All right, thanks, Winston, thanks, Steve. Yeah, I'll be talking about failed labor repair and the management of the athlete's hip. I hope you guys are having a good time in Washington, D.C. These are my disclosures. Can you go back one slide? Okay, so all right, so basically when we see a failed hip arthroscopy and athletes are otherwise, most of the time it's very multifactorial and not straightforward in terms of what's actually causing the repair. There are definite abnormalities that you'll see on radiographic issues that don't necessarily correlate with the patient's persistent symptoms, so I think you need to understand the patient and athlete's history and trajectory and where they're getting caught up and sort of be humble and thoughtful about what you're seeing in imaging versus physical exam and history. So I do probably about 30% of my cases are revision cases, and we see all sorts of different potential causes that we try to address, but it's always hard to sort out what was the problem or what were the three or four problems that we treated that were the thing that made the patient better. And we're focusing on the issues with the labrum, which can be from insufficient tissue, secondary to debridement, or poorly done repair with an everted labrum, or a repair of tissue that was just bound to fail because the tissue is not reparable. We all know that the hip can be a pain generator as it does have free nerve-ending fibers and pain receptors, and I have a high index of suspicion for compromised or insufficient tissue going into any labral case, any hip arthroscopy case. And this is particularly true when we see intersubstantistic changes in an MRI or at the time of arthroscopy, or if we see a smaller everted labrum or labral ossification. And then certainly I have elevated suspicion when a patient has a collagen disorder such as EDS. And so early on in my career, I wasn't real happy with my batting average with labral re-repairs and started doing labral reconstructions, and a technique has evolved somewhat over the years, but it has certainly improved my batting average in these revision patients. So I'll show you one where, as I typically will almost always reconstruct these patients, this is one that I didn't. This is a patient she showed up as a female high school soccer player at 18, mixed gamma pincer type impingement, bate and score of four, which is sort of a little bit loose but not crazy. And so we did a labral repair and a gamma pincer and everything seemed good. Her tissue seemed fine and came back together nicely, she had a small wave sign, but otherwise was good. I probably could have done a little more on the acetabular side, and then fast forward about a year and she's now in college and an intramural athlete and she feels a pop and has a return of her symptoms and has what looks to be a breakdown of her labrum slightly more anteriorly. So I got a CT scan and sure enough I could have taken a little bit more from her acetabulum and I sort of missed the anterior inferior cam, I didn't quite get down far enough. So when I got into her hips she had good tissue still and so we re-repaired her labrum and I attributed that anterior inferior extension of the tear to my lack of perfect bony work there and so we fixed that and she did well for about four years from her re-repair and then I recently came back in with three months of insidious onset of symptoms. She's now likes to rock climbing, but states that her hip is worse than ever. So am I going to repeat the same mistake and do a re-re-re-repair, no I'm not, that's the answer to that. So Brian White showed us in a 2016 paper that his batting average was quite poor with re-repairs with a 50% failure rate versus a 12% failure rate in his reconstruction cases. This is sort of tracked with my experience where we have found good results that are reliable and durable. This is a five-year outcome study that we published last year in AGSM showing that our patients do just as well with the reconstructions as they do with the repair and the repair patients where I'm doing those is typically a much less severe pathology. Similarly with respect to return to sport, this is from arthroscopy in 2020, we had an effective return to sport for the ipsilateral hip in primary and revision circumferential labor reconstructions at 97% average of six and a half months with really good improvements in VAS and IHOP 12 scores. And so what we're trying to accomplish on these is to restore a good seal and so there's variable pathology, particularly anterior inferiorly and posterior inferiorly and tend to do a more complete but we want to have an overlap in both in the front and in the back with the native labrum so there's no gaps so that we are getting a circumferential seal on the hip and then we want to check that at the end. So on the left is a patient right after we finished and we want to see a seal and we want to see good overlap anteriorly and posteriorly with the native labrum or the transverse acetabular ligament and the one that I just clicked through on the right side was a year out from surgery and she was a patient with EDS that I had revised from a previous repair to a reconstruction and she tore her capsule and if I could show it to you, you would believe me. But she had good overlap and good circumferential suction seal. So in summary, I would say that we want to maintain a high index of suspicion for a persistent labor issue in the setting of a failed labor repair and that a well-done complete labor reconstruction would likely improve your batting average. Thank you. Oh, I also want to see you guys all here next October for the big issue meeting.

failed hip arthroscopy

management of hip issues

cause of failed repairs

nerve-ending fibers

labral reconstruction