Good morning, everyone, and welcome to our HIP session. I'm Andrea Spiker from the University of Wisconsin. Shane O from Rush University in Chicago. So we'll begin with paper seven, the effect of pelvic incidents on outcomes following hip arthroscopy for femoroacetabular impingement and acetabular labral tears, presented by Kaveh Tarabian. Thank you, Dr. Spiker. I'm Kaveh Tarabian. I'm a medical student at Rush, and I'll be presenting this study today on behalf of the Dr. Scott Martin Research Team at Massachusetts General Hospital. We have no disclosures. Pelvic incidents, pelvic tilt, and sacral slope are common spinal pelvic parameters used to evaluate sagittal alignment and gauge the ability of the pelvis to adapt to postural changes. Pelvic incidence is a fixed morphological parameter that inherently dictates the values of pelvic tilt, sacral slope, and lumbar lordosis. Perturbations in sagittal alignment may impose misappropriation of low transduction and force absorption and cause pelvic rotation as a primary mechanism of compensation. This may lead to accelerated arthrosis of the lumbar spine and adjacent large joints. In the setting of hip arthroscopy, femoroacetabular osteoplasties mitigate degenerative loading patterns caused by CAM and pincer lesions, but it remains unknown whether or not variations in lumbosacral alignment may continue to pose detrimental effects following hip arthroscopy. The purpose of the present study was to evaluate the effect of pelvic incidence on outcomes following hip arthroscopy. We hypothesized that patients with a high pelvic incidence or low pelvic incidence would display inferior outcomes relative to those with a moderate pelvic incidence. This was a retrospective analysis of prospectively collected data. All included patients who were greater than 18 years of age, underwent primary hip arthroscopy for FAI and labral chairs, had at least one year of clinical follow-up, and had advanced preoperative spine lumbosacral imaging to allow for the measurement of spinal pelvic parameters. We utilized standard exclusion criteria as shown here. Spinal pelvic parameters were measured using MRIs and CT scans. Pelvic incidence is shown here in orange, pelvic tilt in blue, and sacral slope in green. And based on cutoff points defined in previous literature, we stratified patients into low, moderate, and high pelvic incidence groups. Seventy-four patients were included in our analysis, with 28 in the low PI cohort, 31 in the moderate PI cohort, and 15 in the low PI cohort. Excluding spinal pelvic parameters, there were no differences in patient demographics or preoperative characteristics, and there were no differences in the distribution of intraarticular pathologies or procedures performed. There were no differences in preoperative PROs. However, the high PI cohort, shown here in red, displayed significantly worse outcomes across all metrics at 3, 6, 12, and 24 months relative to the moderate PI cohort, and also displayed worse outcomes across most metrics relative to the low PI cohort. Weighted differences in average PRO scores across the entire study period of two years revealed similar trends, with the high PI cohort displaying significantly worse outcomes across all metrics relative to the low PI cohort. Interestingly, however, there were no differences between the low and moderate PI cohorts. Regarding clinically meaningful outcomes, the high PI cohort displayed lower rates of achievement in MCID, PAS, and SCB at 12 months, and PAS and SCB at 24 months as well. High PI cohort also displayed lower rates of patient satisfaction at 12 and 24 months, and although no patients in any cohort underwent a revision hip arthroscopy, the patients in the high PI cohort displayed higher rates of conversion to THA at 26%, however, this did not reach statistical significance. Overall, this study shows that patients with a high PI displayed inferior outcomes following hip arthroscopy, and previous studies have hypothesized that patients with a low PI will anteriorly tilt the pelvis, imposing overcoverage of the anterior superior acetabulum, whereas patients with a high PI will posteriorly tilt the pelvis, imposing functional undercoverage of the anterior superior acetabulum, imposing a more verticalized articular loading surface on the acetabulum, also known as edge loading, and this compensatory adjustment could underlie the relatively worse functional outcomes we observed in this study, however, more research is needed to validate those hypotheses. Overall, this study lends credence towards the prognostic utility of evaluating spinal pelvic parameters during the preoperative workup for hip arthroscopy. Thank you. Thank you, Kaveh. Our next speaker will be K.J. Hippenstiel. He'll be speaking on hip arthroscopy in recreational athletes, risk factors for failure in return to sport, and factors that influence psychological readiness to return to sport. Good morning, thank you for the opportunity to present here today. We have no relevant disclosures to the study. So prior studies for looking at hip arthroscopy for the treatment of FAI have shown high return to support rates of 88 to 96% and improvements in PROMs, but these are focused on mostly on the high level and professional athletes. These elite athletes are difficult to generalize to the overall hip patient population as they have numerous obvious external socioeconomic pressures that can act as confounders affecting return to support rates. Weber and Noe did evaluate recreational and high level athletes with the definition of a high level athlete being a high school or collegiate athlete and found similar return to support rates and improvements in PROMs, but they had a small sample size and thus cannot analyze predictors of failure to return to support. We know that return to support requires both physical and psychological readiness to do so. Psychological readiness has been shown to be a significant factor in return to support and in return to pre-injury performance after ACL reconstruction. And psychological readiness has also been looked at in patients that have undergone hip arthroscopy and this questionnaire has been validated and found to be reliable, but the various internal and external forces that impact an athlete's psychological readiness to return to support have not been elucidated in this patient population. The purposes of our study are listed here. We hypothesize that recreational athletes undergoing isolated hip arthroscopy for FAI do achieve high PROMs and rates of return to support. And similar to the ACL reconstruction literature, we hypothesize that poor psychological readiness is a risk factor for failure to return to support and that male athletes in younger age are positively associated with psychological readiness to return to support. Based on the HSS hip registry, our inclusion criteria for this retrospective cohort study with prospectively collected data include the definition of recreational athlete listed here that underwent an isolated hip arthroscopy with label preservation for treatment of FAI and patients had to have a minimum follow-up of 12 months. Exclusion criteria are listed here. We utilized two questionnaires. The first one confirmed that the patient met our criteria for recreational athlete and if they were able to return to support and what level, frequency, timing, post-operatively, as well as any additional surgeries or complications not recorded in the registry data. And then we utilized this hip return to support after injury scale or hip RSI score, which consists of six questions analyzing emotions related to return to sport, confidence in sports performance, and risk appraisal of re-injury. And this is graded 0 to 100 with higher scores indicating greater psychological readiness. Data recorded and collected from the registry for demographic data and patient-reported hip-specific functional outcome scores shown here at these time points. And for all statistical analysis, P is less than 0.05 is considered statistically significant. Out of the 562 patients that met our initial inclusion criteria, 204 met our definition of a recreational athlete after completing the questionnaire. You can see here 85% were able to return to support, 71% able to return to the same level of play. And the majority were able to return to support at six to nine months post-operatively. All hip-specific PROMs were significantly improved from pre-operatively to post-operatively for all patients, as well as both return to support subgroups at one year post-operatively and for those who were able to return to support at two years post-operatively. The hip RSI score was significantly higher in the return to support group with a mean score of 67 compared to 37. And when evaluating the relationship between patient demographics, PROMs, and the hip RSI score, the hip RSI score was the only statistically significant predictor of failure to return to support at one and two year follow-up. While holding all other variables constant, age and current sports experience were the only statistically significant predictors of the hip RSI score, with every one year increase in the age predicting a 0.5 point increase in the hip RSI score. And sex, BMI, additional ipsilateral surgery, and when one last participated in sports prior to the surgery were not predictive of the hip RSI score. Finally, all hip-specific PROMs were found to be significantly associated with the hip RSI score at two-year follow-up. So in conclusion, recreational athletes do achieve high and acceptable levels of return to support, including at the same level of play, with significant improvement in PROMs similar to what has been previously reported for high-level athletes. The hip RSI score evaluating psychological readiness was a statistically significant predictor of failure to return to sport at one and two years post-op, indicating the importance of surgeon awareness and potential implementation of strategies to assess and improve a patient's psychological readiness in combination with their clinical variables when deciding when to allow them to return to sport after a hip arthroscopy. And higher psychological readiness for return to sport was seen in the older recreational athlete when undergoing hip arthroscopy for FAI. These are my acknowledgments. Thank you very much. Next, paper nine, presented by Dr. Shane Ngo. Patients with borderline hip dysplasia undergoing primary hypertheroscopy for femorocetabular impingement syndrome demonstrate lower outcome scores but comparable survivorship to nondysplastic controls at 10-year minimum follow-up. I'm sorry. Go ahead, Shane. Go ahead and start. Oh, OK. Thank you. It's a real honor to be here. So my talk is on patients with borderline hip dysplasia undergoing hip arthroscopy demonstrate lower outcome scores but comparable survivorship to nondysplastic controls. Stop projecting. Are you on a Mac? Yeah. Are you on a Mac? Let's switch you back to a Mac. There we go. Thanks. Thanks. A propensity match study with tenure follow-up. I have no disclosures relevant to this talk. So we're all well aware that there is a pretty wide range of S-tabular morphology. On the left, you can see a hip that's clearly dysplastic. On the right, you can see a hip with normal coverage. And there's that group in the middle that we consider to be borderline dysplastic that is the subject of this talk that is somewhat controversial in terms of treatment. Some have advocated for a peri-S-tabular osteotomy, and others have advocated for modern hip arthroscopy, which includes labral preservation and capsular placation. Ben Doan published a series at five years comparing PAO versus hip arthroscopy, and he found that MCID was statistically similar. But he did find that second surgery in the PAO group was 29% versus 8% in the hip arthroscopy group. And while this is a five-year study, our question was really, what's going on at 10 years? Mark Philobon published his series of 10 years treating borderline hip dysplasia. He found that the achievement of PASS was about 77%, and survivorship was 68%. But he did note that about only 28.9% underwent capsular repair. So this probably has some role in terms of determining survivorship. And Ben also published his 10-year series on patients who had undergone hip arthroscopy for borderline dysplasia and capsular placation with labral preservation. And he found that survivorship was similar between those who underwent hip arthroscopy and controls that were defined by an LCA greater than 25 degrees at 76% and 77%, respectively. He also did note that in his hip arthroscopy group, they all underwent labral repair at about 71% and capsular repair about 100%. So the purpose of the present study was to evaluate outcomes at 10 years for patients who had undergone hip arthroscopy in the setting of borderline hip dysplasia with contemporary surgical techniques. Our hypothesis was that those with borderline hip dysplasia undergoing hip arthroscopy would have similar functional outcomes and survivorship at 10-year minimum follow-up. This is a level 3 study. Our inclusion criteria were those patients who had failed conservative treatment, underwent hip arthroscopy between January 2012 and February 2013. The borderline hip group had an LCA between 18 and 25 degrees. And our control group had an LCA of greater than 25 degrees with minimum 10-year follow-up. We exclude any patients who had prior hip arthroscopy, greater than one, and any concomitant procedures. As far as surgical technique, all patients underwent contemporary hip arthroscopy, which includes chondrolabral preservation. In addition to that, patients also went complete correction of CAM impingement with impingement-free motion and followed by capsular plication to stabilize the hip. Patients completed patient report outcomes at pre-op and minimum 10-year follow-up, which include hip outcome score, modified hip score, IHOP-12, NBS pain and satisfaction. We also did calculate MCID and PAS based on distribution method. We also did a survivorship analysis using Kaplan-Meier survivor curve. Our secondary surgery outcomes included either revision hip arthroscopy or conversion to hip replacement. This was propensity match one to three, borderline hip versus control, control for H, sex, and VMI. Statistical analyses were performed using paired sample T-tests. This is a review of the demographic information. You can see that we had 28 patients in the borderline hip group compared to 84 in the control group. All demographic factors were similar. The only differences in terms of radiographic parameters were that the LCA in the borderline hip group was averaged about 25 percent. Was averaged about 22.5 versus 31.5 in the control group. The tonus angle was 12.6 in the borderline hip group versus 6.4 in the control group. Cartilage classifications were statistically similar. Treatment were more or less the same. There was a higher prevalence of S-tabular rim preparation in the control group. Our preoperative PROs were the same between groups. At 10-year follow-up, we found that the PROs were similar, except for the hip outcome score sports subscale was higher in the control group. MCID achievement were similar. However, there was a higher proportion of patients who achieved PASS in the control group compared to the borderline hip group. Revision hip was 86% in borderline hip versus 82% in controls. The types of procedures that were performed, revision hip arthroscopy and borderline hip about 10% in control, about 8.3%. Conversion to hip replacement about 3.6% in borderline hip versus 9.5% in controls. This is a look at our Kaplan-Meier curve over 10 years, and there's no statistical differences between the two groups. So in conclusion, contemporary hip arthroscopy demonstrates high reoperation-free survivorship at 10 years, and that patients with borderline hip dysplasia undergoing hip arthroscopy show comparable survivorship compared to non-dysplastic controls, but infer PASS achievement on some PROs. Thank you. Thank you. We have a few minutes for any questions. If those in the audience want to come up to microphones. In the meantime, I have a question for Dr. Hippensteel. So you found that older athletes had higher psychosocial readiness in return to sport. Would you say that this is then a reason to delay surgery in recreational athletes? I'm sorry, can you repeat the question again? So because older athletes do better as far as returning to sport, would you say that this might be a reason to delay surgery, performing a hip arthroscopy to allow a patient to get older before they have their surgery so they have a better chance of returning? No, I don't know if I'd necessarily say that. I mean, as you know, reasons for return to sport can be multifactorial, and so we obviously are just hypothesizing why the older recreational athletes had a higher psychological readiness, but thoughts could be with a recreational athlete that they're less exposed to changing life circumstances, family, career. Their level of play and level of expectation of play is probably lower than a younger athlete, so their fear of reinjury may be lower as well. Shane, great paper. Question for you real quick. So the past scores at 10 years were pretty low still in the borderline group. Has that affected your threshold to recommend a PAO in that setting, or is your thought process the same as it was 10 years ago, you just have the discussion? Yeah, I think it definitely has. I mean, I think that's probably what we've seen is that some of these borderline hip patients might do well initially, and then at some point they might either develop recurrence of pain and symptoms. And so I think for some of those patients, I think a PAO probably would have been a better treatment option. But I think we're still trying to figure out which patients might benefit from just hip arthroscopy versus ones that would undergo PAO. And I think it's a pretty nuanced conversation with these patients, because not all patients with borderline hip are the same. Winston, go ahead. Yeah, so Dr. Tarabian, that was a very interesting study. I think the pelvic incidence and the high pelvic incidence having decreased PROs. Are we screening these patients, and can anything be done to improve the preoperative pelvic incidence in order to give them a better outcome after surgery? You know, I think in a perfect world, yes, we could screen these patients. Truthfully, the type of imaging that it requires to measure these are not routine. That's why the numbers were so low, because most patients didn't have the imaging required to take those measurements. I think with more research, once the effect is more solidified, maybe that can become more common practice. But I think immediately, we need more studies to really confirm this. And I think I noted that, I think you reported that the x-rays were taken supine. Is that correct? Yes, we use CTs and MRIs. There's been some recent research that shows that CTs and MRIs are more reliable than traditional lateral x-rays, which traditionally has been used to take these measurements. CTs and MRIs are just more reproducible. And has there been any talk about doing a prospective study, perhaps getting x-rays pre- and post-op, as well as standing and supine? There has not been, but I think that would be a great direction to go. I think also, you know, using modeling and looking at the force transduction and confirming those hypotheses I talked about in the latter part of the presentation would also be another way to go. So we'll move on to our next topic here. The next speaker will be Chad Mather. He'll be doing a technique video on techniques for capsular preservation and reconstruction. Yeah, great. Thanks. Always great to be here, and I really appreciate being able to speak, especially today. You know, we talked about, we initially talked about talking about reconstruction, but you can't really talk about reconstruction without talking about preventing getting there in the first place. And so that's why we wanted to include both these together. So today I'll try to convince you that it's essential to preserve or restore the hip capsule. Actually, that's not at all what I'm going to do, because it's common sense to do that. You know, you close what you open, you restore normal anatomy. If you entered the knee through the MCL, would you not close it? No, you wouldn't. And I would argue we spent way too much time trying to answer that question when we should have spent a lot more time talking about how to do it better and easier. This is a word cloud from some of the fellows last year, so things that they're worried about or thinking about that they need help with or struggle with. And you'll see the capsules on there, but the bigger words are things where you need management of the capsule to do effectively. So the goal really is to maximize exposure, both visualization and maneuverability, while disrupting the capsule the least, but also doing it in a way that's reproducible. And that's where we really need to go, is to develop techniques that are more reproducible. So before we get into this, just some givens. Remember, this is part of the exposure. That's what we're trying to do. It's not part of the surgery itself. It's part of the exposure. You know, violating the capsule in some way is necessary to treat intra-articular pathology, and that the transverse or inter-portal is more disruptive than longitudinal. Back in 2012, we started realizing we needed to preserve the capsule. And in the early moments of that, it was a little bit like those MIS tittle joints where I didn't feel like we were doing the intended surgery well at all and needed to come up with a different way of doing it. And that's how we developed this idea of using sutures to suspend and protect the capsule. And this is what that finished product would look like. And this is largely how you do it. So we always like to say that capsule preservation starts with the capsulotomy, with the placement of the anchors. It's important to have really clean edges and really have it be complete. Using any of your preferred suture passing devices, I hear I like to pass a number of sutures through here, using some different colored sutures to help you keep your orientation as you go through this. It's important to get as big a bite as possible to preserve that, and then snap those against the skin for some tension. One of the questions I often get are, how many do you put in? And when do you get comfortable with this technique? They're quick to put in. And one of the reasons I put in more than maybe some other folks do is also because they can act like a sled, and then you find you don't need to use those canyons or sleds as much, and that can make the procedure more efficient overall. One of the most important things in preserving the capsule is getting an adequate proximal edge. And this is a little technique that maybe I'll help you there. I call this the airlift. This is what Landry Jarvis, one of my old fellows, came up with this idea. But you'll see there in that video how it opens it up, allows you to get more distal without injuring the head as you come in, and leave a little bit better proximal edge. So now on to the harder part, that peripheral compartment. So this technique here, I think, makes the osteoplasty a little bit more palatable, if you will. So we start here by adding these suspension sutures here. I like to create almost like a goal post here with two of them, again, using different colored sutures so you can organize them. You want to come in and perform the T perpendicular to the fibers. The more tangential it is, the harder it is to repair it. So here I've kind of come in through the dala, but then come in through the anterolateral portal to be perpendicular. The tension with the sutures allows you to really fine-tune the T. And here I'm just assessing my access to the femoral neck, and here making sure I can close this with one figure eight, and that's usually where I'll stop. Now pulling through the anterolateral portal there, you see it doesn't lift it away as much as you'd like, so we make a small posterior anterolateral portal, just a tiny poke, come through and grab that. And that allows you to lift up that lateral leaflet up and away, and often allows you to do a smaller T. And then when it comes time for repair, you've got that leaflet just stretched out there, makes the repair just that much easier. Now raise your hand, though, if you love the visualization access of the T, but you don't like to open and close it. Yeah, get them up there. Yeah, probably all of us, right? Yeah, right. Well, that's what developed this technique, and we call this the sneaky T. It's all the viz without the miz. And so what we do here is we place two more traction sutures across the zona distally, kind of really on either side of the osteoplasty there. And they come in one below, one above, and using that from the outside kind of passing down and focusing inside here. And you'll see as we lift these up, it allows you to access the distal neck quite well. And oftentimes, now you're able to see it, but how do you get there? And so this technique here uses just a small periportal longitudinal capsulotomy coming in with the knife here, and carefully just widening a small window here, a window that's small enough that you really don't need to close. I did in this case because there's some hypermobility here, but for the most part, you don't need to do that. Then come out here, make sure that it's wide enough to get in from the top side. And you'll see here as we come in with both the radio frequency device and the burr, that you really have great mobility and great visualization, again, those keys that we mentioned earlier. But it definitely makes the closure a lot easier. And I think the reality is we know that the longitudinal cut doesn't really add a lot of instability, but the T part of it, as you see in skin, often doesn't heal as well as you might need to worry about that being an issue here. This allows you to have that kind of access without having to repair it. When it does come time for repair, I use figure eight stitches here. One of the biggest tips I would give you here are two things. One is use different colored sutures because it makes it easier to retrieve them. And use the sutures, the suspension sutures you have to manage this. I always tell a fellow, it's time to be Geppetto, you know, the puppet master. And if they can kind of come up and down, much like you would use a forcep to lift the edges of the capsule up and down if you're doing it open, that helps you a lot here. It's really important, too, to be able to come perpendicular and not across the capsule. That's a real key piece, getting all the way underneath. And this here just shows you how you can also placate there as well. And that's what it should look like there with the rectus protected and not encaptured in the enclosure. But then what if you're looking at one of these MRIs, you know, where you've got a capsule defect? Maybe there's some proximal capsule left. Maybe there's not. Maybe it's retracted and stiffened. So what options do we have? Do an anchor-based repair? I've done those. I don't love that. I think they can have a high failure rate. What about limiting extension in post-op recovery? Also doesn't work. People need their extension. They'll either blow through the repair or they'll get back pain. And then there was the allure of a simpler biologic augmentation. And I also found that largely is unpredictable. And so my preferred technique when you're in this situation is an allograft reconstruction with an IT band. I like to come from the outside in. You know, nowadays people have often tried to repair the capsule. We've all made that attempt. So the sutures are there and that can guide you to where the defect was. There's a lot of times the problem is are those mechanical edges and like to clean those up without resecting much of it. Still use the same suspension sutures to control it. And in one where there is proximal capsule like this one, put one anchor in the subspine to secure the graft up there but still pass it through the existing capsule and then pass simple sutures around to be ready for the reconstruction. Use a folded IT band graft with the fibers in line with the direction of pull and then whip stitch it to secure it. Here we're taking the proximal sutures and passing it through, organizing them here as you'll see in a moment with a ruler and then passing them through the graft. You know, when you shuttle it in, you always say you've got to put the video on because if you don't believe in yourself, then nobody's going to believe in you, right? So you've got to put the video on, hopefully it slides in well like this and generally if it slides in well, it's good and if it's not, then it probably is not. And then tie the proximal ones and then pass them distal here, those simple sutures that you had previously placed. And then this is a video of that final and you can see how nice it restricts external rotation and anterior translation with the fibers being oriented to the direction of the femoral ligament. Now if you're in a situation where there's no proximal capsule, there's a variation on this technique. This is a case where you can see just at the start of the case, the large defect here with inadequate proximal capsule. This is a previous technique where we used to use dermal allograft, but what we'll do here is put three anchors spanning the defect, a single-loaded anchor on the ends and a double in the middle in the subspine and use that bridge technique which allows you to compress that across the acetabulum quite nicely there. You see the rectus there being protected with minimizing some of the knot burden. So the outcomes for these reconstructions, we looked these up a couple years ago and in about 21 patients with dermal allografts and the takeaway here is that they get better. About half of them achieve the pass, about 75% have improvement. Some do get to 90 or 100 on their IHOT, but for the most part, I usually counsel them about 75% chance that they'll get appreciable improvement. Then lastly in evolution of my approach has been to move to an IT band rather than the dermal allograft, have a lower threshold to use a graft because I think it is more reliable to use it outside an approach and then occasionally the anchor-based extra-articular reconstruction can be effective here in cases of hypermobility when you can't rely on soft tissue healing. And lastly, I'd like to just leave you with a bit of a reflection and a thank you really. One of my old mentors who was very successful in her own right liked to say that we may have never reached the goals we set for ourselves because we're also such ambitious people, so we sure better make sure that we're doing it with people we enjoy being around. We've really advanced the field, we have a long way to go, but I can definitely say that we're getting that last part right. Thank you. Thank you. Next, Dr. Ngo will talk about the management of the failed labral repair. Great. Thank you very much. It's a real honor to be here. I just want to thank the AOSSM Special Day Committee for the invitation. I'll be speaking on management of the failed labor repair. My name is Shea Ngo. I'm at Rush University Medical Center in Chicago. These are my disclosures, not relevant for this talk. This is a case example of a patient who had undergone a revision hip arthroscopy. He underwent a labral repair, and you can see that at six months, he's back to football. You can't really determine which is the operative and the non-operative side. This is a good result for revision. Any time I see a patient who's had a failed hip arthroscopy, I'm always trying to figure out, like, how much the labrum had played a role in this. And so, in this talk, we'll just kind of go through how to evaluate this, both on imaging, as well as intraoperative inspection, and finally, what to do about it. And I think it all goes back to trying to recapitulate the normal labral anatomy, and I think for me, that entails using a small anchor placed as close to the subchondral bone as possible, and then placing stitches that will not evert the labrum. And I think in doing so, we're able to maintain the biomechanical characteristics of the labrum, and that is to maintain the suction seal, to address stability of the hip, dissipate the contact pressure, as well as address pain and proprioception. So, in terms of our treatment options for labrum, that's pretty straightforward. It could either entail repair, augmentation, reconstruction, or debridement. And my treatment algorithm is fairly intuitive. If you've got good, healthy, native tissue, I'll go ahead and repair it. If the tissue quality doesn't look very good, it looks fairly diminutive, I think our options are either selective debridement, augmentation, or reconstruction. In my own personal practice, augmentation or reconstruction comprises about 20 to 30 percent of revision cases, and less than 1 percent of primary cases. As far as decision-making is concerned, if I see a patient in the office who had undergone a previous hip arthroscopy, I think the history is really important, and I want to understand, like, what is the level of pain currently? How does it compare to the pain that they had before surgery? Is it better? Is it worse? Is it about the same? When was the procedure done? Was it less than a year ago, or was it greater than a year ago? Was this a late failure or early failure? What was done at the index surgery? It's helpful to get an operative report, as well as intraoperative photos, to see what was performed. And was the patient doing well initially after surgery, and was there some kind of traumatic incident that caused kind of a downward spiral? Obviously, the physical exam is important to understand what their gait looks like, and paying attention to their terminal extension, as well as measuring their range of motion on the affected and non-affected side. Provocative testing, I think, could be helpful to help delineate, is this more of an impingement scenario or more of an instability? So, I think the first thing we want to make sure is that the indication for the first surgery was appropriate, that it was actually a different diagnosis that should have been made, such as, you know, was there a suggestion of instability? Perhaps the patient had dysplasia or some kind of orientation issue that required an osteotomy? Or was the patient better indicated for a total hip replacement because they had pre-arthritis? If we have agreed that the right indication was done, but the wrong surgery was performed, we'll get X-rays and imaging studies to determine was the reason for failure of residual FAI? The other scenario is that if you've got an emerythrogram and you see, like, a large capsular defect or capsular insufficiency, that might become more apparent, as well as potentially any labral pathology. Thirdly, is there a cartilage issue? This, obviously, you can see at the index surgery if a microfracture is performed or some other cartilage restorative procedure. MRIs can also be helpful for that. And lastly, the labrum. How does the labrum appear on MRI? How does it appear at the time of surgery? So, three things to consider. One is the preoperative plan, based on what we talked about already. I think the intraoperative assessment is really important, and I think I've relied more and more on that. I tell patients, when we're talking about a second surgery, that there are four things that we can address intra-articularly. That is the cartilage, the labrum, the capsule, and any residual impingement. And at that point, once we focus in on the labrum, we're going to then determine debridement, repair, augmentation, or reconstruction. So, one of the things that I want to try to figure out is, upon distracting the hip, was there a kind of a pop, which would suggest that the suction seal is intact? Then I'll go ahead and use my probe to determine what is the quality of the tissue? Is the base secure? Is there any incompetency between the labrum and the cartilage? And at this point, we'll then take the hip off traction. We'll see if there's nice compression of the labrum against the femoral head. And then we'll also distract the hip to see if we've got any maintenance of the suction seal. If there's any adhesions or loose sutures, obviously we'll address that, so we can see if we can get a good suction seal. This is a case of a 37-year-old woman who has status post-hip arthroscopy about three years ago. On physical exam, her motion was reasonable. She had pain with provocative maneuvers suggesting impingement. Her x-ray, she has good joint space. She has a lateral syringe angle of 42 degrees and an alpha angle of 62. So, based on the imaging, I would suggest that probably the patient's issue is residual impingement. When you get an MRI, you can see the cartilage appears to be well maintained. Labrum, I think, is kind of hard to tell based on this MRI, but when you look at the capsule, you can see that there is a little bit of a capsular insufficiency enters superiorly. So, this is what we see at the time of surgery. You can see that there is delamination at that chondrolabral interface, suggesting, again, residual impingement from a cam deformity. We'll go ahead and just debride that. We'll remove some of the adhesions. I think sometimes if you have a captured labrum, that this affects the normal function of the labrum. And I do want to reestablish that recess between the labrum and the capsule, and I think that's really important just so that the labrum can maintain its normal function. So, if you've got a non-captured labrum, I think that those tend to do better. So, again, residual impingement was kind of our working diagnosis. We want to make sure that we've completely addressed the cam and that we have impingement-free motion. In addition to that, that capsular rent, we went ahead and fixed primarily because there's a small capsular defect. This is a case of a 24-year-old baseball player, status post hip arthroscopy about two years ago. The patient had good range of motion, had a positive pain with impingement testing, had some weakness with flexion and abduction. When you look at this patient's x-rays, I would argue that the x-rays look pretty good. Joint space looks good. No evidence of dysplasia. Cam impingement was well taken care of the first time around. Here's the MRI, and the MRI shows a pretty significant amount of fluid extravasation, attenuation of the capsule, and you can see all that fluid leaking anteriorly. When you look at the labrum intraoperatively, you can see they've got a substantive labral tissue. In my mind, I'm thinking the labrum is probably not necessarily the problem, but does seem to be somewhat unstable, so we'll go ahead and do a re-repair of the labrum to stabilize it, and then again, the capsule seems to be a significant contributor to this patient's issues. We'll go ahead and repair with anchor-based repair techniques. So, a word about MRIs. I think MR arthrograms are really helpful in the revision setting. On the left, you can see a primary hip with an MR arthrogram, and one of the things I want to pay attention to is that recess between that labrum and capsule. On the right, you can see a patient who had had a prior hip arthroscopy, and you can see that the interface between the labrum and the capsule is not distinguishable, and in these cases, if I'm going to see this patient and perform surgery, I'm prepared to do a labral reconstruction or augmentation, and so this is the appearance. I think many of us have seen this in a revision setting. You can see that there's significant adhesions and thickening between the labrum and capsule that really just doesn't allow the labrum to function well. So, basically, we want to release all those adhesions and free up the labrum from the capsule, remove any foreign bodies that might be in the way, such as sutures or suture anchors, and then go ahead and do your labral reconstruction or augmentation to maintain that suction seal in the case of an insufficient or diminutive labrum. So, this is a systematic review that was published by Mike Lee on five studies, 359 patient, minimum two-year follow-up, which showed survivorship between 93.5 percent and 100 percent in patients undergoing labral reconstruction, augmentation, and revision setting. This is Mark Philippon's study looking at his experience with labral augmentation and revision hip arthroscopy, 88 patients with three-year minimum follow-up, high survivorship, 79 percent, high achievement of MCID and PAS, 82 and 72 percent, respectively. This is a study published by the MASH group, a multi-center group, looking at revision hip arthroscopy, revision labor repair versus revision labor reconstruction. Similar in terms of number of patients, 40 to 55. The revision labor repair was slightly younger at 30 years compared to 34 in the labor reconstruction. There was more severe labral tear complexity in reconstruction group, but the cartilage damage was more significant in the labor repair group, and they did find that MCID was similar at 73 percent for repair versus 79 percent for reconstruction. And the achievement of PAS was also similar at 51 percent for repair versus 54 percent for reconstruction. This is Ben Dome's experience looking at revision hip arthroscopy with labor reconstruction versus repair, and found that in repair, 73 percent returned to sport versus 64 percent of reconstruction. So, in summary, when I'm evaluating patients who had undergone a prior hip arthroscopy, I want to know why this hip had failed. Obviously, use our clinical history, imaging studies, and intraoperative assessment to help guide treatment. My goal is to preserve native labral tissue whenever possible. Obviously, augment or reconstruct when it's sufficient. Clinical studies are good for both repair and reconstruction. However, long-term studies will be important to determine which is more durable. Thank you very much. Thank you. At this time, I'd like to invite our panelists up to the stage. Let's see, we'll go ahead and put this up. Here we go. Hi, I'm Mark Safran from Stanford University. We're going to have a case-based discussion with myself and Andrea Spiker from the University of Wisconsin. And we'll try to get through all the topics that they were trying to get to us or wanted us to cover. So we have a great faculty here who have experienced our hip arthroscopists. We've got Mike Ellman from Panorama Orthopedics in Denver, Winston Gwathmey from UVA, Deshaun Lynch from Henry Ford, and Troy Chadmather from Duke, and Shane Ngo from Rush. So the first case is a 26-year-old female. She's a taekwondo instructor who had right hip pain. 28 months prior to her presentation to me, she developed right hip pain doing a high-intensity kicking workout. And over the next month, the pain actually continued to increase. And then it got to a point where she had a severe episode of hip pain as well as associated popping while doing a stretch. At that point, she was then unable to work as an instructor. She saw her orthopedic surgeon at home. He got an MRI. It showed FAI with a labral tear. She had an intraarticular injection with some anesthetic that gave her 75% pain relief. Ultimately, three months after the injury, she underwent an arthroscopic osteoplasty for a cam deformity, chondroplasty, and labral repair. And by her report, she said she did well for about six to eight months. Then about 14 months prior to seeing me, so about halfway from when she had original injury, she developed some right hip pain as well as some pain in her quadriceps. She was sent back to physical therapy. It resolved her quadriceps pain, but her hip pain persisted. Then she moved to California, complaining of tightness in her hip as well as a discomfort with pivoting and kicking. And then it got worse to the point where it wasn't just in her pain. It now wrapped around towards her lower back as well. She noted that she'd been in physical therapy for a year at this point and was still unable to really do her work as an instructor. She saw another surgeon in our community that got a repeat injection of her hip that gave her 80% pain relief. Over this course of time since her surgery, she had had three more MRIs, the latest one being associated with that injection a month prior to seeing me. She was read as having a labral tear on that MRI, not taking any medications, but her pain would get to an 8 out of 10 at its worst. She had pain with squatting, kicking, and prolonged walking, complaint of tightness, and what she described as some intermittent instability, some catching and popping about her hip, and again, unable to work as an instructor due to this right hip pain. So with our preliminary thoughts, if we can, from our panel, you've got a 26-year-old active female with two-year status post to hip scope that did well for about six to eight months, had a camera section with labral repair, but she's still unable to be active. I know Shane kind of went over a little bit about the failed hip arthroscopy, but any thoughts from our panel just kind of off the top of your head before we get into any exam and imaging? Winston, you look like you're ready to ask. The suspense is killing me. I want to see the imaging. This is such a comprehensive story, and I feel like when you have a prior surgeon from an outside community, you don't really know exactly if they're doing the right operation the first time. Does this person have dysplasia? I mean, what's going on here? So I think I want to see the imaging before I can really make a true assessment, but the fact she did well for six to eight months after the first hip scope, at least there's something that can be done here, but the fact she's had this recurrence makes people a bit worried that she had a bad diagnosis the first time around. You know, Mark, I've got a big piece here, too. What you don't need to see the imaging for is to understand this patient's undergoing a lot of distress. I mean, she can't work in a job that she obviously loves. She loves to play lots of sports. She's probably done that her whole life, and that's certainly going to affect this in a lot of ways. The other highlight for me is that she's worse than before the previous surgery. That's always a big junction point. Yeah. Yeah, and this has instability written all over it. Just with this story, we see this quite a bit. I think, you know, 10 years ago, everyone would be thinking residual FAI, and I think that has shifted where we're all thinking, or we should be thinking, that this is more of an instability ballgame in this case. And can I ask the panelists, as part of this workup, prior to her initial surgery, as well as at this point, she's had an intra-articular injection with significant pain relief for a short term after that. What do you make of that? So I was just going to say the one part of the story that was a little concerning was the low back pain component to it. Now is the back pain a separate issue, or is the back pain coming because she's protecting her hip? I think, to Dr. Spiker's point with the injection, that at least gives me some solace that, you know, this is likely a hip issue that's causing these compensatory problems, which, you know, as to Chad's point, you know, the psychological distress and the musculoskeletal angst that we're dealing with. Yeah. Yeah, I mean, certainly, you know, before 2010, the most common cause of hip arthroscopy, failed hip arthroscopy, was untreated or CAM, and now, certainly, instability is more, we're more aware of that. And then the question is, was it a correct diagnosis to begin with and or appropriately treated, right? So let's go ahead to her physical exam. She's 5'2", actually weighs 172 pounds, a ligamentous laxity test, 3 out of 9, but the keys here is that her hip flexion is limited on both hips, but actually a little bit better on her symptomatic hip, but with pain when you flexed her up. Her iliopsoas was a bit weaker on that side and was tender over the iliopsoas on that side. But her impingement tests, her labral stress tests are hurt on the symptomatic side. And 3 of the 4 instability tests that we do in our clinic, the hyperextension external rotation test, the abduction extension external rotation test, and the prone external rotation test were all positive on the symptomatic side. Mark, real quick, do you know which side she more predominantly kicks with, right versus left? Right. So this is her imaging. It was read of post-surgical changes, status post-CAM resection. However, when you look at the AP radiograph, it looks like maybe there's some evidence of CAM anatomy as well, but the lateral looks like there's a reasonable offset. When you measure her center edge angle, it measures 20 to the sore seal, so by the measure of Ogata, and the far edge, it was 29 degrees. Her tonus angle was 11, and her alpha angle was 83. Of the multiple MRIs, just showing you the latest MRI, which was a month prior to seeing me, it's an MR arthrogram, status post-CAM resection, labral repair chondroplasty. But it also suggested that she had signal at her labral repair that was read as a re-tear, though you don't see much bright contrast there, so the possibility maybe that's just normal post-operative change, which we see. And she had a small to medium capsular defect as well. So now, now that you have the imaging, Winston, as well as the physical examination, what do you guys, what do you think? Chad, do you look like you're ready to go, or? No, I was just grabbing some water. I'd get some cross-sectional imaging to better characterize the morphology. I'm sorry? Some cross-sectional imaging to better characterize the morphology, the torsion and so on, yeah. All right. So you get like a 3D CT scan? Yeah, yeah. Okay. Version analysis. What else, what else are you guys thinking? What do you think, why do you think she's having the pain? There's an intra-articular source of pain, obviously, with the anesthetic injection, right? So you've got capsular defect, you got maybe a labral tear, maybe not. You got an alpha angle of, you know, 83. It's borderline dysplastic patient. We didn't have the operative report. She was unable to get that, so I don't know if the capsule was closed and re-tore or if it wasn't, was never closed. But again, possibility of instability. So we've got, we're hitting two of the three points that Dr. Dickens and Toth had asked us to get, which was revision scope and borderline dysplasia in this one case. So what, what else? I think there's signs of macro and micro instability here. So you have capsular defect, you have a hypertrophic labrum, which is classic for dysplasia. I think that's more of a dysplastic hip than borderline, frankly. If you just look at the imaging, I think that the true center edge is, you measured it, 20. She looks, it looks like a hypovolemic socket with undercoverage up front as well. So what I didn't like about it is she's got subchondral sclerosis and she's got a touch of narrowing on that standing AP, which is scary for a 26-year-old or 27-year-old. So she's, she's beginning to get a little bit of arthritic. I think you've got to change the biomechanics of that hip. Well, before I ask you kind of what you guys would do. So Chad, we didn't get a 3D CT. I do get that oftentimes in revisions, but not on a routine basis. She had this, you know, as I reviewed the MRIs, there was no comment on these two sagittal cuts, but you've got something here and you got something there. Uh-oh, uh-oh. That's the uh-oh sign. So no, I mean, is that, is that just your normal, is that from the prior anchors from the labrum? Is that, you know, nothing to... That's a subchondral cyst forming. Well, it's a, it's a, the subchondral plate is disrupted from, I mean, it's far away, but I think that's what you're showing us, right? Yeah. That's a big deal, obviously. Yeah. So what, what does that, what does that tell you? It means there's an anchor in the, an anchor in the joint causing a problem. If there's an anchor in the joint, why does she feel good for six to eight months? Well, they, they can actually, you know, be, I know, you know, kind of subarticular and cause a problem. I actually saw one recently, it was an all suture anchor that was abrading the head and took, it took some time. So I think it's more complicated than just the, the awful one that's sitting there prominent. They can actually be symptomatic even once that, that plate is disrupted. So, so what do you guys, what would you guys do? Would you, I mean, you got a, just plastic patient with instability and a CAM, would you just send her for a PAO with, with an open osteoplasty? Would you, would you do a scope? Would you diagnose scope? What, what, what do you, what would you do? Shane, what would, what would this person get if she came to, to Rush? Yeah. I mean, I think this is one that we'd send to get a PAO, but we typically start with a scope first. You know, if there is obviously cartilage concerns, we would have some, potentially some cartilage grafts options available. If there is an anchor, either soft tissue or hard body anchor, we want to be sure that we take it out. I mean, but there does seem to be a significant cartilage issue that we would do with the scope portion. If there's label concerns, obviously address that capsule. And then we typically do a stage PAO in our institution. I think that's probably what, this is, we, we do a lot of them combined, but this is potentially a big soft tissue reconstruction. That anchor, you don't know what you're going to have to do for that exactly, how long it's going to take to get out. I'd probably favor like, like changing it to staged operation. And I think her, her high demand, her, you know, being involved in a high demand activity combined with that being her livelihood would, would further underscore the need for a PAO here. Anybody doing any different? Or are they just doing just a scope or just going straight to the PAO? The main difference is we would do a combined same day. Scope first, then followed by the PAO. Yeah, that would be my thought process as well too. I think she's already had her opportunity to see if she could get away with a scope with her hip and with everything that she's got. I think it's, you know, you know how the story ends. So, I mean, do you think she got, got, you know, that the first scope was a legit try in the sense if you have still a CAM lesion there or a recurrence CAM and she's got a capsular defect. I mean, do you, you know, is that a contemporary technique, I guess, you know, that Shane talks about? It's not. But, you know, you know, as we know with these subsequent surgery that you have, your, your ceiling for outcomes keeps coming lower and lower. I just feel like she's just not going to be successful managed arthroscopically. Andrea, you're, as a moderator, but you're, you scope and do PAOs. I mean, if she came to you, what would you do? Well, I think this is an interesting corollary to our knee session that we just came out of where we're talking more and more about things outside of the joint, like the tibial slope. And, and here in the hip, we also have that experience where, especially in a revision setting where the soft tissue attempt failed. You know, we want to think about acetabular version. We want to think about femoral version. We want to think about tibial torsion. We want to think about all of these multi, you know, three-dimensional multifactorial issues that could be contributing. But you have a very good point, Mark, that, that not all hip arthroscopy is the same. And so knowing exactly, you know, if a good hip arthroscopy was done versus a failed attempt is extremely important. And I, I, like Mike, we'll do a simultaneous scope and PAO if that's indicated, or, you know, at least take a, take a look inside the joint first. Okay. Well, as we've got less than a minute, so kind of when I took her to the OR and put her under general anesthesia and just pulled on her leg to make sure her perineum was against the post. Cause I still use a post her hip distracted five to six millimeters just with that, which is a clear sign of instability. First thing I saw when I got in there was unfortunately that, which was a concern as Chad was aware that would might happen. So that's a peak anchor sitting in the joint. You can see sutures from her prior repair. You can see some control damage right in that area here. You can see again, a few more sutures as I look a bit more laterally. So you can still see those first two and one more lateral looking at a peripheral compartment. That's her cam resection anteriorly, which looked good also on that lateral radiograph, maybe a couple of arrests of maybe some growth there but otherwise look good. But when you look down more towards the lateral side, that's her anterior resection, but you can still see a fair amount of bone straight laterally. There's the anchor as I was trying to get, get it out. And then you can see after I've gotten it out, she now has a centimeter chondral defect. So there's our cartilage part of the equations here. Whoops. I think we cut you off. Just a technical point about that anchor that the surgeon to put that in probably did not see that was interarticular. It was probably beneath the wave sign. And so I always worry and there's, there's always going to be a chondral wave sign that one region there, and you can even put the anchor in under visualization, just not see it at all. So you have to be aware that it's always a potential in that one region. And also when that happens, nothing went well. It gets all messed up. Yeah. So what'd you do about the cartilage mark? Yeah. So basically what I ended up doing, this is not moving along. Basically what we ended up doing was we did a microfracture at the acid, of the acetabulum. The labrum where that was fixed to that anchor was still a bit loose. Put a couple anchors in that, did a revision camera section and I did a capsular closure and tightening. I only have six month follow-up on her. She's back teaching Taekwondo feels good. I didn't do the PAO. I figured that if we address all these issues, we can always go back and do a PAO if she wasn't doing well. And so that was the approach we took. So, and that's our time. Great case. All right. Thank you all very much. Thank you everybody. Thank you to the panelists.

26-year-old female

hip pain

hip arthroscopy

FAI

labral tear

physical examination

imaging findings

surgical exploration

microfracture