I start out with the, obviously initial eval and initial treatment, but then the hard work's always done on the back end. So a lot of the outcomes really are based on you guys and your good hard work with therapy and then the patients receiving that. But for me, I really try to take a personalized approach with the patients. So I try very hard to listen to like what they've already had done, what symptoms are they having, what are their treatment goals? So I see patients of all age ranges, and so it's very important to me set their timing whether is it their goal that they get through senior season in high school and they have no intent of going on to college? Do they wanna play in the professional level? Like what is the next step for them? And that helps me kind of tailor their treatment plan around that. And so I think that's really been crucial in our outcomes.

Dr. Yoni Rosenblatt: Okay. So that bleeds in beautifully to hip pathology being the topic of today's podcast.

Dr. Callista Morris: Yes.

Dr. Yoni Rosenblatt: Because I always say that corner of the body is so complex, there's so many things that run. So complex...

Dr. Callista Morris: So complex.

Dr. Yoni Rosenblatt: And so many things that run across those things. So a patient walks into your practice and says I got groin pain. How are you then starting to peel away those layers to understand, is this true hip pathology or could this be something else?

Dr. Callista Morris: Absolutely. So where in the groin, so a lot of patients that think that they have hip pathology may not. So I need them to point to me, is it truly in the front, in the anterior groin? Then we're definitely thinking hip. Do they give me that C sign that we all talk about? Like they can't really describe where the pain is that then I'm thinking hip again. If they're pointing to like the outside, not so much intra-articular hip pathology, now we're looking at more muscular stuff. Then I say, when does it hurt? Any injury mechanisms? So like, did they have an acute event that they can feel like they felt a pop that might be more muscular. Like did they pull off one of their growth plates? I also look at their age. Do they have growth plates? Then we start looking at does it hurt them to sit in class or sit in a car? A lot of patients with intra-articular hip pathology have pain just sitting. And so that's pretty important because you're kind of getting into that hip flexion of that impingement area when they're sitting down. Then I go down to what have they tried? So how long has it been there? Have they tried injections? Have they tried therapy? What has and has not worked for their hip?

Dr. Yoni Rosenblatt: Okay. So as you're working towards that subjectively to figure out which way you wanna take it, then what happens objectively? What kind of tests are you running to move things in or out?

Dr. Callista Morris: Yeah, absolutely. Good question. So I do five, I obviously, I do a physical exam. So I'm looking at do they have pain with FADER, do they have pain with FABER? I check their Psoas. Do they have pain at hip flexion and 45 degrees of hip flexion in some internal rotation? You can catch some Psoas pain with that. Check for internal or external snapping. I get a five view hip x-ray in the office, so I always do weightbearing films. They need a weightbearing AP pelvis. It needs to be a good AP. There are some technical considerations when we get the X-ray. I get an isolated AP of the hip, a lateral of the hip, and then they get two special views. One's called a modified Dunn, that shows me CAM morphology more so than other X-rays. And then the other one's called a false profile view that helps me show their subspine, their ASIS and then their coverage on the front of the hip. So those are the first objective things that we look at. And then based on that, do we go down the road of doing diagnostic hip injections? Do we do an MRI? Do we do a CT scan. CT is kind of like the last step in any type of surgical planning for me.

Dr. Yoni Rosenblatt: Okay. So correct me if I'm wrong, if I'm a PT with an athlete with... I'm suspecting some type of hip pain, I make a referral out to a physician. If they aren't receiving these five views of X-rays, are they seeing the wrong hip specialist?

Dr. Callista Morris: I would say they least need a modified Dunn and a false profile. You don't always have to get a dedicated AP of the hip if they have an AP pelvis, a lateral, and then those two other views. They're really important in catching some subtleties in the hip. Now some people will only get the three view and jump straight to advanced imaging in terms of MRIs and CTs. I'm just a little less aggressive in terms of spending the patient's money in that realm if they don't necessarily need it. So I screen them with those x-rays.

Dr. Yoni Rosenblatt: Okay. So what are you looking for in those X-rays that are then gonna lead you down the path of MRI versus now, you're good?

Dr. Yoni Rosenblatt: Yep. So I look at their what we call their over or their under coverage on their cap. So I measure what's called the lateral center edge angle. That tells me are they a shallow cap or do they have a deep cap? So that tells me kind of pincer impingement, hip instability, dysplasia. So if it's under an angle of 26, now we're talking about micro instability of the hip or hip dysplasia, that's a whole different conversation that we have to have 'cause that's a much harder correction with an arthroscopy. Over the angle of 40, now we're looking at pincer impingement. So now I know they're an at-risk hip for a labral tear.

Dr. Yoni Rosenblatt: Okay.

Dr. Callista Morris: Anything in between, like in the normal realm, maybe not so much intra-articular pathology, then we go to those special views. I measure what's called an alpha angle that gives me if they do or do not have a cam bump, also at risk of hip impingement with the cam bump. So if they have an at-risk hip, now we start taking the train towards hip pathology. If they do not have an at-risk hip, we start going towards muscular control, rotational issues, muscle imbalance, that kind of thing.

Dr. Yoni Rosenblatt: So that's when you're leaning towards go back to your PT or go to a PT. Let's see how we get you stronger, more stable.

Dr. Callista Morris: Yep.

Dr. Yoni Rosenblatt: Okay. So how long has that concept of micro instability under 26, how long has that been around?

Dr. Callista Morris: It has been around. How long we have recognized it, not so long. So the under 26 has been around a long time. That's been a standard cutoff for hip dysplasia. But the micro instability, I wanna say they were probably starting to talk about that eight years ago at this point, maybe 10. It's taken off even more in the last five. So 10 years ago, we weren't really focused on it. A few people were talking about it throughout the country, and we started to pay attention. And now it's come to the forefront in like the last five years.

Dr. Yoni Rosenblatt: And I feel like I've been a PT long enough to see hip scopes, labral repairs, labral reconstructions that failed, didn't do well, and they were floppy, they were super mobile. They just seemed to not do really well. And I never really understood why. It sounds like they were this micro instability world, right?

Dr. Callista Morris: Right. Yep. Absolutely. And we used to say, you don't need to close the capsule. Like the capsule's not that important. That's now well-known to kind of beat the wrong answer, like the capsule is very important. And then there was this wave where like men don't need capsular repairs, and women do not necessarily true either. But now we're much more focused on getting a good capsular closure and selecting the right patient to get the hip scope is very important.

Dr. Yoni Rosenblatt: And so I think that is gold for our audience. Listen, because usually the way it plays out, at least in Maryland and PA, definitely in Maryland, we'll get those patients first and I'm working like crazy to get this patient strong, to get this patient better. They're not doing well when I send them out to a hip specialist. I think it's really important for all the PTs listening to know, you wanna send them to a hip specialist that is up to date with current literature. And by the way, that means within the last, according to what you just said, five years, right?

Dr. Callista Morris: Yeah.

Dr. Yoni Rosenblatt: So you gotta be constantly learning. And if you're making that referral, ruling out a scope is arguably more important than saying, yeah, I'll scope you.

Dr. Callista Morris: For me, it's the most important part of my hip exam is like, do I need to rule you out of this before I rule you into this?

Dr. Yoni Rosenblatt: Yeah. Yeah. Okay. Well, that is gold and that is what PTs should hear and know and start to vet our surgeons to say, who is our hip person and why is it a hip person? We have a hip guy down in Maryland who is this massive hospital system's hip guy, and he's not ruling out. He's doing a lot of ruling in.

Dr. Callista Morris: Right. Yep.

Dr. Yoni Rosenblatt: And just because you have the title of hip specialist, I think some of this information with the five view with the under 26 invaluable to the referring PT to say, Hey, this is a hip specialist I know and trust and love. So thanks for sharing that. Okay. Under 26, what kind of x-ray is that, that they're under 26?

Dr. Callista Morris: That's the AP pelvis.

Dr. Yoni Rosenblatt: Okay. So AP pelvis under 26. These patients for me personally are very challenging.

Dr. Callista Morris: Very challenging, yes.

Dr. Yoni Rosenblatt: What do you do with them surgically when they're under 26 on the Ap?

Dr. Callista Morris: So before we jump there, then I talk to them about a diagnostic injection. So almost all of my hips, regardless if they're under 26 or not, I'm doing at least a diagnostic hip injection, a lidocaine under ultrasound. I want that to resolve their hip pain, even if it's for 20 minutes. Then they get an option of having a steroid to try to get us back to baseline. We do know there's upwards of 30% to 60% asymptomatic labral tears in athletes, particularly hockey players. So ice hockey players, especially goalies, you know what position they get in, like 60% of them have tears and don't know it. So can I get them back to baseline with an injection and with therapy, then we can avoid hip scope. I'm not as worried about the tear itself. I want their pain to be on.

Dr. Callista Morris: If their pain goes away with the diagnostic injection and it comes back, now we're confirming the tears that are on an MRI and I'm getting a CT scan, I guess to try to avoid any proprietary places. There's a certain company that I send my CT to and they give me a 3D printout of it, and it's almost like a heat map. It shows me where are they pinching, what is their exact rotation in their hip? So like my X-rays are decent, but they're not as good as a CT. So the CT will give me numbers on the rotation at their hip. Their femoral version is important. Are they inverted at their femur and their cap is shallow? That's a recipe for disaster. That's me sending it to an open hip surgeon. I'm not scoping that. The borderline is when they have a slightly shallow cap at like 22 to 26, but their femoral hip rotation is pointed backwards. So they actually grew so that their thigh bone or their femur, it has a little slight retroversion and it's compensating a little bit for their shallow cap. They're still in a window. They can get a hip scope if they get what's called a capsular plication, so if we tighten the capsule.

Dr. Yoni Rosenblatt: Okay, so you have to tighten that capsule in that point, in that case.

Dr. Callista Morris: Gotta tighten that capsule in that point. Yep. And then there are a few patients that if they're shallow and their hips pointed forward, they still might be a candidate for hip arthroscopy, but they may need what's called a backup, a capsular reconstruction. So kind of like the shoulder where people were doing superior capsular reconstructions, they're doing this in the hip bone. I will tell you, I'm not personally doing that, I just have not been exposed to it enough. I know it exists. I know who needs it on backup. I haven't done one, so I don't do it now. I will send them to the guys that do. There's probably five in the country that are doing it well.

Dr. Yoni Rosenblatt: Wow.

Dr. Callista Morris: And so it's that new. We have access to a lot of them on the east coast, which is very helpful. There's a doc in Philly and a doc in Pittsburgh that's doing it, and then you've got Utah, Tennessee, and Colorado, and...

Dr. Yoni Rosenblatt: That's it.

Dr. Callista Morris: That's pretty much it. Yeah. And so now a lot of them get away with being able just to tighten the capsule and they don't need the reconstruction, but I don't wanna get into a situation where we're in the middle of their hip scope and I said, alright, we fixed it. Your capsule's not tightening up. You need a reconstruction. So that's a long office conversation because it's travel, it's out of network, it's a process for these people. So it's hard, but...

Dr. Yoni Rosenblatt: Yeah, but the point you're making, which is totally worthwhile is not every hip impingement is the same. No two are probably the same and no two hip surgeons are equally qualified to do a given thing. So kind of knowing where you are, where they fit in this algorithm and where to send them is super important. Is there a concept like there is in the shoulder of a performance enhancing labral tear, right? So like we know that elite level pitchers are able to get this unbelievable layback so that they're able to increase their velocity into the triple digits and you go ahead and fix that labrum, forget it. Like these are the guys that Gilada is like, I'm not touching that thing.

Dr. Callista Morris: Right. Yep.

Dr. Yoni Rosenblatt: So does that exist in the hip?

Dr. Callista Morris: No, not that we know of. Yeah.

Dr. Yoni Rosenblatt: Okay. So if you do a labral repair, you tighten up an NHL goalie's hip, he's still going to be able to get to the positions he was pre-op?

Dr. Callista Morris: Absolutely. I'll be honest, the odds of an NHL goalie having a capsular problem is extremely low. They're usually the cam pincer combined deformity guys that we have to actually give them more motion by shaving down a bump. It's usually the young skinny ballet dancers and females who are getting into extreme positions, right? They can get into an extreme position because their rotation in their hip is allowing them to do that. So there are more risk, and an isolated capsular reconstruction is not limiting that. The thing that could limit that is when you get to the next extreme, which is open procedures or osteotomies where we have to cut the bone and move it and physically correct the rotation, that could absolutely limit a person's career, especially in things like dance.

Dr. Yoni Rosenblatt: And so just a standard capsular tightening is not gonna restrict that dancer's necessary motion.

Dr. Callista Morris: Right.

Dr. Yoni Rosenblatt: Okay. Love it. So are you ever going towards a hip scope without getting that proprietary CT imaging?

Dr. Callista Morris: I used to before it existed and now I do not. So it's always in my toolbox one of my preoperative checklist requirements so that I can see what's going on.

Dr. Yoni Rosenblatt: Can I put that in the list of Mus to recommend to a PT or at least to a surgeon to say you don't know what you're properly repairing or attacking without seeing that heat map? Is that true?

Dr. Callista Morris: No, I wouldn't say it's a must. You can see a lot on the MRI. There are other advanced imaging CTs with other companies. They're giving people the same information. It's just the one that I personally use. And I think majority of surgeons are using it. We can get a lot of information on the x-ray. We just aren't making it perfect. We get closer to perfect with the advanced imaging, so I can't say that it's a must. There are plenty of good surgeons that are more skilled or higher volume than I am in hips that are not always doing that. But they know what they're doing and I would never not say that they can't.

Dr. Yoni Rosenblatt: And when you go into that joint intraoperatively, can you see those points of I guess compression or impingement once you're in there?

Dr. Callista Morris: So there is a second technology. I don't personally utilize it. There's some, I shouldn't say there's some issues with it. There are, it is not cheap to use. So from a patient, it adds the cost to it, at least in our centers. And so unfortunately since we're in the private world, we don't have the academic funding for it. But you can actually get an iPad that matches their CT to what you're seeing on the x-ray. So you can get six different fluoroscopy views intraoperatively that tries to match the two, and then you kind of play video game like, yep, my x-ray looks good to my CT. Nope, not so much. So that's the next level that I don't personally have access to, but that's the next level that some people do.

Dr. Yoni Rosenblatt: Okay. Okay. Fascinating. It crazy, 'cause it sounds like there's this whole menu of options available to the surgeon potentially. Definitely available to the patient if they're willing to travel. How does a patient get educated on these menus? I feel like in Baltimore, if you don't go to the place, to the doc that sounds like you, you're not getting that menu. So how do I learn this stuff?

Dr. Callista Morris: Really a lot of the conferences and seeing who's talking, like who's giving the talks on this, that's who knows about it. And that's hard. The patients don't know that, right? Like it's the patients have to talk to you and then you guys say, yeah, you have failed three to six months of therapy. Like, these are the guys and girls that I know that do hips a lot, go see them.

Dr. Yoni Rosenblatt: Okay. So as PTs, so educate us PTs, how do I know who's presenting on this stuff in researching, am I going to PubMed, like break it down like I'm a moron?

Dr. Callista Morris: Good question. Really, there's August, there's a HIP Conference every year, so you could even just go online, see who is listed to present at the HIP conference, AARS is our big academic meeting we meet once a year in March, there are always HIP talks, so that's the easiest one to reference is really the academy, so go to the academy's website, kinda see who's talking on this stuff, and it'll give a general guide as to who is in tune with the HIP world.

Dr. Yoni Rosenblatt: At least you have a name. Okay, that is awesome advice. So, I always wonder about how surgeons got to where they are and how they become the given specialist. Tell me a little bit about Dr. Morris, because you have a DO after your name.

Dr. Callista Morris: Thank you. Yeah.

Dr. Yoni Rosenblatt: And as you worked your way through this medical career, walk me through the difference between DO and MD and if you would have done it differently, like why you went to DO school, and then how does one learn how to do a hip scope if they're also doing UCLs and rotator cuff pathology.

Dr. Callista Morris: Absolutely. So take a step back, I went to Bucknell University, played field hockey there, then I've always wanted to go to med school, I've wanted to do orthopedics since I was eight, that's a whole another podcast conversation. So I've only wanted to do ortho, so that was the goal. There was nothing outside of that goal, terrible answer, but I am a bad standardized test taker, so my 4.0 G...

Dr. Yoni Rosenblatt: It's not a bad answer.

Dr. Callista Morris: 4.0 GPA and socially, I feel like I'm okay on the social realm of things so I'm not socially inept.

Dr. Yoni Rosenblatt: Good. Your very good. Yeah.

Dr. Callista Morris: But the standardized test is what's kinda the first screening tool for med school, and mine was kind of the right at that borderline cut off for a lot of the MD schools and was not for the DOs. So I went in and said, You know what, there really is no difference anymore in DO world than MD world, there will be a lot of controversy behind that, some of my older colleagues, osteopathic school is every single class you get an allopathic school plus an additional class on manipulative medicine, that's basically the nuts and bolts of it, so if there are eight core classes, we have nine.

Dr. Yoni Rosenblatt: So you're smarter.

Dr. Callista Morris: I didn't say we were smarter. We just look at things holistically is how they used to say it, so we do get... We get nine and then training is the same... You can train a DO... Now especially today, all of the residencies are under the same accrediting body, which is huge. That's great. Just from a collegial standpoint, we can all now share information, so the kids coming out now can go to any residency in the country. DOs go to MD residencies MDs go to DO residencies so the training is very streamlined and similar, so then went there, but really in residency, I did not get a lot of hip exposure 'cause it was still pretty in it's infancy, so residents now, get some exposure, I got it in fellowship and I saw out a fellowship that had a Hip arthroscopist, so when I went to fellowship, I did hip scopes with them, I spent extra time with him, and then when I came out, I also went to conferences and courses, there's a lot of courses that you can do, so I dedicated some time to hip courses, and then my partner luckily when I came out did some hip scopes so we used to do some cases together until we got very comfortable.

Dr. Yoni Rosenblatt: What do you say to that first patient that has labral pathology and they're like, you say to them, I think you fit all the criteria to have a successful outcome from a hip arthroscopy. And they say, How many of these have you done?

Dr. Callista Morris: Yeah, so I get that a lot, and I still get that a lot, even though I've been out for a long time, I don't know, I guess I look younger, especially when I get my grey hair dyed out. I said, I do have grey hair, so I tell them, I always say very early on, I said, I'll be honest, you're my first or you're my second hip scope. I did a lot of training, I gave them the number that I did in training, and I say that's what I did in training and in fellowship. I'm now on my own. If you're uncomfortable with that, I entirely respect that decision. Here are the names of some people that I would recommend who've been in the practice longer than I have, so that's how I would approach with patients, some wanted a second opinion, some stayed, and I still say, I say, this is how many I do a year, there are people... So I probably do 25 Hip scopes a year. There are surgeons out there that do 50 to 100, and there are very good hip scope surgeons that do 50 to 100, and I tell them, I was like, my practice is also a shoulder elbow and knee.

Dr. Callista Morris: So I have a combination of all four. I'm not in an academic setting where I am the only hip preservation specialist. There are places that have that and I will refer them to there if that's what they desire, so that's how I approach it now, and most patients in the area are comfortable, there are a few that want that person that does 50 to 100, and I don't... I respect that, I would not ever... It doesn't offend me. I recommend second opinions all the time.

Dr. Yoni Rosenblatt: Okay, and then the first time you... When you're learning how to do a Hip scope, are you practicing first on a cadaver?

Dr. Callista Morris: Start practicing first on a cadaver, and then you are working with your trainers, so you're in fellowship, you have an attending who's been doing this a lot, they're taking you step-wise through it, they might let you do part A, and then they do the rest of it. And then next time you do part B, so you're doing little bits and pieces, each time, hip arthroscopy is very labor-intensive in terms of learning, it takes a lot until you get to be more efficient with it, but cadaver is one way, not the greatest, because it's hard to get the appropriate traction on the hip, but it's one of the only ways we have to do it.

Dr. Yoni Rosenblatt: To practice. Okay, so knowing what you know now as a seasoned vet, how long does it take to become an outstanding hip surgeon? Or how many reps... How many patients should it be?

Dr. Callista Morris: 50 to 10.

Dr. Yoni Rosenblatt: 50 to 100. So it could be a guy with one year experience it could be someone with five years experience that's doing it minimally, but it takes that amount of reps to really get good at it. And what is the most challenging piece of it interoperatively?

Dr. Callista Morris: Access is your first challenge, so Hip access is not like any other joint, we need to use Thoracoscopy. So that's challenge number one. Once you get through that, my personal challenge is still the capsule, you gotta get the capsule open and you gotta get the capsule closed, and capsular management, even now in my practice is one of my hardest struggles.

Dr. Yoni Rosenblatt: Why?

Dr. Callista Morris: So, I'm still working on perfecting that, it's just a visualization thing, you wanna be able to preserve it. The angle on the hip is a little bit different, and so it's just technique, and so I think... I also think it takes 50 to 100 to become proficient. I think it probably takes firstly, 3 to 500 to become that top 10 and I would not put myself in that top 10.

Dr. Yoni Rosenblatt: I would. Okay, so...

Dr. Callista Morris: Well I appreciate that. [laughter]

Dr. Yoni Rosenblatt: Walk us through because I think this is such a missing piece in the PT's knowledge base, patient goes to sleep, then what happens?

Dr. Callista Morris: Yeah, so patient goes to sleep, they get put on a special table, which is a distraction table, there are several on the market, there are historically the ones that we used to use was what's called a post, so there was a big pad that went between your thigh and then you actually have to dislocate the hip, so you're pulling so much force through the hip that the hip pops out of the socket, and we take an X-ray, the X-ray shows is that there's space between the socket and the ball now. You get a little what's called an ARR program, that's step one, you have to adjust rotation so that you know what angle you're gonna approach the hip, and then you use a really long needle and flora to get into the hip, and then you start dilating with a wire and a dilator and then a cannula, and you put your camera in and then you get another portal and maybe a third, and it's all under x-ray with the monitor and with traction, you have to make sure that their foot is really patted in a boot because if the foot slide it's like a ski boot, if their foot slides out of that ski boot, you're gonna lose your visualization.

Dr. Callista Morris: So all of that is kind of the prep, there are new tables on the market that don't use a post, which is very helpful, new learning curve, it's harder to get...

Dr. Yoni Rosenblatt: It is less pull?

Dr. Callista Morris: Less pull, you have to adjust the bed, so we used to operate flat to get traction without a post, you gotta tell them, so now all of our angles are awful week. So a new world, but the no post is the only way that I will personally scope a hip because the post has a ton of complications all the way down to unfortunately erectile dysfunction in men, which is permanent.

Dr. Yoni Rosenblatt: Wow.

Dr. Callista Morris: So the traction on the hip is a must to get into the hip, but it is risky in terms of nerve pathology, we know traction over two hours is a no-no, but even 30 minutes can cause problems.

Dr. Yoni Rosenblatt: I'm so happy that I'm in charge of editing this podcast 'cause I'm just envisioning you saying permanent erectile dysfunction and me saying wow, wow. Okay.


Dr. Callista Morris: It's like a bad commercial for a drug.

Dr. Yoni Rosenblatt: It's a really bad commercial. I've seen... Not personally thank God, I've seen some of those issues like bruising and pain from the post, what percentage of docs are now using post-less?

Dr. Callista Morris: I don't know the answer to that. Yeah.

Dr. Yoni Rosenblatt: Do you think it is the common place?

Dr. Callista Morris: No, I still think it is not the common place, the first post-less traction table came out in 2018, so it was limited launch for the people that designed it in 2017, it came out in 2018. It took me almost two years to get one purchased to so we got one based here in like 2020. Then I went to OSS and it took another year to get a different version of it under purchase order, so then it was like another year, so I don't think we had a bed in OSS till 2022, so it is definitely not the common practice, the Hana table with the post is probably the most common way to do it, just because that table can also be used for total joint surgeons who do direct anterior hips, and so one bed, multiple indications for use, the post-less traction on the hip, one bed for hip scopes. If the center doesn't do a lot of them, nobody is gonna be able to get that center to purchase it.

Dr. Yoni Rosenblatt: How do you restrict, let's call it inferior translation of the body, if you're trying to distract, if you don't have that post, what's holding the body stationary?

Dr. Callista Morris: It actually looks like an egg crate, it's a big foam pad, and their body friction with the foam pad, and what we call a Trendelenburg, you're leaning head back, so your body weight is provided enough counter-force with that foam pad to get the hip out, it's actually pretty genius. I wish I had thought of that but it's pretty genius and then in really muscular men, you can add in what's called an Air arthrogram, so if I can't get traction with just that, I bring the X-ray machine in, I prep their hip, I put a needle in the hip and I physically inject air, that air breaks the seal and then the hip pops out.

Dr. Yoni Rosenblatt: Oh, wow. It sounds aggressive, so... Okay, so now that you have a dislocated hip, you've inserted your portals, you have visualization, walk me through the surgical process and the difference between labral repair and labral reconstruction. And anything else I'm missing.

Dr. Callista Morris: Yeah, so now you're in the hip and the capsule is really thick, and you're not gonna get anywhere in the hip unless you open up the capsule, there's two ways to do it, one is called an inter-portal, so you just... You take different devices and instruments that cut the lining through the camera, and you put it between the two portals, then there's what's called a T-capsulotomy. So you cut it between the two portals and then you make an extra split. I do an inter-portal, a little bit more easy to close, and I can still see everything I need to see, the T-capsulotomy, get's important if somebody has a really large Cam deformity, otherwise, you don't really need the T, once the lining's opened up now, I have to peel the lining off of the labrum without damaging the labrum, and I peel it up off the socket, we also have to try to preserve it 'cause now it's gotta get repaired to the other end. Now we have two leaflets, we're pulling that top leaflet out of the way, when we're looking at the labrum, you can see with the labrum, whether it was torn with what's called a Cam bump.

Dr. Callista Morris: So usually what happens with the camp bump the labrum is torn and the cartilage where the labrum attaches is bubbled, and so that's more cam deformity if there's hemorrhage in the labrum, that's more that the labrum is getting pinched with a pincer or the problem on the cup side, so you can kind of confirm what you thought was the cause when you're in there, and you're like, Yep. I thought it was a pincer, the labrum looks like it was a pincer deformity. We're here for the right reasons. Are we bailing? If we don't see that, no, but it's a good mental reassurance, then does the labrum look healthy, is it a primary repair, so primary first surgeries try to repair it, that's where we're putting anchors into the bone, just like we do with shoulders and we wrap suture around the labrum, you can tie knots. There's knot-less technology. I like the knot-less technology, that puts the labrum back down to bone. I was taught by some of my colleagues actually on a very similar forum that we're at it was kinda like a podcast, it was during COVID, we had nothing to do, we weren't operating, so everybody started talking about hips and people were like, You know, you should really tension these anchors off of traction.

Dr. Callista Morris: And I was like, I never thought about that before. If we tension the anchor on traction, we can actually flip the labrum up, and if we lose suction seal patient's pain doesn't go away. So now I'll put stitches in, I'll let traction down, I tension the anchor and I pull traction again and I wanna see the fluid in the hip kind of bubble or egress that tells me that I regained their suction seal and that we've successfully repaired or restored the suction seal of the hip, that's kind of crucial step number one, and then step number two is addressing what caused it, the bump, and step number three is getting the capsule closed. Labral...

Dr. Yoni Rosenblatt: Okay so... Hold on. Let me cut you off for a heartbeat.

Dr. Callista Morris: Yep.

Dr. Yoni Rosenblatt: So you're taking labrum and when you say repair, so you stitch the tear, which is gonna close up that suction, hopefully when you put it back towards the bone, what are you doing? You're bolting it down inside of that acetabular?

Dr. Callista Morris: Good question. So there's a guide that looks like a straw, and then there's a drill bit that goes down the straw, makes a hole in a bone in the cup, you have to be very careful because since the cup is concave, it can go into the joint bad, right? So we have to make sure the angle is in the bone, then several different anchors exist, some of them have like a plastic screw with suture coming out, and some are just all suture, but either way you use... Whichever anchor you use, it has a suture coming out of it, like a thread, and then we pass that thread around the labrum, so the first step is putting the hole in the bone, and then the second step is putting the thread around the suture and then that suture goes back into that hole.

Dr. Yoni Rosenblatt: Gotcha, okay, and that tightens it up and holds it up against where it should be up against its bone and surface, and that kind of closes it up. Okay, so now shoot back to reconstruction and then what eventually you do with that capsule.

Dr. Callista Morris: Yep. So reconstruction more often or vision settings or if somebody had and you get in there and the labrum is just shredded and it's not repairable, debridements do fairly poorly about only 40% success rate with a debridement, so if patient had a prior debridement and failed it, then reconstruction or you get in there and the labrum and looks really bad reconstruction.

Dr. Yoni Rosenblatt: Okay.

Dr. Callista Morris: Most of the time for me, there are some guys, Dr. Ben Dome, I believe out in midwest is doing some primary restrictions, I don't do them primarily, I do it for a revision, I will have them fail some early stuff because there's still a 40% chance that they don't need that extensive procedure, depending on their level, but you're building somebody else's tissue now, so the bumper... I tell people that the bumper, is kinda like a hair tie or the bowling alley bumper to keep the ball in the lane, we're rebuilding that out of either your IT band right at the hip, so you harvest the central third, you roll it up like the old school fruit roll-ups, and then you suture it and then you tuck it back in with anchors, so you're taking one fitting it in attaching it and then suturing all there around the top and then anchoring it, or an allograft, which is somebody else's tissue, but it is a very labor-intensive processing compared to a repair.

Dr. Yoni Rosenblatt: It sounds like I never thought of it this way, but it sounds like almost the concept of the latter J where you're blocking it from kind of moving out of socket, is that right? Is that the right?

Dr. Callista Morris: Yeah. I wouldn't say necessarily.

Dr. Yoni Rosenblatt: I know it's not a bone.

Dr. Callista Morris: Yeah, I would think of it's more like shoulder instability and capsular shifts or capsulorrhaphy where we're grabbing that answer capsule to rebuild the bumper we're not doing a… There's no… in the hip. You're not adding in a rotator cuff to block the instability portion. But it's more equatable to repairing a labrum back to… then the latter J.

Dr. Yoni Rosenblatt: Yeah, yeah. Okay, okay, so that makes a lot of sense. And then what? Now we gotta put the capsule back?

Dr. Callista Morris: Now we gotta put the capsule back, so the sequence is kind of more so you're in, yes, we're gonna repair the labrum what caused it, do we need to shave down bone on the cup, order of sequence, is shave the cup, fix the labrum. Shave the femur or the femoral head or the cam bump, fix the capsule. So after you've shaved the bump on the cup side, if they need it, and you've prepared the labrum, you take traction down, you flex the hip to about 30 degrees and you start internally and externally rotating it and under direct visualization with X-ray, you can shave down their cam bump, gotta be careful over aggressive resections we've learned are bad, that causes a loss of suction fluid, so if they get too big of a resection as they bend up, they lose a seal 'cause they fall into the hole that you just created and that way really bad is breaking your hip, so if you get a really aggressive Cam resection, you can actually break your hip after surgery, less is, I guess now that our knowledge is better, a little bit less risky 'cause we aren't as aggressive. And then the opposite is true, you can underresect, so you can not take enough and still have impingement, but I would tell you underresection is a much easier problem to solve than overresection, we still don't know what really to do with overresection because we can't get the bone back.

Dr. Yoni Rosenblatt: How are you determining whether you took enough or too much? It's based upon that suction.

Dr. Callista Morris: Based on suction fluoro or X-ray. So we take an X-ray, so you can compare your preoperative imaging, which is why those modified done X-ray is very important. And then the CT scan tells me on a clock face, like 6 o'clock needs a two millimeter resection, 4 o'clock needs a three millimeter resection. And Dr. Larsson came out with a paper several years ago that tells us at what degree do we bend the hip and turn the hip and take an X-ray? What clock are we seeing? So we know, if you've bent to 30 degrees and you're intra rotated 30, you're looking at X on an X-ray.

Dr. Yoni Rosenblatt: Gotcha. Okay. So I've definitely had experience where patients have gone to a hip specialist of the month. They get a resection, they come out, they still have pinching pain towards flexion. Is that an instance of, Hey, he didn't take enough?

Dr. Callista Morris: How early on are they having the pinching pain?

Dr. Yoni Rosenblatt: So, good question. I've seen it early on. We'll do it, let's say within the first month they still have their impingement. And I'm saying, give it time. We gotta let stuff calm down. Fast forward six months post, they still have that pinch. Is that what I should be thinking? Hey, doc left too much bone in there.

Dr. Callista Morris: Too much, potentially left too much bone. Even sometimes though, they can get scarring between the capsule and the labrum. So we're kind of working those kinks out. So like, did they get into rehab early enough? So if you delay rehab, the capsule can scar to the labrum and you can get the pinching pain. So the surgery might have gone fine and if they built up too much scar tissue, we're in trouble. They're looking at different medications we can maybe give patients after to decrease the scar formation. But early range of motion in the hip is crucial. So like non weighted recumbent bike is great. Like get the hip cycling early, so that the scar doesn't form. So it can be some scar formation, so it doesn't necessarily mean it was a totally failed procedure. I'll then, at times when that happens, you can go back to the drawing board, do CT scan. Right? Like new X-ray, like pre and post X-rays. I usually make them fail up to almost a year though of therapy to see if they can rehab past that.

Dr. Yoni Rosenblatt: Yeah. Yeah. Okay. That makes sense. Now this is kind of what you hit on before with your outstanding interpersonal acumen. That is an awesome segue to when do you start these patients in rehab?

Dr. Callista Morris: Week one. If, that's a hard balance as you know. Right? So like a lot of these patients are capped by their insurance capabilities. But I will tell them to get their hip moving early. If they have limitations in their insurance plan, I will start them after my first postoperative visit. Ideally they start at like, post-op day two and three.

Dr. Yoni Rosenblatt: Nice. Okay. Yeah. And we love seeing it.

Dr. Callista Morris: With the like light stuff.

Dr. Yoni Rosenblatt: I get terrified when I see these things a week, two weeks out. I think it's like we're missing that window and it probably leads to some of that scar formation. By the way, it's the same with the ACL stuff, right?

Dr. Callista Morris: Right.

Dr. Yoni Rosenblatt: It's like if you go to a therapist that knows what the hell they're doing, you better be gentle during those first few visits. But it can pay off like crazy by avoiding some of the scar tissue crap.

Dr. Callista Morris: Yep. Absolutely.

Dr. Yoni Rosenblatt: So I love hearing that. Okay. So now along with the millions of scopes you've seen, what do you think the biggest mistake we make as sports PTs when we're trying to rehab these patients?

Dr. Callista Morris: Oh, that's a good question. I don't know if it's necessarily a mistake or a lack of what we know we need to do. I feel like we have a lot of knowledge on how to rehab, throwing shoulder and how to rehab Tommy John and how to rehab ACL for hepatitis. We just brought ACL, we know that we don't yet really have a good refined answer on how do we rehab a postoperative hip, and I can't tell you that. Right? Like, that would be great if you guys could like give, do a little digging on like what the best exercises are early to like, not stress the joint, but I mean, we know that I don't go non-weight-bearing anymore. I put them foot flat. 'Cause their foot flat on the ground has less joint reactive forces than them trying to lift their hip up. So it's just simple things like that. And I think that there's not enough knowledge yet in the therapy world to make it a... What's the word I'm looking for? Easily accessible isn't the right word, but it's hard to find a good hip therapist.

Dr. Yoni Rosenblatt: Yeah. Yeah.

Dr. Callista Morris: Because you guys don't get to see it a lot, right? I mean, you guys are great, but if you live in the middle of nowhere...

Dr. Yoni Rosenblatt: You don't see enough of them. You don't...

Dr. Callista Morris: You don't see enough of them.

Dr. Yoni Rosenblatt: Yeah. I think what...

Dr. Callista Morris: It's an exposure thing.

Dr. Yoni Rosenblatt: I was gonna say, it's an exposure thing. And I think when I get new grads, how do we bring them up to speed? We wanna, first of all, it's a low hanging fruit. Like you wanna always err on the side of caution. Right?

Dr. Callista Morris: Right.

Dr. Yoni Rosenblatt: We don't wanna start loading these guys. We don't wanna start squatting before they're able to do that. I also see therapists run like wildfire from the hip flexor, and I think sometimes to a detriment, I think we forget that the hip flexor needs to get stronger. It responds just like any muscle in our body to load appropriately delivered. And being deliberate about that and spreading that out, I think is a mistake that we make. I go crazy when the surgeons terrify the patients. So if I were to flip that around and ask me, what do I think surgeons screw up the most? It they make their patients so scared to move that knee that the whole, or sorry, the hip, that the whole thing just freezes up, and then we're dead. So Dr. Morris, tell your colleagues to stop scaring the f out of their patients.

Dr. Callista Morris: Sounds good. I have a question for you. I mean, what do you think we need to focus on in terms of like hip and recovery? Like what muscles are you guys targeting? Like I send them and I send general guidelines and I got the general guidelines from a therapist I used to work with out in Cincinnati. But like, I'm always open to you guys saying, now look like you're a little bit behind on the rehab world. Like, we need to be doing this instead. And, so what do you guys look at with that kind of thing?

Dr. Yoni Rosenblatt: So number one, a happy hip joint has a really strong glute around it. So how are you isolating glute? What portions of the glute are you hitting and are you loading glute enough? It's so safe to hit glute so early. And I think we just run away from that. We go into this protective mode and we're just obsessed with motion motion's important, but that glute better be strong. So I think, I love seeing glute recruitment and loading through a given range of motion. I get away from glute sets. I think they're overblown. I think let's put them in a bridge position. Let's get them working on a bridge position from, it's really 30 degrees of hip flexion to neutral, is totally safe. So we get into that very early. We also get into a glute bridge to neutral bilateral.

Dr. Yoni Rosenblatt: And then having them, especially if they're foot flat weightbearing, having them engage, let's say the right glute is the operative side. Get left glute rolling, lift the right foot, realize how little dip transpires in that bridge position, then compare it to the other side. Those have to match before we start progressing properly. How do you get them to match? Well, first it's isometrics, then it's eccentrics, then it's concentric, eccentric. It's just like any other muscle, or any other joint really rehab. So I think that is a must. Two, get them in prone position quick. So let that hip flexor elongate. The position of comfort is hip flexion. Like everyone wants to get into that fetal position. Let's get them long, make sure they have tummy time so that they don't get scarring and adhesions along anterior hip. Can you tell that I had little kids? And then from there, please revert back to being a strength coach. And what I mean by that is understand load, understand your goal and are you dosing this athlete or patient appropriately so they can continue to make gains. Don't be scared of the repaired hip. It's solid. The only way you screw this thing up is bringing them up into knee flexion, ripping them into internal rotation.

Dr. Callista Morris: Right.

Dr. Yoni Rosenblatt: If you avoid that, you're good.

Dr. Callista Morris: Right. That sounds great.

Dr. Yoni Rosenblatt: I'm sure. That's where I live on that. What do you, let me flip it a little bit back to you, which is, what do you wish hip surgeons were better at as it pertains to hip scope?

Dr. Callista Morris: Oh man, I feel like we still need, I mean, we just need to perfect it all. I mean, I think we need to get better at managing even preoperative and postoperative expectations. I think we need to get better at patient selection. I think we need to get better at understanding going away from the intra-articular hip, lateral sided hip pain is this like big box, right? That's a whole nother podcast. And then also understanding there are outliers in this room, right? There are, is a higher rate of concomitant sports hernias. So when you tear your labrum, you put intra-articular pressure increases in your rectus, in your adductor and vice versa. So we know that very well. That's a hard thing to grasp. There's not many people in the area that do sports hernias well. So if they're having recurrent pain, is it really the hip? Is it a sports hernia or do we do it outside the box? But I think we need to manage the capsule. Like you want a one answer, it's capsule or management.

Dr. Yoni Rosenblatt: And how do you get better at that? Where are they dropping the ball with that?

Dr. Callista Morris: Dropping the ball, number one, not straight up, not repairing it. And then, one of the reasons that I think capsular management is the hardest is if I don't leave enough of the limb on the acetabular side, I don't have a lot to sew it to. So I'm still even personally balancing like, how do I make a good interportal capsulotomy so that I can see things, but give myself enough to close it. And so I...

Dr. Yoni Rosenblatt: That's interesting. When you say close it, that's your repair of the capsule. You're closing it and tightening up, some docs are just leaving it open?

Dr. Callista Morris: Leaving it open. Yep.

Dr. Yoni Rosenblatt: Why?

Dr. Callista Morris: Older thought of treatments to the hips that the capsules did not matter.

Dr. Yoni Rosenblatt: God put it there for a reason to quote Jimmy Andrews, right?

Dr. Callista Morris: Yep.

Dr. Yoni Rosenblatt: Like, you should probably put it back, I would think.

Dr. Callista Morris: Yeah. You have to put it back. Yep. Put it back. And so I think the, and there's many ways to try to close it. I think as a society, if somebody can invent an easier way for us to do this, more would get closed and it'd be a little bit easier. But the technology's still evolving in terms of getting the capsule stuff right. So that's where we need to kind of really focus. Everybody knows how to put a stitch around a labral, I'm gonna put an anchor in. We need to get the capsule better.

Dr. Yoni Rosenblatt: I'll put that on my list of things to get better at.

Dr. Callista Morris: Yeah. You admit that and then you'll be good. So.

Dr. Yoni Rosenblatt: [laughter] I'll be good. I'll be good. I'll be coasting. Okay. I love to wrap up with a lightning round, so get ready to answer some, but I want quick answers, doc. I don't want you to pause and say, oh, that was good one, yeah.

Dr. Callista Morris: Okay. I'm so bad at this.

Dr. Yoni Rosenblatt: Well...

Dr. Callista Morris: Oh, I'm bad. This is like, I feel like I'm a family feud right now.

Dr. Yoni Rosenblatt: Yes. And I'm Steve Harvey. Okay.


Dr. Yoni Rosenblatt: You could have a beer with one historical figure. Who is it?

Dr. Callista Morris: Oh.

Dr. Yoni Rosenblatt: It's a good question.

Dr. Callista Morris:
It is a good question. Dead or alive?

Dr. Yoni Rosenblatt: Yes. Either.Dr. Callista Morris: Yes. Either. Well, I wanna consider this person historical figure, but I would have a beer with John Kruk.

Dr. Yoni Rosenblatt: That's a good freaking answer. Why'd you pull that?

Dr. Callista Morris: He was my favorite player of all time. He is the man. He knows sports. Like I'd have a beer with John Kruk.

Dr. Yoni Rosenblatt: He looks like he could drink beer.

Dr. Callista Morris: He could definitely drink beer.

Dr. Yoni Rosenblatt: Good. That's a great answer. That's one of the best answers I've heard, him flipping that batting helmet around in the All-Star game against Randy Johns. I mean, there's nothing better than that. Okay. Who's the best hip surgeon in the world?

Dr. Callista Morris: Oh. I've got top three. You want top one?

Dr. Yoni Rosenblatt: Yes.

Dr. Callista Morris: John Phil, or Dr. Philippon.

Dr. Yoni Rosenblatt: Really?

Dr. Callista Morris: Mm-hmm.

Dr. Yoni Rosenblatt: I know. He's the goat and I've seen awesome outcomes. I just feel like that was a gimme, I would've expected you to say that, so.

Dr. Callista Morris: I know. Well, that's why I said I got two others on the list. But you gave me one.

Dr. Yoni Rosenblatt: Who else you got? Callista Morris and?

Dr. Callista Morris: Steve Aoki in Utah. He's great. He's awesome. And then Struan Coleman here in the northeast up at HSS and comes down to Vincera is also awesome.

Dr. Yoni Rosenblatt: Oh, he's the Vincera guy.

Dr. Callista Morris: He's the Vincera guy. Yep.

Dr. Yoni Rosenblatt: You realize that...

Dr. Callista Morris: He's primarily HSS, but he does every other Mondays at Vincera.

Dr. Yoni Rosenblatt: You realize that if Dr. Myers at Vincera heard you use the word sports hernia, his head would explode.

Dr. Callista Morris: I know, I know. Athletically vulgar. Sorry.

Dr. Yoni Rosenblatt: I think he's now on core muscle injury, but...

Dr. Callista Morris: He's under muscle. Yeah.

Dr. Yoni Rosenblatt: I feel like it changes your mind. Okay. Last but not least, the most impactful book you've ever read.

Dr. Callista Morris: I hate reading. No, I'm kidding. [laughter], I'm just joking. Oh, most impactful book, man. Well, I can't think of the name of it. It was written by a Buck Nian. Oh my God, I can't think of the name. It's not that impactful if I can't think of the name of it, but...

Dr. Yoni Rosenblatt: Exactly.

Dr. Callista Morris: Well, we'll go then I'll have to go my alternative. 'cause I can think of that name, but it sounds crazy, but White Coat Investor.

Dr. Yoni Rosenblatt: Oh, that was good. Do you feel like you embody those principles?

Dr. Callista Morris: I did early on. I'll say I've branched out from those principles, but at least gave me a better understanding. Like we get no education in that and, no education. So that was very helpful.

Dr. Yoni Rosenblatt: Same. We also get no education in that. That book was awesome. What also was enlightening for me was I did a podcast with Dr. Andrew Livingston, who you know and love. And the way he handled student debt and continues to handle student debt and invest appropriately was the entire topic of the podcast.

Dr. Callista Morris: There you go. Yeah.

Dr. Yoni Rosenblatt: I implore you to listen to that. He's awesome at it.

Dr. Callista Morris: I'll definitely listen to that. Yeah. That's awesome.

Dr. Yoni Rosenblatt: Hell yes. Okay.

Dr. Callista Morris: If I could think, I wish I could think of the name of that book, the other one, but it's also finance related, so.

Dr. Yoni Rosenblatt: We'll put it in the show notes. You have been an awesome voice for doctors of osteopathy, for hip surgeons. It was really enlightening to talk to you, I appreciate the insight and this intraoperative stuff because it does play a part in the way the patient looks once they get to us is imperative. And PTs I feel like just don't know this crap. So thank you for enlightening us.

Dr. Callista Morris:

Dr. Yoni Rosenblatt: Thank you for all the insight and your time. Where can we find you on social and how can all of these sports PTs get ahold of you?

Dr. Callista Morris: So we are on You can find me there. You can get ahold of me directly. You feel free to share my email. It's All the local therapists, Andrew and Danny, they've got my cell phone. They text me frequently. So I'm not, probably not gonna put that one out on the airway, but [laughter]

Dr. Yoni Rosenblatt: No.

Dr. Callista Morris: But those would be the two places. I don't unfortunately have the classic social media account. So that one's on a private realm.

Dr. Yoni Rosenblatt: Yes. You have to get that. And you have to get your own pod. You are good at this. I would listen to that.

Dr. Callista Morris: Oh, I appreciate it. I appreciate you having me on.

Dr. Yoni Rosenblatt: Oh, this was great.

Dr. Callista Morris: You guys have been great.

Dr. Yoni Rosenblatt: We'll do it again soon and I really appreciate it. Thank you, doctor.

Dr. Callista Morris: You guys have a good holiday season and we'll talk soon.

Dr. Yoni Rosenblatt: Talk soon.


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