stuck in another ICL because he had two faculty call in last minute. They can't make it. So I'm going to present his. Forgive me for that. I'm going to do a much worse job than he does, but I'll do the best I can. So this is, he apologizes for his terrible care of this patient. He told me to say that. I'm here to defend him. So revision FAI surgery. This is an elite football athlete. So this is Ashish's patient. So this is a 20-year-old strong side defensive end, four-year history of refractory right grade and left hip and groin pain. Surgery in his junior year of high school. He never improved. He had two cortisone injections his senior year to allow him to continue play. He was a freshman at the U of M, unable to participate more than two days without refractory pain and discomfort. He had pain with squatting, cutting, and pivoting, even sitting in while in class. So this is his prospect video. I'm still trying to figure out what that's supposed to show us, but he's playing football. Here is videos. So his coronal MRI. And you can see a little bit right as we come through, some concerning sort of cystic formation in the acetabular dome. Obviously residual cam deformity and a labral tear, looking at the sagittal as we come through. And you can look at both depending on what you want to continue. And they have a ligament disruption too. So that weird sort of cystic process, seen better on the sagittal. See it one more time and kind of focus on the sagittal MR as we come through, right as we come through, right about there. So obviously residual cam, labral tear, sort of cystic formation that we start to worry about in these players and frankly in all of our patients that are marginally concerning for their outcomes. So he had deep anterior groin pain, flexion of 100 degrees, internal rotation on the right was negative five, left was zero, positive sub-spine, positive fader. He had pain at the adductor origin, negative valsalva, no radiation to the testicles. So no significant hernia risk. Two portals were present and he had positive LFCN numbness. So here's his AP of his pelvis. One in frog lateral and here's his MRI read. So since this is Ashish's case and he's not here to defend himself, we're going to do a little different style of this in terms of conversations and discussion. So at this point, Mark, you see a lot of high level athletes. What are your thoughts here? Well, I'm looking at the, it's got a flat offset, bone bruise on the MRI. You see that's a bone edema on the acetabulum. So for me, I'm concerned about the cartilage and this is a situation, low energy like this. In fact, I'm concerned about the, and also the deformity we're seeing almost look, not a standard smooth convexity, almost look arthritic also. Already at that age. Okay. Yeah, I mean, the cartilage sounds concerning, but at this point I'm not sure there's anything can be done about it. And he's got plenty of other pathologies, he's got significant FAI, he's got iliofermal ligament disruption. I'm thinking treating what needed to be treated originally and hoping he gets some improvement and hangs on. So Chad, you showed a magnificent picture of this incredible osteoarticular allograft transplant that, by the way, never try that. So you know, yeah, ever. That's why he does the dark arts of hip arthroscopy when he does these things. So would you want to attempt that in this kind of- If he had a focal defect, I would, but I don't think this is a focal defect. I think it's, I agree, it appears more diffuse, but most of those, the allografts are best for those lateral lesions that are- Yeah, those big lateral lesions that you get from big cam, not from those more medial central, you know, global arthritic type of issues. Yeah, I think that's the point. I think, like you just said, I think this is almost a hip that has its course. And even if you do a perfect procedure, the arthritis might beat you there. Yeah. Is there a CT scan? So here's a CT. Version eight degrees. Little bit of focal isolated cephalic retroversion. And the rim looks like the labor was ossified, so now you're, I mean, he's got potentially deficient labor. Okay. That's a real problem. But I mean, you know, in this case, the goals are different, right? I mean, if he can play a few years and that's really important to him, that's about the best you're probably going to get, but- So these were Ashish's questions. In-season versus out-of-season. Degenerative changes. Implications of that, we've discussed that a little bit. Do we do a revision labor repair versus recon? Revision hip scope? What are the outcomes? Treatment of contralateral side? And how do we counsel this guy? So we've discussed that a little bit, I think. Any question in the audience so far? Anyone else have any thoughts on what they'd be doing? Okay. Well, let's see what he started to do. So this is the uh-oh. So turns out that cyst, not degenerative. That was an anchor that was encountered in the joint. Doesn't look very diffuse either, does it? Pretty focal. So this is some of the issues we have with imaging in 2021-2022 in the hip. And we're getting better and better, but it's still a very deep joint and looking at very small, focal things like this can be hard. So that cystic change, not a cyst, that was a hole around an anchor. Yeah, I didn't see, I mean, when I've seen these, I usually do see on the MR, but I didn't see that on that MR. Nor did I. Yeah. So at this point, you now found something, and in his case, this was why it was his worst case, because it was totally unexpected. So how do we do this? What do you do with the anchor? Do you go in and cut out all the tissue around it, burr it out, manage it? Mark's going to throw in some thoughts. I've seen that multiple times, actually, unfortunately, especially with peak anchor. Sometimes the anchor is placed properly, and I've seen some subset of patient migrate over time for some reason. Maybe it's from the drill that was done previously. So I use, to take them out, actually, I use a microfracture pick, and I try to flick them out. Unfortunately, this was partially perforated through the cartilage. So I use that area, flick it out, and I use a grasper to pull it out from intra-articular instead of trying to grab it from the outside, because sometimes they're buried. If you can grab it, if you see the head and grab it, it's great. Also, what I've done is I use the microfracture pick around the entry point on the periphery, and then make little holes, and then grab it with the micro grasper. But it works. It's good to have microfracture pick for this. I've been through this, unfortunately, multiple times. I told Dr. Saffron I was going to pick on him, so this is the time I'm going to pick on him, because he's sitting here today. So, Mark, I'm sure you've seen some of this stuff in your practice. What would you do here? You know, I mean, it probably depends. Generally, it's probably, obviously, it was the trajectory that they drilled to put in the anchor itself. Most likely, that had been there for a while. The cartilage usually is kind of just beat up. I actually clear off that cartilage so I can see the bottom. As Mark said, I think you just, you don't need to take out necessarily the entire anchor. You just need to take out the part of the anchor that's actually blown into the, you know, articular side, if you will. But, so I do use also microfracture awl. I think that's the easiest instrumentation to try to get to that. And then, and if that doesn't work, you can try to use a shaver, but the problem is with the angle, and that seems to be pretty focal. The ones I've gotten have generally been more advanced cartilage wear from the drilling and the placement of the anchor and the anchor sitting. That actually, most of the stuff around it looked pretty decent. You know, the head was pretty clear. I just try to get that down so it was flush with the subchondral bone and then move on from there. I don't think you have to take out the entire anchor, so that would be my approach. Do you use a burr? Do you burr it down? You could, well, I'd use the pick. I'd try to use the pick because the angle, and when you use a burr, if you have good cartilage around it, you might cause some damage to the cartilage around it, especially in getting at the angle. But if you have to, I mean, in the worst case scenario, but you want to try and stay right at it at the right angle. So you might need to use, from that, probably go from a posterior lateral portal so that you can come at it straight because you'll have trouble getting it around the curve if you're coming from anterior or anterolaterally. Yeah, they come in a few, I mean, I've had one that's like a through and through, and that was almost all the way to conloid fossa. But I agree, like this one, like Mark said, it looks pretty narrow there, fortunately. So you're probably going to be able to, if you can get that out cleanly, you're just going to have a thinner line, which is pretty well tolerated. It's a pretty small defect. I had another one where it was put in more just through the whole surface, and it was also probably in a previous delamination, so now he had a huge defect, and he ended up, by the time we got out, had some bony defects. I did use a procondrix graft for that and MR'd him later, and he ended up doing quite well with that. I had another really interesting case of my own where there was a pre, and the question is, was some of that cyst pre, could have been preexisting? Because I did one where I put a small anchor near a cyst, and I have the intraoperative picture showing it's clearly not in the joint, you know, no bubbling or anything. And then she had developed some symptoms, that cyst grew, had some mechanical symptoms, went back, it had eroded through the articular surface. You could actually see on the femoral head. It was right near or so as to where you could see on the femoral head where the anchor was pushing through and creating some of that real superficial wear. And I sent that around to all you guys in mixed opinions of aggressiveness and treatment for it. All I did was just take the anchor out, and she did flawlessly, perfect. So I do think some of these, less is more, I think that's what Mark was saying too. Question in the back. Along those lines, once you get that anchor out, then you get to the next question of the FAI. They were talking about, I know Dr. Phillip, I believe, listed a study back on offensive linemen in college, and the incidence of FAI, it was 60 to 70 percent of these guys had an asymptomatic FAI. And so, and also when you're talking about hockey goalies, a lot of them are going to be having a lot of this also. And then the question is, when do you jump on the bandwagon to do a cam and or a pitcher in addition to the layup? And I, going to the less is more approach, you know, I, well, once you get that anchor out of there, but I don't know whether, you know, Dr. Saffron, Dr. Saffron, I definitely would treat his impingement in this case, but. Yeah. Yeah, again, it depends on the expectation and the motion at risk is going to be subject to afterward as far as level of activities. I think that's the best way to handle it. If you have someone who's going to go back, play high level sports for at least five years or, I think it's better to treat it. And we've published on that a patient who had surgery in 207 versus 217, played 10 years on an untreated hip, played 10 years with a treated hip. The side we treated that no, no arthritis, minimal arthritis, the side I didn't treat because he had no pain, didn't look good. I had to do a microfracture on it. But again, it's a rear view mirror analysis. It's a, I would have never treated it anyway because he had no symptoms, but you got to look at what he's going to be subjected to. That's I think the, but it's better also you have patient, they're 20 years out with no CAM treatment, just label treatment and they amazing. so it's a tough it's a tough balance all right so let's see what he did so in this case she's kind of went briefly through a limited research on safety and efficacy turns out the most common portals used anterolateral mid-interior poster lateral distal lateral as far as refixation of labrum dr. Kelly's group underwent looked at positions putting in anchors through different portals the safety of these portals in predetermined positions and then they did CTS to assess the anchor locations interestingly in this case and this this surprised me when I read this paper as well that anchor insertion from the mid-interior or Dalla portals basically have the same similar rim access and rates of articular surface injury or so as tunnel perforation so I think many of us by doctrine suggested that and myself included have suggested that Dallas 100% safer than the mid-interior portal but they didn't find that actually and the rates of portal perforation or the perforation through each portal didn't really differ the conclusion is paper was the caution should be employed obviously inserting anchors in the anterior middle media locations and articular surface and so as perforation occurred rate higher than previously anticipated it didn't really matter which rate which position they put them in anchor insertions are important consideration anchor location should be close to the articular surface without causing cartilage injury curve versus straight drill guides I think a lot of us use curve guides many of us like myself with Dalla portal anchor drilling use straight guides but I may change my perspective based on this so Shane know looked at different angles distances suture tips and what they looked at cadaver hips radiographic parameters measured on CT imaging interesting their conclusions where the curve suture anchor guides significantly increase the insertion angle and distance from articular cartilage to the anchor at the one o'clock position angle of the insertion of the two and three were also greater for the curved guide as compared to the straight anchor guy and there was no differences so a curve guide might provide improved trajectory for ankle anchor placement I have not had a portal or I've not had a perforation to my knowledge using Dalla portal it on at least on imaging it appears to provide a better trajectory that being said I think using curve guides and with these studies it's reasonable to as long as you're careful use either position so this is what a she's data used to pull through technique he pulled it out the bottom side did a heseolysis revision labral base fixation anchor this is doing the repairs he did address the cam with the residual cam deformity did a revision osteochondroplasty and then did a key T capsulotomy repairing their portal capsulotomy repair in the interest of time I think you guys know how to do that and then these are the pre and post resection images pre on top post on bottom not surprisingly of an excellent resection and then his recovery those are his post-operated graphs I think dr. Philippon's comments earlier are accurate in the sense that there is some spurring and fairly that spur always causes concern for me in the sense that we're going down a an issue more that's more of a hip health problem more than a cam deformity problem that said I think the revision osteochondroplasty and removing the anchor will provide this kid a significant improvement and his results would in two seasons would suggest that so this is him now and then we're about done with time but any questions or additional thoughts before we go yeah who here uses all suture anchors okay how about peak okay it's a really good question I like the all suture anchor in theory I've had issues with them in terms of pullout so for those who use the all suture anchors have you found pullout issues relative to the peak we're in comparison to the peak yeah yep yep fiber tack has been an issue juggernaut has been an issue I've tried both of those both of them have had pullout issues that said they're both incredibly good anchors but both of them actually did better than actually do the viral raptor which is our control so depending on the type of all suture anchor I would throw out the bathwater I think that it actually had less stretch or less I guess migration because you're preloading it and had higher strength compared to anything else that was out there so I would take a look at that and Tom Byrne published like 6,000 cases and I think he had one pullout or two pullouts out of 6,000 cases so that's great the the Q-Fix anchor I am familiar with that as well we're trying to try to avoid sort of putting out a number of things they've given this Academy but to your point the Q-Fix I will tell you I do use it in MPFL sometimes and I've had it pull out two of a number of times actually on the medial side of the patellas and have backed it saved it effectively with a peak anchor it's a great anchor they do have two different options you guys can talk to Smith and Nephew that's a Q-Fix product about their products but the point is it's a wonderful thing I will say at the far anterior position where I'm really worried about the iliopsoas breach I prefer to use suture anchors but it's it can be difficult yeah yeah I actually I used to use our suture all the time medially for that reason but I went back to an old 2.3 biocomposite I love it it's straight double prong I mean I because of that reason sometime I didn't feel good I could pull hard enough on my ulcer tree anchors I I went back and I I have to say I even design an ulcer tree anchor and I don't even use it then but that's that's my my personal decision I use a biocomposite 2.3 most of the time but sometimes I'll still use it for the psoas you yeah I use a curved anchor and almost always now underneath like on their particular side especially the media ones techniques for circumferential fixation have you ever experienced so you're talking about a suture based chondrolysis that is that what you're referring to well if you look at if you have a circumferential repair and you flex and extend your hip it just kind of cheese grates I haven't but maybe I haven't recognized there anyone else no I've seen I've seen it we're more bulky sometime with the knot being more on the articular side but I've seen what you're talking about I've seen it not necessarily circumferential maybe large repairs but I've seen that yeah well I think if you use a circumferential suture make sure your your knot is on the capsular side and buried I think that's the most because they're not that thing the volume of the knot cause more damage I think a flat suture is less likely but the knot can be a problem I think I'll tell him don't worry I'll pass that along post post free table oh man you're gonna get lots of opinions here but it depends on where you are my personal opinion is cheap honestly I work at a university so they don't really care quite frankly that said I think there are a lot of options out there I will tell you I do not use a fancy table you can just put a pad down and it does the job with any table you have actually and you don't need to in Dellenberg you don't need a fancy boot you can literally do it with a haunted table if you don't want superficial perineal nerve palsy huge huge industry bias I don't see any I don't see any nerve palsies yeah that's because you don't look believe me they tell me they all come they all come I've seen his so no joking aside I will tell you these things are expensive okay so the tables with the stuff that is about a hundred grand all right if you have these the fancy pads the disposal I've looked into this okay cost of medical device is an important concept that I do a lot of research in it and I will tell you disposables for that hundred thousand dollar bed are sitting around six to seven hundred bucks a case not not zero okay so if you're in ASC and you're doing a lot of things that that's a problem it also goes to the patient you can literally put a gel pad down if you want to go super cheap you can put a standard gel pad reusable gel pad down it you can 100% I want to stop all the off-label talking I'm just kidding yeah seriously but my point is you can do any of them okay and I would encourage you to go around look around consider cost all of those things and Mark's still does post and yeah I think I think it's really hard to argue that no I I use the post but also if you only use no post I use a no lambs core table that I've used for years everybody makes fun of me but it's really cheap and actually can use a post less with that table and you can use the any attachment I agree with you can use any kind of yeah any Chad there you can't offend him it's impossible but but but yeah it can do on the cheap and it's it's I think it's what you're comfortable with and when your surgery center is willing to work with the hospital I mean it's the cost is disposables that you know $100,000 for a capital equipment that you're going to use you know 300 times that I use like 300 plus times a year not that expensive to do it right and really I mean you're gonna make that up easily and in your in your efficiency and volume of things but the disposables yeah that that's a that's that managing that is a challenge from across to find something and do it what makes it safe for you like the Smith nephew table and stuff I can't keep pull out as you're trying to which is not a fun thing when you're doing the scope you're trying to get a little more traction the other thing with the guys on the sutures particularly on the all suture you have to think three-dimensionally because if you go off just a little bit after you've made your drill that suture anchor won't really go in well or engage well and so it's nice having a curve because it takes you away from the ear thing for service yes that's fabulous but it gives it it allows you to get the labor down more so it's a true buttress and you get a better seal that way but you just have to be very very careful because it's you're putting that in the angle it's and when I had opposed to I was always taking it out when I was going to peripheral compartment because the lateralization you know that makes the you know lateral work post file work much harder so so I don't for me it's much easier now to the work without opposed if I get medials eat better too because you don't have the post pushing or attention sometimes tensioning the tissues makes it harder yeah but as you tell though a lot of a lot of ways to do things it's been a great ICL thanks everybody for thank you all for coming appreciate

football athlete

chronic pain

surgery options

labral tear

cystic formation

post-operative recovery