Okay, so first Case that we're gonna do today. Yeah So this is a 24 year old collegiate baseball player He's had two prior hip arthroscopy one in 2020 the second one in 2021 after his two surgeries He was still having persistent pain and he really had difficulty with continuing playing baseball at high level. He was looking at playing professional baseball So despite the two surgeries which Initially was for labor repair. The second was for scope debridement. He underwent a series of therapy working with his trainers anti-inflammatories even had injections He had a good range of motion on examination a good strength. Here is x-rays So it's a left hip joint space looks good. He had a lateral center edge angle of 42 degrees and an alpha angle of 65 degrees Again, this is after two prior hip arthroscopy Here's the MRI Why don't we go down the line here Robbie any comments about the MRI There appears to be a medial capsular defect and a big Amount of fluid going up to so as so medial capsule defect labrum Doesn't look great, but doesn't look awful and he's got residual FAI that was probably untreated in his first two scopes Steve any comments about the x-rays? Sorry, I should probably go back. Yeah x-rays joint space looks great You can still see the sclerosis on the head neck junction on that Lateral film and MRI would agree MRI shows a capsular defect It looks like there's thinning of the capsule and then it's got that redundancy where it's pouching out A Winston so as you're thinking about this patient to prior hip arthroscopy is What are what are the things that are kind of sticking out to you in terms of why this this patient is not doing well Yeah, I think an achy pain you're describing He's had since his since his hip arthroscopy probably indicates that he's had some micro instability or some some capsular problems ever since his first scope He was 17 months between it. Did he ever get better Shane? I mean he is better, but he's just not playing baseball at a high level Yeah, I think that when you have this kind of Capsular trouble you're gonna have that achy pain, and I think it's a big problem So here's the diagnostic arthroscopy Catherine any impression just looking at the diagnostic scope here Yeah, so his capsule looks very redundant and definitely you know with that MRI sort of corresponding with a defect I think you definitely have to address address the capsule But also sort of the residual cam at you know once you say 62 degrees for the alpha angle So I think those are the biggest things and then I didn't get a great look at whether the labral Tissue was good quality, and you know we repair it or does he need a labral reconstruction? Femi any thoughts on the labrum just kind of looking at that initial Yeah, I know Shane Difficult case, but you know good case to discuss. I think there's a lot of labral edema there, so I probe it I'd like to see if he's got a focal problem or a more global Labral atrophic changes if it's focal and it's limited and less than a third I can probably try and see if a revision repair would Work, but if it's more than 30% I'd be looking at reconstruction options So I guess going down the line like what are your thoughts or your treatment algorithm in terms of I guess the main issues here? And why do you think he failed? We only go Femi and then we'll work our way backwards Yeah, so I think you know using that zone or layer based concept. You know first layer has got a residual FAI bony Potentially slight overcoverage in the acetabular side and the soft tissue wise has gone labral edema Maybe labral insufficiency when you look at his own three you know the third a capsule is thin redundant and You know partially maybe even unhealed and then the muscle envelope on clinical examination I'd like to understand what that's like clinically to see if he also has a muscle component this hip dysfunction Yeah, so very similar things and then just regarding that second surgery the the breed mint concerns me a little bit And you know you can't go back in time, but maybe addressing that differently Yeah, I presently have two great targets here. I think the FAI I think correcting that's gonna make them a lot better in the capsule. I think the labels probably secondary I think I'd focus on the FAI in the capsule I'd be in the same as Winston I'd be looking at the exam under anesthesia comparing it to the contralateral side looking at stability of the hip with axial traction and then Most likely focusing on the FAI and dealing with a capsule Yeah agree, I think that labrum is one I might leave alone Does not look like when I chop out and do a reconstruction for on first on first look Maybe a Selective repair if there's any instability here, and yeah, but the bony work and and the capsular management I think are the key pearls here Anyone want to reconstruct the labrum? What percentage is involved Shane on this labrum was it more than a third like it was I thought it was about 25% or sure So this patient underwent a primary labor repair, I think I agree with the panel I think the major issues here is the residual FAI you can see residual cam deformity that Needed to be resected that was evidence based on the x-rays And I do believe that the capsule was a significant contributor in terms of his ongoing pain functional status and inability to return to sport so in these cases sometimes a capsular defect is so large that Placation is is necessary In certain situations, I'll have it on standby in the event that the capsule is not completely repairable and requires an augmentation patch But thankfully this patient did have a capsule repair that was able to be completely closed You want to do your next case we get dr. Safran's case up Can we switch the cases So it's interesting you know ten years ago This whole topic would be about FAI and bony work and as you can see in between this case That's coming up in the one that Shane just did I think the importance of soft tissue contributions to the hip All right, we've learned more and more about Largely with Shane's work and some of the work that we've done at Stanford and Mark Philpott's done So this next case the 20 year old male water polo player acute onset of sharp left hip pain with deep flexion Egg beating which is the kicking mechanics that they do in water polo He does have a prior history of right hip pain as well. That was treated non-operatively on Examination essentially he's got good strength and relatively similar range of motion positive impingement labral stress tests These are his plane radiographs. He's got bilateral cam FAI He's got crossing signs on the right greater than left, but again the left is one is presenting with now He has a so-called posterior wall sign so he has some retroversion of his acetabulum Center jangle 24 on the right 21 on the left for his I enter center edge I'm sorry lateral center edge angle, so you've got borderline dysplasia his MRI shows an anterior labral tear and alpha angle of 72 and femoral version is 9 So what you have is large cam FAI with labral tear borderline dysplasia some acetabulum retroversion in a collegiate water polo player So how would you address this this is a little bit different because of the bony undercoverage and retroversion of the acetabulum? So why don't we start on the far end with Femi and work our way down? Yeah, I think you know clearly some anatomical problems here that need to be addressed them I think timing is you know of the essence, but I'd start off with a non-surgical approach to start so you know Intraarticular injection that's diagnostic and therapeutic potentially hyaluronic acid and or a steroid combined and then try and rehab and strengthen the soft tissues around the hip joint and see how They do if they respond to that into a staged FAI surgery downstream after the season is complete. I wouldn't initially address the Dysplasia given that the numbers are so close to normalizing, but I'd focus more on the femoral side of deformity before Considering addressing the acetabular side at this point in a high-level athlete All right Catherine yeah, and then sort of just going along with that if the decision is made for surgery I think that you can not do a bony procedure for the dysplasia But I think this is a person that I would definitely address the CAM But also consider the placation from a micro instability standpoint to see you know that should help with the dysplasia Especially with the retroversion as well All right, would you change how you do your capsulotomy? Necessarily in this face of you did say you you know close the capsule Would you change what you're doing with regard to your capsulotomy to approach this or yeah? I think being domes procedure I do an inter cap intra portal capsulotomy, and then just do a little bit of a shift from that perspective Especially if the large cam you're gonna have even more sort of Patchless capsule there, okay Winston do anything different yeah, I know The capsular aspect of I think is actually pretty important I think you can actually you know improve some the stability by making capsulotomy and closing it with a little bit of placation So I think I'd address the cam address the capsule and probably was DDH alone So I'll change it up a little bit Steve the next question because I would do you have a borderline limit? About how much borderline dysplasia that you would do with the scope versus saying you know what we shouldn't be doing this with this So for most individuals, I think I'm right around 18 and above I would consider particularly in the male patient versus the female I think it's different and I almost think of them as two two separate types of patients I do look at capsular thickness now to get an idea of The really thin capsules is particularly the ones that are two millimeters Or thinner are the ones that are more at risk of having instability afterwards so I do look at the capsular thicknesses as a Potential reason to head one direction with with bony coverage versus scope Where are you looking at that capsular thickness? it's you the the place that we're measuring it is right at the the midpoint of the femoral head on the coronal views and measuring the the superior capsule Robbie anything different so borderline decision-making so femoral version is Normal to slightly below that we know that high femoral antiversion and borderline dysplasia does worse Ben has shown us that and wash you papers have shown us that Retroversion of the acetabulum so the Larson and I published last year people who do worse with acetabular retroversion for arthroscopy are Females and those with high femoral antiversions So both cases all these cases point towards a scope being a reasonable option for this this guy So what about I didn't put in there, but the roof angle it was about eight degrees Is there does that play into your decision-making as well? We know we talked a lot about anterior center at jingle and lateral center at jingle What isn't talked about as much as I think the roof angle which I think is in my mind important as you know the femoral Version is they're getting more and more discussion with the femoral version, but what about roof angle does that play a role? Yeah, roof is important So that's your Taunus angle or your up sloping sore seal eight eight is reasonable you can also look at something called the fear index where you look at the epiphyseal scar and the roof angle and this is Converging and his AP pelvis so that that denotes a stable a stable hip All right, so we're short on time so basically we did treat him conservatively get him through the season rehab them I continue to have symptoms with water polo and lifting ultimately did operate and he had this outside in kind of flap Articular cartilage lesion answers superiorly his labrum overall though was stable once you cleared away that flap Just a little bit of debris mod. He had his cam lesion, which we did the resection and it did close his capsule And then in follow-up he returned to play water polo, and they won the national championship So that's the end of our time on cases, so I want to thank our panel for enlightening us some more on the capsular issues

hip injuries

young athletes

femoroacetabular impingement

capsular defect

labral tear