Voiceover: This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgements when advising their patients. Patients in need of medical care should consult their personal care provider. Welcome to "That's Pediatrics", where we sit down with physicians, scientists, and experts to discuss the latest discoveries and innovations in pediatric healthcare.
Dr. Amanda Poholek: From UPMC Children's Hospital of Pittsburgh. Welcome to “That's Pediatrics.” I'm your cohost, Amanda Poholek, assistant professor of Pediatrics.
Dr. Arvind Srinath: And I'm your co-host Arvind Srinath, associate professor, Pediatric Gastroenterology.
Dr. Poholek: Today our guest is Dr. Michael McClincy. Dr. McClincy is here to talk about the AYA Hip Preservation Program. Dr. McClincy is a pediatric orthopedic surgeon, Head of the Adolescent and Young Adult Hip Preservation Program at UPMC, Children's Hospital of Pittsburgh, and an assistant professor of Medicine at the University of Pittsburgh School of Medicine. His clinical interests include the management of sports injuries and adolescent and young adult patients with a particular focus on hip disorders in this young active population. He's also an active clinician scientist where his research focuses on optimizing the care of young patients with common hip disorders. Welcome.
Dr. Michael McClincy: Thank you very much for having me.
Dr. Poholek: So can we start by having you tell us a little bit about your background and your path to UPMC Children's Hospital of Pittsburgh and also what drew you to Pediatric Orthopedic surgery?
Dr. McClincy: Sure. I'm a native of Southwestern Pennsylvania, actually. I grew up in Greensburg just about 45 minutes east of downtown. Came back to medical school at the University of Pittsburgh and actually stayed on for another six years of orthopedic residency at Pitt. I met my wife there, she's also a pediatrician at the hospital working on cystic fibrosis and pulmonary medicine. We did our six-year residency and during that time I had a lot of exposure to pediatrics. It's about a third of our training overall.
And the decision point that I had was I much preferred taking care of children, especially teenagers, college age kids as opposed to older patients. From a clinical standpoint, I was much more interested in sports medicine injuries and hip topics. I myself actually had hip surgery whenever I was 20 years old, so this was something that was near and dear to my heart. So after my training in residency, we relocated to Boston where I spent two years at Boston Children's Hospital doing subspecialty fellowships at Children's Hospital, both in sports medicine and in hip preservation. And after that we came back to Pitt and I was brought on faculty and I've been here almost four years now.
Dr. Poholek: Oh, okay. Fantastic. So then you have quite a lot of background in understanding all about the hips of young adults and of adolescents. So can you share with us some of the common hip disorders that you see in adolescents and how they're treated?
Dr. McClincy: Sure. The transition to adolescence is tough On the hips, a couple of things happen. First towards the end of growth, the femur, which is the ball part of the ball and socket joint tends to grow a little bit faster than the acetabulum and it also stops growing a little bit later. So what we see is in some people, the femoral head outpaces the growth of the acetabulum and this leads to functional dysplasia.
And now typically we think about dysplasia as being present in babies, newborns treated with things like braces, harnesses, and sometimes surgery. But there's also a secondary group of patients, typically females that will develop functional acetabular dysplasia in adolescence. And whether that starts to rear its head in their early teenage years or into their early 20s, it's a common diagnosis that we take care of at the Hip Preservation Program.
Dr. Srinath: That's a really cool path you've had to where you are today. And thanks for sharing the development of how people can develop hip disorders over time. Can you differentiate the types of hip disorders children at risk for depending on their age and perhaps what can be done to prevent those types of disorders, if anything?
Dr. McClincy: Sure. I think of hips as being normal in the center of a spectrum and on one side is a hip that is impinging where there is not enough free motion between the ball and the socket joint. And this impingement can come from either the ball side, the proximal femur, it can come from the acetabulum, the socket side. And typically these people complain of things like pain with sports, pain with high level impact activities, pain with deep flexion such as long car rides. So that is the impingement side of the hip spectrum.
On the exact opposite side is the dysplasia side. This is a dysplastic or instability type of picture where there's not enough constraint of the femoral head by the socket, so there's almost too much motion and that leads to symptoms of instability. Typically, people have problems with upright activities such as prolonged running, prolonged walking, and again, we see this more commonly in females than we do in males.
So those are the two pathways that these hips go to. Now there are some childhood diseases like Perthes disease, which we see commonly, SCFE or slip capital femoral epiphysis, which once they've healed from their pediatric disorders, can develop these problems of impingement and instability down the road. So sometimes these pediatric diseases follow our patients into adolescence and early adulthood and take on these instability or impinging type of pathways.
Dr. Srinath: I appreciate you bringing up that topic of pain because I feel that the hip is clearly a pillar and no pun intended in the body, but I feel like sometimes symptoms that may be due to the hip may mimic symptoms due to other parts of joints outside, for example, the knee or the back. Can you describe how sometimes they can be differentiated, how that can be mistaken for problems outside of the hip?
Dr. McClincy: Yeah, it's a great point. The sports medicine training I did really helped me understand that our legs, our arms are all, they're made up of different components and each component relies on its neighbor for normal function. So we can get referred pain patterns from our low back to our hip, from our hip to our low back, from our hip down to our knee and vice versa.
Also, dysfunction at the level of the knee can be caused by muscles that are actually moving the hip. So all of the things are interrelated and I think that one of the benefits of Children's is that because we treat kids on a spectrum of ages, we remind ourselves or are well reminded often that diseases can sometimes manifest differently in kids that are growing, that have opened growth plates. So I think they probably get a more thorough examination when they come to see some of the orthopedic specialists here for a lot of lower extremity and upper extremity conditions.
Dr. Srinath: I appreciate you sharing that. Thanks, that's super helpful.
Dr. Poholek: So I have to say, I guess I'm a little bit surprised about hearing that this is something that commonly happens because children are growing. So what are the risk factors that might cause a child to actually experience this as they're growing, if those are known? And then also, I guess what are there injuries that can potentially predispose kids to these types of problems?
Dr. McClincy: Yeah. So two questions. The last question. Are there injuries that can of predispose people to this? The answer is yes.
Dr. Poholek: Okay.
Dr. McClincy: So a lot of these bony morphology, bony shape conditions, pre-exist symptoms by anywhere from a number of months to a number of years. So we're done developing and growing by the age of 14, 15 in girls, 15 and 16 in boys. And sometimes they won't present until they're 17, 18, 19 or even 25 years old.
So the question is why does a hip that is shaped a certain way all of a sudden cause symptoms? And I get lots of patients in the clinic that are talking about things like getting MRIs that show labor tears, and that's a buzzword in hip pain, especially in young individuals. And I think that there is some truth to that.
So probably people go along with these misshapen hips for a period of time and then for whatever reason there is an injury, there's a twist, there's a turn, there's a tackle which causes their labrum to tear, causes their hip to move into a position where it didn't want to be. And it's that laboral tear, which is, it's like someone pulling the fire alarm is how I think about it. So the labrum’s not really the problem, but that is what alerted the patient that something was wrong inside the hip. And then the goal for us in the Hip Preservation Program is to find out what caused that problem. And it could be the shape of the bone, it could be on either the femur side or the acetabular side. It could be that they're just poorly matched for the sport that they're choosing. It could be a muscular thing, it could be an instability movement pattern. And it's our job to tease those things out.
Dr. Poholek: Okay. So that's I think a really good jumping off point to talk about the Hip Preservation Program. So can you share with us what is the Preservation Program? Who gets to be part of the Preservation Program? Is it a referral upon an identification of an injury or a problem? And what are the long-term goals of the program?
Dr. McClincy: Sure. The Hip Preservation Program is fairly new. It's comprised of a physician myself, a couple of our physical therapists, one of which is of our lead physical therapist named Ashley Disantis. And it is a collaborative effort to take care of these patients from a clinical diagnosis standpoint. Things that we've done is we've partnered with radiology to develop low dose CT scan protocol so that we can get a really high resolution look at what our patients bony anatomy is like while at the same time minimizing the amount of radiation these young individuals have to go through.
Dr. Srinath: Nice.
Dr. McClincy: We've brought in some new cartilage mapping MRI technology that they use in other centers like in Switzerland and in Bern, which are some of the pioneers of hip preservation surgery. And we're using those here now to be able to quantify the health or lack thereof of our patient's cartilage before we put them under an invasive surgery. So that's the diagnostic side of things.
From a therapeutic standpoint, our physical therapy group is really working on increasing the comfort and expertise in treating young patients with hip disorders. It's pretty complicated to get their muscle groups working in correct patterns and undo some of the muscular or motor-based problems that lead patients down certain pathways. And we made a lot of progress in improving our overall physical therapy approach and non-operative approach to the care of these athletes and young people.
And then from this surgical side, I have different approaches that I use. The benefits of having both a sports medicine and a hip preservation fellowship is that I'm used to treating things both from an arthroscopic standpoint. And hip arthroscopy is where we use small incisions and it's a minimally invasive approach to do things like repair labrums and do some small level bony work.
We also have the ability to do larger surgeries and this involves like a periacetabular osteotomy, which is a PAO and that is an osteotomy to correct hip dysplasia where we actually make bone cuts around the socket and then move it into a better position to improve the stability that it provides, the hip joint and the cartilage weight bearing area that it provides our patients. We also do something called a surgical hip dislocation, which is where we can really resolve complicated deformities and oftentimes kids with residual SCFE or Perthes deformities benefit from that kind of an approach.
The average hip surgeon is typically comfortable with one of those. They do hip arthroscopy or they do some open approaches as a pediatric orthopedist. It's nice to have both of them in one area so that we can really fine tune the correct procedure for the correct patient. And the conversation that I always have with my patients is that there are big surgeries and there are small surgeries, there are right surgeries and there are wrong surgeries. And finding the right surgery for that patient, either big or small is in their best interest to give them a one-time successful procedure.
Dr. Srinath: So, I so appreciate you bringing up the fact that it's a team effort within the Hip Preservation Program and going into detail about the surgeries and minimally invasive versus more invasive too. I think my question is twofold. So number one, are there more options now to prevent surgical needs for some of these patients? And number two, clearly based on the need for a Hip Preservation Program, I'm just thinking out loud here, it means that the rates of these hip disorders are rising. Am I understanding that correctly or more risk factors?
Dr. McClincy: So a couple things. Yes, the rates of these things are rising, but I think as much of that is due to our appreciation of these diseases as it is the fact that these things are coming up, the numbers are actually increasing, I guess.
Dr. Srinath: Nice.
Dr. McClincy: Hip preservation has two components we talked about why do these hips all of a sudden begin to hurt? And the answer is probably labrum tears or some capsular irritation that an injury causes. But we know that both impingement and dysplasia carry with them a lifetime risk of progressive arthritis, early hip replacements and things of that nature.
So I think that recognizing that early surgical intervention whenever these people are teenagers or young adults has not only the ability to impact their function acutely and in the short term, it also provides a joint preserving affect into adulthood, 30s, 40s, 50s, and 60s. Makes us a little bit more aggressive at treating these conditions currently.
Dr. Srinath: That's fantastic to hear. That's fantastic.
Dr. Poholek: So you also do a lot of research and so I was curious, can you share this a little bit about what are the open questions in the field that people are actively investigating and what are you specifically interested in your research and what goals do you have to better understand some of those questions?
Dr. McClincy: Unfortunately, there are more questions than answers right now in hip preservation. If you look at the world of sports medicine, the knee such as ACL injuries, kneecap dislocations, meniscal tears, or the shoulders such as rotator cuff tears, shoulder and stability are much better studied than anything in the hip. And again, this is a more recent diagnosis. We've really worked on these things probably for the last 20 to 30 years at a fairly high level. So we're playing catch up in some ways. One of the great parts about being at Children's Hospital is the affiliation with the University of Pittsburgh. There are lots of pretty high-level academic labs that I've been able to partner with over the last couple of years.
One of them is the biodynamics lab on the south side and where we can take of live x-rays of people while doing certain activities like walking, squatting, running, and we can really three dimensionally recreate the way the body is moving. And we've so far looked at people with healthy hips, normal hips, asymptomatic hips. And we hope to expand that to people with known problems like impingement and instability dysplasia, so that we can really compare apples to apples about what kinematics and biomechanical changes are happening and hopefully down the road look at what these hips move after the different surgical interventions that we apply to them. Because we really think that by improving kinematics, by improving the biomechanics in the hip, that's going to improve patient function. It would be nice to be able to document in real time the effects, the kinematic effects of our work.
Dr. Poholek: Yeah, that sounds super interesting. So once you have a handle on the imaging, you do the imaging, you see this is normal, this is not normal, what do you feel are the next steps in trying to address the problems? What would be the next approach research wise?
Dr. McClincy: The next approach would be combining things like our cartilage MRI and our kinematic data to see what effect our operations have on both the kinematics these individuals have and then what downstream effects that has on their cartilage loading and cartilage biology. I think we do a pretty good job at eliminating the acute symptoms for a lot of these hip conditions. The question is, are we doing the right things to set their cartilage up, to set their hip biologic health up for long term function so that we get that to 20-to-30-year outcome that we're looking for. And that's going to be the next thing that we look at in the lab.
Dr. Poholek: So then I guess just one more follow up on that. What do we know about repair of hips and cartilage? Is it different for hips than other joints or is it just that's also an area that's just not that well known?
Dr. McClincy: Cartilage repair is pretty rare in the hip, and the reason is that it's very difficult to access the hip. Again, if you have a knee injury or a cartilage injury, the average sports medicine surgeon is pretty adept at both orthoscopic and open, meaning larger incision, approaches to address these cartilage injuries. It's very rare to have a sports medicine specialist who is comfortable at doing an open hip approach. So I've actually done a number of cartilage procedures in patients that have been referred to me because I have the comfort in doing things like dislocating the ball and socket joint, which provides larger access. Again, we get to that theme of a bigger surgery sometimes is the correct surgery for people. So I think that the world of cartilage regeneration, cartilage repair is going to increase as we get more adept at treating these cartilage injuries.
Dr. Srinath: Dr. McClincy, you've talked about tailoring certain types of treatments to different people and how it affects them moving forward in terms of the research that is ongoing here. Are there genetic differences in people that may be predisposing them to perhaps A, a certain condition, B, a certain response to surgery? And is there any interest in your colleagues or you looking in that?
Dr. McClincy: I think that there is some genetic link to certain diseases. Dysplasia has been well linked, there's some familial component to it. They haven't really found a gene yet that is the root cause of that condition, but it is certainly runs in families and we tend to screen those individuals pretty carefully.
Impingement hasn't really had as much of a genetic link found yet. We think that's probably more activity related. Sports participation, especially sports specialization and hyper focusing on certain activities has been linked to it. We know that hockey players tend to have higher rates of hip impingement than the average population. The same things have been found with year-round soccer players, year-round basketball players. So there probably is a component of overuse that leads to this condition in some individuals.
Dr. Srinath: Nice. And just along those lines with hockey players and soccer players, and I think you mentioned basketball players too, right? Is there something about the motion that they're exposed to that they do that predisposes them? Just out of curiosity.
Dr. McClincy: I think that each sport has its own repetitive activities, repetitive motions, and those repetitive movement patterns over and over without any respite can catch up with individuals. So this takes us even beyond just hip conditions to all sports conditions.
Dr. Srinath: Right.
Dr. McClincy: Our society has moved towards having kids specialize in sports at a young age. I have a son in first grade and there's already some chit chat about when we're going to pick a one sport over another.
Dr. Srinath: Wow.
Dr. McClincy: And I think that we have of lost our way a little bit in terms of how we treat these kids like they're young professional athletes. If you look at the major organizations like the International Olympic Committee, the American Society of Sports Medicine, recommendations are that you do a sport for a maximum of nine months a year with three months of complete rest from that sport. And they really recommend that you split those three months into individual one-month breaks. So at most you're doing three months of a sport, taking a month off, three months of a sport, taking a month off. In an ideal situation, I think kids should be exposed to a number of sports and they should be able to play basketball and baseball and football. And I think the diversification of those sports still leads to increased athleticism and strength and health without the excessive risk of these overuse injuries. I'm hopeful that over time we divert away from the current path that we're on.
Dr. Srinath: Thank you for bringing point up. Sorry.
Dr. Poholek: Yeah, that's really fascinating. I guess alternatively, is it worth considering trying to get different sports and coaches and thinking about creating as part of their program, alternative motion practices as part of their routine for training, that can have an opposite effect on that repetitive motion to try and decrease that. Do you feel like that's something that would be beneficial?
Dr. McClincy: I do. And I think that we have tried that. The thing that pops into my mind is baseball and pitching. There was a lot of work over the last decade at limiting the number of pitches that young athletes do, especially kids that still have open growth plates. And I think that it has done a lot of good as long as coaches adhere to that. I think that the level of adherence in coaching is probably certainly not 100%. I think that efforts to educate are probably the biggest bang for our buck here. I think a lot of coaches are doing their best and trying to teach their athletes and they don't really understand all of the potential problems that are being created at times. So perhaps our organizations, our society, places like Children's could do a better job at educating people and keeping our athletes safe.
Dr. Poholek: Yeah. I wonder just how much of it is, like you said, it's just the lack of information and this is an area where some awareness and education. How often does a school system or a coaching system ask for information from a hospital system like UPMC Children's or from pediatricians?
Dr. McClincy: I honestly have no idea. It's a great question. I do know that I could probably count on one or two fingers the number of times that I thought a coach was of purposefully pushing the limit in terms of things that they asked their patients to do. A lot of times I think it's just a coach who didn't understand what was happening.
Dr. Poholek: Yeah.
Dr. McClincy: And I think that some program to help prevent this would be great.
Dr. Srinath: Have folks training regimens been modified based on what they've worked on with you? For example, an athlete comes to you who's been playing soccer all year round, for example, in a certain routine. Have you made recommendations for that coach, for example, to adjust the person's regimen moving forward to prevent recurrence or future complications?
Dr. McClincy: I have, and especially in a couple of cases where you take care of a kid whose parent happens to be the coach, those are probably the most impactful situations where they see from a very direct standpoint how training or over-training can lead to problems. And certainly they've done a lot of work at and changing the way their teams are structured and things like that. So that's certainly good to see. I also see a lot of patients who have gone to physical therapy to work on some of the sort of muscular deficits that we typically see in young athletes, even in spite of their sports specialization. And they'll refer their friends whenever they have the same issues almost on a preventative basis before it gets too bad, go see Dr. McClincy and he'll get you into physical therapy because they really see the benefits of that cross-training and muscular specific activities to keep a healthy set of legs.
Dr. Srinath: And for pediatricians listening along those preventative lines, what are things that they can look out for to clue them in to refer to you and your team for perhaps physical therapy or preventative measures moving forward? If for example, they're taking care of children who are pretty rigorous athletes.
Dr. McClincy: Yeah. I think that kids are pretty resilient and it's pretty rare for a kid to complain on a regular basis. So when complaints localized to one joint and when those joints are causing symptoms for more than a couple of weeks, getting them checked out makes a lot of sense.
There are things like cartilage lesions like osteochondritis dissecans that kids tend to have that adult patients can't get. And those are things that we can really rule out very effectively as pediatric orthopedists with just a physical exam and a set of x-rays. And in the majority of cases that don't have that, they get sent to physical therapy and they get the neuromuscular retraining that they need and go back and are productive athletes again.
Dr. Srinath: Nice.
Dr. Poholek: I'm curious a little bit about intervention and how soon to get treatment. Can physical therapy keep some patients, I'm sure not all, but some patients away from needing surgery? Is it often the case that if something goes on too long without intervention, is surgery become more likely?
Dr. McClincy: I think that physical therapy can certainly keep people out of the operating room. I think that a healthy musculature to functionally position, whatever joint we're talking about, hips, knees, shoulders, can really bypass a lot of some structural deficits that the body may have. So physical therapy is certainly not a lost effort from my standpoint. Everybody that comes through my clinic will get physical therapy before we consider surgery just because retraining those muscles oftentimes can correct the underlying problem. Even though the bony anatomy may not change, it's enough to bypass that where they're no longer having symptoms work that require an operation.
Dr. Poholek: So I know the Hip Preservation Program is a relatively new. Can you tell us a little bit about what the long term goals are? Where do you see growth and what have been some of the challenges in the program so far?
Dr. McClincy: The goals are to continue to expand our expertise. We're really working hard on physical therapy. Children's has such a wide catchment that we are trying to develop specialists not only at our main hospital, but also all of our satellites so that everybody gets the same experience for both preoperative and postoperative physical therapy no matter where they go. The reality is that our reach extends beyond just the metro Pittsburgh area. I've taken care of people from New York and Ohio, West Virginia, Maryland.
Dr. Poholek: Wow.
Dr. Srinath: Wow.
Dr. McClincy: So we are also trying to make inroads with local physical therapists in these areas that we see kids from. So again, they can have that Children's Hospital experience, not only when they're here for their surgery or for their clinic visits, but also whenever they go back out and do their rehabilitation before and after surgery. I hope that our research program continues to build. I really think that that Pitt is very uniquely positioned to answer a lot of questions that need to be answered and to improve our basic understanding of how hips should work and how they work after we manipulate them with surgery. And I'm excited to see this research continue to grow.
Dr. Poholek: Fantastic.
Dr. Srinath: Well, Dr. McClincy, I just want to say thank you for talking about not only the extensive and specialized training that you yourself have, but what your understanding is about hip disorders that children are at risk for, what risk factors they have. The amazing Adolescent and Young Adult Hip Preservation Program that you and your team have developed and the future direction too. It's been really fascinating to have this discussion. Thank you.
Dr. McClincy: Well, thank you very much. It was my pleasure.
Dr. Poholek: Thanks for having you on today.
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Michael McClincy, MD
