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stop him some off, some off you from Boria still there. I know it's getting late there, so we'll do this talk and then we'll go into the case Case discussion section. So FBI am all you wanted to know about femoral acetabular impingement? Uh, disclosures. None of them directly relevant to the stockings that so I want to cover up four main things. What exactly is Femara established? Impingement. How does it present to you in the clinic? How's it managed on where the advances and election for future research in this arena. Now, for any hip preservation surgeon or a training who's interested in the preservation, this is the paper that actually started it all in the late 19 nineties. And Gonzi A makes a fairly bold statement that Femara established impingement is a cause of early osteoarthritis of the hip, and that's why I gained a significant amount of the bench. So whatever be derm in as the classic off pistol grip deformity on This is a picture taken from a textbook in the seventies was possibly Femara established and binge mint leading to arthritic change. We've known about Femara established and pinch. And then we did a paper of this in terms of the historical analysis of FBI. We've known about morphological abnormalities of there since 3000 BC on people have been talking about it and describing it even a slates 1965. But really, it was at the 19 nineties. Paper 1999 paper, uh, when actually from guns on this this colleagues talked about Femara established impingement on gave it that terminology that it's taken shape on a huge amount has been published on it since then. So if you look at the number of publications, more than 3500 already improvement just on FBI from 1999 on words when it came through. And no other procedure has grown so significantly in the last two decades, as a said about Rose to be with the primary indication of being Femara standard impingement. So you can get to see that from 2000 and 2 to 2000 and 12, it grew by 727% and the projected growth from 2013 to 2023 was almost about 1400% in the number of procedures on. That's just the UK in US it's a lot more so. That's why it is a fairly important topic on now for the exam as well. But what exactly is FBI now? Propaganda, responding some subtle in in 1999 talked about it from the Latin word in bridge, which essentially means striking against something. And they described a fair I as a painful contact between the femoral neck and the acetabular him. But the important thing is that a doctor's within the physiologic range off motion off the normal head for back particular patient on the causes of impingement could be on the established side where you've got a profusely oh, or you've got a retroverted as a tablet or you've got an anterior over groups and that's called up in certain type of impingement. Or it could be a problem on the federal side, where you've got approximately deformity or an abnormal and at me and you call that can type of impingement or you've got an overuse off a normal hip. Uh, that is, for example, in a valid answer or in a gymnast. Now, here you are absolutely normal and our committee, but perfectly Spanich away family head both in the AP and cross table lateral. And here you've got a normal anatomy. Now on the AP, um, you'd be forgiven for mixing it because you can't really see an abnormal shape dead. Or if you took a cross table lateral, then you would see that excess bit of both. Now you may wonder, what is that Little legs has been aboard worry about what can that do? But here is an example of what that can land up to it. So here's that excess bit of bone that you saw on the X ray. And every time the patient would bend and drew bit their hip in a simple thing like flexing the hip on a bit off a reduction while driving the car, you'd let get that bit of bone in binging against the labrum. And the article got Lige on that repeated apartment will actually lead to the labrum, tearing off so label there. But more importantly, the article a cartridge big me to share off the anterior aspect of the hip joint, leading to arthritic change in some adults. So that's a perfect mechanical model off how an abnormal shape femoral head neck junction will lead to arthritic change. And that's why it's become very important, because if you leave them untreated and that is what exactly happens in these patients and you'd see patients in their late twenties and thirties with full blown arthritic change after camp type of Femara has stabbed it impingement. And this is what Bonds really showed in this paper that if you've got enough to me like this, where you've got excessive board in the Anterolateral junction or accessible in the front of the head neck junction of the femur than these are the result of defects that you're seeing on the labrum and the article a cartilage and he didn't do it outside SCOPIC Lee. He did open surgical dislocation still to show that, but that's essentially what he showed in his first paper. Now who develops camouflage? And we've done some books. Uh, on this. Athletes are definitely at a higher risk. About 48 to 75% of them are Maalox least, which display the gamma follow gee. 5 to 34% of female athletes would display that and the open hargon osteo try to study, but 17% of the males displayed gamma follow gee once only about 4% of the females. So what we've shown in this paper, essentially is that it's usually the male athletes who are putting a lot of stress on. They're developing hips or the developing growth plate in there. A dollar since between the ages off 11 to 14 are the ones who actually start developing the gamma follow. Gee, So that's the adaptive theory as to why and how camouflage E develops. The been some apology of the bills are impingement. On the other hand, the easiest way to think about it is the pincer grips off the crab. So here you are. Hopefully this will work. Brilliant. So you've got in pencil, you've got an overgrowth off the acetabulum anteriorly or you've got a red rewarded as a tablet. And essentially, when the patient places that hip up the head neck junction, there will come in contact with the labrum earlier on in flexion. So the election is reduced on this repeated Hitting off the labrum in a linear fashion does not lead to a tear of the labrum, but it leads to micro calcification of the labor bill. The time it calcified. It's completely and then because there is less space, it develops a contract with vision posteriorly. And that's how you may land up developing arthritic changes in the hip joint. Now the mechanical theory of pincer is not as well developed as the damn, but certainly for GAM. We know that does how it develops arthritic changes, but that's the second guy off in picture. So if you look at types of impingement, you've got the normal hip, good, normal and neck junction of the femur with a good, normal and suitable um, the can will have a problem with the an egg junction off the FEMA. The pincer has a problem. Any of the acetabular side and the mixed type of impingement will have a bit of built that is a bit of retribution or an antigen overgrowth on a bit of problem on the femoral side as well. So those are your types off it impingement. Now, how do these patients actually present to you? Most of them are young adults present you with the growing pain, and as we've discussed in the clinical examination section, they've got the classical see sign. They may give your history off rotational injuries off mechanical symptoms, off catching or locking. And when you examined them, they have limitation and rotation, especially in flexion and internal rotation of one that is lost. Now. Femoral acetabular impingement syndrome has been described by the water group on that basically is a constellation off patient symptoms, as I've described the clinical signs along with the embellishment desk being positive, which is flexion, a deduction on internal rotation causing pain along with that that diagnostic imaging as well as we've discussed on the previous radiographs. So if you put all these three things together than that constitutes femoral acetabular impingement syndrome now, the impact of this obviously is huge. Most of them are young adults. They're in pain they've got disability on if they've got pain and disability that they can't go to work. So the economic impact on the nation is huge on. A lot of them are in chronic pain because of not being diagnosed locally by the GPS off physiotherapy services. So there's a huge psychological component as well by the time they actually come to visit us in clinic with these problems, So that's the presentation now, in terms of investigations, we obviously need a plane a d radiograph. We need a good cross table lateral because of and seemingly normally be delayed. A graph. Um, you will actually miss the common Benjamin. So you really mean the gross stable lot of really bad. And then we become a lot smarter now, in picking up the subtle signs even on the AP Dada graphs. So on the sacred a graphic and clearly see the anterior wall is there and that's the posterior wall. So the anti imposture Well, on this a period draft, you can see that the anterior wall is crossing over the posterior wall, the so corn gross over sign. And along with that, you can also see the skills fine procuring inside, which is called the still spine. Sign on there and you can see that there. So that's classical for or read through. Worded. As a tablet, you surely will not rely only of the x ray because you will get a CT scan to confirm that. But these subtle abnormalities now you can start picking up on a well penetrated and well orientated a pedia graphs. The MRI scan is useful because it shows you all the three things that don't show you the impingement lesion that will show you the article cartilage on the label tear. But the game changer in this field is really the CT scan on the three D reconstruction of the CT scan. Because that allows me do assess the box of femoral abnormalities. So where the cameras exactly it allows me to see for signs off and he substance impingement on the around the anterior very ill explain. It gives me a good idea of the rotation abnormalities off the femur and the answer to W. And also it gives me a good idea off the posterior joint space is like, so for planning your surgical intervention CT scan with really constructions are really the game changer in this field. As I said, it allows me to see the posterior joint spaces. Well, because on a seemingly normal baby on bro stable lateral on a reasonably well penetrated MRI scan as well, you may not pick up this reduction of posterior joint space, which in my books is a contraindications for him preserving surgery. And then it also allows you to do clinical graphic motions like this so you can send the CT scan to the stump. Make on clinical graphics on day will do collision and Alice is for you, and that is specific for bad patient. So you exactly know where the impingement is happening on how much you need to take off to correct that impingement. So although it does not take any soft tissues into consideration, it's a fairly good mechanical model off what exactly is happening in terms of collision from the bony point of view, and it tells you how much bone to take off. Finally, the diagnostic hip injection is extremely useful. So all these patients of being in pain for a know Peter Fine and what we do is we get them in the hospital on, basically in check their have john bits of local anesthetic and steroid and tell them to give a pain diary for a couple of weeks of the being banishes. Then we obviously no, that the pain is intraarticular knowledge it on staying vigilant, which is responsible for the symptoms. If the pain does not vanish, then obviously it's extra declared. Her knowledge is so they do not get surgical intervention straight away. We get them to physical therapy and a sports position to look at other causes off hip and groin pain in those patients. So that's the world now, after the work up, obviously, what does you go? What are you trying to achieve? And these patients? The goal is joint preservation. You want to achieve the fact that they should not be going into full blown arthritic change. That's that's essentially the eight. And you started management of these patients with obviously conservative management. It's a good physical therapy. And then, if physiotherapy fails, then you're taking off surgical intervention. When you're approaching FBI, you obviously need to think of both. What is the dynamics on? What's the morphology off that hip on derms of dynamics? Um, it depends on what exactly do you land up doing with that? So a surgeon like me was standing and operating whole day or, like string to you now sitting down. If he has a big common binge mentor, a big can, he may still be okay with it because he's not was putting the hip to the full range of motion or actually subjecting that article. A cartilage do a lot of stress, but on the other hand, if this Chinese. A ballet dancer. We'll call it a Korean ballet dancer for today, has a problem with the hip. Then she has certainly be struggling on. Hopefully, this video should work. This is the reason for the bitch. It's it's my book to take the three that you're doing. This'll this'll She has a small room, you know, definitely even with Yeah, because that's what she does with that, right? Okay, just lay bring the point. But that's important. The what you're doing with the hip is as important as what the morphology is. So in terms of surgical technique were looking at improving the joint mechanics by correcting the head neck offset. We want to get the correct waist, and we want to recess the room in terms off pincer impingement. And then we also address the soft tissue of the resulting soft tissue damage neighbor, the bride mentor, repair on our reconstruction and also address the convert damage. So God's started off the open surgical district a shin, and we still do that for some complex cases where we do the trick Country clippers job to me be addressed. The been society first. Then we addressed the camp on. We've taken that off. You can see the cameras taken off. The pencil is taken off a swell there. And that's all you're addressing. The mixed type of impingement through into account. Flip osteo. Bi open surgical dislocation. Now enter his patrols. Could be something that came back Just couldn't be proud about because it started here in 19 in the 19 eighties when Mr Ricky will er my mentor actually did the first one here. And since then, obviously hip arthroscopy has expanded rapidly and whatever gods basically talked about in his open surgical dislocation, we can achieve answers. Cop Italy. So that's the femoral head. That's the labrum, which is stone can see the blade going underneath that to show you the dead. Pretty much like short of surgery. You can put anchors there now to repair the stairs nicely. Um, pretty stable constructs. You can address the article a cartilage damage with micro fracture, debride mint and also scaffolds available. Now you can address the pincer, um, binge meant by with the high speed burr, uh, taking the incident binge. Been down like so, And you can address the camp of Benjamin again with high speed birds through the better for compartment, taking the gambit of a lesion stone and then do impingement this on table. But you can see a clear gap between the labrum on. The family had Neck Junction, so all that a gun stopped about in terms off open surgical dislocation. We can achieve that arthroscopically and that has now become the standard of care for most patients of us. Tablet and Pinch Me, you may ask. Obviously, all these interventions were going out, but what's the outcome? Data for these? So if we look at our own registry, which I chaired over the last three years and now, Mr Mom, beer is the chair, it's got 17,000 pathways on it, with the 110 certainly contributing that data throughout the UK That's the seven I will report published this year. And see that the age distribution, um, majority of the patients, uh, between the ages of 15 to 45 and that's how it should be. On this is the outcome data. We collect a Do Schools. One is the I Hope 12, which is 12 specific hip related questions for young adults, which is a validated score for young adult in pathology on the standard generic iqqu five day, so you can see that there is, well, me clinically important difference present from the preop to the 612 months scores on the I heart. Trouble is a fairly good jump from 32 to 56 on the I'll drill and similar figures seen on the five years Well, so these patients are improving, certainly in the short term. And if you decide it with the gamma lesion alone or the been solution, then you are seeing similar effects in terms of improvement off these scores. So that's the really world registry data. If you look at the randomized controlled trials again, there's Bean. Another condition, but you got it. Two large scale, randomized controlled trials. One is the fashion trial. On the other One is the Fate Trial, the fashion being published in land set on faith being published. BMJ Fashion comes from a warrant. Damon Griffins Group and Fade. The lead center was Oxford on Be contributed to that as well. Both these strands compare surgical intervention in terms of arthroscopy, arvid physiotherapy, that is conservative management for patients with FBI on both these show that in the short term, patients without scopic and Dimension on did better than the conservative management group. But there are still questions, and the questions are on. The patient will be sitting with you and fill it. They ask you, will this procedure I, er scopic intervention for every I cure me? Does that stop me having a hip replacement? How long will it last and water? The long term outcomes and all our research really is focused on these four questions because it is a young disease. It's a young procedure on. Only Time will tell. Actually, what are the answers to these questions? But we've got some sort of get answers, which I'll take it through now. So the first things we looked at were conversion rates on. Does help preservation surgery actually prevent cancer plastic? So we looked at a systematic reviews 200 but apology got all the patients who had him about Ross could be in there. 62 articles included. You had look at the number of trips now 59,000 hits in there and conversion to do it on the part of past. He was about 5600 mean follow up about 46 months and time to conversion two years, about 24 months. So you can safely say that about 9.47% will be converted from him bathrooms to be totally replacement if you take all the data that is existing in this region. And if you look at the factors as to which patients get converted and essentially it's a judge and the other you are, the more chance of you getting converted. Uh, obviously, you should not be scoping under the keeps. If the joint space is less than two millimeters, you should not be scoping them, because these are the factors which lead to, AH higher rate of conversion to total about past. Obviously, this is limited by the quality of data that is available and also the figure maybe higher, because not all medical failures will go on to have a total liquor basement. But there's no doubt that the older you are, the more the chances of conversion. It depends on dignity of osteoarthritis on joint space, but also one needs to remember that this is historical data on there. Mainly, there was debrided mean being carried out off the labrum at the articular cartilage. But techniques have evolved to repair and reconstruction off the label Chondral Junction, and the results may be different or the next 5 to 10 years because the techniques of the world the other bit of work that I did is a part of my bhd was again a surrogate marker off looking at what exactly happens to these patients in terms off reduction of stresses in the joint. So we had done a randomized controlled trial where we had compared conventional about. Ross could be with, uh, navigated hip hop Wants to be. It navigated him about cirrhosis to be. We had accurate camera sections for patients with FBI and camp type of impingement. So we don't cohort of those patients with accurate camera sections and put them through this technique off discrete element analysis of the D. E. A. And that basically showed that once you actually resected the cab accurately than that normalizes the contract stresses in the hip joint with these patients. So in essence of Stargate market, telling you that if the surgery is appropriate and early on gams have been dissected completely, then your restoring the normal interim pressures and hopefully that limits. There is off arthritis development in these patients, but it's actually it's all about picking Vinas and stratification is the key going forward for these patients. So all the patients who have got issues with cysts Adios. We do not have the binder for doing 16 to 18 weeks of physical therapy following the procedure patients have got. I relax it e or have got mental health issues, our patients who are associated with less favorable outcomes, following up stopping intervention on me to be careful about these individuals. Also patients of God rotational abnormalities on being a lot more attention to them now, in terms of CT scans are probably better off with an osteotomy rather than an arthroscopy in these patients. The other problem, obviously, is that there are a number off these operations being cut it out on. Because of that, almost about 25% of the camera section surgeries are in complete 5 to 10% of the answers, but he's required revision arthroscopy 80 to 90% divisions are for residue left me I and there's no evidence of Camry go and the division rates are increasing because there's a failure to understand the anatomy of the camp. There's a failure to access The whole camp is a failure to understand the dynamics on failure to address the learning curve, uh, as well. So my research mostly has bean on actually looking at this accurately trying to get X rays a CT scans and cooperated with clinical graphics getting navigated hip. That's most peace done to make sure that we're able to do our surgery accurately. And precisely the last thing we need to add is get analysis data. But that particular patient and also want access is data because once you've got these two, then you truly make it a postal eyes, um, accurate a section for that particular location because the Amy again here is to prevent arthritis in that 16 or 18 year old who's coming to you with gamma knife off the bitch man and therefore the research program that before built now is based on optimizing outcomes in IT preservation surgery to be looking at surgical risk factors that a stratification of disease and outcomes and civil is looking at the outcome data. As as a part of the speech D got the fate to drive with biologics for earlier way to convince it. Soon a surgical petition of along with navigation robotics that was my BHT. And then Octavian will take this on forward to robotics. We've got non surgical factors, are being looked at in terms of optimizing muscle strength with almond doing. Is Evan nd of that and then average our physicals recently got in an eye chart Doctor fellowship to look at rehabilitation. We also look at mental health over the Bhd is well, so that's sort of the research program based, uh on exactly this and optimizing outcomes, falling it preservation. We focus a lot or something about wants to be training. We don't got a bullet skills, goes annually with eschar along with simulation training, but a fellowship in young adult absurd gery on Mentored in the Bedroom practices. Well, once you actually become a consultant, you know, lucky to have visitors from order, not the full boat in terms of research collaborations on Benical visits as well to learn about a preservation surgery on FBI, if you need more than we've got a whole book on this but to, uh, concept papers, which I'm happy to circulate about, which will give you the basis off the scoping management of FBI and also the garden concepts off what exactly is happening in this arena. But eventually it's a complex into play between the morphology that you see, uh, the activity in the dynamics that you do with that particular hip and finally, genetics and all three be a huge room in determining how the patient presents to you on the eventual outcome. So we have certainly made a lot of strides over the last two D kids in this arena, but equally long road ahead. Future certainly is bright. We're thinking of automatic segmentation and calculation off angles and induces with artificial intelligence and developing prognostic algorithms coming in already stratification of disease will play a key role. Genetics of it, a. Z well, understanding What exactly is going on behind the scenes in these patients and then robotic arms for position surgery pretty much like you have for prostate on. Also now in the abdomen with the kidneys will see these robots coming through. So that's it in a natural. Ladies and gentlemen, thank you very much for your patient listing on. I'll take questions again. Fairly informal, no douche out, and I'll be happy to answer. Thanks