August 2019 - What's inside - International Society for Hip Arthroscopy
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August 2019
What’s
inside
President’s Report Education Committee ISHA 2019 Host Recent Advances in Update from the
Marc Philippon Report 2019 Chairmen Report MRI Imaging for FAI Non-Arthroplasty
Josip Chuck Cakic Luis Pérez Carro Siôn Glyn-Jones Hip Registry
& Oliver Marín-Peña Vikas Khanduja
August 2019
Contents
1. Editor’s Welcome 20. Fellowship Report 2019
Parminder J. Singh Pranai Buddhdev
4. President’s Report 24. Education Committee Report 2019
Marc Philippon Josip Chuck Cakic
6. ISHA 2019 Scientific Programme 25. ISHA Social Media Report 2019
Damian Griffin Derek Ochiai
7. ISHA 2019 Host Chairmen Report 26. 2019 Brazilian Hip Preservation Symposium
Luis Pérez Carro & Oliver Marín-Peña Marcelo Queiroz
8. 2019 Research Report 27. Hip Arthroscopy in Japan
Hal Martin Masayoshi Saito & Yuichi Kuroda
8. ISHA Prizes 2018 30. From an Asylum Seeker to a Successful Trauma
Richard Villar & Joe McCarthy and Orthopaedic Surgeon
Sarkhell S. Radha
10. Article Commentary
Ajay Malviya 34. Systematic Reviews and Meta Analyses in
Hip Arthroscopic and Preservation Surgery:
12. Update from the Non-Arthroplasty Hip Registry 2019 Helpful or Hurtful
Vikas Khanduja Olufemi R. Ayeni
14. Cutting-Edge AR Project to Enhance 36. Recent Advances in MRI Imaging for FAI
Surgical Expertise Siôn Glyn-Jones
16. Physiotherapy Group Report 2019 39. Infographic: Complications of Hip Arthroscopy
Amir Takla & Mike Voight Vikas Khanduja
17. ISHA Membership Report 2019 40. ISHA Annual General Meeting Summary 2018
Al Stubbs Al Stubb
19. ISHA 2019 Fellowships Fair 41. ISHA 2019 Team Poster Competition
Damian Griffin Damian Griffin
Editor’s
on the 11th Annual Scientific Meeting and 98 femoral osteotomies. Mr
Programme. Professor Griffin’s Vikas Khanduja, Chairman of the
Welcome
team have created an educational UK Non-arthroplasty register provides
academic programme that will be an insightful summary of their latest
based around the theme of “The Hip annual report.
Preservation Team”. The debates will
The physiotherapy group has been
Parminder J. Singh be big events on very controversial
a valuable and well-respected part of
subjects: surgery or physiotherapy
the ISHA meetings. This year we hear
for FAI syndrome; primary labral
from Associate Professor Amir Takla
reconstruction; and early intervention
(Australia) and Professor Mike Voight
for the hip at risk. For the first time this
(USA) Co-Chairs of the Physiotherapy
year there will be a poster competition
Group on the physiotherapists
for the best team poster.
prospective on their approach to hip
With the success of the first Asian preservation. There will be a detailed
meeting in Melbourne, the second physical therapy assessment of
Asian meeting will be another great complex hip conditions, advanced
opportunity to meet our Asian strength and conditioning as well as
colleagues and share knowledge, sports specific return to sport drills.
experiences and culture. A half-day There will be an opportunity to hear
meeting will be devoted to the Asian from international tennis & golf coaches
society before the main meeting about the challenges of athletes
in Madrid. returning from hip and groin pain.
Welcome to ISHA NEWS 2019. We
are proud to announce our society is ISHA would like to thank our host The Chairman of the ISHA Research
celebrating its 10th year. This is our Co Chairman Dr Luis Pérez Carro Committee Dr Hal Martin from the
sixth edition of the annual newsletter and Dr Oliver Marín-Peña for all USA been making great progress on
and I would like to express my thanks their enormous preparatory work for how the creation of an US and
to the editorial sub-committee Vikas the forthcoming 11th Annual Scientific internationally accepted physical
Khanduja, Addenbrooke’s, Cambridge Meeting and look forward to the examination of the hip and we hear
University Hospitals NHS Trust, UK and contribution of the Spanish-speaking how Dr Srino Bharam is leading a team
Associate Professor Marcelo Queiroz world to hip preservation. Our society to create an international hip
from Santa Casa de São Paulo Medical members are thrilled to be visiting and preservation registry. We will also
School, São Paulo, Brazil. In addition,
exploring the wonderful European city hear about some recent insights into
a special thanks to all the contributors
of Madrid. some new recent finite element
of this year’s edition of the newsletter.
analysis work.
ISHA was delighted to have awarded
ISHA would like to thank our current
prizes to Mr Pranai Buddhdev, This year our ISHA Membership
President Marc Philippon for leading
Dr Keisuke Uemura, Professor John Committee Chair Mr Tony Andrade has
the society through 2019. Dr Philippon
O’Donnell and physiotherapists Ashley passed on the baton to Dr Al Stubbs.
discusses how our society will continue
Campbell, David Georgy and ISHA would like to take the opportunity
to focus on education, evidence-based
Emma Glynn. to thanks Tony for his dedication and
innovation and collaboration within
hard work over the years. We would
the field of hip surgery. Dr Philippon Article commentary provides also like to welcome our new
discusses how we will want to critically unique independent insights into membership chair Al Stubbs from
evaluate the use of labral end-to-end topic published articles. Mr Ajay the USA. This year Al Stubbs the
reconstruction vs. augmentation Malviya from the UK provides an Membership Committee Chair reports
and the latest techniques in article commentary on the paper the latest figures comprising 427
cartilage repair. “Hip Arthroscopy in Patients Aged 50 members who are in good standing
Years or Older: Minimum Five-Year
Dr Philippon’s goal is to help ISHA gain and current on their annual dues. Our
Outcomes, Survivorship, and Risk
financial stability and provide the best members are based on five continents
Factors for Conversion to Total Hip
product available to our members. and hail from over 30 countries. We
Replacement.”
Dr Philippon discusses the creation of would like to thank each and every
a new advisory board with our industry The role of registries is continuing to one of you for your ongoing support.
partners. influence orthopaedic practice around The ISHA Fellowship programme
the world. The UK National Arthroplasty
ISHA would like to thank our Executive continues to add value to the training
Hip Register (NAHR) continues to grow
Director Anna Lozinska-Brown for her of surgeons around the world. For the
year on year with more than 2,000
enormous efforts to run our society so second time, Chairman of the ISHA
cases contributed in 2018 and with
smoothly and the preparatory work Fellowship Professor Damien Griffin
almost 12,000 total procedures
for the upcoming Madrid meeting. updates us on all you need to do to
recorded in the registry to date; advertise your fellowship programme
The ISHA Scientific Chairman this includes 5,212 arthroscopies in Madrid.
Dr Damian Griffin and the programme for FAI, 444 arthroscopies for
committee has been working hard extra-articular pathology, 896 PAOs
1
This year we welcome our ex-president This year for the first time we hear They can improve cognition by
Josip Chuck Cakic from South Africa from the lead author of the upcoming utilizing graphics to enhance the hu-
as the new Chairman of the Education first International Best Practice man visual system’s ability to see pat-
Committee. This year we hear from Guidelines in arthroscopic terns and trends. For the first time ISHA
one of the travelling fellow’s Dr Pranai management of Femoro acetabular is pleased to present its first infographic
Buddhdev on their ISHA Travelling Impingement (FAI). Sarkhell S. Radha article led by Mr Vikas Khanduja on
Fellowship. ISHA would like to take from the UK, shares an interesting complications of hip arthroscopy.
this opportunity to thank all the hosting autobiographical account “From an
surgeons from around the world. We asylum seeker to a successful Trauma This year Al Stubbs from the USA
will hear from our second ISHA Fellow and Orthopaedic surgeon”. Dr Radha shares with us some of the highlights
Lee Ekert in 2020 due to the timing of provides a unique personal account of our 10-year anniversary meeting in
the fellowships. Dr Cakic is pleased of the struggles, challenges, fear and Melbourne. Our society would like to
to announce several new and exciting success, a Trauma and Orthopaedic thank all those of you who supported
initiatives. In particular, how ISHA is Surgeon faced fleeing the us and travelled last October to
establishing a brand-new regional war-zone Iraq. Melbourne, Australia. A particular
fellowship programme and the special thanks to Nicolas Bonin,
completion of Phase 1 of the Evidence-based medicine (EBM) Programme Chair, and chief local
“Presidential Initiative – The Delphi was introduced as a formal concept by host John O’Donnell, Faculty, Anna
Consensus Study. In addition, we will Gordon Guyatt at McMaster University. Lozinska Brown, and the meeting
also hear about a new educational This has been widely recognised as a sponsors including: Gold sponsors
collaboration with ESSKA and the major advance in understanding how to Smith and Nephew, Silver sponsors
European Hip Society. ISHA is also apply research to clinical practice. This Arthrex, ConMed, Karl Storz,
proud to announce a new relationship year we hear from Olufemi R. Ayeni Medacta, Stryker, St Vincent’s
with Proximie that will allow one to one from McMaster University, Canada, Hospital East Melbourne, Zimmer
basis for training, teaching and his insights on the role of ‘Systematic Biomet. We would also like to thank
interaction. Reviews and Meta Analyses in Hip Parcus Medical, Reveale Surgical,
Arthroscopic and Preservation Surgery: Össur OA, Gameready, TRICE, I Med
Dr Derek Ochiai updates us on the Helpful or Hurtful.’ Radiology, Socrates Ortho, Orthocell,
social media report. Dr Ochiai reports Xodus Medical and Virtamed. Most of
on how ISHA has expanded our Twitter MRI can be now be used in three all ISHA would like to thank all the
reach from 455 to almost 700 followers. different ways; to examine the 600 registrants who were present for
This year we hear about the growing morphology of the joint and the the meeting.
educational opportunities in Latin structures within, to examine the
America. For the first time we are structural integrity of articular cartilage Looking forward to seeing you all in
pleased to hear from Marcelo Queiroz and to examine the quality of articular Madrid!
in Brazil about the Brazilian Hip cartilage. This year we hear from
Preservation Symposium. This Professor Siôn Glyn-Jones in the UK
meeting was organised by the Brazilian on a review article of recent advances
Hip Society with ISHA support, which in imaging for FAI. Professor
took place on April 4-6th 2019. The Glyn-Jones provide a guide to some
society brought together world experts of the recent advances in different MRI
in hip preservation surgery over a imaging modalities when assessing
3-day conference. The meeting had patients for joint preserving surgery.
an excellent audience with 315 par- Professor Glyn-Jones shares some of
ticipants and 90 workshop attendees. Oxford’s experience with the 7 Tesla
Likewise, for the first time we hear MRI scanners and the role of artificial
from Dr Masayoshi Saito & Dr Yuichi intelligence and machine learning. Parminder J Singh MBBS, MRCS,
Kuroda, who are from Japan and Infographics are graphic visual FRCS (Tr&Orth), MS, FRACS
recently completed their fellowships in representations of information, data Editorial Committee Chairman of
hip preservation surgery and the status or knowledge intended to present ISHA - The Hip Preservation Society
of hip preservation surgery in Japan. information quickly and clearly.
The ISHA Fellowship programme continues to add
value to the training of surgeons around the world.
For the second time, Chairman of the ISHA Fellowship
Professor Damian Griffin updates us on all you need to
do to advertise your fellowship programme in Madrid.
2
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President’s Report
Marc Philippon
Greetings from Vail, Colorado. I hope you are all enjoying a beautiful summer. As I reflect
on the success of our society, I cannot help but admire how fast our profession has evolved
over the past 50 yrs. My father is a general surgeon who was trained in almost all surgical
sub-specialties. He always treated his patients with utmost compassion. We are now more
focused on our training, but we still have the same compassion in treating our patients.
It is amazing to think that some of us are performing surgeries only in the hip joint.
Sir John Charley made a major article supporting the use of hip reconstruction. Several years ago,
breakthrough in low friction arthroscopy for the treatment of FAI, we embarked on a long-term research
arthroplasty which became without a bringing international recognition to plan to determine its efficacy. First,
doubt one of the most successful our field and highlighting the positive we investigated the biomechanical
operation of the last century. ISHA is impact of hip arthroscopy. We implications of labral tissue loss and
a hip joint preservation society. We congratulate the research team on the subsequent effects of replacing
should be proud of what we have their milestone accomplishment. lost tissue. We found that by replacing
accomplished over the past decade Prevention, treatment of FAI by hip the tissue, you can restore the suction
with validation of new treatments for arthroscopy, peri-acetabular osteotomy seal. Following our biomechanical
hip disorders, successful meetings are new procedures that are now used research, we reported good outcomes
globally and access to Fellowships to routinely for joint preservation surgery. in patients 2 to 5 years following
train surgeons from all continents. It We will continue to focus on education, surgery and performed similar
is an exciting time for hip arthroscopy. evidence-based innovation and studies in athletes. Currently we
More and more, our success in collaboration within the field of hip are undertaking a study on 10-year
improving patient outcomes has been surgery. There are several areas we outcomes. Recently, we reported on
driven by evidence-based medicine. continue to pursue in our quest for an adaptation of labral reconstruction:
In 2018, the Lancet published an achieving the best patient outcomes. labral augmentation.
original Level 1 evidence research One close to my heart is labral
More and more,
our success in improving
patient outcomes has been
driven by evidence-based
medicine.
Topics will include
assessment of hip and
groin pain, challenges
in differential diagnosis
as well as pre-operative
physiotherapy programs
following hip arthroscopy.
4
Augmentation is similar to findings. Other studies include the stability and provide the best product
reconstruction, however the goal is to addition of platelet-rich plasma (PRP) available to our members. The creation
preserve any; remaining, healthy fibres or bone marrow aspirate to of this new advisory board with our
of the native labrum. A study published microfracture lesions. Outside the industry partners will help optimize our
in Arthroscopy last year showed that U.S., researchers are culturing efforts to better treat our patients with
patients who underwent augmentation mesenchymal stem cells which are innovative and effective technology for
showed superior outcomes to recon- being injected into arthritic knees and all surgeons.
struction. The goal of augmentation is seeded in collagen membranes. We
to keep as much of the native/healthy have recently been looking to improve I remember the enthusiasm and the
tissue as possible. If we heed the microfracture using an anti-fibrotic positive energy when we got together
lessons learned from the meniscus, agent to improve the repair tissue from in Paris to create our society in 2008.
in which removing the entire structure microfracture. Our early results show I have this feeling that our future is
lead to problems down the road, we increased hyaline cartilage formation very bright and that we are all still full
will want to critically evaluate the use and fewer revisions due to scar tissue of energy. With only 4 months until
of end-to-end reconstruction vs. in our patients. However, there remains the annual meeting in Madrid, I hope
augmentation and consider saving as little empirical evidence supporting the everyone is making plans to attend.
much as the native tissue as possible. use of many of these cartilage I encourage everyone to register early
We stand by our technique and never treatments in large patient groups. and invite your friends to join ISHA and
remove healthy tissue. I encourage Again, we must wait for the evidence come to Madrid. The committee has
everyone to read the literature and to show us the best treatment. been working very hard on the content
educate yourself before trying and this will be a very educational
whichever technique you choose. It is also an exciting time at ISHA as meeting. We also plan to have
we are initiating unique partnerships some fun.
Another fast-evolving area is cartilage with industry. We have formed an
repair. Currently the most common Advisory Board for corporate partners
treatment cartilage repair in the United with Arthrex, ConMed, and Smith and
States is microfracture. A recent study Nephew. This is a way for us to work
showed similar results when together with industry while gaining
comparing microfracture to valuable funding for our organisation.
debridement/abrasion. We will watch As the organisations 10th president,
for more studies to corroborate these my goal is to help ISHA gain financial
We have recently been looking
to improve microfracture using an
anti-fibrotic agent to improve the
repair tissue from microfracture.
Our early results show increased
hyaline cartilage formation and
fewer revisions due to scar tissue
in our patients.
5
ISHA 2019 Scientific Programme
Damian Griffin
Professor of Orthopaedic Surgery at the University of Warwick, UK
wants to come up to date with the have two superb Presidential guest
fundamental principles and essential lecturers to speak to us from the
techniques. You could be a clinician’s and the patient’s
trainee or fellow, or a nurse, or physi- perspectives.
otherapist, or a surgeon who is new to
the specialty, or someone in practice Our partnership with industry will
who just wants to make sure you are complement all of this. Our biggest
aware of the full breadth of hip pres- ever exhibition will showcase new
ervation principles and techniques. technologies and ideas, and lunchtime
There will be four parallel streams workshops will give you a chance to
running throughout the day: get ‘hands-on’. You’ll be able to take
English-speaking surgeons, part in a training session on ultrasound
Spanish-speaking surgeons, Asian around the hip, learning enough to
surgeons, and physiotherapists. starting into putting it into practice in
For one session in the afternoon, clinic.
participants in all four streams will
come together for a series of case For the first time in Madrid, there will
We look forward to discussions. This will be an be a poster competition. The theme for
welcoming the worlds exceptional opportunity for us all, this year’s Annual Meeting is ‘team-
preservation community taking advantage of having a work in hip preservation’. To mark this
to Madrid for our Annual faculty of the world’s leaders in hip theme, we are running a competition
preservation gathered in one place: for the best team poster. To enter,
Meeting in October. The
please do support it and encourage just submit a poster that shows the
theme this year is ‘teamwork members of your team to do so. members of your team and illustrates
in hip presentation’. I know how you work together.
we all agree that surgery is The main programme runs from
not always the best way to Thursday to Saturday. This is where This is a great project to give the
help our patients, and even new and controversial ideas will be junior members of your team: it will
discussed. For four seminar sessions, show that you value collaborative
when it is, good outcomes
you will choose among a variety multidisciplinary working, it will
depend as much on the of seminars, each on a topical advertise and promote your
non-surgical aspects of care subject, and including both practice, and your team may win
as on the technical quality instructional lectures and the very an international prize!
of our surgery. best of the free papers submitted to
the Meeting this year. The concept is More details will be on the ISHA
We are going to explore how we to settle down for a couple of hours to website shortly; get your team to
can work best as a team, and the think deeply about one clinical work now on your poster!
integrated programme reflects this. problem, and to have plenty of time
This year, as well as plenty of time to for a really good discussion. Wrapping around all of this is the
learn about new surgical techniques, most outstanding social programme
there will be special sessions on Between these seminars, the plenary put together by Oliver Marin and Luis
developing a multidisciplinary team programme includes debates, guest Perez Carro, our local hosts. Madrid is
and working together. I encourage all and keynote lectures, our business a fabulous city, and they are
of you to bring other members of your meeting and updates on research and determined to make sure we get the
team with you: nurses, physiothera- education in ISHA, and an extremely best possible experience of Spain.
pists, radiologists, anaesthetists and high-quality presentation competition
theatre staff. Who else is part of your for the Richard Villar prize. The See you in Madrid!
hip preservation team? debates will be big events on very
controversial subjects: surgery or
The programme begins on physiotherapy for FAI syndrome; Damian Griffin, ISHA Scientific
Wednesday 16 October with a primary labral reconstruction; and Programme Chair
‘Principles of Hip Preservation’ course. early intervention for the hip at risk. damian.griffin@warwick.ac.uk
It is designed for anyone who Stand by for fireworks! Finally, we
6
ISHA 2019 Host also be opportunities for attendees
to engage in debate sessions and
We hope that you have a chance,
outside the Annual Scientific Meeting
Chairmen Report industry led workshops. to experience the beauty, culture,
fabulous gastronomy and history of
Electronic posters, technical exhibits Madrid, whether this is your first visit,
Dear ISHA Friends and Colleagues, and manifold ISHA Awards are offered or your hundredth. To this end we
to enhance your experience. Last year have arranged for the Gala Dinner
ISHA – The Hip Preservation Society we included for the first time Virtual to be held in the historic Casino de
looks forward to warmly welcoming Surgery Simulation training sessions, Madrid, an institution begun in 1836
you to the Meliá Castilla, Madrid, enabling delegates to develop with collaboration and the sharing of
Spain for the 11th ISHA Annual practical skills using the latest VR ideas in mind. To enrich your
Scientific Meeting. ISHA has grown technology with experienced trainers. experience after-dinner entertainment
since its inception eleven years ago, With the support of Virtamed and 3D will be provided by renowned
and 2018, our 10th anniversary year, Systems, we are delighted to offer flamenco dancer, Eva Manzano.
saw us change to officially include these sessions again in Madrid with
open hip preservation in our name an extended range of procedures. The 11th Annual Scientific Meeting of
and welcome hip preservation ISHA – The Hip Preservation Society
surgeons into our great fellowship of We are delighted to have Dr Victor is set to be our most successful yet as
friends. Ilizaliturri, MD, of the National we welcome delegates and attendees
Rehabilitation Institute of Mexico, hungry for scientific exchange. We
The ISHA 2019 Programme to deliver the keynote presentation thank you for your participation and
Committee has developed an exciting “The contribution of the trust you will enjoy this inestimable
and educational academic programme Spanish-speaking world to hip experience of teamwork at its best in
based around the theme of “The preservation” on Thursday 17th Madrid.
Hip Preservation Team”. To reflect, October. Further keynote
emphasise and develop the teamwork presentations on the topics of the Don’t take our word for it, see what
necessary for evidence-based “Future of Hip Preservation” and “The our Hip Preservation colleagues from
medicine, and new surgical Patient’s Perspective” will form part of around the world have to say.
developments in arthroscopic and the Saturday morning programme.
open surgery of the hip. The ISHA
Annual Scientific Meeting continues Following the success in Melbourne For further information and to register,
to provide a unique international at ISHA 2018 of the pre-conference book travel and accommodation
forum for the exchange of scientific course, we have extended this for online visit www.ishaconference.com
information and engagement in an ISHA 2019 and on Wednesday 16th
atmosphere of friendship, and October we have scheduled a full day https://vimeo.com/349874260
collaboration. for “Principles in Hip Preservation”
to include concurrent seminars for We look forward to welcoming you to
This year the programme is Iberian, Asian, and English Principles, Madrid.
based around seminar themes as well as for Physiotherapists, with a
relating to treatment, prevention combined afternoon Case Study Warmest regards.
and rehabilitation relating to the hip. session. Thereafter everyone will
Seminars will include interactive come together for the ISHA Annual
course lectures and the best research Scientific Meeting from Thursday
papers o the seminar topic. There will 17th – Saturday 19th October.
Dr Oliver Marin-Pena Dr Luis Perez-Carro Professor Damian Griffin
ISHA 2019 Co-chair ISHA 2019 Co-chair ISHA 2019 Scientific
Programme Chair
7
2019 Research Report
Hal Martin MD
is in final stages of a position extension deficit pathology’s
paper to present to the board first influence on spinal loads are
and to the entire organisation in confirmed in recent finite element
Madrid. There are several research analysis manuscripts that will be of
efforts underway in opinion interest to our organisation and to
methods across common hip patients experiencing hip, spine,
Marc Philippon created two goals for pathologies encountered in pelvic, core presentations of
the research committee this year, both preservation treatment including interrelated complaint. It is an
are making progress. Srino Bharam hip instability. exciting time in history to begin a
is leading a team effort to create an more comprehensive understanding
international hip preservation registry The ISHA led book, “Posterior Hip of the hip’s 3 planar influences on
and is making significant progress, Disorders, Clinical Evaluation and other orthopaedic conditions. The
including a creative method of Management “, has sold 6k copies possibility of a Copernican revolution
financial support. The second or downloads and has created an of insight is looming.
directive was the creation of an US increased awareness of the vast
and internationally accepted physical pathologies encountered in this critical Gratefully,
examination of the hip. The committee area of hip biomechanics. The hip Hal
ISHA Prizes 2018
Richard Villar Trainee Excellence ISHA Basis Research Award 2018 Joseph McCarthy Award for
Award 2018 Advancing Knowledge and
–K
eisuke Uemura(USA) Scholarship in Hip Joint
–P
ranai Buddhdev (UK) Preservation 2018
–S
ubmission: Three-dimensional
–S
ubmission: Patient-Reported Femoral Head Coverage in the – Professor John O’Donnell
Outcomes & Success of Surgical Standing Position Represents (Australia)
Hip Dislocation in the Treatment that Measured in-vivo during
of Residual Deformities Gait
Secondary to Perthes
ISHA Physiotherapy Awards 2018
– Ashley Campbell (USA) –D
avid Georgy (Australia) –E
mma Glynn (Australia)
–S
ubmission: Podium - Return to –S
ubmission: E-poster Incidence –S
ubmission: E-poster What is the
dance following hip surgery of Gluteal muscle weakness in prognosis of conservative versus
patients with Femoroacetabular non-conservative treatment in
impingement syndrome Ischiofemoral impingement?
8Article Commentary
Ajay Malviya
a therapeutic dilemma specially survivorship at 5 years (72.3%) it
when they present with signs and does arm the surgeon with useful
symptoms of femora-acetabular information to discuss the possible
impingement with negligible changes need for arthroplasty. In patients with
of osteoarthritis. concomitant arthritic changes in other
joints or other medical comorbidities
In the article “Hip Arthroscopy in this may help the patient in decision
Patients Aged 50 Years or Older: making. The authors have attempted
Minimum Five-Year Outcomes, to identify the difference in patient vs
Survivorship, and Risk Factors surgeon perception in this study
for Conversion to Total Hip using PROs and VASs. This data
Replacement,” Perets, would be critical and can be
Chaharbakhshi, Mu, Ashberg, expanded upon using the minimal
Battaglia, Yuen, and Domb present clinically important difference (MCID)
their results of hip arthroscopy in and patient acceptable symptomatic
patients aged 50 years or older. The state (PASS) (7).
Hip Arthroscopy in study uniquely presents not only the
short term but the mid-term results Ultimately, long term studies,
Patients Ages 50 Years
in a patient cohort 50 years or older. multicentre trials and comparing
or Older: Minimum 5 Year They found a statistically significant similar cohorts of patient with age as
Outcomes, Survivorship, and improvements in both patients the only differentiating feature
Risk Factors for Conversion reported outcomes (PRO) and will help us define this paradox.
to Total Hip Replacement. Visual Analog Scale (VAS) besides
Itay Perets, Edwin O. an overall survivorship rate of
72.3% at 5 years. Ajay Malviya
Chaharbakhshi, Brian Mu,
PhD, FRCS T&O, MSc, MRCSEd,
Lyall Ashberg, Muriel R. Studies within the last 15 years MS T&O
Battaglia, Leslie C. Yuen, suggested that hip arthroscopy Honorary Senior Lecturer Newcastle
Benjamin G. Domb. Ar- carries inferior results in older University
throscopy, Vol. 34, Issue patients and age is an independent Consultant Orthopaedic Surgeon
11, p3001–3009. Published risk factor (5,6). While the current Northumbria Healthcare NHS
study also supports this, it does help Foundation Trust
online: October 6, 2018
us identify risk factors to optimize
our results. This become very
There has been a meteoric rise in
important in the clinical setting while
hip arthroscopy over the last decade.
discussing the expected outcomes
This has become a well-established
and the alternatives available to the
procedure that is also reflected in its
The study
patient and the clinician. This article
incorporation in residency training
identifies high BMI, Tönnis grade 1,
programmes (1). Akin to any surgical
procedure optimum patient selection
remains a key component to good
high preoperative alpha angle, low
preoperative LCEA (Lateral uniquely presents
results. This in turn translates to
high return to sports (2,3) and high
centre-edge angle), acetabular
Outerbridge grade 2, and femoral not only the short
satisfaction rates post-surgery as
reported by Kahlenberg (4). Most
head Outerbridge grade 2 as risk
factors for conversion to THA. term but the
of these studies however focus
Patients 50 or older with hip mid-term results
on young patients and athletic
populations. The subset of patients
pathology may at some stage
be a candidate for total hip
in a patient cohort
older than 50 years of age remain
arthroplasty. By identifying the
50 years or older.
101. Bozic KJ, Chan V, Valone FH III, 4. Kahlenberg CA, Nwachukwu 7. Chahal J, Van Thiel GS, Mather
Feeley BT, Vail TP. Trends in hip BU, Schairer WW, McCormick F, RC, et al. The patient acceptable
arthroscopy utilization in the United Ranawat AS. Patient satisfaction symptomatic state for the modified
States. J Arthroplasty 2013;28: reporting for the treatment of Harris Hip Score and Hip Outcome
140-143 (Suppl). femoroacetabular impingement. Score among patients undergoing
Arthroscopy 2016;32:1693-1699. 2. surgical treatment for
2. Schallmo MS, Fitzpatrick TH, Gold M, Franks P, Erickson P. Ass femoroacetabular impingement.
Yancey HB, Marquez-Lara A, Luo Am J Sports Med
TD, Stubbs AJ. Return-to-play and 5. Philippon MJ, Schroder E, 015;43:1844-1849.
performance outcomes of Souza BG, Briggs KK. Hip
professional athletes in North arthroscopy for femoroacetabular
America after hip arthroscopy from impingement in patients aged
1999 to 2016. Am J Sports Med 50 years or older. Arthroscopy
2018;46:1959-1969. 2012;28:59-65.
3. Frangiamore SJ, Mannava S, 6. Khanduja V, Villar RN.
Briggs KK, McNamara S, Philippon Arthroscopic surgery of the hip:
MJ. Career length and performance Current concepts and recent
among professional baseball players advances. J Bone Joint Surg Br
returning to play after hip 2006;88:1557-1566.
arthroscopy. Am J Sports Med
2018;46:2588-2593.
ISHA International Travelling Fellowship
Don’t miss an opportunity
The ISHA Travelling Fellowship offers you an opportunity to learn
hip arthroscopy from the leading practitioners in this field. During the
Fellowship you will spend time with ISHA approved surgeons in your
home country, as well as with two other ISHA surgeons on two
different continents
Deadline for applications: 15th December 2019
For further information please contact:
ishabureau@gmail.com
11Update from the Non-Arthroplasty
Hip Registry 2019
Richard Holleyman SpR Northern Deanery &
Vikas Khanduja MA, MSc, FRCS, FRCS (Orth)
Addenbrooke’s Hospital, Cambridge, UK
Chair – Non-Arthroplasty Hip Registry, UK
Introduction Summary of 2019 Report
The Non-Arthroplasty Hip Registry (NAHR) in the UK was The NAHR continues to grow year on year with more
launched by the British Hip Society in 2012, in response to than 2,000 cases contributed in 2018 (see Figure 1)
the guidance published by the National Institute for Health
and Clinical Excellence (NICE) on open and arthroscopic
femoroacetabular surgery for hip impingement in 2011.
NICE had recommended inclusion of this type of surgery
into a non-arthroplasty hip register.
Since its introduction, the NAHR has been refined
continuously and data entry has been simplified. The
Minimum dataset (MDS) includes two validated patient
reported outcomes scores: EQ5D and iHOT12 and
operative findings at surgery. Surgeons conducting this type
of hip surgery enter data, and patients are then contacted
for information about their progress via e-mail at regular
intervals post-operatively. Cases from both the National
Health Service (NHS) and the independent sector are and with almost 12,000 total procedures recorded in the
included in the NAHR. registry to date; this includes 5,212 arthroscopies for FAI,
444 arthroscopies for extra-articular pathology, 896 PAOs
and 98 femoral osteotomies. Surgeons are able to enter
data retrospectively and we are grateful to those who upload
their historic data which has led to a further increase in
Surgeons are contributed cases particularly in the last 2 years. 2018 also
able to enter data saw record numbers of surgeons (67) contributing data to
retrospectively and the registry.
we are grateful to
those who upload Work continues to improve, in particular, the return of
their historic data post-operative outcome questionnaires although 2-year
which has led to a return rate remains too low to draw reliable conclusions
further increase in for the majority of procedures.
contributed cases
particularly in the With the maturity of the dataset continuing to grow,
last 2 years. several projects have now been completed examining the
effectiveness of our surgical interventions and are nearing
publication:
12PAO for DDH & FAI Our first study reports the outcomes for 630 patients undergoing a PAO for either DDH (89%) or FAI (11%). EQ-5D Index and iHOT-12 scores were reported up to 2 years post-operatively. For both pathology groups there was significant (p
Cutting-Edge AR Project to
Enhance Surgical Expertise
A new collaboration with augmented
reality healthtech company Proximie
is enabling ISHA to scale the expertise
of its members for the benefit of
patient care.
ISHA is actively encouraging
members to get involved in this latest
Unlike other new technologies,
Proximie works without expensive
The power of the
initiative, which will see them be able hardware or fancy wearables. Its platform lies in its
to interact with ‘live’ surgeries via the cloud-based technology functions
Proximie platform using audio, visual on any computer, tablet, phone or ability to connect
and augmented reality features; be hardware that is commonplace in
remotely proctored by a global expert an operating theatre at a really low surgeons together
from any location in order to enhance
their surgical techniques and access
bandwidth, meaning it can be used
in nearly every location.
who otherwise may
pre-recorded footage of procedures. not have come
Proximie’s Bryn Davies said: “We
Proximie was co-founded by NHS have had over a 100 ISHA members across each other.
surgeon, Nadine Hachach-Haram, sign up to this exciting project so far
who saw the benefits of surgeons and would love for more to do so for
travelling to less advanced countries greater collaboration and sharing of
to share their skills but how that impact knowledge. The power of the platform
was constrained by time and lies in its ability to connect surgeons
resources. Her innovative platform together who otherwise may not have
speeds up that process, by allowing come across each other. A surgeon
a doctor to get an expert opinion in the UK can learn directly from
remotely. It works by layering another in South Africa or America
digitally created content onto a live without leaving home, and vice versa.”
video stream using AR to provide
‘hands-on’ virtual assistance, enabling As well as ISHA, Proximie works with
the effective transfer of clinical and numerous medical associations across
surgical expertise in a scalable and various specialties as well as some
compliant fashion. medical device companies.
14ISHA board member and Hospital in Johannesburg, South Paul Haggis, ISHA member and hip
consultant orthopaedic surgeon at Africa. Once the centres are set up, arthroscopy fellow in Bournemouth,
Circle Reading Hospital, Tony An- a timetable of events will be UK, said:
drade, has been piloting Proximie in scheduled with monthly live
the UK. He said: “Proximie’s ability cases, surgical collaborations and “I think Proximie is great. It will
to connect surgeons from across post-operative discussion all using definitely be useful with surgeon
the world in real time, together with augmented reality recorded and made mentorship programmes (e.g. Tony
engaging augmented reality video available to ISHA members. There Andrade providing advice when I do
content means it can help us deliver have been four live collaborative my first labral graft in a few years), and
our mission of promoting and events so far which took place in June I am very excited about ISHA using it
improving patient care through and July where surgeons from Brazil, for live surgery demonstrations. It was
collaboration and education for Columbia, Ireland, Singapore, USA, very easy to log in - even in the middle
our members. France and UK joined the real-time of a busy fracture clinic!”
events and post-case are reviewing
“It is exciting, as it is so simple to a number of cases led by Dr Andrade
record a series of live surgery cases and Dr Cakic. If you are interested in becoming
which enables us to engage the ISHA one of Proximie’s six sites as part
community in a unique way. All of Future plans may also see the of this project, would like to sign up
these procedures will be stored on the addition of new features such as 3D to the project or have any questions
ISHA Proximie platform and shared anatomy being streamlined alongside or feedback, then you can get in
with our global community.” the surgical video to aid education touch by contacting Bryn Davies at
and learning. bdavies@proximie.com
As part of the project, Proximie will set
up six sites to record and stream live Proximie will also be attending the
or pre-recorded content to share with ISHA annual meeting in Madrid in
the ISHA membership. Andrade is one October where there will be live
of these along with Chuck Cakic, ISHA demonstrations of the platform with
past president and an orthopaedic hip members of the team on hand to
surgeon based at Life Fourways answers any questions.
“I think Proximie is great.
It will definitely be useful
with surgeon mentorship
programmes (e.g.Tony Andrade
providing advice when I do my
first labral graft in a few years),
and I am very excited about
ISHA using it for live surgery
demonstrations. It was very
easy to log in - even in the
middle of a busy fracture
clinic!”.
15Physiotherapy Group
Report 2019
Associate Prof. Amir Takla
& Professor Mike Voight
Following the successful Mike Voight, Amir Takla Ashley The Physiotherapy Group’s primary
introduction of the concurrent Campbell, RobRoy Martin, Keelan goals are to bring together bright minds
Enseki, Tim Tyler, David Georgy, and in physiotherapy and sports medicine
Physiotherapy program three
David Kohlrieser have already agreed to share new research, discuss current
years ago in Rio and more to speak on their published work in topics and present evidence-based
recently the well-attended Madrid 2019. practice. We look forward to
program in Melbourne in 2018, contributing to a stimulating academic
we are delighted to report that During the Congress, we are program in Madrid this year that will
the academic physiotherapy delighted to be able to offer foster learning, discussion and
presentations on detailed physical inspiration. See you in Madrid 2019.
program for Madrid 2019 is
therapy assessment of complex hip
taking shape. conditions, advance strength and
conditioning as well as sports specific A/Prof. Amir Takla B.Physio, Mast. Physio.
As in previous years, the Annual return to sport drills and the opportunity (Muscu), MAPA, MSPA, MMPA
Scientific Meeting will run over three to hear from international Tennis & golf
atakla@unimelb.edu.au
days with the Wednesday having the amir@australiansportsphysiotherapy
coaches about the challenges of
Physiotherapy specific workshop and athletes returning from hip and Professor Mike Voight PT, DHSc, SCS, OCS,
interlinked physiotherapy presentations groin pain. ATC, CSCS, FAPTA
during the congress. On the first day Professor – Belmont University School of PT
of the Congress, the physiotherapy The physiotherapy group now faces Mike.voight@belmont.edu
group will run instructional workshop the significant challenge of market-
assessment and treatment workshop ing and spreading the news of our
for physiotherapists and sports program to attract delegates to our
medicine delegates. Invited
physiotherapy and sports medicine
annual meeting. We look forward to the Topics will include
support of the Spanish Physiotherapy
speakers will present alongside the Association and local Sports Physical
assessment of hip and
surgeons on the diagnosis of hip Therapy Groups. In addition to our groin pain, challenges
related conditions, rehabilitation and
the physiotherapist’s role in treatment
targeted advertising plan, we ask our in differential diagnosis
surgical colleagues to inform their
of hip conditions. Topics will include physiotherapy and sports medicine
as well as pre-operative
assessment of hip and groin pain, groups about this year’s ISHA physiotherapy programs
challenges in differential diagnosis as
well as pre-operative physiotherapy
conference. We have been following hip arthroscopy.
directing them to the ISHA website
programs following hip arthroscopy. and or putting them in touch with one
We are excited to announce some of of our team.
the international physiotherapists
16ISHA Membership Report 2019
Al Stubbs MD
As of the close of our 2018/2019 Please thank the membership
membership year, the membership committee members when you
committee is happy to report that we see them:
have 427 members who are in good
standing and current on their annual Tony Andrade (Past-Chair)
dues. Our members are based on Olufemi Ayeni (Canada)
five continents and hail from over 30 Filiep Bataillie (Vice-Chair) (Belgium)
countries. Many thanks to Anna John Clohisy (USA)
Lozinska Brown, Executive Director, Andrea Fontana (Italy)
and Caroline Mackenzie of Open Christoph Gebhart (Austria)
Audience for facilitating membership Bent Lund (Denmark)
updates including dues payments. Oliver Marin-Pena (Spain)
Marcelo Queiroz, Vice-Chair (Brazil)
New to the membership roles this Joerg Schroeder (Germany)
year are corporate members who Allston Stubbs, Chair (USA)
will work closely with the ISHA Board Sun-Jung Yoon, Chair (Korea)
of Directors to ensure that we are
Greetings to our ISHA optimizing our goals of membership
Membership! We have satisfaction, industry partnerships, and Thank you for the opportunity
society growth. We are excited about to represent our membership
been very fortunate over the this new framework and the synergies and society.
last year to reconnect with that it offers around hip preservation
many members from all over teamwork. Al Stubbs
the globe. As you may Chair, ISHA Membership
have noticed, ISHA has
evolved into “The Hip
Preservation Society”
and, in turn, changed
it’s internet footprint to
accomplish a more Our members are
based on five continents
responsive website design.
Your membership committee
hopes that the new website
will provide you a more
modern interface for
understanding your
and hail from over
membership benefits as well
as remaining current with 30 countries
your annual dues.
17ISHA 2019 Fellowships Fair
Damian Griffin
Professor of Orthopaedic Surgery at the University of Warwick, UK
Do you run a hip by their poster so that anyone who
preservation fellowship? is interested in coming to do your
Fellowship can come and introduce
If so, please consider
themselves and ask questions.
participating in this venture at
the Annual Meeting in Madrid. ISHA is determined to help young
surgeons become properly trained
For the second time, we will hold a in hip preservation; this is a practical
Fellowships Fair. All you need to do way to help them make the
is to prepare a simple poster with the international connections to do that
details of your fellowship. We will training. If you run a fellowship, please
display all of these posters in one let Anna Lozinska-Brown or me know
area of the conference centre, so that - we will even send you a template
young surgeons who would like to poster to make it really easy!
train in hip preservation surgery can
read them throughout the meeting
and find out about the full range of Damian Griffin,
international opportunities. For one ISHA Scientific Programme Chair
short period during the meeting, all damian.griffin@warwick.ac.uk
of the Fellowship Directors will stand
ISHA 2019
Annual Scientific Meeting
Madrid, Spain 17 - 19 October 2019
19Fellowship Report 2019
Pranai Buddhdev
BSc MBBS MSc(OrthEng) FRCS(Tr&Orth), London, UK
physiotherapy alone (FASHIoN & FAIT 3D imaging in these patients to
trials). With the Non-Arthroplasty Hip ensure adequate CAM resection.
Register (NAHR) now due for its 4th I appreciated the time he took to focus
Annual report, I opted to spend time on my career aspirations and having
with some of its pioneers – Mr Marcus recently commenced a consultant post
Bankes, Guy’s Hospital, London, within his trust, look forward to my
Mr Vikas Khanduja, Addenbrooke’s ongoing involvement with his service
Hospital, Cambridge and Mr Tony and his valued mentorship.
Andrade, Royal Berkshire Hospital,
Reading. I was truly offered the home As the future ISHA President and
advantage, being granted the acclaimed hip arthroscopist, I relished
opportunity to attend clinics and the opportunity to visit and spend time
theatre sessions in both the public with Mr Tony Andrade in Reading.
(NHS) and private sectors by all of He bestowed his knowledge on the
these mentors to maximise my importance of both femoral version
exposure. and concomitant tibial torsion in
patients with impingement and
With a firm desire to pursue Mr Marcus Bankes is truly a great demonstrated this during a femoral
a career in hip preservation trainer who teaches by example; from derotation osteotomy over an IM nail
the approach to his minimally invasive utilising the novel Sure-Shot device.
surgery in the paediatric and
PAO and hip arthroscopies, to With his preference of performing hip
adolescent population, it was understanding the importance of arthroscopy in the supine position, we
with a huge degree of honour obtaining and interpreting standardised were able to discuss the intricacies of
and excitement that I was intra-operative imaging with a locked managing difficult cases, including the
able to participate in the ISHA chassis base, to the way he endorses role of scoping the peripheral
Travelling Fellowship 2019. a therapeutic alliance with his patients compartment first in muscular
through empowerment and education individuals, a recent case of a
Having recently
and the way he always remembered combined ligamentum teres and labral
completed both domestic something about each of his patients. reconstruction, and the potential
(RNOH, Stanmore) and As the undisputed selfie king (see applications of the disposable
international (Royal below), it was endearing as to how handheld mi-eye2 scope system
Children’s Hospital, approachable he was, hosting both in his practice.
Melbourne) fellowships, the departmental MDT and taking time
with the local paediatric orthopaedic Within walking distance of the
I yearned for the opportunity
surgeons to discuss complex cases. infamous Big Ben & Westminster
to fine-tune my skills from the Abbey, I also managed to attend the
vanguards of established and Mr Vikas Khanduja taught me the London Hip Meeting, where there was
innovate practice in the hip ‘scope’ for future research within the an update on hip preservation with
preservation and arthroscopy field – heralding from his involvement a host of speakers. Previous ISHA
fields both in the UK as chair of the NAHR, ISHA, SICOT President Prof. Richard Field pre-
and his own PhD. I learnt his pathway sented the ISHA Delphi Consensus
and abroad.
for managing FAI patients and saw which examined 150k cases by 165
him perform numerous hip surgeons whilst Johan Witt spoke on
The United Kingdom has published
arthroscopies in the lateral position the influence of hip morphology on
worldwide acknowledged studies in
(as Mr Richard Villar did). With an intra-articular injury in FAI and Tony
the last 12 months in both the
increasing number of referrals for Andrade spoke on rotational
Lancet and British Medical
ongoing pain following hip abnormalities of the hip.
Journal, both from independent
arthroscopy, I had the unique
studies showing improved patient
opportunity to witness his planned
reported outcomes following hip
setup for the use of intra-operative
arthroscopy compared to
20With Tony Andrade & Vikas Khanduja, With Marcus Bankes, Jit Balakumar (Melbourne) & Jonathan Hutt at ISHA 2018,
3D Imaging C Arm in Addenbrooke’s theatre, London Hip Meeting Panel
My first stop on the international mean arterial pressure management, fortunate enough to see two
component of my fellowship was to documentation of IV fluid dispensed, generations of Dr J Clohisy (his son
Barnes-Jewish Hospital in St Louis, urine output and blood loss in his is a resident at WU) perform a case
USA to visit Dr John Clohisy who operative note, and his personal call together, where the labral tear was
performs over 300 hip preservation to the patients’ families from theatre managed arthroscopically prior to
cases/year in addition to his before moving to the next case in performing a rectus-sparing PAO
arthroplasty practice. The the adjacent theatre). through a small Ganz-type incision.
Washington University campus
was vast and impressive with the On his clinic day, there was a large Whilst in St Louis, I also managed to
operating theatres over-looking Forest team of doctors, research nurses and visit Perry Schoenecker, a legend in
Park (larger than NYC’s Central Park!). administrative staff. He personally saw Paediatric Orthopaedics, at Shriner’s
More impressive was the efficiency of each of the fifty patients booked into Hospital who took the time to impart
Dr Clohisy’s high volume practice clinic after being seen by his fellow/ his wisdom on his approach to
(7-10 cases/day) made possible from resident, performing a clinical numerous paediatric hip pathologies.
the early start times, preparedness of examination, interpreting radiology and In the evenings, I managed to visit St
the team (X-rays were all posted on communicating his diagnosis and plan. Louis’ iconic gateway arch, the tallest
the walls with all necessary I had the opportunity to speak to Dr in the world, watch the baseball at
radiographic measurements Jeffrey Nepple and his research team, Ballpark Village and even sample
displayed), and a stringent approach who are key to the success of the some of the famous ‘toasted ravioli’
to each case from start to finish (his ANCHOR Study group, about how to in The Hill, St Louis’ famous Italian
informative and transparent consent run and fund studies. With an ongoing neighbourhood.
process, anaesthetic optimisation RCT investigating the role of combined
including muscular relaxation and PAO and arthroscopy, I was also
On his clinic day, there was a large team of doctors, research
nurses and administrative staff. He personally saw each of the
fifty patients booked into clinic after being seen by his fellow/
resident, performing a clinical examination, interpreting
radiology and communicating his diagnosis and plan.
21After a brief visit to see the wife their protocols. As part of the journey infamous wet lab where I spent a day
and kids back in London, I flew to to the capital to Switzerland, I also with my own hip cadavers practicing
Switzerland to the home of open hip managed to take in the beautiful swiss the techniques observed and visit
preservation in Bern to visit Prof. scenery with train rides from Zurich the basic science research and gait
Klaus Siebenrock at Inselspital. and Geneva, visit the Bears of Bern, analysis labs.
Having worked alongside Prof. Ganz, and of course, purchase plenty of
he has cultivated a unit with a focus chocolate! The local ski-slopes not only
on training a group of surgeons provided fantastic views each day,
proficient in hip preservation My return to the USA began with but also, some interesting arthroscopic
techniques, and it was a unique a visit to Dr Marc Philippon at the cases, including a patient who had
opportunity to see the traditional Steadman Clinic in Vail. This sustained a posterior hip dislocation
Ganz-approach PAO. There was a institution is world-renowned for with numerous loose bodies which
sense of relief when lead-aprons were its management of injuries in elite were excised, and where Dr Philippon
not donned at the beginning of the athletes (including the US Olympic assessed the vascularity of the
case as he only uses intraoperative team), as exemplified by the signed femoral head using an arthroscopic
radiography to confirm his correction shirts on each and every corridor. USS doppler probe.
once the cuts were complete. With a fantastic case mix of primary
and revision arthroscopic procedures
I found my GCSE (high school) I learnt numerous technical pearls
French and German extremely useful including how to manage different
during clinics in understanding the labral tears using different anchor This institution is
consultations and was honoured to types depending on location, capsular
be invited to the Olympic Orthopaedic closure using the ‘Quebec City Slider’, world-renowned for its
Sports Clinic with Prof Siebenrock, a the use of augments and the management of injuries
dedicated sports clinic where meticulous and dynamic CAM in elite athletes (including
numerous high-level athletes present. resection customised to the patient’s
I learnt about the long-standing use of individual sports and lifestyle the US Olympic team), as
traction MRIs (15kg) in Bern to help requirements. I had the opportunity to exemplified by the signed
identify intraarticular pathology and transfer my theatre experience to the shirts on each and every
corridor.
With Dr John Clohisy, Gateway Arch & Barnes-Jewish Hospital, With Dr Schoenecker (Shriner’s Hospital)
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