All right, thank you everybody. It's an honor to be here today. Here are my disclosures, none of which are relevant to today's talk. So today I'm going to discuss when open hip reservation surgery is clearly the right answer in the failed hip arthroscopy. And then we're going to spend most of our time today discussing when it may not be obvious that we should instead convert to open instead of attempting a revision hip arthroscopy. So open surgery is the clear choice when you have hip dysplasia. The normal lateral center edge angle is defined as greater than 25 degrees. And if the lateral center edge angle is less than 18 degrees, it's clear that the patient has dysplasia and hip arthroscopy alone is not the right answer. Reinhold Ganz described the periacetabular osteotomy that we use today in 1988. So with the periacetabular osteotomy, we perform a series of osteotomies around the hip to allow us to move that acetabular fragment. And the goal of the PAO is to cut the acetabular fragment completely free from the rest of the pelvis, rotate it, and then this will then provide added acetabular coverage of the femoral head. Now another often very clear indication for open hip surgery instead of arthroscopy is Perthes. Perthes disease is more commonly seen by pediatric orthopedic surgeons. But as a sports surgeon, you will see adult sequela of Perthes disease. This is a hip that you should recognize. It's a pathognomonic hip for Perthes. You'll see coxa magna or a widened femoral head, coxa plana or a flattened femoral head, trochanteric overgrowth, coxa breva or a shortened femoral neck. And the patient may have a shorter leg on the affected side, acetabular dysplasia or osteochondritis desiccans. So here's an example of a 30-year-old patient who presented to my office with insidious onset of right hip pain over a few months. So he had never before had hip pain and never been diagnosed with Perthes, but he admitted to having noticed that he walked funny throughout his lifetime. So you can see here that he has almost all of the adult sequela of Perthes disease. And in this patient, given the good quality of his articular cartilage, we performed a surgical hip dislocation, open femoroplasty, a relative femoral neck lengthening, and then a concomitant PAO all in the same surgical setting. And then, of course, when a joint is too arthritic for hip preservation, we know that a total hip replacement is a better option. So now let's focus on those situations when open surgery is not always the clear choice. The first and probably most popular topic is borderline hip dysplasia, which we've heard a little bit about already this morning. So borderline hip dysplasia is defined as a radiographic lateral center edge angle either between 18 and 25 degrees or between 20 and 25 degrees, depending on the literature. I typically use 18 to 25 degrees. And almost 90% of all borderline hip patients will have labral pathology. So this is really important to keep borderline hip dysplasia in your differential when patients present with labral tears and even femoral acetabular impingement. So I'd also like to point out that this pattern of cartilage wear in this picture is quite classic for hip dysplasia. In dysplasia, you'll see that the cartilage is still attached to the inferior base of the labrum and that the defect or the detachment is actually further down within the acetabulum itself. Now there have been a number of studies which have demonstrated that hip arthroscopy can work in borderline dysplasia, and this would apply to the failed hip, which has had a prior hip arthroscopy as well. But when considering hip arthroscopy in borderline dysplasia, we really need to consider, especially in the revision setting, that not all hip arthroscopy is the same. Now there's a significant difference in outcomes with hip arthroscopy in the borderline hip depending on whether the labrum and the capsule are repaired or not. So without capsule or repair, there's been up to a 60% failure in hip arthroscopy. And almost 40% of these patients go on to have accelerated arthritis. So as we heard, the capsule is a very important component of our hip arthroscopy, and this pertains to preventing the failed hip as well. I'd say the takeaway from this data is that if you have appropriately indicated somebody with hip dysplasia or borderline hip dysplasia for a hip arthroscopy, you have to be extremely careful with the soft tissues and perform a complete capsular closure, if not a capsular imprecation. Also keep in mind that in borderline dysplastic patients, there is a very long list of factors that are associated with poor outcomes after hip arthroscopy. So some of these are non-modifiable, but others are technique-based or modifiable. And in the event a patient has already failed a hip arthroscopy, I give this list a very serious consideration before offering a revision hip arthroscopy in this setting. Now in general, I think it's important to recognize that hip arthroscopy in borderline dysplasia is much less predictable than when done for other pathologies, and that unlike hip arthroscopy in a straightforward FAI hip, there are very high reported failure rates in this particular group of patients. So in this study here in the second bullet point, borderline hips had a 32% failure rate defined as not meeting the MCID or needing a revision surgery after hip arthroscopy. So what is it that we can do to appropriately identify the borderline hip patient? Well we know there are a number of radiographic parameters which have been described for the dysplastic hip. We've heard about a number of them today. But in my practice, I would say I use the lateral center edge angle and the tonus angle the most. When you're measuring the lateral center edge angle, it's very important to know where the source seal ends laterally. So in this patient, this is the wheat-bearing source seal of the acetabulum. This upturn is not actually providing any acetabular femoral head coverage. So if you measure your center edge angle to this point here, you're going to get a very different number than if you measure to the more lateral aspect, which is actually not covering the femoral head. And in this diagram here, this is the same x-ray. I've measured the lateral center edge angle looking at those different lateral end points. And in my opinion, I would measure it with this image on the right before you get to that lateral upturn of the source seal as the most accurate measurement of the lateral center edge angle. And you can see there's almost a 10-degree difference depending on where you draw that line laterally. But even if you do a good job of measuring the lateral center edge angle, there have been reports that up to 39% of patients who have a normal hip as defined by that lateral center edge angle actually are dysplastic by some other measure, including the tonus angle. So the tonus angle, or also known as the acetabular inclination, is considered increased if it is greater than 10 degrees. And this is a sign that there might be some hip instability. Now other described radiographic measurements include the femoral epithelial acetabular roof index, or FEAR index. And here a line is drawn in the middle third of the physis scar, another line through the medial and lateral aspects of the source seal. And then if that angle diverges laterally, that's considered a positive FEAR and a sign of hip instability. The cliff sign has also been described by Dr. Safran as a radiographic finding consistent with hip instability as well. Now the false profile view can give you a sense of anterior acetabular coverage. And this is also good for looking at that subspine morphology on a patient as well. The center edge angle on anterior center edge angle is also considered normal above 25 degrees. So if we look back at those papers that said it's okay to do hyperthoroscopy in a borderline hip dysplastic patient, we should probably emphasize that these are published by high volume expert hyperthoroscopists who can achieve these results. So there are certainly some borderline patients that should not have hyperthoroscopy alone, especially in a revision setting. In some patients, you may actually have to get a 3D CT image in order to see how undercovered their femoral heads are and then make the decision to proceed with something other than hip arthroscopy and specifically periacetabular osteotomy. So what are the absolute red flags for performing a revision hip arthroscopy in a borderline hip dysplastic patient? I would say anybody who has had a low center edge angle and or a high tonus angle, and then significant consideration of ligamentous laxity as well, as that can lead to quite a bit of hip instability. I'd also encourage us all to really not fear the PAO. So we use the periacetabular osteotomy for a number of different indications. So patients with classic hip dysplasia as defined by a low center edge angle. You can also think about anteverting or retroverting PAOs to change the angle of the hip socket. And we can also use it for various degrees of hip dysplasia, including borderline dysplasia, significant anteversion or retroversion of the acetabulum, focal undercoverage of the acetabulum, or even sometimes hip instability in a completely normal radiographic hip. Now after PAO, a majority of patients do go on to return to preoperative or higher levels of activity. And the PAO has shown excellent outcomes in this borderline dysplastic group. Also keep in mind that the diagnosis of hip dysplasia is technically radiographic, whereas the diagnosis of hip instability is clinical. But they often do go hand in hand. Now there are several provocative maneuvers that we can use to test for hip instability. And I typically use the anterior apprehension test or the prone apprehension relocation test the most. And then I do get a Beaton score on every single patient that walks into clinic to test for ligamentous laxity. So if the patient scores greater than 4 or 6 points, they will be considered ligamentously lax. And this may indicate that their hip capsule is also lax and that you might want to consider open surgery instead of arthroscopic alone. Now it's really important to realize that there are significant consequences of choosing hip arthroscopy in a patient that should probably have a PAO instead. The prevalence of failed hip arthroscopy undergoing subsequent PAO has increased 192% between 2008 and 2015. And it happens at an average of about 30 months postoperatively. So in some cases, by trying to scope the hip first, we're setting these patients up for failure, but we're also subjecting them to worse outcomes when they eventually get their definitive PAO. And about 33% of patients who fail a hip scope and who needed a PAO in the first place have to then undergo a second hip arthroscopy to address soft tissue and labral issues. So there's also the possibility that this might happen. This is rapid catastrophic progression of end-stage osteoarthritis. And this has been reported multiple times in the literature that in a borderline dysplastic hip or a dysplastic hip, the patient has a hip arthroscopy. And within a year, they have no joint space remaining. Now a second situation where open surgery may not be obvious is with femoral version abnormalities. And the quickest way to get a sense of a patient's femoral version is to watch them walk. So if a patient walks with an internally rotated foot progression angle, this is a sign of possible antiversion. If they walk with an externally rotated foot progression angle, this is a sign of retroversion. Now normal femoral version is considered around 15 degrees. And in my practice, I don't really often indicate femoral derotational osteotomy. But I'll use the general guidelines if the antiversion is greater than 30 or 35 degrees, or if the retroversion is less than or greater than minus 10 degrees, these are indications for possible femoral derotational osteotomy. You can do this with an intramedullary saw and nail. This is probably what I do most often. You can also use an intratrochanteric osteotomy and blade plate, a subtroke osteotomy with plate, or a distal supracondylar osteotomy with plate. And in each of these methods, increased retroversion is treated by rotating the distal fragment internally. And increased antiversion is corrected by rotating the distal fragment externally. Now a third situation when an open procedure might be better than hip arthroscopy is when considering whether or not to use a surgical hip dislocation. So the surgical hip dislocation was initially the gold standard for FAIS treatment. But now that we are getting so good at hip arthroscopy, we don't do surgical hip dislocations very often. Indications can include a severe hip deformity, whether that's a significant version abnormality, a high-riding trochanter, coxa profunda, or coxa protrusio, or even for certain femoral head chondral lesions. So here's an example of a patient who presented with right hip pain, coxa profunda, a diminished femoral head-neck offset, and a labral tear. So for coxa profunda, you can see that with an open surgical hip dislocation approach as diagrammed here, you can very easily chisel away global excess acetabular rim. And then you can perform an open CAM decompression as well as an open labral reconstruction with allograft. So postoperatively this 30-year-old patient has a less constrained joint with improved hip function, range of motion and resolution of pain. Another indication for surgical hip dislocation is focal, relatively small osteochondral defects which can be treated with an open surgical hip dislocation and OATS procedure. And here you can see when you're postoperatively a resolution in this patient's osteochondral defect after OATS and resolution of pain and symptoms. So always keep in mind that arthritis could be lurking in some of these hips. So hip preservation may not be worth it, even in patients like this 27-year-old with a history of Perthes. So if you look very closely at the femoral head, you can see a large osteochondral defect in the central femoral head. So in this case, all of our options for hip preservation may not successfully treat her pain and this patient went on to get a total hip replacement. So one other thing that might come up is SCIFI. This is another known cause of hip osteoarthritis, another pediatric condition. Now in SCIFI, the metathesis translates anteriorly and externally, rotates while the femoral epiphysis remains in the acetabulum and falls inferior to the translated metathesis. So in some instances, we can change the secondary CAM-type deformity enough that we can preserve the hip. So this can be done with hip arthroscopy in less severe deformities or with an open hip preservation procedure in severe deformities. So this is an example of a 20-year-old female who had SCIFI as a child with the screw removed. And this was arthroscopically performed CAM decompression, which allowed her to have improved function and motion postoperatively. There are some additional procedures that can be attempted open, such as the modified DUN procedure here. But one of the problems with this very involved procedure is that it can lead to avascular necrosis. So in summary, conversion of the failed hip to open surgical alternatives can include the surgical procedures of the surgical hip dislocation, femoral derotational osteotomy or periacetabular osteotomy, and of course the total hip replacement when hip preservation doesn't make sense anymore. As you indicate your patients for revision hip arthroscopy, be sure not to miss those borderline dysplastic patients which may be better served with a PAO, femoral version abnormalities or those unique cases where surgical hip dislocation may be better than hip arthroscopy, or even those occult arthritic hips. So because borderline dysplasia is what you'll probably be seeing most often, make sure you're familiar with the tonus angle and how to correctly measure the lateral center edge angle, and then how to evaluate for clinical instability in the hip outside of the radiographic diagnosis. Thank you. �

open hip surgery

hip arthroscopy

hip dysplasia

Periacetabular Osteotomy

Perthes disease