Good morning. Welcome to this HIP session as we're sort of batting clean up on the last day of this spectacular AOSSM meeting. I'm Thomas Bird from Nashville. Winston Guathme from UVA. We're moderating this. We have three excellent papers. Then we're going to have a couple of talks from some of our star faculty. And then Winston's put together some great cases for our panel to discuss. But I'll turn it over to Winston. Thank you all very much for sticking around. We appreciate you all being here. It's a great group of people here. So we're going to start with our papers. So we're going to invite Jonathan Lee up to talk about hip arthroscopy versus physical therapy. Thanks, Jonathan. Thanks. Morning, everyone. My name is Jonathan Lee, and I'm an incoming first-year medical student at Sydney Kimball Medical College. On behalf of the Dr. Scott Martin Research Team, we thank AOSSM for the opportunity to present our research and for a wonderful conference so far. My co-authors and I have no disclosures. So acetabular labral tears secondary to FAI are a common cause of hip pain that pose an elevated risk for progressive hip osteoarthritis. Past literature has shown that arthroscopic labral repair portends good outcomes in younger patients. However, for patients over 40, studies report an increased risk of conversion to PHA and worse functional outcomes. While older patients with limited osteoarthritis may still benefit from hip arthroscopy, these outcomes have not been assessed with level one evidence studies. The purpose of the present study was to compare the efficacy of hip arthroscopy versus physical therapy in patients older than 40 with symptomatic acetabular labral tears and not have severe osteoarthritis. Consecutive patients in 2013 to 2020 were enrolled within the eligibility criteria. Inclusion consists of age greater than 40, symptomatic acetabular labral tears, and a minimum of three months of formal physical therapy. Exclusion criteria consists of significant osteoarthritis, clinical suspicion of acute hip processes, hip dysplasia, and prior ipsilateral hip surgery. Patients with a minimum of 24-month follow-up were excluded from analysis. Patients of less than 24-month follow-up were excluded unless they converted to PHA or underwent revision hip arthroscopy within those first 24 months. For these patients, their problems prior to failure were included in our analysis. So patients presenting with an MRI-confirmed labral tear and positive clinical exam findings first underwent three months of formal PT. After three months, patients were re-evaluated and those who failed conservative management were offered surgery. In this study, however, instead of offering surgery, we were randomized into either the surgery or physical therapy cohorts. Crossover was allowed if a patient felt that they did not achieve adequate improvements after a minimum of 14 weeks of PT, in addition to the physical therapist advocating that the patient achieved the maximum benefit that they could from physical therapy. Our primary outcome was a modified Harris-Hipps score and IHOP33 score at 24 months, and we performed linear mixed-effects modeling with an intention-to-treat framework as our primary analysis. We also conducted modified-as-treated and a treatment failure analysis. So in total, 110 patients were prospectively randomized into our randomized controlled trial. We had 57 in the surgery group and 53 in the physical therapy alone group. After dropout and loss of follow-up, a total of 97 patients remained. Nobly, 32 patients in our physical therapy group did cross over to surgery. So these are our demographics. So in Nobly, we had 40 males and 57 females with an average age of around 48 years old and an average BMI of around 26. As shown by tonus grade, our patients had limited osteoarthritis, with the majority having either tonus grade 0 or 1 hips. So in both the intention-to-treat and modified-as-treated analysis, patients in our surgery group achieved significantly greater PROMs for all metrics except for the Haas SSS. For our primary outcomes, which were IHOP33 and the modified Harris-Hipps score, these were especially true. But given the limitations of the intention-to-treat analysis, given the high rates of crossover, we also conducted a treatment failure analysis. So the treatment failure analysis compared PROM scores between patients in the surgery, physical therapy, and crossover groups, using scores of 24-month follow-up or at time of failure. As previously mentioned, failure was defined as undergoing revision hip scope, converting to THA, or crossing over. So in this analysis, the surgery and crossover groups showed significantly greater improvements for all PROMs compared to the physical therapy group. However, post hoc analysis revealed no significant differences in improvements between the surgery and the crossover groups. In terms of conversion to THA, six patients converted, three in the surgery group, two in the crossover group, and one in the physical therapy group. There were no significant differences between cohorts. And for revision hip scopes, a number of patients underwent a revision. So in conclusion, patients over than 40 years with limited osteoarthritis showed great improvements with surgery and physical therapy relative to physical therapy alone. However, additional physical therapy prior to surgery did not negatively impact post-operative improvements at 24-month follow-up, as evident by our crossover group. This suggests significant improvements from surgery either initially or after extended physical therapy. So as hiperthroscopists and sports medicine surgeons, the clinical take-home from this exam, from the study, is that age over 40 years should not be considered a contradiction for arthroscopic acetabular repair. And delaying surgery for a minimum of six months for PT does not negatively impact post-operative outcomes and may allow some patients to avoid surgery altogether. These are our references, and thank you for your time. So our next speaker is Prem Ramkumar, who is seeking about his long-term follow-up after modern hip arthroscopy. Thanks to everyone for the opportunity to present, and thanks to Dr. Brian Kelly for allowing me to be the front man for over a couple decades of his work. So in terms of background, there's no real quality study that has demonstrated hip arthroscopy is a true joint preservation procedure. There's no long-term study evaluating modern hip arthroscopy techniques, which specifically we outlined as labral preservation, femoroplasty, and capsule repair exists. And then the arthroplasty literature, and half my practice is that, is that it skews quite negatively against hip arthroscopy despite major methodological flaws and outdated techniques. And so there's an unfortunate narrative from my arthroplasty colleagues that basically shows several disturbing trends that basically are burned into the literature that say these findings suggest that correction of FAI to a normal morphology may only minimally impact the natural history. Similarly, 20-year-old, 20-year follow-up studies basically suggest that hip scopes actually accelerate total hip arthroplasty. In these studies, the labrum was resected. There was no cam decompression, and the capsule was certainly not closed. So in terms of evaluating the impact of just one modern technique, people from Wash U, Dr. Cloacy, showed that these data already suggest that it does alter the natural history of FAI at long-term follow-ups. So our purpose was essentially to characterize natural history of FAI with respect to joint degeneration, understand the relative impact of modern hip arthroscopy techniques, those three that I mentioned, but we're doing this only by radiographically comparing the hips of patients who underwent unilateral primary hip arthroscopy compared to the nonoperative side over the span of at least a decade. So the way we looked at this was we looked at two years of patients from 2010 to 2012, 619 consecutively from Dr. Kelly's practice, inclusion criteria for FAI, minimum 10-year follow-up, and they had to have all three techniques, and we excluded contralaterals, revisions, concomitant procedures, inflammatory arthropathy, unavailable preoperative X-rays or 10-year radiographs, which was minimum, and lost a follow-up. And preop and minimum 10-year radiographs were evaluated at each time point, just at those two intervals, and we compared the operative and nonoperative hips using tonus grade or the presence of a hip arthroplasty using two reviewers. And then we also did a small subgroup analysis looking at the CAM size and then whether there was instability features on X-ray, age, and preop tonus grade. So in terms of results, it was 100 total patients, so 200 hips. Demographics were about age 34 years old, 50-50 split about in terms of sex, and the mean follow-up was 12 years. 100% had bilateral radiographic FAI, and the follow-up was 74%. The most relevant table is actually probably the bottom one, but it basically shows from the top table that regardless of which side had the arthroscopy, arthroplasty conversion was basically 50-50. And then when you look at comparing the operative hip 10 years later, then comparing the nonoperative hip 10 years later, and then comparing side to side at the 10-year later standpoint, there's a couple themes that come out. The first being that the natural history, as we defined it, was essentially saying that the nonoperative hip is unchanged 52% of the time and advances to a worse tonus grade the other half, so about a coin flip. But the side that was scoped had unchanged tonus grade 72% of the time and only advanced to a worse tonus grade 28% of the time. And then looking at the two hips in the same patients 12 years later, there was basically no difference in tonus grade about 70% of the time, but in a small subset of 25% of patients, the scoped hip did have a lower tonus grade. And then in 5% of patients, the scoped hip actually had a worse tonus grade. So from a statistical standpoint with these small numbers basically shows that the absolute risk reduction for undergoing hip arthroscopy obviously in symptomatic patients that met our inclusion criteria was 20% and relatively it's 42%. But just examples of x-rays, the right side was scoped and you can see the left side progressed. The left side was scoped and you can see the right side progressed. The right side in an older patient was scoped and the left side went on to a hip resurfacing 12 years later. Looking at the subgroup analyses, 93% actually had refixation, 100% preserved, none of them were resected. Of the 200 hips, 91% of those hips grades only changed by zero or one grade only over a span of 12 years. There were very rare instances in which case it was worse. And then the common themes that emerged from patients who did, who had a worse tonus grade after hip arthroscopy are well described in the literature, that there are patterns of both impingement and instability. And of course as you know, even Jonathan mentioned that pre-op tonus grade being higher, so cartilage status is still important. And then conversion to arthroplasty, similar concepts, impingement and instability features as well as pre-op cartilage status and age. And then patients that did better were those who had larger cams and only predominantly had impingement features alone. This is all concordant with what we know in the literature. And so the conclusion is that we established that the natural history of impingement by looking at the non-operative hip shows that you advance about half the time, sorry 58% of the time over a 12 year period for asymptomatic hips. But there is a favorable alteration in the natural history when you use modern techniques because that only advances 28% of the time over a decade. And when you compare head to head hips 12 years later, there's a majority of cases, no radiographic differences, but there is a better OA grade in about 25% of the cases. Worse OA grade in about 5%, but that was predominantly because of tonus grade status and instability. So secondarily, hip arthroplasty was not found to be dependent on which side underwent the hip scope, contrary to a lot of my arthroplasty colleagues' beliefs. And we already talked about the impingement instability pattern. So study limitations is a non-operative side, a true control. It may not be, but that's been established so in the literature. Why are we only looking at x-rays and not patient-reported outcomes? You know, we didn't have access to all the patient-reported outcomes over that period. Well, the symptoms do not necessarily match radiographs as we all know. Joint degeneration on x-rays is pretty much what a lot of my arthroplasty colleagues need to indicate, so that's still valuable. Is a single surgeon cohort generalizable? Dr. Kelly may not be generalizable, but the modern techniques are. And then loss to follow-up, 26% is still a lot, but it's below par for the course of a 12-year period. And then finally, is tonus grading from x-ray a reliable metric? It's fair to moderate inter-rater reliability. You know, radiographic tonus grading is mitigated somewhat by a two-surgeon grading system. And it's a practical grade of choice for insurance medical legal documentation, which is why I like that choice to look at. MRIs 10 years later would be logistically and financially impractical and potentially confusing, but a study just came out in AJSM saying that getting an MRI to evaluate cartilage status doesn't actually improve reliability of grading hip arthritis. The strengths, I think we kind of already talked about them for the interest of time. I'll skip it, but the take-home is that I believe Dr. Kelly's work has shown that we validated hip arthroscopy as a joint-preserving operation. Thanks. So our final paper this morning is going to be Mark Cinque, and he'll be speaking on early support specialization for FAI. Thank you to the meeting organizers, and on behalf of my co-authors, we're really honored to be up here, so thank you. I'm Mark Cinque. I'm a sports medicine fellow at the Stubman Clinic working under Dr. Mark Philippon. So FAI, as we all know, is a very common cause of hip pain in young athletes, and approximately 60 million U.S. athletes are participating in organized athletics. And there's been a trend over the last decade of increasing number and decreasing age at early sport specialization, despite evidence showing that it does not lead to elite athletic status. AOSSM, many people in this room, helped generate a consensus statement not long ago defining early sport specialization as participation in intensive training programs or organized sports more than eight months per year, or participation in one sport such that other sports are excluded in patients younger than 12 years old. So we use that as our definition, as a working definition of early sport specialization, which we'll touch on in a bit. The repetitive motions associated with many of these sports can lead to friction and impingement, leading to labral tears, cartilage damage, and bony overgrowth, and these are not observed as frequent rates in patients that are non-active. So the purpose of this study was to evaluate whether early sport specialization contributes to the development of FAI and to evaluate if this specialization, in particular sports, portends particular FAI pattern development. Our hypothesis was that younger age at time of specialization and greater exposure to high-volume sports specialization would be correlated with radiographic findings consistent with FAI. Our methods were we included patients between 18 and 30 years of age at the time of evaluation, ranging over a 12-year period between June 2011 and August 2023. To best capture and kind of mirror the AOSSM definition of early sport specialization, patients were identified if they reported becoming highly specialized in their sport and the age at which they became highly active in this sport. Athletes that were included were all at the collegiate, Olympic, or professional levels. Exclusion criteria included history of a prior hip surgery, lateral center edge angle less than 18, or history of congenital hip dislocation or rheumatological disease. Appropriate demographics and age at specialization were collected. On the right is the table demonstrating the stratification of different athletic groups. This was done in conjunction with prior literature, and so it matched up to the best of our abilities. Radiographic diagnosis of FAI was based on a crossover sign for pincer impingement and an alpha angle greater than 55 degrees for cam impingement. We defined borderline dysplasia in accordance with prior literature with center edge angles between 18 and 25 degrees. All patients had failed nonoperative management, and sports participation was assessed via electronic patient-reported survey. So we had 520 hips in 470 athletes, with the majority being at the collegiate level. 72, so about 14%, had borderline dysplasia as previously defined. The mean time of presentation for surgery was 22 years old. The mean age at sports specialization was 10.4 years. That should read 6, not 1. So our results, earlier age at sports specialization was associated with higher alpha angles across all athletes. A significant positive correlation was found between the years of exposure to single sports specialization and alpha angle as well. The association between years of specialization and alpha angle was strongest amongst two groups, the flexibility sport athletes and the other sport athletes, which are defined as sports that we have a list of about 50 sports, and if they don't match into one of those, they're designated, or they select other. When analyzing all 528 hips, there was no significant correlation found between the lateral center edge angle and the age of specialization or the number of years of single sports specialization exposure. However, there was a significant negative correlation found between lateral center edge angle and the years of single sports specialization in that other sport athlete category. The study is not without limitations. Correlations between early sports specialization and radiographic FAI must not be interpreted as causation. The assessment of early sports specialization in our intake forms is a proxy for the AOSSM definition, but relies on patients to recall their volumes of training and the age at which they began specializing, so that may induce some bias. And the data from our database does not allow us to understand the breakdown of sports in the other category. However, it was the smallest group of patients across all of the stratified sport groups. So the take-home points, younger age at the time of single sports specialization had a significant negative correlation with ALF angles. Increased years of exposure of single sports specialization had a significant positive correlation with increasing ALF angles. And the lateral center edge angles appeared to be less affected by early sports specialization and the length of exposure to specialization. Thank you. In the interest of time, we'll skip the question and answer session. I did review all these manuscripts and I can vouch for the fact that they all sort of pass the litmus test of being excellent studies. Thank you guys. You guys can switch them out. So we're gonna invite our two featured speakers today. So our first speaker will be Dr. Kojo Owusu-Akshaw, who will be speaking on the Capsular Approach, and then we'll have Dr. Shane now after him, okay? So thank you guys. Great papers, guys. All right, good morning, y'all. Appreciate y'all hanging out until Sunday. Nice of y'all. I wanna talk about Capsular Approach, a big topic, so I'm gonna try to keep it to eight minutes. No disclosures relevant to this talk. So increasingly, we're understanding the importance of the soft tissue stabilizers as it pertains to hip arthroscopy outcomes. This recent 10-year study did show us that two modifiable risk factors were there for conversion for total hip in the course of 10 years, and that was labeled debridement and capsular non-repair. In fact, this is congruent with an increasing body of literature showing us the importance of effective capsular management. We've seen in high-level athletes that capsular closure was associated with a faster and better return to sport. We've seen from a perspective randomized controlled trial standpoint that improved outcomes were seen with capsular closure. And with meta-analyses, we've seen from a large group of patients that capsular closure was, again, associated with better outcomes for patients. Now, we all understand that hip stability is a complex interplay of factors. We're talking about dynamic stabilization. We're talking about bony morphology and considerations for the chondrolabral stability. But today, we're gonna focus on this chondrolabral, or rather this capsular complex and the fibrocapsular ligaments that invest into it. Increasingly, we're understanding that micro-instability is, in fact, the cause of hip pain and the capsular complex is rather a primary stabilizer than a secondary one. So, as such, failure to manage the capsule thoughtfully does put us at risk for ineffectively treating our hip scope patients and maybe even, in worst case scenarios, creating iatrogenic issues for them. Now, the capsule rather than being considered as one structure, needs to be considered as really a confluence of several kind of investing fibrous ligaments that come together to form this complex. These are ligaments and we need to respect them as such when we're thinking about arthroscopic surgery. The iliofemoral ligament is gonna get a lot of love in today's talk, the Mac Daddy, the big guy that's right in the front. So, originally, it's near the AIS and sort of on the intertrochanteric line. Now, it's composed of two major distinct bands, the lateral band being thicker and stronger, protecting you from anterior translation, with the medial band being slightly smaller and extending more distally. No disrespect to the others, the pubofemoral ligament plays an important role in external rotation stability with the hip and extension and the ischiofemoral ligament hanging out posteriorly is restricting us internally. And last but not least, the zona obicularis, acting as sort of a circular collar of fibers around the base of the femoral neck, acting as an aperture is giving us some axial stability as an important consideration when we're talking about a T-capsulotomy. But we're gonna focus on this iliofemoral ligament because really it's an example of form informing function anatomically. Dr. Philippon's group showed us via biomechanical study that if selective sectionings performed of the iliofemoral ligament in the labrum, you'll see a non-physiologic anterior translation and external rotation, no surprise there. But what I think is a key point there is that the iliofemoral ligament actually played a larger role in the labrum in protecting from this translation. So that's again reinforcing this concept that it's a primary hip stabilizer rather than a secondary one. And as such, we need to be thoughtful about how we manage this and treat this when we're treating it arthroscopically. Anatomically, Dr. Safran's group showed us that there are implications surgically related to the iliofemoral ligament's position and its size. Now anatomically, it can be described as standing from around 12.45 to 3 p.m. I always say p.m. because nighttime's the right time, as y'all know. When it's within striking zone, no? No. It's within striking zone of traditional arthroscopic portal placement. The anterolateral portal being near the lateral aspect and the anterior portal being close to the medial aspect, right? So you can understand qualitatively if you're performing a traditional interportal capsulotomy, you're gonna affect the iliofemoral ligament considerably. And this has been quantitatively verified by Dr. Philippon's group, showing us that the traditional interportal capsulotomy may affect the iliofemoral ligament 50% or greater. So it emphasizes the importance of treating it respectfully and closing it when it's sized. And Dr. Noh's group did confirm to us that a larger capsulotomy size increases the kinematic impact and did show us that congruent with the clinical studies we saw before, complete closure can restore the biomechanics of it. So if we park here for a second and do a little summary around this iliofemoral ligament, the other ligaments indeed all need to be respected as such, as ligaments they are. So we need to be judicious about how we make capsulotomies because we know that we're interacting with it considerably and when it's in size and when it's injured it needs to be repaired appropriately. So if we're talking about capsulotomy approaches, we're really looking at a balance between access and impact. Do we have enough access to perform or correct the pathology at hand? Are we gonna decrease our impact or minimize what we do to the biomechanics of the joint? So if we're looking at these different capsulotomy approaches, we can take them from least invasive to most invasive, going from the periportal to the interportal capsulotomy and then to the more traditional T-capsulotomy plus interportal. So Dr. Zane's group really nicely described for us in the study the periportal capsulotomy concept, this being a sort of minimally invasive way to get into the central compartment in particular. Now you can tell from the images on the left and the right, viewing anteriorly and viewing anterolaterally respectively, we're looking to dilate our portals rather than actually fully cutting the iliofemoral ligament which is there denoted by the blue arrow. Now early outcome studies have shown us that this is a safe and efficacious way to treat patients with early outcome studies being good overall. You can appreciate from the middle diagram there that we're minimally affecting the iliofemoral ligament. And so in some cases, it may even obviate the need for closure depending on the situation and patient. If we're extending now to the interportal capsulotomy, as you all know, that's the traditional connection of your two standard anterior and anterolateral portals. But even here, there are considerations that need to be made in terms of placement. Dr. Noll's group did show us that if you're translating your anterior portal laterally to more of a modified approach, the way Dr. Kelly described for us, you can actually decrease the amount that you're affecting the iliofemoral ligament. In fact, perhaps from 74 to 32% of the, rather, the ligament's width. So that can be seen qualitatively by those two arthroscopic pictures there. Viewing anterior laterally compared to the right versus the left, you can see that your entry point is affecting less of the ligament. Another important consideration for interportal capsulotomies is capsular suspension. A few people described this nicely, and I like it very much myself. The concept being that you can keep your interportal capsulotomy smaller and use your suspension stitches to allow for access, and use sort of a moving window technique to work. So we're using a suture pass, as you can see there, and we're retracting, or my assistant, rather, is retracting them proximally to give me access to the central compartment. Now, a few things that I think need to be considered when we're talking about this. A really nice consideration here is the capsular edge is protected, and it kind of nicely exposes that capsular labral junction, or that plane. So when we're doing our rim preparation, as indicated, we kind of know we're kind of safely in the right place. Then we can go and perform our capsular, or rather, our central compartment work, as indicated in this case, a basal repair of the labrum. You know, conversely, we can then move those capsular stitches distally when we're trying to work peripherally. So putting those stitches down on the bottom part of your interportal capsulotomy, having them retracted, now we have access to the femoral head and neck junction, and if there's cam morphology to be addressed, we can do it that way. Again, the same concepts apply. We need to be careful about protecting our capsular edges when performing this, and I find if we're using a smaller capsulotomy, there needs to be a comfort level, I've found, with switching portals. So you see I just switched from viewing anteriorly to viewing anterolaterally, and we're ensuring that we're gonna be restoring our convexity all the way around, or concavity, excuse me, all the way around. So viewing from both sides, we feel better about it. Of course, fluoroscopy is our guide. So once we've kind of completed that work, of course, we remove our retraction stitches, and now we have access to our capsular edges and to find what needs to be closed moving forward. Now, techniques for preparing, rather performing a repair may vary, but some concepts need to be applied, or you need to make sure we're getting full thickness capsule bites using the passing suture device of your choice. But I will say the techniques, or rather the principles all remain the same regardless. It's important to make sure we're getting adequate tension, it's important to make sure we're getting good arthroscopic knot tying, if that's the type of technique that you're using, to get a nice watertight seal and complete our repair. And finally, the T-capsulotomy, maximally exposure certainly needs to be closed given the size of the impact upon the capsular structures. Now, some anatomic considerations here, there's an importance to carefully defining the interval between the iliocapsularis and the gluteus minimus, always cutting chores into trochanteric line. We need to consider the zona obicularis as kind of a distal boundary, because we don't want to certainly create any iatrogenic axial loss of stability. So wrapping it up, I think when we need to consider a capsular approach, we need to respect the capsular complex as the important structure that it is. Any discussion about it is really a discussion of balance. Are we getting adequate exposure to treat the pathology at hand? Are we minimally affecting the biomechanics? Now, this is gonna vary by surgeon. Of course, certainly you need to use the approach that's more comfortable for you. When we're taking into account patient-specific morphology and micro-instability risks, it's important to be thoughtful here. Thank you. Dr. Shane, now we're gonna turn things around and look at the back of the hip and kind of start the second half of this session talking about hamstring injuries. And so Dr. No will be speaking on endoscopic hamstring repair. Thank you, thank you guys for coming on Sunday here. So I'll be speaking on hamstring repairs endoscopically. My name is Shane No, I'm at Rush in Chicago. These are my disclosures, not relevant for this talk. When some people think about summertime, they think about summertime fun and water skiing. When I think about summertime, I think about hamstring injuries. Water skiing, at least in the Great Lakes and Midwest region, is probably the most common reason for hamstring tears, so they're definitely coming in an office near you. That's here. Which button do I push here? Oh, here we go, okay. So just a review of anatomy. When you think of the hamstring, you just wanna know that obviously the gluteus maximus kind of drapes over sort of that deep gluteal space complex. If you're gonna be doing this open, you'll wanna retract the gluteus maximus. That'll give you excellent exposure of the ischium. Keep in mind, obviously, if you're working with the hamstring, that the sciatic nerve is within a centimeter from the ischium. The other thing to keep in mind is that you wanna understand sort of the footprint anatomy of the entire proximal hamstring complex on the ischium. The thing that I started to appreciate, it's definitely more lateral than it is medial, so when you're doing a repair, you really wanna replicate that lateral-based insertion, and you wanna probably go a little bit higher than what you think, but keep in mind that laterally, you have the footprint of the biceps and semimembranosus, and medially, it's the semitendinosus. This is a study that reviewed the results of high-grade partial thickness hamstring tears treated non-surgically, and what they found was that 60% of these cases returned to sport, and 40% actually had to be converted to repair. When looking at complete hamstring avulsions, the return to sport rate for non-surgical treatment was about 54%, and operatively, return to sport was 96%, so at least in complete repairs, we know that those tend to do better with repair. This is an MRI of a patient that I see in the office, and I think the thing to keep in mind when I'm looking at these MRIs is is this a complete hamstring avulsion? If it's totally avulsed, this is one that I'm gonna consider either doing open or either a scope-open approach, so when I look at this MRI, I think this is definitely a complete avulsion. Patients will be placed in a supine position, and I actually like to do this kind of starting with the scope, and then I'll convert to open, so here's kind of my technique. I'll, again, draw just on the gluteal crease, and I'll make the incision kind of in line, so if I have to extend the incision, I'll go ahead and do that. The benefit of starting endoscopically is you get excellent visualization of the whole deep gluteal space complex, particularly the ischium. I think open, it's really hard to see the ischium, but with the scope, your visualization is really good, so you pass your anchors. You'll find the sciatic nerve. You'll make sure that everything is far away. We'll place that two-anchor fixation in this particular case, and then we'll kind of go to open, and we'll just kind of complete the incision from that inframedial to the infralateral. It's probably about five centimeters or so, pretty similar to what I would do open anyways, and then I'll go ahead and retrieve the hamstring. I'll tag it. I'll grab my stitches that I placed from the anchor itself, and I'll do a modified whip stitch configuration with locking stitches, and then go ahead and tie the hamstring down to the ischium, and this gives me kind of the benefit of the visualization of the endoscopic approach, but I think I get a robust endoscopic repair, and then you can put the camera inside and just take a look and see what it looks like, and because it's so deep within the deep gluteal space, it kind of retains the water well, and you can assess the stability of your repair construct, so this is kind of my typical indication for a endoscopic approach, a high-grade partial thickness tear, and the reason why I favor this endoscopically is I think it's harder to see it open, and you can't really retract it out of the wound, and so this is one that I think if you just keep it with the scope, you'll have good visualization access, and again, same positioning, same incisions, except that we're just not gonna complete it. Keep in mind the anatomy will go ahead, go underneath the gluteus maximus, and then once we do that, we're gonna just remove some of the bursa. We'll get great visualization of the ischium, and then the next thing that we wanna do is that we just wanna go laterally and just identify the sciatic nerve. Sciatic nerve is very close. If you're gonna be doing endoscopically, you wanna know where it is throughout the entirety of the case. Just make sure that you're just not gonna confuse it for the tendon. It's going along the same direction, and you obviously don't wanna make that mistake, so now we know where everything is. We've kind of cleared out our view. We can find that raffae between the semimembranosus and the biceps, and we'll go ahead and go through that, and once you go through the superficial layer, you can see the bony ischium kind of well in view. You just kind of put your scope underneath it, and here you can see it's denuded of the hamstring itself, hamstring tendon, I should say, and then we'll do our ischial prep like we did in the previous situation where we'll just use a burr to decorticate, and that'll give us a bleeding bed of bone. We'll pass our anchors, and then we'll go ahead and pass our stitch configuration, so traditionally, I had started doing this with either a simple or a mattress stitch configuration, and you can use whatever you have available. You can either use a proximal suture-passing device. You can use a tissue-penetrating device. Whatever is kind of right in front of you and easy to do, I think, is acceptable. In this particular case, we used a suture lasso, and then once you pass the stitches, usually I'll just kind of incise the hamstring itself, do like a mattress configuration, basically close the book and tie it like I would with a gluteus medius repair, and you get a really nice repair, and I would say that the majority of my patients did extremely well with this approach, and they're fun procedures to do, and I think the thing to keep in mind is that if you do have a board to open, it's a pretty easy conversion, so here's a completed repair, and again, patients really do well with this particular technique, and unfortunately, once in a while, I would see a couple patients that would re-tear, and so that was my kind of conflict was how do I justify doing this repair if I'm only doing a mattress stitch configuration if when I'm doing an open, I'm actually doing like a whip stitch or some kind of a running stitch configuration, and we know that the biomechanical studies show that Krakow stitch configurations or modified Krakow's locking stitch configurations are better, and I think to optimize biomechanically the strength of repair, you want to have at least three throws that are running, and in best case scenario, locking as well, and so how do I do that endoscopically, and this is kind of what brought us to our current technique, which is a modified whip stitch technique doing it all endoscopically, so this is a right hip patient, obviously prone. We've already passed our anchors. We'll go ahead and pass our stitches. We'll use a tissue penetrating device, and now we'll use a antegrade tissue passing device, and we'll just basically just run it up approximately, and then we'll run it up distally. Again, I want three sets of stitches going in one direction, and then we'll go ahead and use the matching stitch and use that to fixate it back down. Once we do that, then we'll go ahead and do that with a second set of stitches, and the first one is always with a tissue penetrating device. We'll go ahead and retrieve that, and now we're using the black and the white stitches, and again, using the same antegrade tissue passing device, we'll pass that sequentially, and you just want to make sure you've got good tissue plane exposure and that you want to manage your sutures very well so that you're not going to entangle the stitches and just create a situation that's hard to get out of. Now we've passed all our stitches with the white and black, and then we'll go ahead and focus in on the white and the blue, and now that you've gotten a set of your stitches, now you can actually pull retraction on those stitches so you can get a little bit more anterior, and so remember, when you think about the anatomy, you've got that raffae between the semi-membranosus and the biceps, and now you really want to get as far anterior as you can so you get a nice, really complete repair. Now we're just using the tissue penetrating device, and we're just going in, retrieving, going back around, retrieving, and doing our stitch configuration in that way. We've got now the other side of the stitch, and then we'll go ahead and use that as our post-end, and at this point, now it just becomes tying the stitches as we would normally, so when you tie the stitches, you want the hip and extension, you want the knee inflection, and you'll go ahead and tie, and you've got a nice, robust repair with a modified running stitch configuration, and I guess in my view, I was thinking if I'm going to do this all endoscopically, I want to try to replicate the open approach, and I think that that's kind of the evolution with any conversion to endoscopic or arthroscopic approach is that we just don't want to compromise the repair, and I feel like in this way, we get the best of both worlds. We get the visualization endoscopically. We get the biomechanical strength open. We get great visualization of the sciatic nerve, and I think that this is kind of our modern technique of how we're repairing hamstrings endoscopically, so in conclusion, proximal hamstring tears are amenable to surgical repair, which may be associated with improved return to sport compared to non-operative management. Endoscopic repairs are associated with fewer post-operative complications, and a modified crack-out running stitch configuration may provide increased biomechanical strength compared to traditional mattress configurations. Thank you. So thank you, Shane, for showing us that simple technique. So I'm going to invite Dr. Andrea Spiker up to, we're going to talk hamstrings for a little bit. We've got 20 minutes left on this panel, and the goal of this is to kind of just go through our decision-making when it comes to hamstring injuries and kind of give you the expert opinion as far as what's kind of the thing we're doing these days, and real quick question, Shane, as you're showing us those pictures right there, the video is beautiful. you can see the nerve, you can see the anatomy. Like, how do you get to that space and how do you, like, what are some tips for identifying and protecting the sciatic nerve? Good question. I think, you know, when I'm establishing my portals, I think sometimes you might end up kind of getting caught up in the gluteus maximus muscle. And so you just really want to make sure, it's just like getting into the subacromial space. Like sometimes when you get into the space, like you've got a great, you know, room with a view, you're kind of within like the bursal sac itself. And it's the same idea. You just want to get within like that deep gluteal space. And once you're in it and you just don't have the muscle tissue, you know, in your way, you can really open up that space well. And once you do so, then you, obviously, the first thing I want to do is I want to find the ischium. And the best way to do that for me is I just put the trocar, just hit the ischium, and I just, you know, kind of keep the trocar close, put my camera inside and just kind of back up a little bit. And then I know that I'm, you know, as long as I could see well, then I'll start to debride and move laterally. And a couple pearls with that is that I'll use just like a shaver without any teeth, so kind of a smooth tip shaver. And then I'll kind of bluntly dissect while I'm kind of evaluating more laterally. Usually there's kind of like this kind of raffia of tissue between the ischium and the sciatic nerve. And so you just want to make sure that you're on the other side of that, and then you can visualize the nerve and kind of go about your business. So part of this panel right now, we're gonna discuss open versus endoscopic repair and also just treatment of hamstring injuries in general. On the panel, how many are you all doing endoscopic repairs? Are all y'all doing endoscopic repairs? Yeah, can you tell me about like, because I do endoscopic repairs myself, like it seems like a pretty tough leap to make. And maybe talk about, or maybe Audrey could talk about kind of how you learn how to do it endoscopically and what was the, you know, what pushed you over that to be able to learn that? Yeah, I'm happy to talk about that, Winston, because I always did open repairs. And so, you know, my indications for repair of hamstring greater than two tendons torn, greater than two centimeters retracted, and a lot of these partial tears, I was very hesitant to go in and do an open takedown and repair, because as Shane mentioned, the sciatic nerve is sometimes, you know, right in the vicinity and it's difficult to actually take down the torn tendon. And so thanks to work by Shane and Chad and all of you, I've been exploring endoscopic, and I think that initial leap, as Shane described, that scope and approach, it has been the way that I started. So I would scope and then, you know, if needed, just connect the two portals and then proceed with my open procedure. But I think the introduction of endoscopic repair has really expanded our indications. So those patients that I previously wouldn't approach with a partial tear, chronic pain, now I think we can really offer them a great solution for fixation of that tendon. Yeah, I agree 100%. The scope and approach was really my kind of training wheels to step into things to get started. For me, using fluoroscopy a lot in the beginning was important to make sure I was in the right space. And that was kind of Chad Mather's advice to me as I was getting started with it. But kind of using that scope and approach and, you know, consenting every patient, saying, hey, we're gonna, you know, potentially start this off endoscopic and then have the option to go open if we need to. And I think the beauty of the scope and approach is that if you connect the portals, like your incisions are basically the same as what you would do open. And the fluid extravasation, once you, you know, open it up, you can basically drain all the fluid within that deep gluteal space. And so it's really, you haven't really lost anything. So if you're planning on doing it open anyways, you could just start with the scope and just kind of see what you got and see how comfortable you feel. And if you're not feeling comfortable, just extend the incision and just go open. So I think that's the benefit of this approach is that, you know, that you don't lose anything by trying to scope it initially. Yeah, I love the terminology scope. And I believe Chad Mather might have introduced us to that lexicon. But I will say that the SGM and the actual anatomy there, once you've seen under an endoscope, actually kind of changed your entire idea of what that actual anatomy is. So we have a couple of hamstring cases that I've just pulled from my own practice. I just want to kind of go over with you guys, make sure I did the right thing. I hope that you guys think I did the right thing. We'll just kind of go through these kind of as quickly as we can, just kind of get through as many kind of just topics as we can. So I had a 17 year old high school kid. He's a dancer and he wanted to show his friends he could do the jump splits at prom. And so he injured himself. This kid's 17 years old. His athletic trainer actually calls me and says, he has some pain in the back of the thigh. And here's his MRI right here. And I'll just kind of go straight to the point as far as what this MRI looks like. Coach, maybe you can kind of talk about this injury, what your indications are for MRI actually, you know, should I've gotten an MRI this quickly in the 17 year old kid? I mean, people pull their hamstrings all the time. So maybe your approach to this injury. Yeah, for sure. So, I mean, with a young kid, a dancer in particular, for a hamstring, you have to have a pretty high index of suspicion, because he's going to have a lot of functional loss if we miss it. So, I mean, certainly the traditional presentation things, I'm worried about ecchymosis on presentation, looking at prone strength testing and seeing if, you know, if I'm worried about a hamstring injury. So I agree with the early MRI for sure. Your options are, of course, you know, non-operative versus surgical. Someone this age, a loss of hamstring strength is going to affect his functional goals considerably as a dancer. So we're certainly leaning towards open with this tendinous retraction and all. I agree with Dr. Spiker's recommendation, greater than two centimeters retracted. I think it's a good indication to consider repair. And you mentioned rehab. So, I mean, post-operatively, I'm pretty conservative. I'm starting them off braced really at the knee, keeping the knee rather flexed. Toe touch weight bearing in the beginning and gradually progressing them as the soft tissue, you know, kind of healing occurs, so. All right, do you think this is a direct to surgery? Do you try some physical therapy first? And what do you think? I think for this patient, this is a direct to surgery. Maybe an older, less functional patient, certainly not a dancer, then perhaps not. How about you, Shane? Yeah, I would agree. You know, young patient, active, you know, with basically a near complete avulsion, if not a complete avulsion. I just don't think it's going to heal as well. And I think the outcome studies that I showed in the talk shows that the operative approach does a better result in terms of return to sport. So I think in my mind, like I would just indicate her for a surgery. So Andrea, if this person doesn't have surgery and still has symptoms three or four months later, what are the risks of non-operative treatment, I guess I could ask you? Yeah, and I would say to answer that in regard to your first question, how quickly should we act? It's very important to move quickly with these. I think the amount of scarring that occurs in the first two weeks after injury is incredible. And the sciatic nerve is so close that now you're dealing with sciatic nerve scarring to the torn tissue. So after about six weeks, I think it becomes a much more difficult procedure, more risk to the sciatic nerve, and much more complicated for the surgeon as well. Yeah, the mic's, Dr. Bird, some wisdom? No, just I was going to ask Andrea, in the course of getting this scheduled and you're trying to find where to put it on, would you kind of use two weeks as your cutoff? I think ideally two weeks would be phenomenal, but most people don't make it to clinic until four, six, eight, 12 weeks after injury. And so I think it's, you try to get them in as quickly as possible once they've arrived in clinic. But I think speaking to the larger medical audience is important too, because a lot of people make that assumption, 17-year-old dancer has a hamstring strain. But as we were discussing, some of those significant physical exam findings like echemosis, significant weakness, pain in the ischium are really important to pay attention to. So the big question here, since it's a topic we're discussing, open or endoscopic? This is an open for me. This is a scopin for me. This would be, I would do a scopin as well. I mean, I think, you know, Jovan does a nice job doing it all endoscopic. And I think at this point, I just want to make sure I've got a really good repair. I think this is one that's pretty much complete. I'll be able to get it out of the incision pretty well. And again, I just don't want to compromise on the biomechanical strength of the repair. So I just want her to get, this patient, to get the best result as I can. Yeah, so this is my case, obviously. Like all y'all mentioned, I think getting this early is really helpful. In fact, if you get there within two weeks and you get to the gluteal fascia and the crural fascia, the approach is made for you. The ischium, you can palpate easily and it's pretty easy to pull the tendon out of the body. Six, seven, eight weeks later, this is going to have, all that white will fill in with scar tissue. The nerve's harder to find. So for this, I actually did open. And another question, after the surgery, are you bracing these patients? Are you toe touch weight bearing? How do you do that, Dr. No? Shane. Yeah, I put them in crutches and a knee brace, flexed at 45 degrees for about four weeks. And then I'll start to extend their knee brace and then get them off crutches between four to six weeks. Good, yeah. Yeah, I'm thinking the same, along the same lines. Andrea. Yeah, same with the knee brace to take the tension off of the hamstring. I do about six weeks of crutches and then get the knee brace. Tell me more about that knee brace. You say locked in flexion or is it, do you, so just tell me how you do your knee brace settings. So while they're weight bearing, I lock it at 30 degrees of flexion. And then in the first few weeks, we unlock it to 90 when they're sitting. And then after that, we get rid of it once there's enough healing on the tendon itself. The same for everybody? Yeah, I agree. With ambulation, certainly locked at 30 to begin. I'll increase the range of motion, like she said, but I'll have to do it with PT first. I don't want them doing it on their own. Yeah, yeah, that brings a good point. I actually don't even start therapy until like a month post-op, just because there's not a whole lot for them to do. You just want to let it kind of scar down and heal. And is your rehab pretty standard regardless of the magnitude of the tear and retraction? I would say that's when, since I've been introducing more partial thickness repairs, then I don't actually follow that rehab protocol if there's enough tendon intact to begin with. So this is more for a complete tear repair. Yeah, I'd agree with that. I do leave some leeway within the protocol for the physical therapist to work. So with a smaller tear, I'll give them more to work with in terms of progression quicker. With a larger full thickness like this, I'm pretty stringent about it. It's the same injury, but now he's 60 years old. Does that change what your approach versus a 17-year-old? Would anybody rehab this or is it still surgery? Andrea? So I think for a 60-year-old physical laborer, I think the approach is the same. Once you get into patients that are a little bit older, I talk about the three potential downsides of not operating. And those are, number one, hamstring weakness. Number two, a bald ischium, which can be painful to sit on. And number three, sciatic nerve symptoms, if there's too much scarring to the nerve. And so as that retracted hamstring fires, it actually tensions the sciatic nerve. And so those are the reasons to do surgery in a much older individual who may not be active. But in this patient, I would probably approach it the same as a 17-year-old. Any changes? Yeah, I would agree. I mean, I think if there's a work injury or this is a high labor patient, I would fix it. I think they're gonna lose a lot of strength if they don't. I think all of us have been influenced by patients who did not have surgery. They come to your clinic six months after injury with exactly the symptoms you're describing, the sitting pain, the firing of their hamstring pain. So that's led me, at least, to be more urgent with these types of injuries, at least from my own practice. So we're gonna change it up a little bit. This is actually a football player, college football player. He's sprinting, and he has this injury, a complete tear of the proximal pinus tendinous junction. So you have a complete tear, but now it's a little bit more distal. And it's a tendon gap. So Shane, what would you consider with this injury? Is this a surgical problem, or is this a non-operative problem for you? Yeah, so this is at the myotendonous junction, a grade three strain, non-surgical. You know, I'd put the patient on indecine and basically start physical therapy. Kojo, anybody? Kojo? Yeah, I agree completely. I think, I'm kinda using some of the ACL talk that we use, this is converting this patient into a cobra as a concept. So physical therapy to kinda restore that eccentric hamstring strength and get them back at it. But I agree, it's non-operative. Orthobiologics? I've considered it. So I've used PRP in a few of these situations. Now, I'm very, you know, transparent with the patient that this is, you know, pushing indications. But for those where strength is improving, but pain remains an issue, I'm thinking about adding orthobiologics for inflammation control in the pain. I'm waiting for a little bit more data. In our region, it's not easy to procure these orthobiologics procedures and they tend to be out of pocket. So I really don't use them very often. I'd be curious to hear what Dr. Bird would do if it was like a Titans player. Well, at the professional level, obviously money's not an issue. And there's some soft evidence that, I mean, Jim Bradley's probably had more experience than anybody, and the thing he would always emphasize is it doesn't quicken the recovery, but it lessens the re-injury rate. But he's got some more recent data that it may, as far as return to play, may shorten it by about six days. And six days doesn't sound like much, but that's basically one game. And in our world, if you can get somebody back one game earlier, so I think everything's kind of risk-reward. The biggest downside, I think, is the cost. But I think on that front, where that's not part of the equation for these professional athletes, have a pretty low threshold for using. At what point would you use it, and what are you telling the player about when to expect to return? When to expect to return? Return to play, yeah. And as y'all know, treating these, it's kind of a crapshoot trying to guess. You sort of always give them, like it's six to eight or four to six. You never give them an exact amount. Just, and it's hard to, from my perspective, it's hard to say how much it's gonna, when will they be back? But just kind of whenever it is, this may shorten that time a little bit. Anybody in the panel consider a cortisone, like dexamethasone, for symptom management? I see some shaking heads. Well, the data that these patients, a lot of time, use is their buddy on the other team or someone else had got PRP or whatever it might be. And if you don't do it, sometimes you feel like you're not treating the patient. Sometimes you just need intervention of some sort. So in this case, we actually did do a PRP injection. We did, he came back to play a couple weeks later, but it was one of those things where a lot of times a patient or the athlete, the athletic trainer, or the team kind of drives that decision to some degree. I don't see much of a downside to it, frankly. I mean, do you see a downside to doing it? When did you do the injection? A PRP under ultrasound. Like what time point? Within a couple, I mean, this guy injured himself on a Saturday, probably by the following Wednesday or Thursday, we have him in the PRR office. Mainly just to intervene to some degree. And when you use PRP, is there any period of downtime after the fact, any restrictive period where they're not allowed to do it? Yeah, we tend to shut them down for about a week anyways after the PRP injection. I mean, they would probably be down anyways. We set them down on purpose as part of it. At least that's what we do in our practice. But I'm not, you know, our sports medicine, primarycare.com manages a lot of that stuff too. So we have time for maybe one more case of an aerial acrobat, whatever that means. She was spinning on some type of device and she was doing the splits and rolled into a side split. And so she has this injury, this high grade partial thickness tearing. And I have another MRI slice for this. And this is actually an injury that 10 years ago I treated completely differently than I do now. So kind of curious on this, Andrea, what would be your approach to this? She's exhausted. So PT, she had injections, cortisone right into the area that actually resolved her symptoms for about two weeks. But that, it was transient PRP and now she's still symptomatic. Yeah, and I think this is what I was referring to earlier. So very early in my practice, I would leave this alone. I would re-inject it over and over and over again, rehab. And I think now, you know, after seeing these patients come back, it tends to be quite chronic, especially when you get that crescent sign where the entire undersurface of the proximal hamstring is delaminated from the ICM. And so I think this is where an endoscopic approach now in our armamentarium is a really great option for this type of patient. And the chronic retritional tears, like especially in runners, like distance runners, like these are, it's hard to run with these, even seemingly like partial tears. Like for some reason, the runners have a hard time with it. And these are the ones that I probably see the most common that they've tried and failed conservative treatment, sometimes for years even. But if you repair them, like Winston is showing, like they actually have really good results and they are able to go back to running at least, I think we reported like 80, 85%. So, you know, we've taken them from a situation where they just can't run anymore to the point where they can return running, which I think is pretty, you know, pretty significant. Winston, what are your thoughts if this patient shows up acutely with that same MRI? So I think in the acute, I mean, I'm supposed to be asking you questions, Cody, thanks. But I think in the acute setting, I think that's what we do. I mean, I try to not opt these initially, you know. I think a lot of them do fine. If you actually MRI, a lot of the FBI, or any patient you MRI, a lot of them have that crescent sign in their MRI. They have, you know, anterior hip pain or something like that. They have no symptoms back there. So I think it's okay to have this MRI appearance. But if I can render them asymptomatic, then I will with non-operative means. It's the ones who exhaust conservative treatment that I tend to move toward. I think for some of you sitting out in my office in the audience wondering, you know, am I doing a disservice to my patients if I'm not doing these endoscopically? The morbidity of the open approach is really minimal. As you start to take this leap, the endoscopic approach is actually pretty simple and straightforward. You just need to be patient and deliberate and use good technique. These are great ones to start with because, you know, everything's risk-reward. And I think for even some of the cases with less obvious partial tearing but chronic tendinopathy that's failed everything else are great candidates for an endoscopic approach. And I would rather use an endoscopic approach on them than subjecting them to everything that goes with the brace for six weeks with their knees bent and the onerous aspects of that. Also, as you're looking at this evolution, and again with my gray hair, I remember back when we were doing arthroscopic FAI correction and the open surgeons who were trying to sort of — there used to be this tug of war of open versus arthroscopic. And a couple of techniques with the mini-anterior approach combined with arthroscopy, there were several papers on preliminary results. You never saw anything with longer follow-up because as they got more facile with the arthroscopic component, they abandoned the open part. Well, this evolution is completely different because the arthroscope can be a great adjunct, as Shane showed, where you can just — the visualization is so much better, but you can basically do it with an open mindset and just use the arthroscope as to give you a little better visualization. So, I don't feel compelled that you've got to learn how to do these entirely endoscopically. So, I think with that nugget of wisdom, I think we can end our discussion here today. So, thank you all for coming. Thank you to the panel. Thank you, Dr. Byrd, and I think it was really excellent. Thank you, everyone. Thanks, Shane.

J. W. Thomas Byrd, MD

F. Winston Gwathmey, MD

Jonathan Lee, BA

Prem N. Ramkumar, MD MBA

Mark E. Cinque, MD, MS

Kwadwo Owusu-Akyaw, MD

Shane J. Nho, MD, MS

Stephen K. Aoki, MD

Marc Philippon, MD

Andrea M. Spiker, MD

AOSSM meeting

hip arthroscopy

physical therapy

acetabular labral tears

femoroacetabular impingement

hamstring surgeries

labral preservation

capsular approach

endoscopic techniques