We've seen a lot of exciting stuff here, and I think oftentimes you'll find these people are more vehemently agreed than opposed to the spectrum of options available. Any quick concluding remarks there? Yeah. Thank you all for excellent presentations. I think there are good arguments for both endoscopic and open. I think one of the questions that we always have is, if you are to attempt an endoscopic repair of either the hamstrings or the abductors, what is that criteria that you will use to change your mind and then go open? I'll start. I think it's always, you need to have that as an option. I think that a couple of the things that help me, I know Mike mentioned with visualization and bleeding, I think tranexamic acid has helped quite a bit, so I use that routinely in all my arthroscopic, especially these procedures. So I think that's one option. I think you want to keep the pressure very low for most of the procedure, and you just have to have the equipment ready and available to make that decision sooner rather than later. If I have any trouble exposing that subgluteal space, which in some cases, for some reason, it's very scarred, it's really difficult, and in fact, I think Thomas was there one time when you saw me struggle and we had to open one. So you just have to be ready to do it. I think we're all very facile with the open technique, obviously, except for maybe Yovon. I'm not sure. I forgot how to do it. But I think you have to just have a low tolerance to do that in the beginning. I think for me, low-functioning patients, you know, older patients, I think it's appropriate for the endoscopic hamstrings. The younger, higher-functioning athletes, like I said in the talk, I favor the open. I think, you know, it's important for, you know, learning curve-wise, if you're going to do these endoscopically, you know, I know I practiced a lot before tackling this, and I think, you know, at these courses, when you go and do hip arthroscopy and whatnot, you know, take that little bit of extra time and go and look in that space, just like you would in the gluteus medius and whatnot, so that you're comfortable by the time you're actually trying it on a patient. I think I would agree with all the comments. I went through the same transition, right? I scheduled everything as scope versus open. Other pearls that you can use, have anesthesia be on your side, be friends with them, because if they can keep systolic around 100, that makes a tremendous difference. I agree with TXA. I would tell you epi in the first two bags, but let anesthesia know that prior to beginning. Don't forget about Poiseuille's law, resistance to flow in a tube is radius to the fourth, and the 4.5 millimeter scope sheath is not the only scope sheath. There are companies out there that make them as wide as 6.5, and you guys can do your own math behind that, but that's an incredible amount more flow that can allow you for better hemostatic pressure. Yeah, I don't have anything more to add. I think, you know, the one thing, Carlos, I've tried some of the, sometimes you do get some big bleeders around the sciatic nerve. How do you deal with those when you're doing them endoscopically? I had one, I literally, it was a total red out, and I had a whole bunch of people watching me, and they just left to go to the airport, and they're like, good luck with that. Fun, yeah. Anyway, I ended up putting clips on it, and it ends up being fine, but there are some vascular leashes that are around the sciatic nerve sometimes that can be, it can be a little tricky. Yeah, one of the tools, I don't know if you saw the little dissector that I used, that actually has quadri on it. It's a general surgery instrument that works pretty effectively, so I always have that available, because if I start to see one of those bleeders, then you can actually effectively hit it before, you know, and I also always have clips available, but I have had a couple of those as well. Yeah, I think all of us have been there, and that leash that Brian's describing is very consistent. It's right parallel to the base of the ischium. It's almost always there, and I try to avoid it if I can, but I've got all of Carlos' tricks on the back table just in case. We have one question from the audience. This is a question for any of the panelists. What is your approach to non-operative management for the abductor tears, and when do you pull the trigger for surgery? Is it dependent on the tear type or patient? So, I can start. So typically, by the time patients come in to me, they've tried a lot of physical therapy, and it really depends upon the size of the tear. If they have a high-grade partial tear, I'll continue to try some, you know, focused physical therapy, work on abductor strengthening, and some of the TFL and gluteus max strengthening, try to compensate for it. If it's a partial tear, I will try some orthobiologics into them. If they have a high-grade tear, and there's retraction or fatty infiltration, you know, historically I've thought that, you know, by the time they come in, they're pretty debilitated, a lot of pain, difficulty walking. I do have a handful of patients where they were scheduled for surgery for these fatty infiltration ones, and I was going to do gluteus maximus transfer, COVID, you know, delayed their ability to come in, and they've come back, and they're actually doing quite well with minimal pain, and they've developed ability to compensate for it. So I think you should always make sure you've exhausted your physical therapy. The one issue in the abductor is if you do have a complete tear that's retracted, just like a shoulder rotator cuff, you know, the longer you wait without having to see any tension on the proximal muscle, the more likely you'll develop into fatty infiltration, and the gluteus maximus transfer is not a perfect procedure. It's sort of a salvage procedure. So if you can do a primary repair, I think you're in much better shape. I would agree with everything Brian says. Six weeks of non-weight-bearing for somebody who's in their geriatric years is difficult, so I max out non-op orthobiologics. I try to stay away from corticosteroids because typically by the time they get to us, they've had three or four already. A bursal tortle injection is something that you can do as long as they don't have comorbid conditions, and again, get them plugged in with a good PT and try and get them through it without surgery. I'd agree. Yeah. Well, thank you, everybody, and thank you all for excellent debates.

surgical options

hamstrings repair

abductor tears

endoscopic techniques

open techniques