All right, good morning. It's 7 a.m. My name is Mark Safran, and I'm the moderator of this session on the failed HIP scope, how to successfully manage and not replace it. My potential conflicts of interest are available on the academy website, and I believe as are my co-speakers. What we're going to do is we're going to kind of go over evaluating the patient with the failed hip arthroscopy, and an approach on how to manage these. I'm going to kind of myself focus more on the evaluation and manage some of the soft tissue issues, which we'll discuss, but we have Shane Ngo here from Rush in Chicago, who will be talking about how to deal with labral deficiency. Mark Philippon, who comes from all the way up the road in Vail, Colorado, probably has some jet lag, but he'll be talking about capsular deficiency and management of that. And then Andrea Spiker from University of Wisconsin will be talking about open management of some of these bony deformities and when things just can't be salvaged with a soft tissue procedure. So there are many causes of failed arthroscopy. We're going to focus on the salvageable causes. We're not going to focus on non-arthroscopically or PAO even related issues. In other words, we're not going to be really talking about poor patient selection, which, you know, is I think very important in hip arthroscopy. We're not going to be talking about the management of advanced arthritis or extra-articular impingement. So when I see a patient that has had a prior hip arthroscopy and they come to see me, there are several things that go through my mind that we need to consider. First is some things about, you know, rehabilitation or rehabilitation related issues, such as are they stiff? And are they generally stiff? Or do they have adhesions? Do they have weakness? Do they have tendonitis? And we'll kind of discuss those things. About did they have the right diagnosis to begin with? Was it actually intra-articular hip pain to begin with? You know, a lot of times people will see patients with an MRI showing a labral tear, FAI anatomy and pain in the groin, but the pain in the groin might not be related to the FAI anatomy or the labral tear at all. You know, a lot of times these people will have ileosous issues. It's funny, you know, 20 years ago we would always say that these patients are the ones, the hip flexor that isn't getting better was actually something, somebody had intra-articular pathology. Now everybody has had a hip scope and they missed the fact that they probably had a hip flexor tendonitis so it's probably the underlying cause. Maybe didn't try the rehab first. We'll talk a little bit about hamstring dominance and its role in causing anterior muscular pain, particularly ileosous. We'll talk a little bit about referred pain and you've got to always think about that. There's a lot of things that, sources of pain that are not in the joint that can refer to the hip itself. And then when we look at the fidelity of the surgery, did they have under resection or over resection and that might be playing a role. There's the fact of instability in these patients and they might have had preoperative instability that might have been missed or misdiagnosed. It could be post-op instability that could either be iatrogenic, could be due to soft tissue deficiencies. And then there's the other considerations, heterotopic bone, subspinous impingement that may or may not have been recognized and femoral version issues as well as dysplasia. And so again, I'll cover most of the stuff in black here. The stuff in red, we're going to have focused, more concentrated discussion and talks on by our esteemed faculty here. Soft tissue deficiency, as we talked about, the labrum and the capsule as well as dealing with things like femoral version or dysplastic hips. So when you look at the literature, most people tell you that the number one cause of failed hip arthroscopy tends to be residual or untreated FAI. That traditionally has been the number one cause up to 95% of cases and there's a lot of literature that would talk about that. But even as was discussed earlier in this meeting, actually we're seeing more, and though it's still a bit of controversial what defines a good cam resection, over resection is also an issue now. And in fact, Ben Dohm presented their work showing that over time when he's looked at failed hip arthroscopies or even just hip arthroscopy where people had prior surgery that the percentage of cases of under resection has decreased and over resection has increased. And then certainly you can have cases like this one where you have probably over resection maybe anteriorly but certainly under resection straight laterally. And so that's an issue. In my practice, I think an increasing cause of failed hip arthroscopy is actually instability of the hip. And Brian Kelly actually did a study looking at HSS at 229 revision hip arthroscopies and they still found that FAI, residual FAI was the number one cause of failed hip arthroscopy. But the number two was actually hip instability with a fairly large percentage of capsular defects. And Shane Noe has done some great work showing that if you don't close the capsule and those that had revisions close to 80% had capsular defects. And even if you close the capsule, those that have revisions, about 12% or so have, can have a capsular defect so it doesn't heal or rips apart. So things to consider if just even postoperative instability. And then smaller HO and adhesions being causes in the literature somewhere in the less than 10% generally for the HO and adhesions. It varies on the literature somewhere. Some cases it's upwards of 60%, some less, much less than that. So incomplete rehab, it's interesting. This is getting less of an issue in the sense that there were some surgeons that just didn't believe that patients needed formal PT after hip arthroscopy. They kind of got a scope and were kind of sent on their way. Kind of like what people would do with a partial meniscectomy in the knee. But I think a lot of people realize that postoperative physical therapy is very important in these patients. But sometimes patients don't go to physical therapy in spite of prescriptions. Some insurances don't actually provide adequate amounts of physical therapy for these patients. And so you will see people that are under rehab. And then one of the things that I see also is a physical therapist that's not as, doesn't treat many of these non-arthritic hip patients that are getting hip scopes. So an inexperienced physical therapist can sometimes be too aggressive. And these patients can end up getting tendonitis and have hip pain from being rehabbed too aggressively. Or maybe not aggressively enough. And then they end up getting stiff and getting adhesions. So you have both ends of the spectrum. So one of the main problems that we see with the incomplete rehab is stiffness. If you don't move them much after the surgery or they're in bracing for prolonged periods of time, they can have generalized stiffness. Or they can have adhesions as the cause of the stiffness. And so when you look at the normal hip anatomy, you have a, the capsule does not insert into the labrum like it does in the shoulder. The capsule inserts separately into the acetabulum. And there's usually a space between the labrum and the capsule itself. And obviously if you get scarring between the labrum and the capsule, then when you try to move the hip around, then you're kind of tethering the capsule potentially or the labrum. And that can be a source of pain. And so when you have these patients with ways to prevent this type of thing, you know CPM itself doesn't always do it. The hip is a ball and socket joint. It's not a hinge joint. So you need to do circumduction exercises. And Mark Philippon has talked about that for 15, 20 years now. And then now they're doing also Losartan as a way to try to prevent adhesions as well. But if you have a patient that comes to see you and they've had a hip scope and they're stiff, we have the physical therapists work with them with doing joint mobilization techniques as well as traction techniques to try to help gain that range of motion. But sometimes that can help gain that motion. But sometimes the scar tissue can be more mature, if you will. And so you can get these adhesions. And some people make the mistake of only looking in the central compartment. But here you can see in the peripheral compartment, very thick adhesions between the capsule and the neck. And this patient that came to see me, she had been on prolonged bracing and crutches after her hip arthroscopy done outside. And her hip was just really stiff. And we ended up having to deal with really thick adhesions like that. Very often you will see adhesions in the central compartment. Basically that scarring between the capsule and the labrum, as I showed you, that they should be independent. And we'll talk about that. So if you do have these adhesions, again, you would look in the peripheral compartment here. I'm just using a shaver to kind of get rid of those thick adhesions. Here you can see I'm bringing an RF probe. And here there's a cleft between the labrum and the capsule. But then you see as we go further, I'm just looking from posterolateral portal, as we go further laterally, there's an adhesion between the capsule and the labrum itself. And so here I just use an RF device to cut the adhesion between labrum and capsule and make sure that there's space between the labrum and the capsule and that they are able to move independently. Weakness is another thing that we see. It can be a source of pain in these patients postoperatively. Usually we're talking about the gluteus medius and the iliopsoas specifically. But you also want them to work on their core muscles. And so the key is that you start slowly and gradually build the strength of the glutes, the iliopsoas and the core. And if you go too quickly, you can sometimes flare up the muscles and the muscles that we end up seeing getting flared up. Oftentimes in these patients, particularly with inexperienced physical therapists, iliopsoas tendonitis, you can get and they have pain, as you can see, coming from the back or down in the front of the hip, down into the thigh or even knee. You can have adductor-related tendonitis. That's, again, not uncommonly seen, particularly in FAI patients when you give them more clearance and they don't have the bone limiting their range of motion. Now it's soft tissue trying to limit their range of motion and their muscles have to work over a greater range to try to stabilize the hip. And then the piriformis is also an area where you can see a fair amount of tendonitis. Again, I see less of this now when patients are seeing more experienced physical therapists, but they can sometimes get these flared up. And so you want to be attuned to those sources of pain. And if you have that, obviously the key for treating it is you want to back things back down as far as the strengthening, let the inflammation calm down, work on stretching, nonsteroidals, modalities can be helpful. And I have no problems doing, having done ultrasound-guided injections, if need be, for the piriformis, the adductors or the iliopsoas to calm things down to allow for the rehab. As I said, one of the other causes, potentially do they have the wrong diagnosis up front. As I said, just because they have FAI on x-ray and they have a labral tear on the MRI doesn't mean that that's the source of their hip pain, right? Up to 70 to 80% of asymptomatic adults over the age of 18 have labral tears. You know, 30 to 50% of the population has the anatomy of FAI, 96% of our water polo players have FAI anatomy. They don't necessarily have pain, right? 90% of NFL players have it. So, yeah, they have a labral tear, yeah, they have the FAI anatomy, that may not be the source of their pain. And a common, I think, mimicker is the hip flexor tendonitis or iliopsoas tendonitis. We also see a fair number of patients, my practice tends to be women between 30 and 50, tend to have this, what the people on the East Coast call glute inhibition, what I call hamstring dominance, depends on which way you're looking at things, where they're firing, to extend their hip, they're firing their hamstring before they fire their glute, and that puts more strain on the hip flexors. They could just be referred pain from somewhere else that was never the hip joint itself, and, you know, somebody just looked at the X-ray and MRI and went straight for that surgically. So that's why pretty much every patient that I operate on gets a preoperative injection with anesthetic, just anesthetic, not necessarily cortisone, to confirm that the pain is coming from the hip. So, you know, some of the things that I think get kind of lost in there is really the physical exam to really help differentiate these sources of pain. So looking for the iliopsoas, you could evaluate the iliopsoas tendon below the inguinal ligament or above the inguinal ligament. And so I put the patient in a kind of figure four position, have them hold their leg up to put their sartorius on tension. Then I have them relax the leg as I feel just medial to the sartorius, and then I have them do a straight leg raise. And what you'll feel is the iliopsoas will hit up against the tip of your fingers. And so if that's tender, obviously you want to check the asymptomatic side first and then compare it. But that is actually a pretty sensitive test of being able to detect for iliopsoas tenderness. You can also palpate again above the inguinal ligament more, there you're palpating more of the muscular component of it. We checked the iliopsoas with hip flexor strength. So the iliopsoas is isolated as a hip flexor from 70 degrees of flexion on up. So I do seated hip flexion as the testing to look at their strength as well as whether or not that reproduces their pain. For hamstring dominance, well, I think injections, again, can help confirm the diagnosis to the patient and to you. Selective injections, ultrasound-guided injections. I prefer over fluoroguided injections. So when you have a fluoroguided injection for the iliopsoas, they're aiming for the lesser troch. And the burst is not as well demarcated, if you will, down by the lesser troch. So I prefer them using the ultrasound being a little bit higher, more towards the femoral neck. There they can get into the burst so much easier and you're getting, I think, a more selective injection for the iliopsoas. The other thing you wanna check for is this hamstring dominance. So if you see here, we have this patient laying prone. I've got two fingers on their glute, two fingers on the hamstring, and then I just have them extend the leg. And you feel which one goes first. The glute should go before the hamstring. If you feel the hamstring go first, then they need some muscular re-education to fire the muscles in the right order. And that'll take some of the strain off the iliopsoas. You wanna, again, rule out other sources of pain that are not articular. You wanna look at the periarticular muscles as I kind of already started with. The low back, obviously, is a big mimicker of hip pain. Anything in the GI tract, including hernias, can fake you out. I've had a patient that had a femoral hernia that was actually the source of their hip pain. And then genitourinary causes as well. So again, I think an intraarticular injection helps make it more clear or specific that their pain is coming from in the joint. What we try to do is we have them get an impingement test before the injection. So our radiologists will do the impingement test or people that are doing injections, they'll do an impingement test, give them an intraarticular injection with some anesthetic, usually about 10 cc's, and then five, 10 minutes later, do an impingement test again and see how much pain relief they get. I look for at least 50% pain relief. Different people use different numbers. That's what they will use as their threshold, but I think 50% because the injection itself can be painful. And depending on, at least for us, at this time of year, where we have new radiology residents and fellows, sometimes patients don't get much pain relief because they were a bit of a pincushion trying to get the injection in the right spot. I think using 3DCT scans for people that have had surgery can be very helpful, particularly if you have these commercially available collision software tools. They can help show you some of the things such as AIS, sub-spine impingement. If you get a false profile view on x-ray, you can see that, but a 3DCT scan can show you sub-spine impingement. And you can see where the resection is and is not. So this is from one of the commercially available companies. You can see the resection anteriorly, but laterally, not such a great job on the resection. But with this collision software, you can see where the impingement is occurring. Did it go distally enough anteriorly? Do you need to do some more work laterally? And again, is the sub-spine region part of the cause? So I think this could be very helpful, particularly when you're seeing a lot of these patients or until you get comfortable having to evaluate a lot. But I almost always get a 3DCT scan on somebody that's had prior surgery, so I know what's been resected, what's not, or maybe where there's regrowth. This is a patient, you can see, that has some residual impingement and some flexing of the hip up. You can see the labrum over here, and you can see the femoral head-neck junction. And you can see this kind of cobblestone type of appearance where there's been some regrowth at the head-neck junction. And obviously, if there's under resection, you can see you can do a revision resection and check for impingement that way. For over resection, that can happen on the acetabular or femoral side. So this was a patient that came to see me pre-op and then went elsewhere for surgery. And at a year post-op, he was not very happy about how he was doing, so he came back to see me. And you can see the X-ray that he was made just plastic. And this is a very difficult problem to treat arthroscopically. You can also see, you're gonna get big over resections on the femoral side as well. And Mark Philippon's been very creative. I didn't actually ask him to give a talk on there, on his re-emplissage techniques with the soft tissue or bony techniques. But I think there's still some work. I don't think, I think it's very easy, that the acetabular resection is very easy. I just send somebody like that to Andrea, she can do a PAO on them because that's all I've got for her, for this patient. But the re-emplissage, I think we need some more data, but that's a promising potential. And we can talk about that in their discussion. Instability, sometimes you'll see these patients that are just kind of the loose-jointed patients, but I think we're learning more and more about micro-instability in patients. And so these patients aren't always the same and have more laxity. Again, I consider micro-instability of the hip symptomatic laxity, just like we do in the shoulder. A lot of people will have this preoperatively. And if you don't address that, and that might be their underlying cause, then they may still be symptomatic. Again, it's being increasingly recognized as a cause of hip pain, though FAI is certainly more easily recognizable. But more experienced arthroscopists, when you're doing your FAI surgery, capsulotomies are very common, both interportal and T-capsulotomies, people are getting more aggressive with, to allow for visualization, to be able to do a better resection. And I think what we found looking at the Hipster database at this point, that about 80% of capsulotomies now, at least of the people that are submitting, are actually closing their capsulotomies, which is, I think, the right direction to go. But again, we can still have some issues related to that where it may not heal. So, when we talk about potential iatrogenic instability, the question is, were they susceptible, but stable? So, somewhat loose, jointed, and cutting the capsule and leaving a defect made them unstable. And so, that's your ligamentously lax patients, right, from mobile patients. But also, potentially patients that have loss of the labrum, or they have a capsular issue, again, capsular defect. Again, we'll see patients who have FAI, but have borderline dysplasia. The dysplasia may or may not have been recognized, and they had surgery for the camera section, and maybe a capsulotomy that wasn't closed. But because of that borderline dysplasia, they now became unstable. And it's not, and one of the problems I see is that sometimes people will just measure the lateral center edge angle. But you also gotta look at the anterior center edge angle, because they could have a relatively normal anterior, lateral center edge angle. But they could have a high acetabular index, or tonus angle. Those are also signs of instability that you need to look for. Put people at a higher predisposition to iatrogenic instability. And then again, we'll talk about capsular and labral defects. So, here's a patient that has a bit of a CAM lesion, has some borderline dysplasia, so it may not have been recognized preoperatively. And again, not doing good capsular management can lead to instability. They could have preoperative instability due to microtraumatic causes, or generalized ligamentous laxity. One of the things that we found is that a thin capsule on the axial oblique MRI, just lateral to the zona peculiare, so it's less than three millimeters. In women, particularly, they're at a higher risk of having some instability as their native or baseline status. Steve Aoki did some work also showing that if the capsule is less than three millimeters at the one o'clock position in somebody that's already had a hip arthroscopy, they had a much higher risk of requiring surgery for instability as a revision procedure. We talked a little bit about the capsular defects, and MR arthrograms are better at showing you capsular defects than MR without contrast. So when I see a patient that's had a prior surgery and they come to see me for a failed hip arthroscopy, in addition to the 3DCT scan, we get an MR arthrogram to look for these capsular defects. As I said, some very good work from Shane on people that have had failed hip arthroscopy and they didn't have their capsule closed, 70% of those patients that he was revising had capsular defects and iliofemoral ligament defects. And then if you did close the capsule, 7.5% of his patients had capsular defects earlier from ligament defects if he went in patients that required a revision. And again, Steve Aoki showed that the sensitivity of the MR arthrogram was much better than an MRI without contrast. For my patients that are lax that don't have a defect, I do a little bit different procedure than what a lot of others. I take out a piece of the capsule straight laterally in this area between the iliofemoral ligament above and isiofemoral ligament below. And then I just do a kind of a capsule replication, which I think tightens up both some of the ilio and isiofemoral ligament. If they have a defect like this, you know, this is the femoral head, there's your labrum, there's the capsule, that's a view of the iliopsoas you don't normally get from the central compartment. The key is to close the defect, but it's not just sewing it back to the labrum. As I talked about, you sew to the supraacetabular region, so here I've got some anchors up above the labrum, up into the acetabulum, and then capturing the capsule and bringing it down to the supraacetabular labral region. More on the capsule defect from Mark when it's not repairable. And then for the labrum, if they've had a prior labrectomy or prior labral repair reconstruction and those have failed, and if you have poor tissue, I think labral reconstruction can certainly work. For me, in a primary situation, I only really do it in lax patients or those that have borderline dysplasia. Otherwise, I do labral reconstructions more in revision situations, but we'll have more on this from Shane Ngo. Just kind of rounding things up, heterotopic bone, you can see it about 4 to 10% of the time based on the literature. It's really the source of pain in patients, but when I see it and if they do have pain, we end up taking it out, which you can do orthoscopically. And here's a 3D CT showing that, a pretty large, one of the larger ones that I've seen in my practice. But again, it's really a source of pain. And then subspinous impingement, you want to look for subspinous impingement. And again, a 3D CT scan will show that more clearly, but you can't see that in the false profile views, and it's there if you look for it. And most standard imaging does not show you femoral aversion. And so I think, at least at our center, anybody gets an MRI at our center of the hip, they take a few cuts through the knee, and we measure femoral aversion on MRI in all our patients. And so I think you just need to be aware because excessive aversion, femoral aversion, or retroversion can be a source of pain in patients or failed hip arthroscopy. So publications suggest revision hip arthroscopy is not as good, so you want to try to do it right the first time. But I think if you identify the cause and address that, then I think you have a good chance of making the patient better. You want to first be sure that the source of pain is actually truly intraticular. Identify and treat the cause. Oftentimes you'll find it's not an intraticular source that requires necessarily surgery. I think instability is being recognized more frequently as a cause of hip pain. And so you want to be sure that it is an intraticular source. And if you address that, I think the outcomes can approach primary. So thank you very much. So next up, we have Shane Ngo, all the way from Chicago. OK, thanks, Mark. Good morning. Thank you guys for waking up with us. So I'll be speaking on labral deficiencies in a failed setting. My name is Shane Ngo. I'm at Rush in Chicago. These are my disclosures not relevant to this talk. I think we're all aware of the critical importance of the labrum in terms of its structure and its function. When the labrum is intact, you get a nice stable hip with a good suction seal. In some cases, the labral tissue is insufficient. Or if there's a segmental defect, unfortunately you lose that seal. So in most cases, you do want to preserve the labrum, whether by repair or reconstruction or augmentation. And this should then restore the biomechanical characteristics of the labrum. I think it obviously goes back to the labral anatomy. For me, the two things I think about in terms of labral anatomy, one is that it is continuous with the cartilage. And in addition to that, it is circumferential. So you want to try to think about that as you're thinking about how to approach a labrum. But the structure then determines the function of the labrum. And in terms of maintaining an anatomic labra repair, by doing that, you'll then preserve the suction seal, maintain stability, as well as dissipate the contact pressure forces going across the joint. A couple pearls in terms of repair, you want to make the repair as close to the labrum as possible. You want to use a small anchor. You want to go close to the subchondral plate, but obviously not through it. And then either mattress or simple stitch configuration, depending on the quality of the labral tissue itself. In terms of decision making or treatment options, I would say that there are four main options in my armamentarium repair, reconstruction, augmentation, and selective debridement. I would tell you that reconstruction, augmentation, I kind of put in the same bucket. It really just kind of depends on what residual labral tissue is remaining. But the technique and the principles are more or less the same. As far as my algorithm, it's pretty straightforward, very quite simple. On the left, you can see the labral tissue looks pretty good. It's very substantive. So that patient will get a labral repair in my hands. If the tissue quality doesn't look very good, like it does on the right, there's a situation where the tissue quality is not very good. And so basically, my options are either selective labral debridement, augmentation, or reconstruction. In my personal practice, I would say the indications or the prevalence of reconstruction is probably about 20% to 30% for revisions and like less than 1% for primary cases. Mark went over a lot of this, but some of the things I think about when I'm interviewing the patient if they've had a prior hip arthroscopy is what kind of surgery do they have and when was it done? Is it like an early failure or is it a late failure where the patient's initially doing well and they had some kind of event like a trauma that may have caused the pain to recur and become more problematic? How is their rehab? Mark talked a lot about this, but I do think the rehab is really important. And in some cases, some of these patients might do better if their rehab is more optimized. On a physical exam, I'll measure their gait. I'll look at their range of motion. I'll look for both stiffness and looseness and laxity, compare it to the opposite side. Obviously, provocative testing to see if there's anything that causes pain. You know, one of the things to keep in mind is, you know, was actually the right diagnosis made if everything objectively looks pretty good. But if we believe based on clinical history, physical exam, and imaging studies as well as lidocaine testing that it's coming from inside the joint itself, I tell patients that there's basically four main things that we're going to impact if we do another surgery. One is any bony pathology, residual impingement? Second is, is there any capsular instability, defect, and insufficiency? Third is it a cartilage issue? Is it, you know, do they have a little bit more chondral wear? Or in some cases, we've seen like suture anchors that have penetrated the subchondral plate. And lastly, is it a labral problem? And oftentimes due to adhesions where it's kind of matting down the labor in the capsule. And a lot of times we won't know until we look inside the hip. So I tell patients that a lot of our decisions intraoperatively are kind of game time decisions based on kind of what we see. And it really gives us a better clue as far as this is a, is it a labral problem? Is it a capsular problem? Is it a bony problem? And just trying to put everything together. So I think we kind of talked about a lot of this. I do put a lot of stock in the intraoperative assessment. The other thing that I think is really important is like assessing like their amount of distraction or traction when you put them under anesthesia. And so one of the things that I ask when we set up the patients, did they have a pop when you distracted the hip? If they do have a pop in a failed setting, to me, I think that the labrum is probably functioning to some extent, especially if it's like a pretty dramatic prop that you would see like in a primary setting. But the other principles that I want to look at is number one, tissue quality. I want to assess that chondral labral junction. Is that interface intact? Is it welded well together? Is there any incompetency in there? Is the base secure? Are there any loose sutures or loose bodies that have to be removed? Are there adhesions? I think the adhesions Mark taught us is like really important in terms of just making sure that labral capsular interface is like basically free of adhesion. So everything is kind of moving and functioning well. Is there a compression of the labrum across the head as well as maintenance of the suction seal? And in my mind, I'm thinking like, you know, this is a good quality labrum. Like this is one that I would not reconstruct. Frankly, I just remove the loose bodies, just kind of free up some of the adhesions. And in my hands, like a selective labral debridement would be appropriate because to me, it looks like it's functioning very well. The patient had a good pop on intraoperative exam. You know, and I guess the way I approach is a little bit more kind of case by case and individualized rather than just taking the labrum out for everybody and reconstructing everybody. But if you do happen to encounter a labrum like this, where you've got diminutive tissue, where there's a radial split, I mean, this is one that clearly has to get either augmented or reconstructed. You know, there is some good remaining tissue kind of below. So I do think I just try to incorporate as much as I can. But you really are using that graft to kind of span that defect, kind of bridge across like the two aspects of the labrum so that you can have like a continuous, you know, kind of labrum going across the entire joint. So I think in my mind, I try to be pretty critical about like what the quality of the tissue looks like and what I'm going to do thereafter. So I just want to touch on the biomechanics. I think that this informs a lot of my decision making as well. I think we're all well aware of some of the biomechanics of it. You know, clearly, if you have a torn or segmental defect, the biomechanics in terms of the fluid seal stability and contact pressure are not good. Reconstruction does improve the biomechanical characteristics, but not as well as repair. When you look at the segmental labor reconstruction clinical outcomes, they're all very good. New York has published on this, Dean Matsuda as well, and the outcomes can be as good as labor repair. One of the questions that we wanted to answer was what about this total labor reconstruction or circumferential labor reconstruction? How does this fare biomechanically? Should we be doing this or not? And so we, you know, went to our biomechanics lab. We did some contact pressure, cadaveric testing, and basically we had three groups. We had an intact, a labor repair group, and a total labor reconstruction. And we really want to be very keen in terms of trying to replicate the total labor reconstructions that are being done clinically, you know, going from like the transverse ligament to transverse ligament, removing the entire thing, placing like 10 to 12 anchors, and trying to be as meticulous as we can so that we're trying to replicate what's being done clinically. And then doing tech scan studies, looking at contact pressure, and you can see that, you know, the heat map is different between intact, labor repair, and labor reconstruction. And when you look at the contact area, you can see that there is a significant difference between an intact hip and a labor repair versus labor reconstruction. And so even though it looks great at time zero, it doesn't seem to replicate the mechanics as well as we think it does. We don't have the audio on, but when you have an intact hip, you do have a nice suction seal. And even with repairing the labrum, you do maintain that suction seal. And at least in our cadaveric study, when we did the suction seal analysis, like there was no seal remaining. And even though I thought arguably the cadaveric, you know, reconstructions look very good, we just kind of lost that seal. So what about labral augmentations? We've also done some biomechanical testing on that as well. And again, using a similar biomechanical testing protocol, you know, what you see is that the intact and the rim prep groups all have like a similar load displacement curve. But whenever you do like significant amount of intervention with the labrum, whether augmentation reconstruction, you can see that the load displacement curve changes dramatically and you just can't replicate that. So what about this labral reconstruction, total labral reconstruction? I would say that it is something that you want to be familiar with. I would say I do it pretty rarely. This is, you know, a case that I did a couple of years ago in a patient who had labral ossification that was pretty significant. You can see on the x-rays, this is what it looked like on the left pre-acetabular rim resection and this is afterwards. You know, but a couple of things, I mean, you know, basically you want to do a pretty thorough acetabuloplasty. You'll use your fluoroscopy to make sure that you've removed all of that bone so you can really bring that acetabular rim back to where the anatomic position is. And then just kind of keeping in mind where the overgrowth is and just not making a recess but bringing it back to where the normal position should be. And then using fluoro kind of all the while. But here after you do this, with this amount of labral ossification, like there's like just no labral tissue remaining. I mean, you can argue that you could just leave it like this, but it just kind of felt like a labral reconstruction would be appropriate. Measuring the graph could be pretty tricky just because of the size of the defect and the inability to replicate that arc. So I think you just have to take a guesstimate. Some people will leave it long intentionally and just kind of trim it at the end. But I'll try to place like one or two instruments just to kind of replicate the arc if I can. And then placing anchors, I'll place them first sequentially. I would say generally my rule of thumb is if I'm going to make a 10 centimeter graft, I'll put one anchor for every centimeter. If I do a four centimeter graft, I'll do four anchors in total. So it just depends on the length of it. And so I want to place all my anchors first. I want to place them as close to the subchondral bone as possible so that you're able to create a labral graft that's not inverted and sitting well against the acetabular rim. Graft passage could be pretty tricky, especially when you get to these longer grafts. I will basically fixate down the medial side. But I'll also have sutures going through the far lateral side as well. Some people like to use rescue sutures there as well. But once you kind of fixate the medial side, you can see the labrum is just kind of sitting within the joint. So you do have to manipulate that by using your tissue graspers just to kind of get everything kind of on the face of the acetabular rim itself. And you also want to pull tension on the graft too so that the graft is not bunched up and redundant. And so basically you want to pull traction as high as you go. This is a sequential reconstruction. It's fairly finicky. Things can go south pretty quickly. So you just want to make sure that your team is kind of well aware of what you're trying to accomplish and that they're helping you as best as they can. Because while you're trying to tie, somebody has to be kind of pulling in and pulling tension on the graft and keeping it out of the way. And I do like this tissue grasper that's pretty smooth, like a loop retriever, because I think it's just a little bit more gentle on the tissue itself. And so once everything has been passed, you've got a nice labor reconstruction that I think is not averted. You're able to maintain that suction and seal. Try to replicate the hoop stress as much as you can. And again, not something that I do very commonly. But every once in a while, you'll see a case where you think it's necessary. So this is an interesting categoric study that was done by David Maldonado and Mike Bamphy just looking at circumferential labral allografts. And when you see on the left, the intact blue bar, you can see how much that they call distance rupture was pretty high. And then when they had deficient labrum, you can see that that distance rupture went down when they did a circumferential labral reconstruction less than 6.5 millimeters. It still was not normal, and it only became normal when that circumferential labral reconstruction was greater than 6.5 centimeters. So when you look in the figure on the left, you can see that on the left represents that kind of larger graph, greater than 6.5 millimeters. And I'm a little bit cautious about that just because the labral tissue is so large there, it just feels like it's just going to overstuff the joint a little bit. And to me, I'm just thinking like there's going to be like a ton of adhesions going on here. But again, this is a categoric study. I think this is what they found. But you know, take it for what you will. So let's just see what the clinical outcomes look like. Here's a systematic review that was published on five studies, 359 revision hips, two-year outcomes and their total hip replacement free survival was about 93.5% to about 100%. This is a study from Mark's group looking at labral reconstruction, augmentation, and revision settings. And what they found was that there was a 79% re-operation free survivorship, 82% achieved MCID and 72% achieved PASS. And this is a multi-center study from the MASH group looking at outcomes of labor reconstruction versus labor repair in a revision setting and finding that the MCID was similar between revision labor repair and revision labor reconstruction. There were some differences in terms of demographics. The revision labor repair tended to be younger. The severity of the labral tissue tended to be worse in the labor reconstruction. And the cartilage damage tended to be a little bit worse in the labor repair group. So there are some differences, you know, but nevertheless, I think what we found is there is no significant difference in terms of MCID or PASS when doing revision labor repair versus revision labral reconstruction. This is another study that Ben Doan put together looking at, again, circumferential labor repair for the irreparable labral tear in the primary setting, two-year follow-up, and finding that there is no difference between two of the groups in terms of modified Harris hip and the IHOT as well as the IHOT PASS. This is a study looking at revision hip arthroscopy with labor reconstruction in athletes, minimum two-year follow-up, for irreparable labral tear. And what they found is when they compared revision repair versus reconstruction, that return to sport rate was higher in the labor repair group. And when they looked at conversion to total hip replacement, they found that re-count was about 10% and repair was about 17%. So there's no significant differences in terms of return to sport or revision cases when doing reconstruction for revision versus repair. And the MASH group also looked at repair versus reconstruction. And the reconstructions were actually circumferential reconstructions and, again, did not find a difference between repair versus reconstruction as well. So I think in terms of the principles of biomechanics, again, the things that inform my decision is a couple of things. One is that I do want to avoid violation of that chondralabral junction. And I think that's why some of these larger graphs have a hard time in terms of matching up with the biomechanics, at least at time zero. So the larger the reconstruction is, the more it's violating that chondralabral interface. In addition to that, the hoop stresses between graft and host tissue obviously have to be kept in mind. You do want to maintain that anastomosis. But if you have a normal labrum, that hoop stress and the anastomosis is already there. And so that's always kind of a limitation in terms of any reconstruction that we're doing, which is, I think, why the augmentations, if you've got sufficient tissue, might be a little bit more forgiving. And my opinion is I think you want to avoid non-anatomic reconstructions just to prevent overstuffing the joint as well. So in summary, restoring labral anatomy is critical. Preserve native tissue when possible. Augment or reconstruct when the tissue is insufficient. And again, in my hands, I'm basically kind of thinking of them the same as just whether I incorporate native tissue or not. Keep in consideration labral graft size, width, and type of reconstruction that you're doing. And always kind of keep as your guiding light, recapitulating the normal anatomy. And I think that this should affect the long-term clinical outcomes as well. Thank you. Great. Next, our next speaker is Mark Philippon, who doesn't generally need much introduction. He's one that's helped lead us in pushing things forward and dealing with complex issues. so I always try to give him the ones that we have the least amount of information on because he's got the most amount of information than anybody. So I'll have Mark talk about capsular defects. So thanks. Thank you Mark for inviting me and to my team in Vail for putting this talk together. So we, I remember about 10 years ago I was in Seattle at AOSSM actually I showed the first video of capsular recon on a baseball player and I remember the audience was looking at me like I was from Mars. So today I'm happy as an ICL we're able to discuss this. So my disclosures on the booklet there. So just refreshing on the anatomy of the capsule. Way back when in 2000 I start talking about the ilioformal ligament as a reinforcing ligament of the capsule and I learned that from one of my patient that kept telling me that when he was on his back leg, he felt his hip collapsing and we started looking and we thought the ilioformal ligament was a big contributor to stability and Mark actually, Dr. Safran is an expert on instability and he's doing a lot of great work. Thank you Mark. And so the ilioformal ligament really is one of the strongest ligament in the body, resists extension, exploitation. So if you have an athlete that's doing a lot of rotation sport, it's very important. So when we do surgery unfortunately, some of us will incise the ilioformal ligament so if we don't repair that will create some issues. The ilioformal ligament is important as well as the pubofemoral but truly the ilioformal ligament is the one we we think is important and when people, I was listening to Shane about his talk here, when people these do these big circumferential reconstruction which I've done as well, they cut through the medial capsule and a lot of them, when I revise them, unfortunately there's a huge gap there. So a lot of the issues, not only the graft but the yetrogenic problem in the capsule. So again, like I said, also I forgot about the zona oblicularis which has a great function as well to really circulating the neck and helping with stability as well, a different orientation of the fibers. And we talk about the thickness and this is an old, relatively old paper we wrote in 2015 with Dr. Lapraud and our team in Vail and we look at the thickness which is, again we talked about that earlier, is very important as far as stability. So the maximum thickness was at two o'clock, that correspond to the ilioformal ligament and from the thickness from the edge of the labrum was greatest at nine to three o'clock. So I refer you to that paper if you're interested in more extensive information on the capsule. So why does it fail? Well, capsular tears obviously, prior open surgery, prior hip arthroscopy unfortunately, no capsular exposure, capsulectomy, post-abruptures. I use abnormal sutures, number two vicral, very thick sutures. I know intuitively you would say it's better to use permanent sutures but for me I like the reaction from the number two vicral and you just have to be careful for the first three weeks and I think it works really well. But most of surgeons now use non-abnormal sutures. Improper healing and adhesions can cause some issues. Now I'm looking at the hip arthroscopy. If you do a really small capsulotomy at the right location and I agree with what was said before, sometimes you don't have to close it and there's a paper that will come out actually soon. I was just getting a text from these guys. It should come out pretty soon on a properly done capsulotomy, lateral teleoformal ligament and you, size is important as well, like smaller size less than 20 millimeters. You probably don't have to close it. But anyways, I personally recommend to close it. So what happened when we failed that capsule? I think it will affect significantly your your congruency. It's all about congruency and if you have a deficient labrum and a deficient capsule that will lead to instability. Now how do we define gross instability versus micro instability is still open to debate but it definitely exists in my opinion, especially people who are watching a sport. And the capsule plays an important role, especially at the level of the teleformal ligament. This is an old video. Baseball player, golfers, quarterback during the sideline. Again, this was back in Pittsburgh. When I was in Pittsburgh, we'll look at, we put surface markers and analyze these patient with force plate and look at the stress, especially the various plane of motion, especially in external rotation. And you can see the spike there when they do the external rotation in all sports, taekwondo, golf, just throwing the sidelines and baseball players. So these sports are definitely sports at risk that will affect your capsule if you have deficiency. So how, what can we do if you have a failed capsule? First step, sometime we'll just inject PRP, see if we can have a response. Capsular repair, capsular recon, and capsular augmentation. These are, but I'm more in the middle. For me, in my hands, that works, that's what works the best if we have a truly symptomatic capsular deficiency. Capsular repair. So for us, we do a laterally based capsulotomy. I try to stay as much lateral to the uniform ligament. And also, I kind of oblique my capsulotomy. And if you can ask my, when we repair a labrum, you can ask our fellows that train with me, sometimes it's difficult because I try to put all my anchors on the lateral side. So I don't even, sometimes if I'm below three o'clock, I will have to go medial, but I do a separate capsule hole. And we close our capsule. My capsulotomy is about 22 millimeters with, closed with two side-to-side cabexity slider vical suture. So it's, it's, and, and the, the nut I use is one, one pass with a double, double, double suture lines with vical, and it works really well for placation technique. So that's how we like, and I, I have to say I'm still doing medially when I close my capsule because I can't put my suture medially sometime. I still do a couple stripes of monopolar RF, and some surgeon who have from, from the past are still using that technique sometime in the shoulder. But again, very carefully, a couple pass that's it to create a contracture. So this is an old slide from Arnosky looking at in vivo healing after capsular placation of actual model. And you can see that there's increased evidence of tissue injury in open shift group compared to the placation. So I do a placation. This is the way I do the capsular thermal cap. Again, I just do a couple pass, very careful. This patient, this device actually is very good for synovitis as well, so I use that for my synovectomy. And again, you have to be very careful. This is monopolar, and again, this device is still on the market. There's better device now that you can use, but just you have to be careful how you use it not to burn a capsule because there's been disasters in the shoulder. So if we look at capsular repair versus non-repaired, conversion, conversion rate to THA was 14% in non-repaired capsular group, and conversion rate to THA in the repaired group was 4%. And this was a, actually I see one of my, the person who wrote that paper is in the audience today. Great paper, and again, this was early information, the importance of a capsular repair and improvement on the scores with the repaired group. So the Haas ADL, the non-repaired group was 84, repaired group 87, modified iris 76 to 87 in the repaired group. So this was again midterm outcome after capsulotomy repair versus non-repair. Now let's go to the meat of the matter, capsular reconstruction. Like I said, this technique was developed by necessity. We saw these, this is actually a tough, I don't know about you guys, seeing these defect medially. The psoas is right in your, I mean this, this is a really difficult problem. There's no way you can close that primarily. So that's why we came up with that technique to use a graft to close that defect. So why we perform this? We want to restore the capsular envelope, have a good sealing mechanism. We want to block, it's like a hernia actually, if you look at that psoas, it will, on motion, that psoas will herniate to the joint and that, you can see how inflamed it is. So you want to definitely patch that area. And then we're hoping that we restore normal kinematics and reduce, reduce the risk of idiopathic instability with the reconstruction. So we discussed that, the effect of capsular recon on the destructive stability of the hip joint. So if you look at the intact capsule versus the defects of reconstruction, you can see that there's a greater force, maximum destruction in reconstruction state compared to capsular defect state. So we improved the situation with our capsular recon. But reconstruction's force also was nothing different from the intact state. So we know that bio, at the bench level, biomechanically doing the recon is positive for the patient. So again, these are something we see, like what happened with the adhesions and with the defect, it's pulling on the labrum as well, causing some separation sometime. But most importantly, the medial sleeve is really inflamed, a great source of pain for the patient in our hands when we examine them. So this is actually, yeah, that's the video I showed a few, I think a few years back. So this is an IT band allograft. You can see we still do our vical suture. We place it arthroscopically to the lateral portal. That's what I recommend. Don't place it to the anterior portal because it's difficult to pass. But we pass it to the lateral portal. This is placing the anchor in the subspinal region. Actually, to be honest, to do a capsular recon arthroscopically is not that difficult. Placement of the anchor is very far away from the rim. So we start medially. And usually I use a 2, 3, and also 3 anchor medially. And you just, you know, shuttle your graft through, get your proximal fixation first, then do your distal anastomosis with, I use again, number two vical suture to the host capsule. And I start, I work medially to laterally because most of my defect usually are medial. Sometimes I have lateral defect as well and we want to protect the minimus. But again, this is just working. It's like building a ship in the ball. You just have to use your two portals. Take your time. Just make sure you have strong anastomosis. Your capsule thickness, I like to have three millimeters of thickness. And then again, this is a subspinal region. We want to make sure we have good stability there, good, good fixation. And then you just do your distal anastomosis. And in general, the defect that we repair or close are between 4 centimeter to 2, from proximal 2 to 3 distal. So at this time, we were using a shuttle technique. Now we use a device. This is sometimes you can use a flexible tool to help you maneuver with the sutures. Because especially medially, sometimes it's really difficult to get your suture in the right location. So I use that device to help me maneuver. And that device is really easy to pass next to your portal. So today, again, we, this is without traction, subspinal region. I do my measurement. I use high technology for that. I just use my shaver to measure. But sometimes I use a ruler like Shane does. And so I measure my defect. And then preparing the graft is very important. Actually, I'm blessed because I have great fellows and they prepare a beautiful graft every time. I used to have a great nurse, Penny, used to work with me. She was my graft meister. But now our fellows pick up the work and they do a great job. So you just basically do a peripheral suture line. I'm very picky about how tight it has to be. Because when you show the technique to the soft tissue, you want your graft to be super stable. And sometimes we'll put reinforced cross sutures in the center. And then I used to do this. I used to put a little loop distally. I don't do that anymore to facilitate the management in the joint. But again, this is just a simple preparation. Just while they're doing this, I do the stuff in the joint. So it doesn't cause... Now commercially, I know they have pre-made graft that you can use. But I still make my own graft with IT band allograft. So I used to pass my graft through cannula. Now I don't do that anymore because the graft is too big. So I just free pass it as long as I have a good suture fixation at the top. And as I said, if you pass it through your lateral portal, there's no problem. And then again, same technique. You want to make sure you have enough slack. And when I test my graft fixation, I flex and extend it to make sure there's not excessive tension. And you know, we just have to make sure we do the proper measurement. And when we tension it, you want to have enough tension, but not excessive tension because you don't want a graft to rip. And my rehab actually is the same as a primary closure with this. So again, you can use the ArthroPierce, but I'll show you some now with the new... We have very, very good instrumentation now that makes it this SmartChain. Plus you save a step by doing it. But again, I mean, I like that technique. It's very safe, allows you to go more medial sometimes. And again, we do this as the last part of the procedure. Sometimes we have to revise the osteoplasty, but it's relatively, if you follow all the steps, it's relatively straightforward to do that technique. Second look, actually, we have a few patients we have to go back in. By MRI, they look great, but this is how it looks. You can see my graph here on the top. Actually, inferior sutures there, inferior pictures. And then we had some adhesion on this patient. We just removed the adhesion. The patient did well. So this is the graft selection. We talked about that at another meeting recently. In my hands, a dermal allograft doesn't do as well as the IT band allograft. Actually, my pass rate was 42 versus 85 in the IT. So in my hands, I still use an IT band allograft for this procedure. I tried a dermal, it's easier, but in my hands, I didn't have the same results. The mid-turnout comes looking at this technique. Again, it's early. So this is a salvage procedure. So we had 39 patients. On average, this patient had two prior hip scopes. As you know, multiple revisions are not as easy as far as having great outcome, achieving great outcome, but we had six of those that convert to THA at two and a half, two at 2.1 years and four revision. But the three-year survivorship was 86%, and mean survival was 5.7. So I think these are acceptable results for a complex problem that we're trying to solve. So basically, I like to use the IT band allograft. I fold it three times. I make suture loops in some occasion, but this has gone away. And make sure when you fix your distal fixation that your host capsule is firm enough and good enough for the sutures. And then again, like I said, I like to place my proximal anchors first, insert the graft to the outer portal, and make sure you have the right measurement for your capsule. So I think this is something any hip arthroscopists who work at the Referral Center should have in their armamentarium. And again, there's a lot of, this is a work in evolution. We're better at what we used to do to perform this, but I think it's a good solution for complex problem. And once you master the technique, actually, it's pretty straightforward to perform. So I think we're making some progress in that space. And unfortunately, the more hip scopes are being done, the more capsules are being shaved, the more, yeah, the more we do this, the more we'll have to deal with this. So hopefully, in the future, we'll have pre-prepared graft, make it easier to perform, and have better outcomes. Thank you. Okay, so to wrap up the lectures, our last speaker is Andrea Spiker, who comes to us from the University of Wisconsin, Badger Country, if you will. And let's see if we can get this right from the get-go. There you go. Thank you, Andrea. Thank you. So there's four empty seats here in the front row, if you guys in the back want to come up and sit down, you're welcome to. So thanks so much. You know, this has been an excellent session covering a lot of our options when we encounter a failed hip arthroscopy. I'm going to focus on when you probably shouldn't try to do another hip arthroscopy when encountered with a failed hip scope. So here are my disclosures. So today, we'll talk a little bit about when it's obvious that you shouldn't scope it, it needs an open surgery. But I'm going to really focus most of this talk on when it's not that clear. And that would be in borderline dysplasia, femoral version abnormalities, cases like SCIFI, and when you might consider a surgical hip dislocation. So open surgery is the clear choice when we encounter frank hip dysplasia. And so we know the normal lateral center edge angle is 25 degrees. So if a patient has less than 18 degrees of coverage with a lateral center edge angle, this is a clear indication for the periacetabular osteotomy. And the PAO is the gold standard treatment for hip dysplasia. This was first described by Reinhold Gantz in 1988. And with four separate cuts around the acetabulum, the acetabular fragment is completely free to rotate and give more coverage to the femoral head. So unlike the pediatric pelvic osteotomies, the difference with a PAO is that the fragment is not hinged anywhere. And so we have total freedom of movement of this fragment. And the pelvis itself is actually still intact because the posterior column hasn't been violated. So the goal here, as I mentioned before, is to cut that acetabulum fragment completely free. And then we rotate it in order to provide more coverage to that femoral head. Now, another clear indication for open surgery is Perthes. So Perthes disease is obviously more commonly seen by our pediatric orthopedic colleagues. But as a sport surgeon, you are going to see the adult sequela of Perthes. So this is a hip that you should recognize just by looking at the x-ray. It's pathognomonic for Perthes. You see coxa magna, or a widened femoral head, coxa plana, or a flattened femoral head. You've got trochanteric overgrowth, coxa breva, or a shortened femoral neck. And you may have a shorter leg on that side because of all of these changes. Acetabular dysplasia also goes hand-in-hand with Perthes as well. And then, very commonly, you'll have osteochondritis desiccans in this setting as well. So this is an example of a 30-year-old patient who presented to my clinic. And he had an insidious onset of right hip pain over just a few months. He'd never before had hip pain, never been diagnosed with Perthes. But he noticed that throughout his lifetime, he felt he walked kind of funny. So you can see he has almost all of these adults so-called of Perthes disease. And so if you encounter this in a patient, this is probably the right approach. So what we did is, given the fact that he didn't have osteochondritis desiccans and he had very good intact articular cartilage, we performed a surgical hip dislocation, open femoroplasty, a relative femoral neck lengthening, and then a concomitant periastabular osteotomy. And it's not a normal hip, but it's a better hip and gave him more function and motion. Now, of course, when a joint is too arthritic, this is also a very clear indication for open surgery, namely a hip replacement. So let's focus now on those situations when open surgery is not always the clear choice. So first, and probably the most popular topic, is borderline hip dysplasia. So borderline dysplasia is defined as a lateral center edge angle between 18 and 25 degrees. Or in some literature, you'll see it defined as between 20 and 20 degrees of coverage. Now, almost 90% of borderline dysplastic hips are going to have labral pathology. So be aware of this if you evaluate somebody who has a labral tear. It's important to keep this in your differential. And I'll go through how to diagnose this a little bit more in the next few slides. But I'd also like to point out this pattern of cartilage wear that we see here. So this is classic cartilage delamination seen in dysplasia. So unlike the femoral acetabular impingement to chondrolabral cartilage wear, you see in this situation the labrum is still attached to the cartilage. And the cartilage is delaminated further down into the acetabulum. And so if you see this while you're scoping a hip, just keep in mind this might be actually more of a dysplastic picture. And if that patient doesn't do well post-operatively, that you should consider some open procedures down the line. Now, there have been a number of studies that show patients can do very well with hip arthroscopy in the setting of borderline hip dysplasia. But as we've heard before, not all hip arthroscopy is the same. And so there's a significant difference in outcomes of hip arthroscopy in the borderline hip, depending on whether the labrum and capsule are repaired or not. And without capsule repair and with labral debridement, there's up to a 60% failure rate. And 40% of those patients are going on to have accelerated arthritis. So the takeaway from this data is that if you have appropriately indicated somebody with borderline dysplasia for hip arthroscopy, you have to be extremely careful with the soft tissues. You have to repair the capsule, you have to repair the labrum or reconstruct it in order to restore that anatomy. Also keep in mind that in the borderline dysplastic patient, there's a very long list of non-modifiable factors, which are associated with poor outcomes after hip arthroscopy. So if you look over here, these non-modifiable factors, you're not going to be able to change between the index arthroscopy and a subsequent failed hip arthroscopy. So this is a very important list to keep in mind. And maybe in this case, you would revert immediately to open surgery instead of attempting a second hip scope. Now, in general, I think it's important to recognize that hip arthroscopy in the borderline dysplastic patient is simply just less predictable. And there's a very high reported failure rate in this group. And even in the setting of the appropriate soft tissue management, one study demonstrated a 32% failure rate as not achieving an MCID or needing yet another revision surgery after hip arthroscopy. So I'll spend the next few slides just focusing on how do we appropriately identify the borderline dysplastic patient. And you know, we've classically used the lateral center edge angle, but you've seen all of these other measurements of hip dysplasia that have been described. And there's significant variability in the literature amongst authors who are using different predictors of borderline dysplasia. But I would say my workhorses in my clinic are the lateral center edge angle and then the acetabular inclination or Taunus angle. These are two of the most powerful measurements of dysplasia that I know of. And when you're measuring the lateral center edge angle, it's really important to pay attention to how you're measuring it. So look at where the sore seal ends laterally. And in this patient, the sore seal has an upturn. So if you measure the center edge angle to this point, you're going to get a very different number than if you measure it to this point. And what I've done in this image is I've measured the lateral center edge angle in three different methods. I would argue that the image on the right is the appropriate center edge angle. And you can see there's almost a 10 degree difference here. So make sure that you're appropriately measuring your center edge angle. Now, even if you do that correctly, it's probably not enough. Up to 40% of normal hips as defined by that lateral center edge angle are actually still dysplastic by some other measurement, including the Taunus angle. So here again is the Taunus angle. You want to measure the slant of the sore seal. And if it's greater than 10 degrees, this is an indication of hip dysplasia. I think clinically we use 12 degrees or 14 degrees. But just be aware of this number. Now, another radiographic measurement that you can use is the femoral epiphyseal acetabular roof or FEAR index. And you measure this by drawing a line in the central third of the fiseal scar, another line through the medial and lateral aspect of the sore seal. And if that angle diverges laterally, this is an indication of instability. It's a positive FEAR index. And then Dr. Safran has described the cliff sign. So here, if you look on an AP of the hip and notice this cutout, this is also associated with hip instability. The false profile can also give you a sense of anterior acetabular coverage. And this is also a good way to look at that subspine morphology. And so if we look back at these reports that hip arthroscopy can work in the borderline dysplastic hip, I really think we need to emphasize that these are high volume expert surgeons who are achieving these results. And so making sure that you are able to do what they're doing with the soft tissues is incredibly important if you're considering another hip arthroscopy. And in some patients, it may not be clear how undercover their hip is until you get more advanced imaging like a 3D CT scan. So in this hip, you can see based on the CT scan, the femoral head is much more undercover than you might estimate just based on the x-ray alone. And this CT scan shows a patient with a normal lateral center edge angle as seen from the front. But as you rotate this hip, posteriorly, you can see she has no acetabular coverage. So this is another reason why these 3D images might be helpful. So what are the absolute red flags for doing an arthroscopy alone in a borderline hip dysplastic patient? I would say that low center edge angle and a very high tonus angle. And then also recognize that the PAO is a very powerful procedure in all of these indications which have expanded from our historical indication of hip dysplasia. So that focal undercoverage, even in a patient with a normal lateral center edge angle, significant acetabular retroversion, these are all reasons that you might consider a PAO. And the PAO has been very successful. So up to a 95% survival rate at 10 years, up to a 92% survival rate at 15 years. If you look even further at 20 years, a 72% survivorship. And then there's one study that has the longest follow-up at 30 years. And they show a decrease, up to 40 to 60% survivorship. But I want to point out that there's a big difference in their survivorship in PAOs that were performed in the 1980s compared to those that were performed in the 1990s or after. So this study looked at those PAOs performed in the 1980s and it was up to a 56% failure rate. So the techniques have advanced. And now if you look at those performed in the 1990s or later, it's a 7% failure rate. So big difference in our technique. And one of those differences is simply the approach. So this was the classic approach for the PAO. This is now what we use, a very small bikini incision. So I think in general, it has become a less morbid procedure. And outcome scores, again, significant improvements up to 10 years. If you look at those who get both a hip arthroscopy plus a PAO, up to an 82% return to sport rate. And even in looking at those with borderline dysplasia, PAOs patients have very successful outcomes. Again, who shouldn't get this PAO? Tonus grade greater than one if they have arthritis. And then think about older age. As you get older, the survivorship at 10 years does decrease. So consider all other alternatives in that situation. Always keep in mind that hip instability is a clinical diagnosis. And so looking at the examination maneuvers that will test for clinical instability, even in the setting of relatively good bony coverage is important. The Baton score is something I get on every single patient that walks into my clinic as a sign of hypermobility. And just keep in mind that if you chose the hip scope incorrectly in a patient who's actually dysplastic, there is an incredibly high rate of failure. And one of the ways a patient can fail is this catastrophic progression to osteoarthritis typically happens within a year after surgery if the patient is dysplastic and you perform a hip arthroscopy. Now, quickly on femoral version abnormalities. This is a tough one, but one way that you can quickly look at a patient's femoral version is by watching them walk. We typically want about 15 degrees of antiversion. And that femoral version refers to the line behind the posterior condyles at an angle of the femoral neck. And if this is greater than 15 degrees, typically 25 to 35 degrees of antiversion or less than minus 15 degrees, that's where you might consider doing a femoral derotational osteotomy. You can do this with an intramedullary saw and nail. You can use an osteotomy with a blade plate. You can do a subtroke osteotomy in plate or even a distal supracondylar osteotomy in plate. And in each of these situations, you're trying to rotate the distal fragment internally if the patient is retroverted. You're trying to rotate the distal fragment externally if the patient is antiverted, and you just want to go back to that 15 to 20 degrees of antiversion. Now, this is an interesting topic, looking at tibial derotational osteotomy in the setting of hip pain. Tony Ondrad and his group published this last year. And their theory is that in excessive tibial rotation, a patient will try to move their foot neutral and thus cause hip impingement. So they're derotating the tibia to relieve the patient's hip pain. And they reported on 32 patients, but noted significant hip pain improvement. So this is something coming down the pike and we'll pay more attention to in the future. Now, what about a surgical hip dislocation? This, again, was the gold standard treatment of FAI originally. I very rarely do this nowadays. And this is an example of somebody that you might consider doing it in. This is a patient with coxa profunda, diminished femoral head and neck offset. You can do a surgical hip dislocation, actually chisel away the acetabular rim, do an open cam decompression, open labral reconstruction, and then give that patient more normal coverage afterwards. You might also consider it in the setting of a focal, relatively small osteochondral defect of the femoral head. You can do an open surgical hips dislocation with an OATS procedure. And if you look here at the patient's pre and post-op, you can see that that can restore a very focal lesion of cartilage defect in the femoral head. But even when you think that you have the answer based on these slides, make sure that you're aware of occult ulcerative arthritis. So this patient has a very large osteochondritis desiccant lesion. And so even though this is a young 27-year-old patient, we recommended going to a total hip replacement instead of trying something that we just discussed. Now, SCIFI is something that you might encounter. And remember, in SCIFI, the metathesis translates anteriorly and then externally rotates while the femoral epiphysis remains in the acetabulum. And in these cases, you might consider open surgery, but there is a role for a revision arthroscopic procedure in this setting. And in this patient, she had significantly limited range of motion. She was 20 years old at the time of surgery. And with a arthroscopic femoralplasty, it was able to give her a much more normal looking hip without going to this more aggressive open osteotomy. This is the modified done. I don't do this. I would refer to one of my pediatric colleagues, but you can imagine this is quite a morbid procedure and the potential risk of this is avascular necrosis. And so maybe that arthroscopic procedure is the better way to go first in a young patient like this. So in summary, conversion of the failed hip to open surgical alternatives can include the surgical procedures of surgical hip dislocation, femoral, and now maybe tibial de-rotational osteotomies, and then the periacetabular osteotomy. So as you're looking at the failed hip patient, don't miss borderline dysplasia, femoral version abnormalities, and maybe those unique cases where you could do a surgical hip dislocation instead. And because borderline dysplasia is the one that you're most often going to be seeing in your practice, make sure you're familiar with how to appropriately measure the lateral center edge angle and how to measure the tonus angle and how to evaluate for instability outside of the radiographs. Thank you very much. Okay. Thank you. Thank you. Great. Thank you all. Great speakers. Great talks. We'll open the floor for questions. And while we're waiting, actually, I'm going to throw out a simple one across the board here. So there, you know, controversy as to what is borderline dysplasia you put up there, 18 degrees, 20 degrees, you know, and I also, I think what's probably underestimated significance is actually the tonus angle, the roof angle, and its role. I don't think that if you had a center edge angle of 25, but a roof angle of 25, that I would still want to do that as a scope. So, and you threw out some numbers regarding femoral version. So let me just actually go start down the path. Mark, what is your threshold number for enter center edge angle? Well, let's just say lateral center edge angle and roof angle and femoral version. So we'll start with your, what's your threshold for lateral center edge angle where you just say, you know what? I think we need to, this dish should go to see Joel Mata. What would you say? So for me, it depends if it's a male or female. And in male, I think we have more room to maneuver, but based on a lot of the work from the group and I have Dr. Mata in the office, our threshold is a little lower now as far as sometime if I have a center edge angle of around 25 with a lot of anti-aversion on the femoral side, we'll do a combined procedure. If it's a female with some evidence of maybe laxity, so we'll be at a lower threshold. I also use something that hasn't been mentioned. I use the Sharpe's angle. There's a good article by John Fagan and Sir John Charlie in 1973 in Core where Sir John Charlie used to use the Sharpe's angle to help him define. So I use that a lot for me. So my number is 42. So if it's 42 or above, I'll have a lower threshold for KAL. Yeah, and I gotta say, I'm trying to oversimplify. Certainly, I think neck shaft angle and femoral version make a difference in what I'm saying for what I take as an acceptable or not acceptable lateral center edge angle. But in my practice, I won't do capsular placation if somebody has a lateral center edge angle of less than 17, right? That's kind of my stop number, if you say. So counting other things being normal, what's your stop angle for a scope on where you just say, you know what? I just wouldn't do it. I mean, there might be the one off, whatever, but what's really your stop angle? Yeah, for me, even if it's 22 now, yeah. So if somebody has a center edge angle of 21, you're saying, no, you gotta go to Jomana? Well, I just feel, yeah, it's changed over the years. You know, people say 20. For me, I'm nearing more, I'm more conservative now for hip arthroscopy just because I really believe the rim loading is especially in a female, that it's to build, it's, I won't, I mean, I've had good results at 20 degrees, but now it's, I have more sense of 21, 22 degrees. Okay, Shane? So, I mean, the borderline hip is kind of the biggest question, I think, in hip preservation. We just recently put together an abstract looking at kind of our outcomes in our borderline hip population, and we looked at LCA and all the other different parameters, you know, tonus angle, anterior center edge angle, fear index, anterior wall index, anteroversion, and so forth. And what we found is that, you know, for patients with borderline hip, which we define as, like, 20 to 25 degrees, obviously the LCA is, like, pretty kind of a crude parameter that Andrew was talking about, and so we have to look more carefully in terms of what we're doing. The tonus angle is helpful if it's greater than 10 degrees, but I think the three factors that we found that had the biggest impact in terms of their conversion to, like, PAO was LCA less than 20, positive fear index, and an anterior wall index less than 30% or so. And so I think when those three factors were combined, we had, like, a 60% conversion to PAO rate, and then if there's only one of those factors, then our conversion to PAO is much less than that. So those three combined tended to have, like, a really bad outcome. So, but if we were gonna pin you down on a lateral center edge angle number of the source seal, what would you say where you just sit there and go, no? Well, I would, yeah, less than 20. Less than 20? Andrea? Yeah, I think it's very reasonable at 20 degrees of lateral center edge angle to at least get the opinion of somebody who does open. And they may come back and say, with all of these factors, they don't need a PAO, they can do a scope, but I think it's appropriate to ask somebody else at that point, and it's a very complicated calculation. Absolutely, I think it's hard to isolate, but I know I try to, you know, I'll sit there, like I said, I've gone further and further down, I was only doing 22 degrees 15, 20 years ago, and then I went down to 20 degrees, and then I went down, I've gone down, but I pretty much have a hard stop at 17, and ideally, you know, 17, and ideally the tonus angle is less than 10, but, you know, so there's other factors that kind of go into it, as I was saying, but trying to mine hard. Well, I was gonna give a corollary, so I do PAOs in my practice, too, and I'd say when I started, I was very conservative with who I indicated for a PAO. They had to have, like, less than 18 degrees of lateral center edge angle, and over the years, people do so well, they recover so well that now it's, you know, 24 degrees, 25 degrees of lateral center edge angle, and I'm doing a PAO, so it's, you know, for all those other reasons. And what, when you think market, I wanna say is also depends on the status of the cartilage, right? If this is cis, if I see that it's gonna go down fast, I wanna do a scope, so I think the status of the cartilage, and male, like I said, male versus female, an NHL hockey player, some of them are borderline, it's plastic down to 20. Large cam, you do a cam decompression, it'd be great. Yeah, and it's funny, because I've gone the other direction, right? I used to send people with center edge angle less than 25 for a PAO, and they'd get sent back to me, but it's not bad enough, you can do something with the scope, and that's how I started kind of going further down the path, but you have a question? Yeah, with that blue line, yeah. The question is, if you are doing a scope again, what do you guys think? I mean, you know, you want to understand what the underlying cause was, but again, if they have borderline dysplasia and you think they're unstable or whatever, again, then you think the instability is the cause and you don't have a capsule defect yet. Did they repair the capsule before? Did they even try to placate it or not? So I would try to, you know, make sure you have some labrum there as well. Do they need a labrum reconstruction? You know, what's the quality size of the labrum? And try to address what the defect is that's bringing them back. You've confirmed it's an inter-articular cause. Yeah, I mean, I think people, it's pretty much consensus, but you guys can tell me if I'm wrong. I mean, but pretty much consensus, if you have somebody that's borderline dysplasia and you're going to do a capsulotomy, then you need to be repairing that capsule. And particularly even considering tightening, you know, to some degree or placating. And again, trying to be a bit more, that in my hands, I know Shane said the same thing, 1% of the time he's doing primary, reconstruction of primaries. That's the situation for me. A patient that has a normal center of jangle, if you will, and if they have an irreparable labral tear, for instance, we know that the body can regrow labral-like tissue in that area. And I don't think there is, quote unquote, what I'd say, they may be labral dependent, they may not be unstable. But a person that has borderline dysplasia that has irreparable labral tear, that's to me an indication to do a labral reconstruction primarily to give them such a shield, give them some more surface area. But Mark has a lot of experience in that. I don't want to diverge, but I had a patient who had a great PAO done actually in Denmark, very experienced surgeon. This patient has a lot of issues. But young lady, perfect PAO done, persistent pain, she had her hip scoped a couple times after the PAO, labral treatment and stuff, and chondral treatment. And again, the PAO, I just text with the surgeon in Denmark, perfectly done. So she came to us for the third hip scope. So I scoped her, and what I did, I don't want to diverge, but I reconstructed her LT, just reconstructed the LT, and she felt the best she's ever felt. And she did really well for about a year. She re-injured herself. So I re-scoped her, and at the re-scope, I took some, I just did her recently, biologist got a result of biopsy. She developed PVNS. So my point is, there's a lot of collateral factors that happens after these big procedures. Again, the PAO was perfect, but all I did is gave her barioproprioception with the LT, she did really well. And fortunately for her now, she has PVNS. So there's a lot of parallel thing that we can help diagnose with the scope. And again, on the MRI, I couldn't even see that she had PVNS. So now we're going to put an end to the, she's young, we're going to have to put an end. I mean, hopefully she'll do well for a while, but we don't just PVNS, we convert her earlier than later. I'm just making the point that you have to look at the parallel pathology as well. I think one thing they kind of... I would also add, just be extremely careful with the rim. So I think more and more, not doing a pincer resection, just leaving the rim alone is the way to go. And you can always make more space on the femoral side if needed, but especially in a borderline dysplastic patient, just don't take away any room to make them even more dysplastic. So as we're just about time, I have one comment. It's funny. When I heard Martin Beck about six or seven years ago talk about the fear index, and at that time, he basically was saying if it was greater than plus five versus less than plus five, and you just mentioned positive or divergent being the number one. We looked at the fear index specifically in instability patients, both with and without this borderline dysplasia, because that was with that borderline dysplastic group that Martin was doing only. We also found that a higher fear index was associated with instability than a lower fear index, but the numbers weren't the same numbers. And I think when you look in different papers where that threshold is, it would be great if it was positive or divergent, they're unstable, and it's not convergent. That doesn't happen, at least not in our subgroup of patients. So you need to be a little bit careful of that. That's why, to me, I think one of the bigger drivers of the fear index is actually that tonus angle, right? The roof index. And so let me just, I know Ernest Shilders wrote a paper a number of years ago, probably about 10 years ago, where I think he presented, I actually don't think he ever published it, where he found that his failure rate of hip arthroscopy was significantly higher in people that had a tonus angle greater than 14. Do you guys have a threshold number on the tonus angle that you're, you know, just like in the center edge angle, do you have a, because there's not much in the literature that actually guides people. The 14? Yeah. You remember that when he presented that? Yeah. So Shane, do you? I think while it's been described as greater than 10, I agree, I use 12 or 14 degrees of tonus angle as something that's more concerning for me. And I would say I measure it from the ischium. Some people measure it from the teardrops, but the problem with measuring it from the teardrops is that in a PAO, you change the angle of the teardrop. So if you want something consistent before and after a PAO, you measure it from the ischium, which doesn't change. So I do all my measurements off of the ischium as well, so that there is none of that concern. But just one of the things, you know, when we're talking about, you know, 14 is good and, you know, 13 is bad or whatever, I mean, the funny thing is I measure all my patients with our fellow in the clinic and then I measure them at the time of surgery and I'll be off by two, three degrees, so a couple of those. So, you know, we sit here and talk about, you know, one or two degrees, what would make a difference or go, not go, but at the end of the day, I mean, our measurements tend to, you know, be a little imprecise even when I use the, when I look at my numbers versus when we have the Sectra kind of automated, you know, the measurements that I don't always agree with their measurements. So. I agree. If I have a borderline dysplastic patient, I usually measure their center edge angle and tonus angle four or five times myself in clinic just to get my average. And if you're not sure, just get a CT scan and there are some softwares out there that will kind of help measure it for you if you need that, things of that sort. Oh, you have a question? Yeah, you kind of started to ask about the femoral version number that people were looking at. You know, at the point where you need not do a primary hip scope without considering the femoral osteoarthritis. Okay. Yeah. That was the third set of numbers. So, we'll start. Andres, you started with the talk. So, I'm not sure I heard you correctly on it. So, go ahead. Okay. Yeah. And I don't do very many femoral versions. That would be great. Okay. Yeah. And I don't do very many femoral de-rotational osteotics. I mean, maybe five a year. And so, I would say I'm pretty conservative, meaning I let the range go pretty high. But I'd say above 35 degrees of anteversion and then below 15 degrees of retroversion. So, the more retroverted than minus 15. So, when you say below 15 degrees, so are you saying zero, which is 15 less than normal, or are you saying minus 15? So, less than minus 15. So, I will accept up to 15 degrees of retroversion for a scope. And then once it goes beyond that, I think de-rotational osteotomy. So, if it's measured on the MRI as minus five degrees, are you saying that's more than 20 degrees off from what would be normal? So, you would not de-rotate? Minus scope, yeah. Minus scope. A minus five. Yeah, exactly. It's hard talking in positive and negative. So, yeah, zero degrees would be neutral. And then anything below zero, I consider retroverted. So, I would accept up to 15 degrees of retroversion and still scope it. And then that's just my threshold. Shane? I'm the same. I mean, I think for me, like... Yeah, I think Dr. Martin in our practice actually, we had the topic and you rarely, rarely would perform an osteotomy. His answer is more they don't do, you don't do well, it's a difficult procedure and we've had patients who had osteotomy, they actually went back to get it corrected, re-corrected both on the femur side and the fibula. So it's honestly, it's my threshold for that is very high. And I think they also have like these maladaptive rotational issues, not just the femur, like the downstream, the tibia, the trochlea, it's hard to like correct all that, I mean there's some surgeons that do like a total kind of rotational correction, but it's a lot of surgery. Yeah, we have a guy that does our rotational work and he and I go back and forth, we don't have a set number and we'll have, but for me, certainly I get more concerned over 30 and if they're over 35, he tends to follow that through. And retroversion number is different, there's some people that use zero, I think Robbie Westerman's group, I think they use zero or minus five. So some people are a little bit more aggressive with the retroversion. But it is, I go back and forth with our guy because he's like, look, it's a big operation, blood loss, they said, why don't you scope it first? I'm thinking to myself, take care of the bony problem first and if they still have problems, then do the soft tissue because if you just do soft tissue and they have a bony abnormality, it's going to probably recur is generally my thought. So but nobody has any hard numbers on that, but I think one thing to consider is, so as I had mentioned, all my patients that get an MRI of the hip, we get cuts through the knee so that we get the femoral version. But understand that because the acquisition time is slower in an MRI than a CT, it's less accurate than the CT scan. So be cognizant, if you really think and you really want to know, or if an MRI suggests and you're concerned about it, you probably should get a CT scan. And the case that kind of set that off was an athlete that I had seen that had had both a CT and an MRI at two different, very well known places with very prominent surgeons that do a lot of hip arthroscopy. And the MRI of this hip that did not have a derotational osteotomy and the CT ranged from minus seven to 24 degrees, to plus 24. On the same patient, nothing was done for the rotation. So there's, I think, and there's different techniques on how you measure. I mean, we didn't really get into that. There's different techniques, but there's a lot of variability. But the CT scan is probably the most precise. So if you worry about it, that's what I work off of. So, yeah. So we do a lot of cardiofemoral work in our institution. And he's doing derotational osteotomy, he's doing a femur for the cardiofemoral institution. But the work for that is the CD rotational profile, and then long leg fumes, AVP, and lateral. So I'm measuring all the hip parameters, and they're completely different, just separating the hip and the femur. Because then we feel that the whole surgical balance of the hip changes. Some of them even come, like we fix the knee problem, and they come back and they're happy because they're saying, oh, now I don't have back pain and hip pain anymore. So I'm kind of working on a paper just to show that Tony's angle is basically, I don't think we should be using just an isolated CT scan. Actually, we published a paper, four cases that were sent to me for patellofemoral instability that we did derotational osteotomies and actually resolved their patellofemoral issue. I mean, so, you know, that's, but that's all goes into the complexity of the whole alignment and the rotational alignment that we don't really look at unless you get the axial imaging. But, Dr. Workman, you had a question? Yeah, yeah. It might be open in a can of worms, but when we're doing what we think is an otherwise good FAI procedure and patients are struggling a little bit post-op, I guess the question is, you know, I'm concerned about adhesions and tendon irritation and whatnot. I kind of wanted an idea from the panel what they are doing that, what I think is the critical first six weeks in terms of balancing activity post-op, bracing, not bracing, protecting So, I know Mark's done a lot of work on this area. So, adhesions. Yeah. And tendonitis. Yeah. So, what we do for us, my weight-bearing status, if the bone quality is good, I'll get them weight-bare at 10 days full weight-bearing, 50% for 10 days. I still use a brace because I think the brace is helpful for them to prevent flexor adenitis. When getting them out of the car, they can use that to protect their flexor. I protect their flexor for a few weeks because that's also something that will slow them down. For adhesions, we do circumduction three times a day, clockwise and unclockwise. I think it's very helpful. We wrote a paper with Cliff William on that, showing that it decreased the adhesion, the revision rate for adhesions significantly. And then we use oral Lusartan, TGF veteran blocker, off-label. For us, it's been helpful as well, low dose. This is off-label, so you have to tell your patient that it's a blood pressure medication, so you have to be careful with that. But truly for us, we progress them the first six weeks, especially the first three weeks is very important. And I'm more aggressive now with my extension protection. I used to protect them longer. Now, this is sometimes a problem. They get flexion contracture. So, I'm more aggressive. I protect the extension now for 10 days. I used to do it 21 days. And my exome rotation, I protect them now only for 12, 13 days. So, I'm a little more aggressive. But again, you have to have a good therapy team. That's the key. But your first six weeks are crucial. And we do therapy twice a day if we can. Any other tricks from the panel? I have the same. I mean, for me, I don't routinely use Lusartan, but I think it's an interesting concept. One thing we've started doing, we've always done circumduction per Dr. Feldman's protocol, but now we're actually getting patients on all fours and kind of having them do circumcisions and rock back and forth. And that seems to help. We'll get them started within a couple of days. One thing that I've found, we were talking about this a few months ago, is if patients develop a little bit of stiffness after surgery, and you believe it's extra capsular, and the way that I test it is I have them do the butterfly position. So, I have them lie down flat on their back, put their feet together, drop their knees out to the side. And you'll typically see that the surgical knee is sticking straight up. So, they have pain anteriorly. I think that's pericapsular scarring. And I've started doing a manipulation under anesthesia in the operating room. So, we take them back, we give them IV sedation only. I have the hips stabilized, and then I'll actually do the circumduction myself. And I have a techniques video, so you can see how we do that. But I've had pretty good results, and we have our two-year data coming out soon. But that's a nice, pretty non-invasive way to address that if you get that patient. I wouldn't do it before three months, because I don't want to pop open any capsule stitches where it's not healed yet. But any time after three months, if they're really stiff, I think it's a nice option to try. So, I brace, but, you know, I have the patients come. I don't check the range of motion at two weeks, you know, because I have them on crutches. I have them on abrasives to labral repair, capsular, placation. But at six weeks, I check the range of motion. And if I'm concerned about the range of motion, I'm usually pretty confident about the healing by that point. I'll have the therapist start to add in some joint mobilization and traction techniques, you know, to be a little bit more aggressive on that, so that usually when I see them back at three months, they generally have regained their full range of motion. Where I get concerned, and I don't know what everybody's threshold here is, but my threshold, I won't take somebody back for license of adhesions. I wouldn't consider it before six months from post-op. I don't know if anybody's more aggressive than that. But that tends to be, I think, if you start to detect early on at six weeks, the exception for that is my microfracture patients, because they've been on crutches for six weeks, they're going to be stiffer than the other side anyways. So I'll recognize that and just make sure the therapists are aggressive about gaining their range of motion as well. And then cortisone, as of all time, three months after? Yes. Yeah. Yes, absolutely. But for me, not before three months. Yeah, same here. Yeah. All right, we're open. Sometimes I'm more aggressive. Sometimes if I see it six weeks and I feel that flexor inflammation, I'll use a steroid sometime through the joint and underneath. I go through the joint, keep going, I go underneath the psoas, and I go through the top. That's because I've had, I've been burned with flexor denial. Sometimes it lasts for a while, so I want to cool it down. So that's where I'm more aggressive with steroids. Extra-articularly, I consider it. Intra-articular, I try to wait the three months. But I always caution the patients, you know, that if they get iliopsoas tendonitis, it'll slow their rehab down a good month. And so I kind of instill that fear in them so they don't try to power through because then they get more flared up. Well, thank you all for staying through, and thank you for a great panel for a great job. Thank you, Shane.

hip arthroscopy

failed arthroscopy

hip instability

femoroacetabular impingement

labral deficiencies

capsular deficiencies

revision strategies

open surgery

hip dysplasia

Periacetabular Osteotomy

rehabilitation protocols

biomechanical restoration

Mark Safran

Mark Philippon