All right, welcome to the session on HIPPS Don't Lie. Shakira will not be able to make it today, but instead we have Andrea Spiker. We're going to talk about the data on laboral tears and FAI. My name is Mark Safran. I'm from Stanford University, and I'm co-chairing with Dr. Andrea Spiker from the University of Wisconsin. And so we have time for both the presentations and hopefully some good discussion, and then we have some nice case presentations. We have some technique presentations, and then we'll end the session with some nice case presentations that's open for discussion, so. All right, with that, we'd like to start with our first paper. Dr. Mario Havisi, Long-Term Outcomes of Primary Hip Arthroscopy, Multi-Center Analysis at Minimum Tenure, Follow-up with Attention to Laboral and Capsular Management. Thank you for your time and attention. Our disclosures are on the MyAcademy website. So hip arthroscopy is and continues to rapidly advance, and there's increasing availability of generally positive short and midterm outcomes. And recently, we've seen the evolution of long-term outcomes as well. However, long-term outcomes are generally limited to smaller cohort studies, single-center, sometimes single-surgeon studies, and single-technique series, particularly as they relate to laboral repair. However, there's been a shift to restoring anatomy over the evolution of hip arthroscopy. In terms of labral treatment, we moved from labral debridement on the left over to repair and, at time, reconstruction, and this has been supported by prospective data, including Colvin's data out of HSS. And in terms of capsular management, we've moved from capsulotomy, and what I would argue was, back in the day, capsulectomy, over to closure, capsular repair, and capsuloraphy. And this has also demonstrated improved outcomes, as demonstrated by Shane's Nose Group out of Chicago. Things have clearly changed. That being said, are we moving the needle in terms of our outcomes? So the purpose of our study was to evaluate long-term patient-reported outcomes of primary hip arthroscopy at minimum 10-year follow-up, and this was over a unique time period spanning the evolution and emergence of both labral and then capsular repair. We wanted to determine patient-acceptable symptom state achievement, revisions, and conversion to arthroplasty rates, and then also analyze the risk factor for conversion to total hip arthroplasty, the thing that we're trying to put off as hip preservation surgeons. In terms of our methods, we looked at primary hip arthroscopies performed between 1988 and 2013 at three academic centers, namely Mayo, Minnesota, Arizona, and Florida. And we looked at patient-reported outcomes, namely visual analog scale, technoactivity scale, hip outcome score activities of daily living, and sports physics subscale, modified Harris hip score, and also subjective satisfaction. And then we also looked at reoperations and conversion to total hip arthroplasty. In terms of our results, we looked at a total of 290 primary hip arthroscopies, mean age was 40, and as is common, two-thirds were females. And given the time period analyzed, 59% of the patients had a labral repair, and 11% had a capsule repair, but they were followed for a mean of 12 years with a minimum of 10 years and a maximum of up to 24 years of follow-up. At final follow-up, contacting these patients, their mean VAS at rest was two, three with use, their technoactivity level was four, their HOS activities of daily living was 82, sports physics subscale, 74, and their modified Harris hip score was 79. Notably, when asked at 12 years mean follow-up how satisfied they were with their surgery, they on average rated an eight out of a scale of zero to 10. Looking at patient acceptable symptom state achievement, long-term pass rates of 51 to 63 were noted, and these are generally smaller than are noted at short midterm follow-up, and this probably reflects an age-related shift and pass at 10 plus year follow-up as these patients age as well. In terms of reoperation and risk factors for conversion to total hip arthroplasty, 96 hips or 33% ultimately underwent a reoperation, and this included 65 hips or 23% that converted to total hip arthroplasty. Now, demographic risk factors for conversion to total hip arthroplasty was older age, a higher BMI, a lower preoperative lateral center edge angle, larger alpha angle, and a higher tonus grade preoperatively, and I would argue that these factors are generally outside of our control as surgeons. More notably, if we look at total hip arthroplasty rates by combined labral and capsular intervention, those patients that had a capsular repair and a labral repair had a 3% rate of conversion to total hip arthroplasty compared to those patients that had no capsular repair and a labral debridement had an almost 31% rate of conversion to total hip arthroplasty at minimum 10-year follow-up, and this is indeed statistically significant. Namely, both labral and capsular repair appear to be predictive against conversion to total hip arthroplasty, and both are notably potentially modifiable risk factors. Now, you might say that techniques have evolved over time and this is just a time-dependent outcome that we're looking at, and actually it isn't. If we look at our Kaplan-Meier curves, whether we're looking at labrum, which is on the left, or capsule, which is on the right, repair tends to do best whether you look at two-year outcomes, five-year outcomes, 10-year outcomes, or beyond. So in terms of our discussion, there's been a substantial evolution of techniques over the time period analyzed, and labral and capsular repair are macro factors. They're overarching technical themes. However, there's other factors at play, such as the evolution of instrumentation and the understanding of FAI, such as with Gans' 2003 paper, which was seminal. Our study is unique in its ability to compare historic versus modern techniques, and we noted a nearly tenfold decrease in conversion to total hip arthroplasty rates over time. This study is unlikely to be repeated. There's clinical equipoise no more. This supports the restoration of native labral and capsular function. And to that point, in conclusion, patients undergoing primary hip arthroscopy demonstrated high satisfaction and acceptable outcome scores at long-term follow-up. 33% of patients underwent re-operation with 23% undergoing total hip arthroplasty, and conversion to total hip arthroplasty was associated with preoperatively present patient factors outside of our control, such as age, alpha angle, and tonus grade. But total hip arthroplasty was also associated with modifiable risk factors, such as a labral and capsular repair directly in our control, and this highlights the importance of restoring native anatomy. I thank you all for your time and attention. If you'd like to read our full paper, here's a QR code where you can read it. Thank you. Next, we have Charlotte Langley from Dalhousie. Does higher quality camera section correlate with better patient-reported outcomes? Hi, everyone. My name is Charlotte. I'm a medical student from Dalhousie, and I'm going to be talking about whether higher quality camera section correlates with better patient-reported outcomes. So this is an important question because while we rely on objective measurements to gauge surgical quality, the true value of these measurements lies in whether or not they actually align with the patient's experience and translate into improved outcomes. So... Okay, so, yeah, the disclosures can be found there, perfect. So specifically, we looked at CAM impingement, which involves an abnormally shaped femoral head and can be treated with arthroscopic surgery, as shown in the image here. So radiographic measurements are often used to assess surgical quality, with one of the most common used in CAM impingement being the alpha angle. As shown here, it reflects the degree of femoral deformity, with higher angles indicating more severe deformity, and reducing the alpha angle is an important surgical target. So while this is an important objective metric, the literature is unclear if these radiographic measurements actually correlate with the patient's experience. Specifically, patient outcomes are often assessed using patient-reported outcome scores, which are self-report surveys that ask what the impact of hip pathology on symptoms, function, and quality of life, as shown with two example questions from the IHOT here. So our goal was to determine if higher-quality camera section, which we defined as an alpha angle less than 55, correlated with better patient outcomes, which we measured using patient-reported outcome scores. And we conducted a retrospective analysis of 95 patients who underwent primary hip arthroscopy for CAM impingement, with a minimum of two years, averaging five years follow-up. Some of our primary inclusion-exclusion criteria can be found there. So we assessed the quality of surgery with alpha angle on three different radiographic views. And we did this to comprehensively evaluate CAM impingement from all potential areas of impingement. So the frog leg, the DUN, and AP view to look at the anterior, anterolateral, and lateral aspects of the femoral head-neck junction. And then we looked at the correlation with four different patient-reported outcome scores, as well as the correlation with if patients consented to or underwent revision surgery. So we found that a majority of patients experienced alpha angle reduction to less than 55 degrees across all three views, as shown here. There was a correlation in findings between the frog leg with the DUN, and the frog leg and the AP, but the DUN and the AP were not found to correlate. And there was also significant improvement in the scores across all four PROs, as shown on the x-axis there. And on the y-axis, you see the PRO score with higher values indicating better outcomes. So in terms of the correlation, there was a negative correlation between alpha angle and PRO variables up to five years post-surgery, indicating that higher quality surgery did correlate with better patient-reported outcomes. So specifically highlighted in the DUN view here, alpha angle correlated with all four PROs. And this highlights the importance of obtaining the DUN view for CAM impingement and potentially using imaging from this view in preoperative planning to determine the amount of resection required for successful surgery. And although there were differences across the three views, all three views had a correlation with an IHOT variable, and specifically in the frog leg and the AP view, it correlated with the change from pre- to post-operative IHOT. And this is important. This is widely used in hip arthroscopy due to a strong validity, reliability, and responsiveness for outcomes from this procedure. There's also significant correlation between alpha angle and likelihood of revision operation, however, is only seen in the frog leg and the DUN view, as seen here with the x-axis being the views, the y-axis being patients undergoing revision surgery. And this may demonstrate that the frog leg and the DUN better predict likelihood of revision surgery, which aligns with current literature showing that these views are important for assessing CAM-type morphology due to their views of the most common areas of deformity. So in terms of the previous literature, a recent systematic review found no consistent correlation between radiographic correction and functional outcomes. There included a couple example studies here, so the first one being no correlation on cross-table lateral view. The second study had findings that were aligning with ours in terms of revision surgery, as shown in the graph. And then the last one, there was a correlation at two years post-op on false profile. So why did our research show correlation despite these inconsistencies? There can be several factors. First, there's a number of complex factors that influence patient outcomes aside from solely resection quality. So factors like patient demographics, symptom characteristics, joint parameters. There's also different definitions, as I mentioned, across radiographic views, as well as different measurements and cutoffs for adequate resection, and then different PROs and inconsistent lengths of follow-up. So we used strongly validating measures and longer durations of follow-up. There's some limitations due to the retrospective nature, which I've listed there. So by assessing resection quality radiographically, we provide important insights into the patient's subjective experience of surgery and show that radiographically, by assessing resection quality, we can better predict patient outcomes. Thank you. Sorry. Thank you. Next, Dr. Benjamin Dohm. The pendulum has swung. A 14-year analysis of patients presenting for failed hip arthroscopy shows rising incidence of CAM over resection and decreasing incidence of under resection. Thank you, Dr. Spiker and Dr. Safran, great to be here with you all as always. So this is a great follow-up to the last talk, which discussed the optimal resection. In this study, we looked at 14 years' worth of trends in prevalence of over and under resection for femorostabular impingement. And spoiler alert, we found that the pendulum has swung. So my disclosures are listed with the AOS. We know that the labral seal matters by this point. It is chondroprotective. Under resection may result in residual FAI. Over resection may actually disrupt the suction seal. So with that in mind, we think that the goal of a CAM resection is sphericity, spherical femoral resection. This is not a new idea. This was actually the description of femoroplasties with original surgical dislocations. These are pictures from my time 100 years ago in Switzerland when we used spherical templates to model the resection. It's actually fairly easy to do open because you have binocular vision and can see three dimensions. It's harder to do arthroscopically because we do not have binocular vision. So we're actually seeing this in two dimensions with the arthroscopic view and also with the fluoroscopic view for that matter. So we can use our fluoro to visualize from multiple angles and to accomplish what we can think of as surgical sculpture, the pre-op views being at the top and the post-op views being at the bottom, aiming for a perfect sphere in every view. There are adjunctive tools that we can use, such as intraoperative fluoroscopic-based guidance and three-dimensional reconstructions with mapping, all of which can help us toward this goal of an optimal spherical resection. So what does this look like? Under resection, these diagrams we adapted from Martin Beck's original diagrams describing FAI. Here's an under resection causing CAM-FAI. We know that well. What about over resection? In over resection, this has been better understood lately, I would say, that this will disrupt the seal. It will disrupt the contact between the labrum and the femoral head, and we put all this effort into labral repairs and reconstruction to make a great labrum, which will accomplish exactly nothing if it's not in contact with the femoral head. So when the patient sits down or flexes the hip, this is what may happen with an over-resection. Here's a view of it arthroscopically. So this is a revision case where there was previous over-resection. Very hard problem to solve because we can't put bone back, at least not easily. There's some procedures we can talk about, but watch what happens. Rush of fluid out of the joint and the hip actually subluxes. This occurs as the hip is flexed and that seal is broken. So although we have, I think here, a good labral repair, which seals against the femoral head and extension, when we flex it loses the seal. This paper on the search for the spherical femoroplasty showed that cam over-resection led to inferior functional scores before and after revision hip arthroscopic surgery. So it does matter, at least clinically it matters. So the purpose of the current study was to describe the prevalence of under and over-resection over time. We defined over-resection as more than 5% of the diameter inside the circle. And under-resection is anything outside the circle. An optimal resection being within 5% of an optimal sphere. And we looked at it on both DUN and AP views. This is on an AP view. You can see an over-resection here measured on the right. And this is an under-resection seen on a DUN view. And you can see the yellow triangle on the right demonstrating the area of under-resection. So in 622 hips with AP and DUN views, we found mean prevalence rates over this 14-year period of 48% with an optimal resection, 20% with an over-resection, and 31% with an under-resection. But what was interesting is how that changed over time. And this graph is really the crux of the findings of the study. So the red line here is neutral or optimal resection. That increased over time. That's good. The orange line is over-resection. That also increased over time. That's bad. And then the gray line is the under-resection, and that decreased dramatically over time. And we can talk a little bit about why that may be. But we see the lines crossing very clearly. So under-resection decreased, over-resection increased. The steadily decreasing under-resection was negatively correlated with the increasing over-resection and neutral resections. And look at the ratios. The ratio of under-resection to over-resection actually reversed entirely. It was 4 to 1 more under-resections in 2010. It was greater than 2 to 1 more over-resections in 2020. So in conclusion, over 14 years, it's pretty clear that the pendulum has swung from under-resection to over-resection. Perhaps that's because of the attention given to under-resections in a lot of the earlier papers. But as of 2020, over-resections were more than twice as common as under-resections in patients presenting for a revision. We know that over-resections predict poorer outcomes and are difficult to fix. And hence, I think they're something we want to avoid. So we may conclude that we should teach our fellows in residence caution and meticulousness in performing a spherical femoroplasty. Thank you, and greetings from Chicago. All right. So we've got just a couple of short minutes for questions. Are there any questions from the audience for our speakers? Actually, Ben, I'm going to throw this one out to you because it's all about FAI and kind of will pertain to the others. So in a normal native hip that doesn't have FAI, and you know, we're also trained classically with gons, and you flex the hip up, if you flex the hip all the way, the seal breaks normally in a normal situation as well, right? So how is this different? And you know, when we talk about the suction seal being so critical, we know it happens in a normal native hip as well in a situation. So it's a great question, and you know, I think we can talk a lot about what is actually normal, and is there even a normal? So I've certainly seen what you described, where in as normal of a hip as I can find that breaks the seal if you flex all the way. I think that happens after a point. Hopefully it doesn't happen too much in the normal function. And I don't think we really know what's the clinical significance of that. So you know, another debate we could have is, is it normal to have a spherical femoral head? Most of us don't. So is it normal to have one? Probably not on the average. But I think if we are going to mess with God's work and reshape it, then the best shape I know to aim for is a sphere. And so I think our guiding light today, at least, is aimed for that. Okay. Now, it's because, you know, when you talk about that, we did some work with CT scans on cadavers back in 2007, 2008, and the femoral head's not a sphere, right? And that goes back to even Cathcart with his elliptical hemiorthroplasties as well. So I mean, I think it's what we should be going for. And I think, you know, all your work is great work. We don't know what a normal, you know, what a normal outlying really should be. I mean, that's described. We don't know what we should be aiming for with the FAI. But we've got to start somewhere. And I think you're right. People were missing FAI, and now people are recognizing, well, that's good. But now maybe a little over a section can certainly be a problem. And I think we're going to learn from Josh Harris about how to make sure we're doing the right way. So, but, right? I have one quick question for Mario before we go on to the next section. So Mario, there are still a lot of people out there who are not performing labor repairs. There's, you know, still some doing debridements, and then probably more who are not doing capsule closures. Do you feel that your study has definitively answered the question of whether we should close the capsule or not? I would hope so. I would say that, clearly, some people are more labor-dependent or capsule-dependent than others. We've all seen the person that has that pincer, that Agricola, our Dutch colleagues would say that have a lower arthritis rate because they just have a large bearing surface and they're natively well-contained. So for some, the suction seal is more important than for others. That being said, to go to Ben's point, if we're going to mess with God's will to restore what is native, I think that has existed throughout orthopedics of the more that we restore native anatomy, the better off our patients tend to do. And it is pretty profound that in hip preservation or in orthopedics, rarely do we say that we get to decrease failures, the ultimate failure being the total hip for hip preservation by tenfold. And if you can decrease it by tenfold, then that's probably something you should proceed with doing. All right. Great. Thank you. Oh, I'm sorry. Jeff Nepple, please. Quick follow-up for Mario. Congrats on that nice long-term study. Can you comment on strategies in finding these patients? It's a struggle for all of us to do these long-term studies. And then also clarify your follow-up rate. So you ended up with 290. How big was that group to end up down to 290? Sure. That's a great question and thank you. I can't give you the exact percentage, but it was above 70% follow-up. So we have followed these patients really closely, understanding that there were very few hip arthroscopies in 1988, 1989. And then if you looked at our one-year period now, we're in the hundreds now. In terms of following them, we've been blessed in that many patients are local and have gone on to total hip arthroplasties. And then they show up in our total hip arthroplasty register as well. That keeps them close to us, which helps. And then having established follow-up, and I get to stand on the shoulder of giants there where it was the expectation for these patients from the very beginning, much like Coventry did for his total hips and total knees, to say, we would like to see you at one year, at two year, at five years, at 10 years. And so these patients naturally return for their 10-year follow-ups. And then our research fellows call them and email them incessantly, which also helps. Perfect, thanks. Yes. All right, so we'll move on. Next, we have Josh Harris, who was able to escape from the electricity, I don't know, the lack of electricity absence in Houston to at least Denver, but the planning and technique for the perfect CAM resection. Josh. Well, thank you, Dr. Safran. Thank you, Dr. Spiker. And thanks to AOSSM for the invitation to present. It's actually very nice to be in Denver. You guys have air conditioning. For the last five days in Houston, that's a picture and video of Houston with power. We currently don't. And so it's 105 degrees in my house as we speak. So it's nice to be here. It's nice to see everyone. So here are my disclosures. We're gonna be talking about the perfect CAM correction. I think it's a great segue from the discussion that we just had. The more I learn about this, I think the less I know, and I really don't yet know what a perfect CAM resection really is. And so why does it matter? And so a few years ago, we did a large survey study where we surveyed high volume, experienced hip arthroscopy surgeons, and 91% of surgeons said that the most critical part to get correct was the CAM osteoplasty. And we know from most of our literature that the reason for revision in most situation is residual CAM deformity. So CAM is important. And so just like most things in orthopedics, you really, in order to avoid revision, you wanna get it right the first time, you get it right the only time, do your last surgery first. And I think in order to actually achieve that, it's both patient selection and surgical technique. It's an and statement. And I think that the patient selection may be as important, if not even more important, than the actual osteoplasty that we're doing to generate that successful outcome. The reason why that's so important is we know that CAM morphology in and of itself is really common just in the general asymptomatic population. And that's why the Warwick Agreement really guides us nicely in combining that patient's clinical presentation, their subjective symptoms, their objective physical exam, with the imaging that we see so frequently on our plane radiographs and advanced imaging. And the plane radiographs, there are at least 10 plane radiographs that are used in common clinical practice that look at least 180 degrees of that proximal femur. And that's what you can see here. And in my practice, I use the standing AP pelvis, I use a false profile, done 45 and done 90. But remember, just like we were saying in the last session, it's not just the alpha angle and what exactly is spherical. And so I think the plane radiographs, as Dr. Byrd said in our ICL this morning, the plane radiographs do have blind spots. And I think that really kind of shows you nicely that plane radiographs are two-dimensional, static representations of what's a really complicated, three-dimensional dynamic process. And so when you go to that advanced imaging, MRI, despite being largely a soft tissue test, it does have some good utility in a couple of situations for assessing the CAM. You can really determine your arc of asphericity, which is the omega angle that you see here, and you can find the apex of your CAM. In addition, you can also see the soft tissue CAM, which you'll see in your adolescent individuals. You'll see impingement edema, you'll see an impingement crevice. So I think MRI does have some utility for the CAM, but the best imaging that I think that's out there for the CAM is CT scan, a low-dose CT scan. It will allow you to see those blind spots. And in addition to the 3D picture that it gives you, you know, a picture is worth a thousand words, it also gives you femoral version. And I know from femoral version, it's a much better associate with rotational motion than just the CAM in and of itself. And I think if you have the opportunity to use collision detection models, CT allows you to do that, and the collision detection models do have some limitations, but they really show you where the impingement is occurring. And the crazy thing with this is impingement sometimes occurs where the CAM deformity is not actually located. So you can fix the CAM, you can correct your alpha angle to whatever you think that perfect number really is, but impingement can still occur in a different location. So that's why this is a surrogate for what's really happening in vivo in real life. And this top video kind of shows nicely what Dr. Dohm was just showing. This is a cross-sectional view from Dr. Chawla that shows the pre and the post, so the before and the after the CAM. And when you're looking at it in arthroscopy, I really like to do the dynamic exam both with arthroscopy and with fluoro before you do your resection. And that allows you to see at what degree of flexion and rotation the CAM is hitting the labrum when it's hitting the chondrolabral junction, because that allows you to determine to know what to do. And I think in order to know what to do, you have to know what not to do. And I think that when you're searching for that spherical femoroplasty, this is an obvious example that I hope you guys never see this. This is obviously, this is not my case, and this is the one that I think you'll probably see more. And I think the rookie mistake when you're getting into CAM osteoplasty is too proximal, too medial. And this is what you see here on the radiographs. And when you get into mid flexion, this doesn't require high flexion. This is between 30 and 60 degrees. You can see the femoral head is coming out. You're losing congruency. And I think your clinical outcomes are gonna suffer and the rate of total HIP is certainly gonna go up. And so what you're searching for is a spherical head-neck offset correction. As Dr. Philippon showed, you're searching for the blue slope. You don't want the steep slope. You don't want the black slope. You certainly don't want the residual CAM, the green slope. You're searching for that blue slope, which is the perfect smooth correction. I think the group from Utah, Steve Aoki, has really shown nice work in a few studies that if you remove that dense sclerotic cortical bone, if you get to that cortical cancellous junction, that's where you're gonna get your CAM right in most situations. And you can fine tune using your fluoroscopy. And I think a great study by Jim Ross and Chris Larson from I think a decade ago, they use a common six radiographic views, three views in extension, three views in flexion. And that's going to correct the most common locations where you're gonna find the apex of your CAM between 1145 and 245 on your femoral clock face. And so what I do, this is my technique. I use a T-taxolotomy with traction sutures in the medial limb and lateral limb. It allows you to see that peripheral compartment really, really nicely so that you can do your optimal femoral osteoplasty. And so I take the soft tissue off with radiofrequency first. And then what you're doing is you're trying to remove enough bone. We know that that CAM, remember that greater than 90% of revisions are from that residual CAM. So you're trying to get enough bone, but not too much. You certainly don't want to over-correct. So you've got to get it right. And so I start right distally, centrally, right at the apex of the CAM on forward until I get to that cortical cancellous junction. I fine tune it on reverse. And then I start to use fluoro. And you're just trying to get to that junction where you have a smooth osteoplasty. And this is what it should look like at the end. But the same dynamic exam that you used before your correction, you want to do the same dynamic exam. Take that hip through the range of motion so that you know, both from that up the neck view and then the side view that you're showing right here, that it's sliding under the labrum, under the chondrolabral junction, and it's not hitting, you have clearance. And I think with time, with more literature, we're going to find out what that perfect spherical femoroplasty really looks like. And so in order to get it right, in order to get that perfect femoral osteoplasty, preoperative planning is just as important as the surgery itself, if not more important. And it requires skillful interpretation of both the two-dimensional and three-dimensional imaging. And that accurate correction should restore sphericity and the offset, and that optimizes your chance for a successful outcome. Thank you. So next, Robbie Westerman will give a talk on the failed hip scope, getting out of trouble. Mark, are you okay seeing those big capsulotomies in that last talk? All right, I'd like to thank AOSSM and Andrea and Mark for having me to talk about the failed hip scope. These are my disclosures, none of which are relevant for the talk. So we all know that well-performed hip arthroscopy has tremendous potential to help patients in terms of improving satisfaction and providing high rates of return to support. But when considering correction of FAI, either from the acetabular side or the CAM side, surgery needs to be both properly indicated and properly performed to achieve optimal outcomes. When thinking about indications and surgical performance, we really should think about experience and volume, first of all, when thinking about the failed hip scope. And some of these New York State database studies have taught us a lot. This is a study done out of HSS that showed the revision rate based on the annual surgical volume of surgeons within the state of New York. And only after you complete 340 or more hip arthroscopies per year does your revision rate go below 2%. What about learning curve? So there's a lot of residents and fellows and early career surgeons here. Only does your rate of revision drop below 10% once you get over 500 cases. So the learning curve for arthroscopic latergy might be 30 or 40. And in hip arthroscopy, it seems to be much higher. So what do these things tell us? Your revision rates are going to be high in your first 500 cases. And it's going to be high if you're performing less than 340 cases per year. So the low threshold in a difficult setting to refer these young patients to a high volume referral center because these have big impacts on patients' quality of life. So here's our outline. We'll talk about some possible reasons for revision. I kind of think of these as structural things first. I prefer to correct a failed hip structurally first. And secondly, soft tissue corrections to be considered. So first is uncorrected or unrecognized impingement. This has already been brought up by Ben and by Josh. This is an 18-year-old male football player that was sent to me after a hip scope. He never got back to his senior year of football. You can see on his down lateral view, he still has a 88-degree alpha angle with a large proximal under a section of his cam. This is a case that can be treated with just a revision osteoplasty. He did not need any type of labral reconstruction or any other joint work. And this is not new. It's been taught to us by Brian Kelly more than 15 or 17 years ago that this is one of the leading causes of failure in hip arthroscopy. More subtly is the uncorrected pincer. So this is a 36-year-old female, two years out. She may be improved for two or three months, corrected with a revision pincer resection with a good surgical result. What about unrecognized dysplasia? Surgery is going to tell us and teach us a lot about PAO surgery. This is an 18-year-old dancer that I saw one year out from an isolated arthroscopic labral repair. You can see by her standing AP pelvis, she has a terribly shallow socket, was much worse after her index surgery. Some might measure that all the way to the lateral bone, but to me, that's a lateral center edge of only 12. If you have difficulty deciding if a hip is unstable, use the femoral epiphyseal acetabular roof index. If that diverges laterally, that denotes instability. In a revision, in this case, even in the best of hands, even Chris Larson and Ashish Bedi showed dismal results with isolated hip arthroscopy in the setting of adult dysplasia. So this is a case that is treated with revision hip arthroscopy along with reorienting or a structural correction with a PAO, as you can see, with the normalization of the lateral center edge angle and well-balanced anterior and posterior walls. In the setting of mild or moderate dysplasia, they can also have a lack of head-neck offset, as you can see here. It is our preference in all cases of PAO to perform a concurrent head-neck offset correction as well. We published this in JBGS a couple years ago, showing that that's the only way to achieve optimal joint mechanics after PAO surgery. Dysplasia is not only in the acetabulum, it can be in the femur as well. So if you have a patient with high amounts of internal rotation with walking or with their supine exam, you should get a cross-sectional CT scan, look for high femoral anteversion. And this is a case, especially in a revision setting, that should be looked at, because Vakas and the group out of England had showed us that 51% of patients with FAI have abnormal femoral aversion. So this is a case that can be treated with staged bilateral femur de-irritation osteotomies, revision labral refixation, and you can achieve a good clinical result with normalization of your gait pattern and resolution of hip pain in a difficult situation. What about adhesions or capsule labral issues? We published a systematic review last year. This is an example of capsule labral adhesions after hip arthroscopy. The incidence is between 0% and 7%, according to our review of the literature on higher and revision settings. No difference in knotted or knotless anchors, and substantial clinical benefit was seen with lysis of adhesions. So when you see these adhesions and you're doing your revision scope, you can consider an isolated lysis of adhesions. You don't always have to have a labral reconstruction graft. You don't always have to take out the labrum. As you can see in the bottom left of this image, once a lysis of adhesions was performed, the labrum actually looked pretty good, even though we had a graft ready just in case. You can test it by letting your traction down and analyzing the sealing properties and mechanical properties of your labrum after a proper lysis of adhesions. And this actually is a good way to get out of trouble and a simple way to revise something that's structurally otherwise sound. What about other capsule issues? This is a patient 40 years old. She fell four weeks after surgery. She's been on crutches since four weeks after surgery. She came into my office. This is her MRI findings and her done lateral view. Her MRI demonstrates a clear capsule of disruption. This is another fairly simple corrective problem. As long as structurally the hip is sound, there's no dysplasia or any other mechanical factors to correct. You can simply perform a capsule repair or a placation with six or eight simple interportal stitches as you can see here. We also opted to revise her head and neck offset correction at the same time as her revision. And finally, labral re-injury. So this is a young patient that came to me after she had a labral reconstruction or labral repair done and her MRI looked super weird and she basically had this labral deficiency. I'm not sure if this happened during her primary repair or if it was a traumatic injury afterward. And for these cases, at least in my hands, I have no way of putting that labrum back with a repair or any other modalities. So we do have a graft, usually a tibialis posterior or peroneus as Thomas Bird has taught me to use in order to reconstitute areas of labral deficiency such as this. You can do this. My preference is to only reconstruct or put graft in areas of the hip that are abnormal. I have a hard time taking out healthy tissue in order to fill that in with an allograft. There is some debate about this topic as well. There's two systematic reviews comparing circumferential to segmental labral reconstruction. Both showed equivalent outcomes, short-term improvements in PROs. So I recommend using the technique that's most comfortable in your hands in restoring the labrum. And it is my preference to not remove healthy labrum and substitute that with an allograft. So in conclusion, unrecognized impingement is still a leading cause of hip arthroscopy and also look at the acetabular side as well. Unrecognized dysplasia should be treated with concurrent PAO with the revision scope and also you should be able to correct your head and neck offset in the setting of PAO surgery as well. Adhesions and capsule issues are common up to 7% after primary hip arthroscopy and license of adhesions has a very powerful role to play and evaluate for capsule if patients have falls and they're doing well in the fall, feel a pop, use an ultrasound or MR-arthrogram to evaluate for capsule or injury. And when you're concerned about labral re-injury, have a graft ready in all revision cases and segmental and circumferential reconstructions can both work well and choose the technique that works best for you. So thank you for your time. All right. Our next speaker needs no further introduction, but Andrea Spiker about video technique on when arthroscopy doesn't cut it, how to get the PAO right. All right. Well, thank you. So the PAO is the gold standard treatment for hip dysplasia as we've heard. So I'm going to discuss the technique and what we're looking for. So here are my disclosures, none of which should be relevant to this talk. So here to set the stage, I'm going to introduce you to this patient. She's a 21-year-old female. She presented to my clinic with left hip pain. She had two prior left hip scopes at an outside facility, but continued to have similar if not worsening pain. Her MR arthrogram demonstrated a recurrent labral tear. She had very limited motion, inflection, and internal rotation on the left hip, multiple positive impingement signs, and her lateral center edge angle measured 18 degrees with a modified alpha angle of 81 degrees, so significant residual cam. So I indicated her for a revision hip arthroscopy with concomitant periacetabular osteotomy. So here's my operating room setup. These are my planned incisions. The lighter marks are her old portals, and then you see the PAO incision. So I started with a hip arthroscopy, and you can see intraoperative findings here. She had a labral tear adjacent to her prior repair, synovitis over one of the knot stacks medially, a capsular defect with a visualization of the psoas tendon, which is also frayed in this area of the psoas. So then I proceeded into the peripheral compartment. If you note that picture in the upper left-hand corner, you can see edge-loading wear on the top of the femoral head, and that's present even when the hip is off of traction. I prefer to do an arthroscopic cam resection in my periacetabular osteotomies, as Robbie mentioned as well. And so here, the cam resection was performed. And then I do a dynamic flexion of the hip, and as we talked about earlier, you notice a dropout of this hip. And so in this instance, I think it was more related to her dysplasia than over resection, but you do see this as a sign of instability as well. I then performed a capsular closure. I prefer to do this arthroscopically. I find it easier than doing it open. And then while I'm doing the capsule closure, my nurse is putting in a table extension into my hip traction table. She's taking the feet out of the traction boots. See, I'm still doing the capsule closure on the screen up there. She does this on the operative side as well. After I pass the interportal sutures, I straighten the leg. And then we actually remove the hip traction table. And now I'm left with what is the equivalent of a Jackson flat table. While they're doing this, I'm doing a part of my PAOA dissection. So I'm elevating the iliocapsularis muscle off of the capsule here all the way immediately until we find the psoas tendon, which will reveal itself in just a second here. You can see I'm elevating the iliocapsularis, and there's the psoas tendon. While my PA is closing the portals of the hip arthroscopy, I'm draping the other side of the table. And then I start with my PAO incision. So the first step here is to elevate the abdominal obliques off of the iliac crest. You can see it's a very small bikini incision that we're using. Then I take a cob, elevate the iliacus in a subperiosteal fashion off the iliac wing. Then I do a sartorius wafer. So I'm taking just a small piece of bone with the sartorius, elevating it immediately. And this is a really interesting finding. This is what I'm identifying here, SIS, AIIS, and right there on the pubic ramus is this all suture anchor from her prior surgery. So it had perforated onto the superior pubic ramus, irritating the psoas tendon. Then I clear off the pubic ramus with a cob in preparation for my pubic cut. Here I place a radiolucent retractor to hold the psoas tendon medially in preparation for that pubic cut. And then I use crigo retractors to go around the superior pubic ramus to protect the obturator neurovascular bundle in preparation for the pubic cut, which you can see here. I change it out to larger retractors to protect that pubic ramus. Here I began the pubic cut with a saw. And then I'll complete it with a stepped osteotome to protect the neurovascular structures. You can see the fluoroscopic image as to where that osteotomy is taking place. And then I take a curved chisel and place it medial to the femoral neck all the way down to the ischium. So you can see on the fluoroscopy image where it is on the lateral view. And then you see on the model where it is inferior to the hip joint. Then the supraacetabular cut comes next. So here I'm protecting the abductors with a Holman retractor. And we use a saw to make that supraacetabular cut. And then I take a straight osteotome to make the posterior column cut. I'll take a angled retractor to connect the posterior column and the ischial cuts as seen here. And then I'll place a Schantz pin in the AIIS to use as a joystick once that fragment is free to completely move it where we need it to go. I use a long, curved osteotome to complete any residual bone that might be connecting that acetabular fragment to the intact pelvis. And then with a lobster claw in place on the pubic root, the Schantz pin in place, you can actually then move the fragment. It's a combination of antiversion, lateral coverage, and medialization. Then I place K-wires, and that is followed by screws to hold the fragment in place. And here's the finished product. So you can see her lateral color coverage is now improved. And this was done on Tuesday, so I don't have anything other than the post-op films we obtained in the operating room. But you can see we try to match the post-op film to her standing AP pelvis film. So what are we actually trying to do in these situations with the acetabular fragment? We're trying to improve the lateral center edge angle. We try to improve the anterior coverage, the anterior center edge angle. We want to flatten the tonus angle, or the acetabular inclination. We want good posterior wall coverage. We want to medialize the joint. And at the same time, we want to antivert the acetabulum. So in summary, the periacetabular osteotomy indicated for hip dysplasia can be also recommended for acetabular version abnormalities, or even normal lateral coverage, but if you have focal posterior undercoverage, or clinical hip instability. As you saw, it works very well with hip arthroscopy in the same surgical setting. And I feel it's a very effective surgery that reverses the natural history of dysplasia, so it's definitely something we should consider for our dysplastic patients. Thank you. Okay. Chad Mather, are you around? Come on up. Come on down. All right. So we've got a little bit of time for some case-in-case discussion. And Ben? Where'd Ben Dunn go? Here we go. All right. So thank you all for the great presentations and techniques. We've got a couple cases that will hopefully stimulate some discussion. So... I love your cases. All right. Best case presenter ever. Not just in the hips. Everywhere. Everywhere. Oh, you want hip cases? Oh, okay. All right. So let's see if we can get this to work. Here we go. First case. 22-year-old male college tennis player. Four weeks prior to seeing me, had acute onset of sharp left hip pain. He was running to the net to get to a low ball on an abrupt stop. This is actually showing a different player. But in this position, this one, his right leg is out in front. But basically, he was kind of in this kind of position, but it was his left leg in front of him, leaning forward to get a low ball. And it was not on clay, because it's California, and we don't have clay in California. Had pop and immediate pain in his hip. He could walk, but he had to retire. He couldn't continue playing. Next day, he got up and was absolutely unable to bear weight on that leg. No prior history of hip problems. So that next day, he said the pain was excruciating, unable to bear weight. So was taken to the emergency room on some crutches. They gave him some nonsteroidals and muscle relaxers, told him nothing was broken. And a month later, when he came to see me, he was complaining still of groin pain. No radiating pain. He noted pain, though, when he would really try to push off or really bear harder weight on that leg. So he couldn't really run or push off. On exam, he was six feet, weighed 160. These were his physical exams. But basically, of note, his iliopsoas strength was a little bit weaker on that side compared to the other, but not terribly weak. He did have significantly limited internal rotation of that leg compared to his contralateral side. In all reality, when we put him in a figure four position, he had a little bit more external rotation on the symptomatic leg, which went along with his external rotation and flexion. His impingement and labral stress tests were both positive, but had a negative logger roll test. So just rolling his leg did not cause any pain. Stench field was negative. No snapping of the iliopsoas. And these were his radiographs. He has a CAM lesion. He's got a bit of a high neck shaft angle. You can see he's got a crossing sign. He's got a posterior wall sign. He has the ischial spine sign, and his center of jangle was 26 degrees. MRI showed anterior labral degeneration with a small perilabral cyst, some ligamentary spraying and degeneration, a small chondral lesion, as you can see on this, on the bottom right. There's a chondral lesion on the femoral head, just superlateral to the fovea. Another cut you could see small, what looked to be chondraloose bodies. His alpha angle was 65, femoral version was 14. So what you got is a 22-year-old male tennis player with acute onset of hip pain on his non-dominant side, had CAM lesion, acetabular retroversion, so anterior but maybe posterior labral tears, loose body, and a femoral head chondral lesion. So with that information, Ben, I know you take care of tennis players as well, so you've probably seen this, so I won't ask you, no, I'm just kidding. So I'll ask you to start off. What would you do? Well, it seems like he probably had a subluxation event, and that's consistent with the chondral damage. He has acetabular retroversion, so he's more at risk for a posterior subluxation event. I was wondering when I saw that he had more external rotation on the affected side, if he also had relative femoral retroversion, it'd be interesting to compare his version to the other side. But in any case, so at this point, we're now, I think, two months out from the end of the One month out. One month from the initial injury, and he's still unable to bear weight. He can bear weight, he can walk, but he can't play, he can't run, and just continues to have some groin pain. So our usual thing is at least three months of conservative care before considering surgery. I'd say the exceptions are if somebody can't walk, can't bear weight, or is really not getting better at all, or getting worse. So it seems like maybe some of those things are the case. Do the loose bodies push you one way or the other, the fact that you saw some loose bodies? Would you say, would you push things up, or would you still wait the three months, or what would you do different? I think if there's truly a loose body that is stuck between the cartilage surfaces, then that becomes urgent. Most of those loose bodies, though, find their way into a space, either in the capsular recesses or in the caudal lobe fossa. So I don't, assuming it's not caught between the caudal surfaces, I don't think that does push me. And certainly he had a concentrically reduced joint on the MRI, so that wasn't it. So let me ask you, so Robbie, I mean, if he's one of your, I hear they play tennis in Iowa, what would you do with this guy if he was one of your Iowa Hawkeyes tennis players and he came to you like this? Yeah, so we see, I see probably one, not in tennis very often, but it's like a jammed hip. We see one every year in football, and they sometimes have a little cartilage change on their MRI, and they're usually out for four or five weeks or so for that type of problem. But if he's not turning the corner, I might consider trying to calm the joint down with like a HAPRP, like give him some more rehab, give him some more time. I'd probably repeat your standing AP pelvis view, it looked a little bit inlet to me, and especially in the case of like a retroversion, posterior instability case, I'd probably repeat the AP pelvis with a little bit better alignment and get a CT scan to think about future options while the joint's being calmed down some more. Okay. Josh, you do anything different? I'd probably be, have low threshold to try a shot, a cortisone shot just to calm the joint down. It may not be a bad idea to see if you can, because it's only been a month, if the joints can grow and the loose bodies aren't causing any third-body wear, I think a cortisone injection would be acceptable. So what would happen, I mean, so he's better than he was the day after, certainly, but he's not anywhere close to where he wants to be, he can't go on the court, he can't train, he can't do anything. What would push you guys, based on that clinical exam, or in this history, to say, you know what, he's got some loose pieces, he's got a labral tearing anteriorly, posteriorly, we should do something sooner rather than an injection and more rehab, so. I would have a pretty low threshold to do something. You have low thresholds? Yeah, he's super high activity level, nowhere close to that, he's already had one sublux A, he's going to go do the same movement he just did, now his hip's more unstable, so, and I wouldn't use a steroid injection because I think the likelihood that would help him would be so low, and then you'd really, in this situation, try to delay the surgery. If I was doing anything, I might do like a, like a tortle injection with some local, and then you could, if you needed, feel like you needed some diagnostic aspect of it. So if you were to do something, what would you do? I would treat his CAM, his soft tissues, like a pretty basic hip scope for him. Andrea is the PAO guru on the panel, you know, he's got a CAM lesion, he's got this, you know, retroversion, some, you know, posterior wall undercover, and what seems to be likely a posterior subluxation event, do you think there's a role to consider doing a PAO, because if you're just doing something soft tissue wise, you know, are you just setting him up to have the same thing happen again when he, you know, down the road playing tennis or another sport? It's an excellent question, but I think in this case, because there are some clear etiology for his being a large CAM, which can cause that levering effect and that posterior subluxation, potential for loose bodies, maybe there's some cartilage defect that you could address with a chondroplasty, you know, I think I would probably do those things first before attempting a PAO on this patient. Okay. So he and his, you know, college coaches as well were pushing to want to do something sooner rather than later, that he wasn't improving fast enough, and they were, he was working with the trainer pretty much daily for those three plus weeks before he saw me. So if you were to do something surgically and it was a scope, the real question comes down to, you know, when you have a person that has a hypothetical that's not an unreasonable hypothetical, somebody has a hip, posterior hip dislocation, and you're going to go take out a loose body because they don't have a concentrically reduced hip, are you going in there and repairing the labrum at that time, or are you not repairing the labrum knowing that the likelihood of, you know, recurrent hip dislocations are a pretty uncommon thing? So are you going to go ahead and repair the labrum or are you going to just take out the loose bodies and get out of town? So just a quick yes, no, Ben, we'll start with you. Do you take, do you repair the labrum or not? Fix everything. Fix everything. Labor of impingement. Okay. Andrea? Agreed. Robbie? Are you talking about like a trauma patient with an incarcerated posterior wall fragment? Let's say one of your football players on the Hawkeyes dislocates his hip on the field, right? It's a low velocity hip dislocation, but it's a true dislocation. Yeah. I mean, for an athlete and somebody who wants to return to high-level function, I would, yeah, fix everything. For a trauma patient with an incarcerated posterior wall fragment, which I see one or two times a year, I would just take, remove the loose bodies and let them fly. Josh? Fix it all. Fix it all? Okay. Fix it all, especially his impingement, because that's probably why it dislocated. Okay. So when we got in there, so we did, I did scope him, got in there, you can see chondromalacia on the central femoral head. You can see that there's a lot of synovitis. There's some tearing of the ligamentum teres, so you see that that caudaloid fossa is very inflamed, hemorrhagic, with some tearing of the ligamentum teres, and again, periphobial chondral damage. You see some small chondral loose pieces in the hip, and then you see this posterior lateral labral tear. So I'm looking from a posterior lateral portal, which I know is unusual for you guys who do your interportal capsulotomies, but here I'm probing from my anterior lateral portal and looking right down by my posterior lateral portal, and you can see that his labrum nicely pulls off at the labral chondral junction here. Huh? It's a good one. It's a good one. All right. And so what I did with that, I did a chondroplasty of the loose cartilage in the periphobial region, did a synovectomy, debrided the ligamentum teres, took out the loose bodies, and I did repair the labrum. So I'm looking from the anterior lateral portal, probing from the posterior lateral portal. And then I resected his cam, and I did it through a capsular window, straight laterally. Here you can just see, looking at the posterior seal, if you will. And then I did a capsular closure, tightened up his hip capsule a little bit as well. And just for follow-up, after that, he returned to play the next season, won the ITA tournament, which is pretty good, and then he went on to the NCAAs. So, Andre, your second case might be good. So we'll give one other short case. Any questions about that case? Just for guidance, Chris Larson and I published our retroverted patients in arthroscopy a couple of years ago. The factors that did better with the scope were male sex, lower femoral anteversion, and active athlete status. So he kind of has a normal version, but he has two out of three predictive factors for doing okay with the scope. So in deciding between antevert and PAO, he has two out of three positive factors that say that he'd be fine with the scope. Absolutely. And that's been my experience as well. All right. So in our last couple of minutes here, I'm going to present a case where I don't have a conclusion. This patient's come to clinic, and I have not operated on her yet. And this might also be a nice way for us to leave our audience with some parting words of advice. So here's a 25-year-old female. She's a former gymnast and cheerleader at the collegiate level, so very active. She had two outside hip arthroscopies, at which time in both of them she had a femoroplasty as well as a labral repair. There was no capsule closure performed at either hip arthroscopy. She now has daily significant pain in that hip. She is unable to be active in any way. So here's her AP pelvis. And again, we're talking about her right hip here. So measurements, pretty normal. She's not dysplastic. She doesn't really have a large alpha angle on the dumb lateral, which I will show shortly. I got CT measurements, and everything checks out within pretty normal limits here. So here's an image of her MRI. There is no labral tear. And this is just a quick image of what we're going to see next here. So here's her done X-ray here. This is a still shot of her CT scan of that femoral neck. And then here are some close-up views of the femoral neck. Now one other thing that I think is quite interesting. So in my PAO video, I showed you the anchor which had perforated the pubic ramus from her prior hip arthroscopies. And if you look here, I think that that's what happened here. So the prior surgeon had placed these two anchors in the subspine region and perforated. And those two anchors are sitting beneath the psoas tendon. So she has a lot of psoas irritation from that as well. So I always stick a wire down my drill guide after I drill those most medial anchors to make sure I feel solid bone on the other end and that I'm not perforating like you see here. So I'm going to ask the panel, what should we do with this patient? A lot. And maybe as you think about it, tips on how you can prevent this scenario from happening in our patients. A couple of things. I immediately thought of it when you said there was no labral tear. Well, she probably didn't have a labrum because a hip that's this bad, two surgeries, probably have some bad labrum. And if it's either not there, it's ossified, it'll often be looked like or red as there not being one. So that would tell me I'd be planning for that. And then those holes there, probably there's going to be some loose anchors, which probably at this point favorable for her because that's something that probably is bothering her a lot and is easy to fix versus things on there that are not easy to fix. Any other answers? How old is she? 21? 25? She's 21 to 25. Do you think there... So I had a question about Ben's paper too. So oftentimes when I see a patient with over a section, and you looked at AP and the DUN view, I also see under a section. So they have both over and under a section on the same femur, right? So I'm not sure if she... I mean, if you brought this hip up in deflection and internal rotation, I mean, she's still going to probably impinge around three o'clock where no cam work was done. So it's kind of hard to say like, and even in your 3D CT scan, you showed like the over a section, but they still had under a section distally. So yeah, I mean, I think this is a difficult patient. I wouldn't promise a perfect results. I would have... I'd probably meet with her two or three times before I signed her up for a surgery and develop a good relationship. And I think that's important. I might try targeting injections around the psoas and the joint to try and determine what the most bothersome thing is about that. So I know if a psoas diagnostic injection doesn't really relieve much, I'm not having to go extra articular and way up and look for those anchors, like between in the psoas recess. I'd be prepared to reconstruct her labrum. I'd want to find something else structural to fix too. So I'd probably look at her femoral version to see if a derotation could be added as well. I always hope for something structural to fix along with a soft tissue repair. Yeah, her normal version. I mean, I think, you know, as you described, I always do put my anchors from further down from two, right? Two, three o'clock, four o'clock. We always, after we drill, we sound to make sure that we are, even though I'm using an all suture anchor, that retracts back anyways, but because it's easy to perforate out into the psoas tunnel and that certainly can be the source. The key is to figure out if her pain is just psoas related or not. So I think doing an ultrasound guide injection for the psoas region to see if that's the main pain generator versus is her hip unstable because of this potential loss of seal over a section and again, the status of the labrum, what was done to the labrum the other two times. Because, you know, if you think it's an instability type of issue because of loss of seal versus, you know, because of poor labrum, you can do a labrum reconstruction. You can, Mark Philippon talks about doing this for emphasize for filling the over section or as is noted, you know, at the straight anterior area, there's still loss of offset there and trying to determine if they're having some impingement. So it's complex that the static, if, you know, I don't know that there's enough information for me to say, oh yeah, I would go after this specifically, but I think getting more information and doing it in a systematic fashion to find out which is the cause and kind of try to go, certainly I want to try to correct all the different things because you don't know what the one pain generator is, but there's multiple different ones here that you have to sort through. Thomas? For somebody who's had one operation, this is a very common time, I don't want to tell you exactly how many, but most important is what Robby said, get to know them, get them working with therapists, try on injections, calm them down, get a read for where they are, but ultimately there's a lot of things going on here, one of which is most of the resection is latally based, and that's one of the problems, if you're just using two portals, if your first portal is off a little too anterior or posterior, your next portal is going to go relative to your first portal, that's where you'll see these when sometimes they took too much latally but not anterior, or conversely took too much anterior but not enough lateral, and the other issue here is the most menial act that you have is kind of at the base of the AIS, and I suspect it's probably more lateral pathology medially on the rim, along with the fact that you can't medially on the rim, so I think those are things that you're going back into, what are you anticipating you're going to find that you might be able to do something about, and certainly for a 22-year-old who's miserable, I would have no qualms about offering a third operation because there's not a lot of other better choices for that. Yeah. Well said. Following on to that, in an older age group, maybe you give up and think about a hip replacement, but not in this age group. So I think step one is call the index surgeon and invite them to the next course you're teaching. There are a multitude of possibly preventable problems here, but to list them off then, most likely you have labral insufficiency, degree of instability associated with labral insufficiency and probably capsular insufficiency by this point, protruding anchors tickling the iliopsoas and over a section, mostly lab, as Thomas said. So if we're doing another arthroscopy, I'm going to want to tackle all those things. I'm going to want to remove the protruding edges of the anchors by working under the iliopsoas and burying down whatever is protruding. I'm going to do a labral reconstruction nine times out of ten here and try to produce a great seal. In terms of the over a section, we can try to round out the corners or we can do a remplissage. I think Mark's done that with IT band graft. We've done it with dermal allograft rolled up. And I think that's asking a lot of the healing capacity of the femoral neck, but in limited numbers we have seen good results. And then lastly, she's going to need some kind of a capsular closure, glycation, or reconstruction, depending on what the capsule looks like. So a lot of work to be done here. That's a good rundown. I agree with all that. But I would leave the defect in the neck alone, first round. I wouldn't touch that. I agree with you. It's a lot to ask. And I think that you could fix those other things and that could help her a lot. She'll be fine with that over a section. Well, thank you all for your excellent insight. I think we can end on this thought and just remember why we talk so much about what we talk about so that we can prevent scenarios like this one. So thank you all for joining us today. And thank you to the panelists and speakers. Thank you.

Marc R. Safran, MD

Andrea M. Spiker, MD

Mario Hevesi, MD, PhD

Charlotte Langley, BAH

Benjamin G. Domb, MD

Joshua D. Harris, MD

Robert W. Westermann, MD

Richard C. Mather, MD, MBA

hip pathologies

labral tears

femoroacetabular impingement

hip arthroscopy

total hip arthroplasty

CAM resection

periacetabular osteotomy

hip dysplasia

surgical techniques

patient outcomes