A few minutes here, we'll hit on some discussion and hopefully a couple cases. So Aaron Critch from Mayo has joined us up here. So quick question for the panel to start. What percentage of female patients with borderline dysplasia are optimally treated with arthroscopic approach? Maybe Aaron, you wanna start and let's go down the line? Ballpark. I think it really depends on, you know, who you're seeing in your clinic. And I agree with Andrea, you know, it's not just the dysplasia part of it, it's also the clinical diagnosis of instability. So for me, this is probably 50-50, I would say, but again, it depends on who you're seeing. Mark. Yeah, I mean, it depends on a lot of factors and what you define as, you know, as borderline dysplasia. You know, if you can have a center edge angle of 22, but if you have a tonus angle of 16 or 17, I'm more concerned about that patient than somebody who might have a center edge angle of 20 and a tonus angle of 10. So, you know, I mean, it depends more on your practice and what you're seeing. Definitely more females have instability than males in our practice, that's for sure. But I couldn't give you a number. How about in your clinic? Whatever comes into your clinic, what would you say? What comes into my clinic? Probably 80% hip scope, because I generally try not to see the PA, that dysplastic patients, but yeah, probably 80%. All right, Shane. Yeah, I mean, I think that, you know, of all the patients that I see, females, borderline dysplastic, I would say somewhere between 60 to 65% treated with the scope. Andrea? I think this is a really complex, nuanced question, because females in general have a lot of those other factors that lead you toward a PAO. So more antiversion, more ligament dysplasity, more established antiversion, so under coverage of the femoral head. So, you know, all things being equal, I would probably agree with Shane. It's probably about 60% that end up being treated just fine with a hip scope, and 40 with a PAO. Lily? I agree with Andrea. I tend to be more nervous with the females with the borderline dysplasia than with a big, muscular, stiff male comes in. And so more at that 60, 40 percentage. Yeah, interesting. More agreement than I thought. I'd probably say 60 as well. And I think that highlights, in these series that are published with arthroscopy, you're picking the right patient. I think that's really important. If you pick the wrong patient, it may be a different route. So let's hit on a case. So 16-year-old dancer. Dancers are always the most challenging patients in clinic with left hip pain. It's been going on for a while. She's been able to dance for a while, but it's gotten really bad recently. No clear reason. Anterior groin pain, a lot of popping, now had to go on crutches. She's done therapy and got relief with an injection. So here's her AP pelvis. Her exam has somewhat limited motion, but it's globally painful. An IRF of only 15. Pain with basically anything you do to her hip. She's very weak in her hip flexor, and you can make her snap. Her Beaton score, three out of nine. So here's her other radiographs. So some component of a CAM and distal sclerosis in a dancer. Erin, you want to lead us off here. Here's her x-ray standing. She's got some pelvic obliquity, and then if you sort of tilt it to level the pelvis, that changes your measurement. So you could measure her lateral center edge between 21 and 24 here. Any thoughts on this picture? Yeah, so first of all, I'd say it's good to see that the appropriate non-operative management was undertaken because sometimes these dancers can be quick to wanting more invasive options. Here, looking at her radiographic indices combined with what you told us on the physical exam, which were really no signs of instability, this is one that I'd feel a little bit more comfortable heading towards arthroscopy, but certainly getting more information with a CT scan if you were worried about anything would be helpful. Okay, so here's her MRI. Try to get these all running at once. Mark, anything you're looking at in this borderline hip on MRI, labral size, ligamentum? Yeah, I mean, I'm looking at ligamentaries. I'm looking at the labrum and, again, the location of labral pathology because if it's more instability, you're gonna see it more straight anterior or straight lateral. If it's that low of a tonus angle, my guess is it wouldn't be a lateral labral tear, it'd be more of an anterior. Again, if we get a better sense of acetabular version, though, I think that'll be difficult to get on this. And usually with our MRIs, we also get our femoral version. Yeah, so I'd say here, a little bit of a maybe large labrum but not dramatic. And then here's her CAT scan. I think the 3D view from the front can be very helpful. Also gives you femoral version. So femoral version's not bad at 13. Shane, what are you thinking with this kind of combined picture? Yeah, so I think one other comment I was gonna make about the MR arthrogram is that she did seem to have a kind of a high volume capsule as well. But it kind of goes along with the picture. I agree with Aaron. Everything kind of seems to point towards the scope in this case. The only thing that kind of worries me a little bit is the crutches. But other than that, based on her objective findings, her x-rays, her femoral version, her radiographic parameters, MRI, to me, this sounds like a scope. Yeah, sometimes that severely painful hip with cortisone injections, not a bad option to calm her down, get her off crutches. Mark? Yeah, I mean, I would say that though she had an attempt at rehab, I probably wouldn't, I wouldn't say it was complete rehab because you've got probably a painful iliopsoas snapping hip which is generally gonna be weak. Again, the iliopsoas I see is getting inflamed like this because it's overworking in a person with some mild instability or in dysplasia. I would, in this scenario, I wouldn't jump to an arthroscopy. I would actually jump to giving her a single, either you had an intra-articular injection that got rid of 100% of her pain, but I would actually test her, see if her iliopsoas was tender and or still weak and inhibited. If it was, I'd actually have her get an ultrasound-guided injection along the iliopsoas as well as for the joint to actually calm it down and actually give her an opportunity to actually truly rehab. If she's that limited and that painful, she may not have been able to give PT the effort necessary. So I probably would have added that as a junk before considering going to surgery. Yeah, I think that's a good point. Sometimes hip flexor tendonitis can really go bad and that injection settles everything back down. Here, she got better with the intra-articular nearly completely. So we're a little more confident in that. Andrea, any thoughts? Yeah, a couple of points. Can you go back to the x-rays, AP pelvis? So dancers are an interesting population because they're getting into positions that are often supra-physiologic. So one thing as a 16-year-old dancer, you could talk to her about modifying her dance, you know, maybe picking up something where she's not going into splits or putting her leg over her head. She's basically impinging herself in ways that most people wouldn't. And actually, if you go back to the done, you can see there's this dent sign. I see this in a lot of football linebackers too, where they almost dent out the cam because they're getting into that deep flexion position. So back to the AP pelvis, a couple other points. It almost looks like she has a leg length discrepancy. Like that right leg is a little bit shorter than her left leg. So if she does a type of dance where she could potentially put a shoe lift in her dance shoe, that would be a good option. Yeah, that's perfect. It measures out about a centimeter. I mean, that's easy to fit in a shoe that she's functionally making her hip more shallow than it needs to be. Absolutely. And then the last thing I think I would agree with doing a scope in this patient, two things sealed the deal for me, maybe three. Her tonus angle, I think it looks pretty close to zero. It's not too elevated. The second thing was her CT scan. You get a gestalt of the coverage of the hip and it really looks like it's pretty decently covered. And the third thing is the femoral version, which is normal. Yeah, so that's a very similar to what I thought. Her AIS here is pretty prominent for a female that some components. So I did an arthroscopy on this. The area in the sub-spine extremely red and irritated and synovitic with deformity around there. So fix the labrum. She had a small ligamentum teres, partial tear that was ablated as well. And then ever okay to release the psoas in this patient. Aaron. For me personally, I tend not to. I try to talk them out of it. Again, I think it's a lot of patient education in the office beforehand, but that would be more of my approach. I would be a little bit reluctant to release it. If I may, I wouldn't touch the iliopsoas. I think the iliopsoas is functioning as a stabilizer of the hip. And I think that a lot of times the reason it hurts in these dysplastic patients is that it's trying to maintain stability of the hip. And I think you end up and it gets overworked and that's why it gets inflamed. I think you cut it, you weaken it further and I think you make their instability worse. Yeah. And you can go back and tell her, I mean, when we injected your hip, it felt so much better. We didn't do anything to your psoas that is a good proxy. And then correcting her offset and repairing her capsule. Here's her florals, trying to get as distal there as possible. So she did well at a year back to dancing and hasn't come back yet. Hopefully it stays that way. So we'll hit on one more quick case here. Another left hip in a 16 year old female. Similarly, it's been going on for a while, got some relief with an injection, is not a dancer, is not actually particularly active, has pain with impingement, limited motion, no apprehension and prone lateral or supine position. So here's her radiographs and numbers. Andrea, thoughts here? So here, I think, again, those three things I was looking at, I haven't seen the CT yet, but as far as the tonus angular acetabular index, that's elevated. I think that just the overall appearance of it is a little bit more undercovered, especially laterally. If you look at the CT scan and you're looking at the lateral aspect, it almost as if the acetabulum is just lifting away from the femoral head. There's no concentricity, it's not covering it. And so this feels to me more like a PAO case. All right, raise of hands here. Who votes for a scope up here and in the audience? Scope? PAO? Kind of split, so I scoped her. Fixed her labrum, maybe not the most impressive tear to start, decompressed her subspine, osteoplasty closes her capsule. Gets a little bit better, but is back at a year now worse again. So maybe even worse than where she started. Her repeat MRI isn't too impressive. Now, where do we go from here, Andrea? So in these cases, if there's no further intraarticular pathology, I would do a PAO alone. If there's any concern for intraarticular pathology, which sometimes the post-op MR arthrogram is inconclusive, then I would do a hip scope PAO. Yeah, I think it's always hard with previous surgery. In these, we tend to look in to see what's going on, but that was similar thought. We'll kind of move along in the interest of time, but looked back in at the time of scope, maybe a little bit of adhesions, but the labrum seems okay. So she had a PAO and recovered very well at a year is a complete resolution of symptoms that sometimes with a scope, we have some of these patients that get partially better, but maybe not better, that I think sometimes the PAO, if it's the right surgery, they can have a pretty smooth sailing after that but hopefully this doesn't go south, but sort of one of those, maybe a little more unstable on the imaging from the start, but it's hard to make that decision. Any final comments on borderline, Aaron? Maybe hit us with the most important factor in your mind as we go down in this population. Imaging, patient, bait and score. Yeah, I think it's a little bit of everything. Something we didn't touch on too much was a little bit of trying to discern those patients' symptoms. Is it more flexion positional or is it a little bit more global pain, standing pain, walking pain, more muscle fatigue? I think that can also help you decide in clinic as well. Mark, your thoughts? You want a careful history and physical examination, certainly figure out where it's coming from, but one of the things in these borderline is plastic patients. I think there's stuff that we can treat with soft tissue, but there's some that where the biomechanical, the bone, there's just not enough bone to give you support for that to withstand the forces of weight bearing. And so for me, what's worked in my hands is again, the tonus angle of less than 16 I'm comfortable with. More than 16, I'm not. More than 17, I'm not. And a lateral center of jingle, again, my threshold is 17 for that because I think if it's less than that, you try to tighten them up, I think it's gonna just stretch right back out and you're gonna have problems again. Shane? Yeah, I obviously agree with what Aaron and Mark had to say about a kind of a global picture. I mean, I think it's hard to pin it down to like one thing because it's almost like, you know, kind of a gestalt of like everything that they're giving you. I guess a couple things that come to mind to me that I've always kind of thought about is one is motion, like range of motion, especially if they've got like super physiologic range of motion, especially with like inter rotation, that's always kind of a red flag for me and something that I really try not to touch. But that also suggests that there's probably some versional issues that are going on on the femoral side. And I think probably on the x-ray evaluation, you know, just making sure that you're pretty judicious about, you know, making sure you're measuring your x-rays, you know, the same way every time. And especially like looking at the acetabular indices, I think the tonus angle is probably the one that's probably the most important just because that kind of shows us how conforming the joint is or not. But yeah, I think for every patient, it kind of poses like different things that you have to consider. Yeah, that's a good comment on motion. I think most of these cases were chosen with some limitation in motion, which makes them more controversial. But the female that comes in with 40 degrees of internal rotation with no real cam deformity, it's hard to blame it on impingement unless they're doing some kind of crazy activity. Andrea, final thoughts? Yeah, I would say I think one thing that's become very clear is that this is not straightforward at all. And so I'd say phone a friend anytime you have questions. I do both surgeries, but I think getting second opinions, third opinions are often a good call prior to actually doing surgery on the patient if you have any question in your mind. Yeah, and I think that's the better approach in hip preservation in general. Most people have a team of people or a team of people in town that you bounce things off that I think these are great patients to approach that way, really valuable. Well, thanks for everybody for hanging out on a Friday afternoon and talking about hips. Enjoy the rest of your day. Thank you.

hip specialists

treatment approach

borderline dysplasia

arthroscopic approach

periacetabular osteotomy