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Um next session uh is on hip arthroscopy. I just want to run you down a bit of history. What exactly we do and where we are in hip arthroscopy. So uh this chap called Berman in 19 th basically said that it was manifestly impossible to insert a needle between the head of the femur uh and the ace table. And this was through uh some of the experiments he did on cadavers. And after that, he came up with this uh sentence and basically what he was showing here was probably the compartment of the hip uh as as you can see that's the head neck junction. So he probably never got into the hip. And that statement meant that for a long time, there wasn't any development of hip arthroscopy. And obviously, it's a complex nature of the joint. It's a ball and soccer team joint. So why? And how would you put a camera in? There's a lack of interest in sports medicine, but 1980 sort of renewed interest. And then 1999 to 2002, the Swiss group described fe tablet impingement as I talked to you all in the previous uh previous uh lecture. And then 2000 onwards, there has been rapid growth uh in advance to the extent that the International Society for Hip or Hip Arthroscopy at that time was formed. And this was the first meeting of 4 to 150 surgeons in New York. I was still uh the first year consultant, just finishing my fellowship. And this guy was largely responsible there standing behind Ricky Villa. Uh again, a huge, huge listening to Cambridge to be able to stop that. And then 2009 onwards, uh essentially a tidal wave in terms of the numbers of uh procedures done. So you can see the growth between 2002 and 2013 was almost uh 727% for hip arthroscopies and projected growth in the last decade has been almost uh 1400% in the number of procedures being done and huge amount of regional variation uh as well. You can see where we come in uh on that. So, pushing, pushing the boundaries there. So if we, if you look at my own uh personal history with the, with the hip arthroscopy, so I was a trainee in uh Royal London in 2004, uh wanting to do revision hips and working with Gareth Scott uh at the time. And I asked him uh II really want to do revision hips. And uh who would you recommend? And he said that uh there is this chap in Cambridge called Ricky who's his good friend uh through the J BJ British at the time. And why did you go see him because he is doing the large largest number of bulk allografts uh in the country at that time. So I take an appointment with Ricky, er, and uh go and see him and uh he takes an interview and he invites me again the next weekend, gives me an editing test. I used to have an editing test those days, uh pass the editing test and then he calls me in the third week and says that uh um you can be my fellow in 2006 in Cambridge. So I finished my training, get uh ready all set. I was living in London at the time and we move our, we put our house on rent and we move uh to Cambridge all set for the fellowship and then I get a text from him uh a week before the fellowship saying 0630 hours at Wellington Hospital. I really wish I had saved that text or taking a screenshot, but that's what it said. I was wondering why is this guy calling me to Wellington Hospital, which is in London in Northwest London. Anyway, I go there and basically what that he had left Cambridge and moved his whole practice to London. And um that's where they planned up being a fellowship in London. So I was traveling, passing my own house, which I had actually put on rent from Cambridge to London for one year. The other interesting thing which happened was that in the whole year we didn't do even one revision hip, but we did over 450 hip arthroscopies. So it completely flipped his practice and he had, he had pressed the accelerator on hip arthroscopy of that hip. So I didn't go to him wanting to learn hip arthroscopies. I wanted to be a vision hip surgeon, but that's what I got in that one year, over 450 hip arthroscopy. So lesson number one for me was serendipity and you really need to believe in serendipity because if you start thinking about it carefully, then there is a proper size to serendipity. If you've got a prepared mind, if you have an unexpected event, you recognize the potential of the event, seize the moment you amplify the effects and then you and then you evaluate effects and that's how you maximize serendipity. So that's for any anybody out there or everybody out there. If something is happening to you, and you're wondering why just believe in that process because there is something we gonna come out of that. That's lesson number one. The second thing is that subspeciality is very well defined and it's evolving uh rapidly in the last 20 years itself that I've been a consultant. Uh It's evolved significantly and this I showed you in the last uh lecture that it's the most anatomically complex joint with 28 different muscles. And with all these diagnosis coming along and just when we had got on top of uh hip impingement or feri impingement, all these new syndromes, the extraarticular hip impingement syndromes like the subspinous impingement or the deep blue syndrome. And isofibre impingement are being described and then causes of hip pain. You need to think of them as extraarticular musculoskeletal causes or extraarticular nonmusculoskeletal causes or articular causes. And then you need a comprehensive clinical examination. As we've discussed, think of the hip in four layers in five position and 21 steps to hip examination. So that's lesson number two, that the hip young adult hip has evolved significantly and you really need a comprehensive way of evaluating that clinically. The third thing is that uh there have been huge advances in investigation on how we actually investigate these patients. And for us, the 3D CT scan has been a game changer. So obviously, you will get plain radiographs and ap and crosstable lateral. You will get uh MRI scans which will show you the lateral tear, the arter cartilage problems and also the impingement lesion. But the game changer here is the 3D CT, the 3D CT will show you the CAM abnormality. The 3D CT shows you the problems with the subspinous impingement. It shows you the posterior joint space, it tells you the femoral version the acetabular version and it allows you to plan your operation. And then based on these uh 3D CT scans, you can see the posterior joint space, the extremity looking pretty normal and you will have a good joint space anteriorly. But when you do a 3D CT scan and look at these sections, you'll see that the posterior joint space is reduced and the patient may not be suitable for hip preservation surgery. And what the 3D CT scan also allows you to do is to get independent individualized collision analysis models like this. So we know exactly where the impingement lesion is and how much bone we need to excise to actually produce an impingement free range of motion. So 3D CT scan game changer in in investigation, then obviously for complex deformities, we are getting 3D printing and actually seeing that uh before the operation, explaining it to the patient as well. Uh makes life much much easier. The fourth uh pearl is that the diagnostic hip injection um is essential in our practice because a lot of these patients are being referred from all over the region and also Northern Ireland and they may have joint pain for a long period of time. So before we embark on any surgical intervention, we actually get them in, we fill that up, but the hip is joined up with some local anesthetic and steroid and make sure that the pain actually disappears before we actually embark on any kind of surgical intervention on that. The other important aspect of point number five, learning. Point number five is that not everybody is suited to hip arthroscopy, beat for hip impingement or dysplasia or whatever. So you got to pick your winners and you got to have clear indications and we need to stratify disease process. So excellent outcomes are based on the patient. Excellent outcomes would be based on the morphology of the hip and finally, your technical ability again, as I said in the previous lecture. So if you look at the Danish Ship Arthroscopy Registry, you've seen that age, uh basically about 40 gender females, articular cartilage, significant degree of particle cartilage damage and high BMI leads to poorer outcomes we've seen in our own series that if you've actually got large deformities in this, for example, SUV, or you've got large lesions, bone edema or articular cartilage damage and also cysts, those are the patients who are actually going to have poorer outcomes following hip preservation. Some of them are actually better soon.