Dr. Robert Christian and Dr. Samuel Van de Velde are orthopedic surgeons with two different specializations, but one common goal: alleviating pain and preserving their patient’s native hip function for as long as possible. With Dr. Christian’s sports medicine and arthroscopic surgery background, and Dr. Van de Velde’s expertise in periacetabular Ganz osteotomy, the uniquely qualified pair run a combination clinic focused on hip preservation - one of few in the country to offer this type of collaborative treatment approach.
Dr. Christian and Dr. Van de Velde’s backgrounds are a complementary combination. At their clinic, they see, diagnose, and determine treatment for their patients together. Dr. Christian takes on minimally invasive procedures, utilizing arthroscopy to address extra bone growth that can limit range of motion and can lead to labral tears. Dr. Van de Velde specializes in a more invasive type of surgery: periacetabular Ganz osteotomy. In complex cases, the two surgeons combine for a full-day surgery, where they each use their specialized surgical approach. Through their unique collaboration, the duo is able to provide optimal treatment for their patients, and help to preserve their hip function for as long as possible.
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Catherine: So I want to hear the story about how you two met.
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Dr. Van de Velde: It was a cloudy Thursday evening…
Catherine: Was it really?
Dr. Van de Velde: I don't know, I don't know.
That’s Dr. Samuel Van de Velde.
Dr. Christian: I mean, I honestly don't remember like the first time we actually met.
And that’s Dr. Robert Christian.
Even if they don’t remember the exact moment of their first meeting, the two physicians kept in touch, and they soon realized that they have a unique connection. They’re both orthopedic surgeons who specialize in an innovative new field: hip preservation.
Dr. Christian: Hip preservation is with the goal of preserving the native hip and pushing the solution of arthroplasty, hip replacement, farther and farther down the road.
But they each specialize in treating a different type of hip issue, and so they use very different procedures to address their patients’ needs. Dr. Christian specializes in arthroscopic hip procedures. Where Dr. Van de Velde does a surgery called periacetabular Ganz osteotomy.
Dr. Van de Velde: This is a maximally invasive [00:01:00] surgery.
Dr. Christian was a minimalist and Dr. Van de Velde was a maximalist.
Dr. Christian: Sam and I are very different. We come from very different places, very different trainings, very different perspectives.
But as Dr. Christian and Dr. Van de Velde continued talking…
Dr. Christian: I actually was frankly shocked, at how similarly we think about the hip. In terms of like, you know, our temperaments match very well. We both try to be, and I think are extremely thoughtful when it comes to taking care of complex hip pathology.
Dr. Van de Velde: To not be dogmatic and, and set your ego aside.
These two physicians knew, from experience, that hip patients’ needs are often complicated. And they benefit from a balanced, comprehensive approach.
Dr. Christian: Because we both know that our practices for them to succeed. I need somebody that does periacetabular osteotomy because a significant portion of patients that show up to my clinic need that as one of the many solutions for their symptoms.
Dr. Van de Velde: And even though I was trained to do hip arthroscopy as well, I know that, Dr. [00:02:00] Christian is significantly faster, better, efficient at it, so why would I do a mediocre hip scope while I have a partner who, A, likes to do it, and B, does it much better than I do?
So the two doctors decided to combine their expertise, and practice hip preservation as a team.
Dr. Christian: What I remember is, coming home at the end of the day saying, like, this could, this could really work.
I’m Catherine Price and this is Advances in Care.
In this episode we’re joined by Dr. Samuel Van de Velde, and Dr. Robert Christian. Both are orthopedic surgeons at NewYork-Presbyterian/Columbia.
These two orthopedists have combined their surgical expertise to push the emerging field of hip preservation forward. They care for their patients as a duo, from consult, to the operating room, and all the way through post-operative care– all so that their patients can return to the activities they love faster, and continue enjoying active lives for years to come. [00:03:00]
THEME OUT
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Dr. Van de Velde: I remember like my first years of residency if someone came with hip pain. Anyone over, I would say even 10 years old with hip pain, we just did not know what to do. We just looked at it and said, well, it kind of looks normal, or I see a little bit of dysplasia, but you know, let's just do some physical therapy and, and just basically try to push it away.
Hip dysplasia happens when the acetabulum is too shallow to support the head of the femur bone. Most people who have hip dysplasia are actually born with the condition.
Dr. Van de Velde: The key underlying problem of hip dysplasia is the abnormal formation of the acetabulum during growth. With time, in most children, this resolves. But in some patients it doesn't.
So the accepted idea was that young people would just grow out of their hip dysplasia. But over time, if the condition isn’t treated, [00:04:00] it can lead to tears in the labrum.
Dr. Van de Velde: Once the position is off, specifically of the acetabulum, it completely upsets the whole homeostasis of the joint. And so that's when these secondary structures kick in. The labrum tries to do the job for the bone. The isoas, which is a tendon that runs in front of the hip, becomes thicker to try to contain the hip. And so patients present with these secondary symptoms such as labral tears, clicking of the hips, we call it micro instabilities. Pain when you're standing and, and it feels like your hip is sliding out.
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Dr. Christian: Those of us that do what Dr. Van de Velde and I do, do think that there is some effect of repetitive activity that leads to abnormal contact between the femur and the pelvis, the acetabulum. And that repetitive contact, just like if you rub your fingers together until you get a callus on your skin on your palm, you get extra bone formation between those in that location of abnormal contact that leads to [00:05:00] increased hip impingement in the longer run.
Over time, hip impingement can also damage the labrum, and lead to arthritis. These compounding issues create a recipe for an early hip replacement.
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Dr. Christian: Now, a hip replacement, a primary hip replacement, is an excellent surgery. But the problem is, is that outcomes after hip replacement revision. So the second hip replacement, the metal and plastic that gets put in doesn't last forever. Metal and plastic parts are more like a set of new tires for your car. And so, the first hip replacement does fantastic. But the second hip replacement of going back in and redoing that metal and plastic does not do as well.
This conundrum is the reason the field of hip preservation exists. The idea is to find ways to intervene early on with young patients, alleviate pain and preserve their native hip function for as long as possible, in order to postpone doing a full hip replacement and risking complications down the line.
Dr. Christian: In the last 10 to 15 years, the understanding of the role the soft tissues play from [00:06:00] cartilage to labrum, to hip capsule, and all the associated muscles, has so drastically improved, that we, now know all these other different ways to intervene in the hip to improve function and symptoms.
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The surgery that Dr. Van de Velde specializes in– periacetabular Ganz osteotomy or PAO– is one tool in that tool kit. It’s an open surgery usually performed on young adults with hip dysplasia that fixes the abnormal positioning of their too-shallow hip socket.
Dr. Van de Velde: My goal is to normalize the morphology.
First, Dr. Van de Velde cuts an incision across the front of the hip joint…
Dr. Van de Velde: I don't want to brag too much, but I pride myself on, on truly having the smallest incision. It's about two inches.
I carefully cut the bone around this acetabulum. And then I reposition it so that the, uh, joint is exactly back where it, where it sort of spreads out of the force in the way it's supposed to be.
Internally the entire socket has been reoriented. So it’s a painful [00:07:00] procedure.
Dr. Christian’s surgical approach, on the other hand, is minimally invasive.
Dr. Christian: The arthroscopic side is really going in and addressing extra bone growth that limits range of motion and function and leads to things like labral tears.
I go in with an arthroscope, a, a camera and long instruments through minimally invasive, uh, usually three to four small, small incisions on the side of the hip joint.
And that lets me go in and first diagnostically evaluate the cartilage and the labrum and things like that inside the hip joint itself. And then to affect change in those areas, so that, usually means addressing bony changes on both sides and repairing things like labral tears and then closing the capsule on the way out.
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Dr. Christian: There’s, you know, a school of thought among some providers, especially while athletes are in their playing career, to do the surgery that is easier to come back from that may be just the arthroscopic surgery.
Compared to a hip arthroscopy, the more invasive PAO procedure seems daunting. But the truth is: arthroscopic surgery [00:08:00] on its own might not fully fix the issue behind a problem like a labral tear.
Dr. Christian: I think the right way to think about that is that the labral tear itself is really the smoke rather than the fire and just like if the fire department shows up to your house and sucks the smoke up but leaves the fire going they didn't do you a lot of good.
Some surgeons will decide to just repair the labrum or try to do arthroscopic hip preservation without identifying the root root cause. And that can be not fully addressing impingement, not addressing dysplasia.
Dr. Van de Velde: You're actually further destabilizing the hip joint. The socket becomes even shallower after the hip scope. And actually, not only you're not giving a permanent solution, but you're actually often creating a worse problem.
Dr. Christian: From an arthroscopic perspective, you can't really effectively add stability to the hip joint. Overall, most of the stability of the hip joint comes from the bone.
Dr. Van de Velde: And unless you address the underlying abnormal positioning of the bone, it is bound to fail.
Failure would mean another surgery to fix the tear [00:09:00] again, and more time off from the activities that the patient loves.
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This is the crux of why Dr. Christian and Dr. Van de Velde choose to work side-by-side. By combining their unique perspectives, they can optimize care, and avoid issues post-surgery that might set their patients back.
Dr. Christian: Dr. Van de Velde and I really get down to the reason that the labrum is torn, and then making sure that we optimize things so that when I repair the labrum, that doesn't have the same risk of happening again.
Once a month, Dr. Van de Velde comes to Midtown, which is kind of like the midpoint between the two hospital campuses, and we run a hip preservation combo clinic where we see patients together.
After getting necessary imaging and things like that. We can, uh, you know, put our heads together and make sure that we're talking about the right treatment for the right patient.
Dr. Van de Velde: It's very rewarding then to sort of diagnose it. And tell them how the pain is truly related to, for example, your borderline hip dysplasia, and that we’re able to fix that.
Dr. Christian: It's about, you know, really giving each patient and each hip a 360 [00:10:00] view to understand the unique anatomy that is causing their hip to hurt and to fail.
It helps us make sure that we're totally on the same page about what is the next step or the right step for a given patient.
You know, almost unanimously, I don't think we've really ever disagreed.
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Sometimes the patient will only need the arthroscopic procedure. But other times, their diagnosis will point to a more complex problem.
In those cases, both doctors prepare for a combined surgery, where they perform a hip arthroscopy and a periacetabular osteotomy back-to-back.
MUSIC IN
Dr. Christian: It's a full day. So, uh, surgery usually starts at 7:30, which means, you know, approximately a 6am arrival to get everything set for the patient. And then the surgery starts with my side of things. I use a table, which is a postless setup. We're able to just pull on the legs, open the hip joint using a sticky pad underneath the patient rather than, historically [00:11:00] speaking, there was a post put between the legs to hold the patient where they are so that you could pull the traction. And so the table's really revolutionary, lets me come in and out of traction as I need to over the surgery.
I use fluoroscopy in the operating room to judge my resections and I use a tablet that uses the fluoroscopy and has a program that makes my measurements in real time.
Then, to ensure accuracy, Dr. Christian compares those measurements to the pre-operative plan he’s mapped out.
Dr. Christian: It actually changes from yellow to green as my measurements become accepted. Which helps, just speed up the efficiency and in addition to you looking at the x-ray and saying my mind thinks that looks right. It's actually the computer, you know, measuring and saying, yeah, you've hit your target in that plane.
This allows Dr. Christian to work faster, limiting the amount of fluoroscopy, and thus radiation, his patients are exposed to during the procedure. Then…
Dr. Christian: I leave everything just like I found it. From an anatomic perspective, my side of the surgery is, all said and done, about two and a [00:12:00] half to three hours and then at that point, we close my skin incisions put a dressing on the patient, and then get everything set up and do a whole room flip for Dr. Van de Velde’s portion. So I'll let Sam take it from there.
Dr. Van de Velde: Son once Dr. Christian is done, I usually get a text message that the capsule is closing. And so then I work my way to the operating room and then I basically get rid of all the fancy equipment…
And – there’s one more thing that changes when Dr. Van de Velde enters the OR.
Dr. Christian: My guess is that the music changes when my portion of the procedure is over.
Dr. Van de Velde: Yes…[Laughter]
Dr. Christian is more of a Guardians of the Galaxy soundtrack kind of guy. Whereas Dr. Van de Velde goes for something more… up-tempo.
Dr. Van de Velde: I mean, there's scientific research about this, right? There’s a beautiful study done where they had surgeons do a standard procedure and one portion was done without music, one portion was done with [00:13:00] random music, and one portion was done with ACDC. And, and so any music was faster, made surgeons more focused, and ACDC truly upped the speed, efficiency of the surgeon, like significantly. So I, I have to put on ACDC. I can't go against science.
Once ACDC is on the stereo, Dr. Van de Velde’s periacetabular osteotomy portion of the surgery can begin.
Dr. Van de Velde: I do the PAO as if nothing has happened. So I just completely start a new prep. I have my very basic equipment, which is a couple of specialized osteotomes to divide the bones.
There is always a risk of blood loss and this is not because of arterial or venous bleeding, but it's because the pelvic bone is the most vascularized bone of the body. So we keep low blood pressure. We recycle the patient's own blood and give it back through what's called a cell saver.
I use fluoroscopy throughout the entire procedure. So, I reposition the acetabulum exactly [00:14:00] where I want it to be. Once the correction is done I test the function of the hip during the surgery.
So very often, patients have some, some limited range of motion, which is truly bothering them during any every day activities. And so with the acetabulum reorientation, I can play with what's called the version, so the direction in the sagittal plane, and allow for, for normal range of motion to occur.
Very often patients show up with, I would say, zero degrees of internal rotation when the hip is flexed. You need about 20 degrees of hip internal rotation to comfortably put on your shoes. So that's where I keep going until it's absolutely perfect. Um, and so no patient ever leaves the table without that.
After Dr. Van de Velde achieves that hip rotation gold standard– and over 6 hours from when the procedure began– the surgery is finished.
Dr. Van de Velde: …close up the skin with dissolvable sutures. I measure my incision. I compare it to the incisions of Dr. Christian's– in a very competitive way [00:15:00]– and I always text Dr. Christian afterwards.
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It’s an intense procedure– these patients are often young adults who may never have had surgery before, and they’ve just had their pelvis broken and screwed back together. So individualized follow up care is vital to Dr. Van de Velde and Dr. Christian.
Dr. Christian: It's a very, very unique surgical recovery. We are constantly trying to improve, you know, the process and the care of the next patient. And that's really what it's all about. That trust is huge and this is not a surgery where you don't see the surgeon until the two week or three week follow up visit afterwards. We're right there every step of the way
Dr. Van de Velde: The initial recovery of a hip arthroscopy also requires four to six weeks of crutches and gentle physical therapy. And so by doing the combined case, we sort of overlap the recovery for an arthroscopy with the one of a PAO without needing to go through them twice.
And so we've been doing the combined hip scope [00:16:00] and PAO now on several college athletes. And most of them are back at the exact same level that they were before.
Apart from Dr. Van de Velde and Dr. Christian, there are only a few hip surgeons who practice these specific surgeries together. The two physicians attribute the success of their practice to their shared outlook… and to the collaborative environment at NewYork-Presbyterian.
Dr. Christian: When Dr. Van de Velde and I started working together, you know, there's a lot of trust that goes into sharing that patient, both the success and any potential risks or complications or things like that that come with surgical care.
Oftentimes there can be relatively large disagreements and Sam and my perspective is so similar that we haven't really had that, and it makes for, you know, effective and efficient care.
The ability to provide a multifaceted and individualized solution for a complex problem and not have to tell somebody that you need to go somewhere else or that [00:17:00] we can try to get away with just doing an arthroscopic or we don't need to address this because we're only going to do the PAO or, being able to say this is the right solution for your hip is the best part.
And, a lot of places, a lot of practices, a lot of institutions are not set up to do that. I think it's really a question about, you know, doing the right thing for the right patient.
THEME IN
Dr. Christian: Orthopedics is all about returning people's function. Very rarely are you saving lives, but you're oftentimes saving lifestyles. And the ability to do that and keep people with the activities that they love you know, recreationally, socially, personally, is really, you know, the powerful side of orthopedics, and the rewarding side. Having patients come back and saying they've been able to get back to whatever it is that makes their lives complete.
And, as Dr. Van de Velde says, having a partner to collaborate with, who shares your convictions, makes the job all the more rewarding.
Dr. Van de Velde: When you don't have that collaboration, it's easier to sort of see [00:18:00] where you would put the patient through a certain treatment pathway just because there's not the option to work together. And then for us, it truly, it doesn't matter. I mean, we just sit together and we see which one, which pathway is the best. There's not the sort of barrier that we have to have to sort of send the patient away to a different provider. We can just treat it together.
Dr. Christian: I think that, you know, finding somebody that you enjoy working with is critical.
Dr. Van de Velde: It's so helpful in an emerging field to have a colleague you can talk to and discuss cases and keep perfecting your techniques. And be able to truly be able to say to patients, we're going to give you the best possible treatment.
Dr. Christian: You know, it's been really really fun frankly to do this together.
THEME SWELL
Thanks so much to Dr. Samuel Van de Velde and Dr. Robert Christian for speaking with me today. It’s a rare thing for two surgeons to work together like this– but it’s that spirit of [00:19:00] collaboration that’s making all the difference for their patients.
I’m Catherine Price. Advances In Care is a production of New York Presbyterian Hospital. As a reminder the views expressed on this podcast solely reflect the expertise and experience of our guests. To listen to more episodes of Advances in Care, be sure to follow and subscribe on Apple Podcasts, Spotify, or wherever you get your podcasts. And to learn more about the latest medical innovations from the pioneering physicians at New York Presbyterian, go to NYP dot org slash Advances.
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