If you guys have any questions, please, by all means, ask right now. We can go through. We can go through some cases if we want to. Ivan, I have a question. So that's a great talk. So I like your 3D printing. So when we do our surgery, we always spend a lot of time on the 3D dynamic analysis, we call it. And that's why I really believe what you showed, and I'm curious to see how long Tom is going to do, because I know there was a medial bump there, but how significant it was clinically, I don't know. You'll find out. How many months out is he now? So he's now three years out. Oh, three years out. He's three years now. Yeah, I've been doing prints for about five years, so the first case was probably seven years ago. I was using 3DCT at the time. I thought that was good enough, actually. I thought I was ahead of the curve doing 3DCT, and then I just was missing it. Because for us, the radiologist shows you how it rotates. I don't have the ability. I know Shane has a program that you can actually control and manipulate that I think makes it better so you can see, because it all depends on the lighting of it. So I didn't recognize the cam down inferiorly. But clinically, was there a big difference with that medial distal? It looked very distal. Yeah. So you saw a big difference clinically? He improved significantly after? Yeah. So he improved significantly afterwards. I was actually surprised, and that's why I think that, before I said, look, I think it's more cosmetic. They don't really get to that point, and I've kind of lied to myself that way. In fact, before I said, oh, look, if I get an AP and I don't get a perfect camera section, I'm like, they don't do the splits. It doesn't affect them. And I'll tell you, some patients it doesn't, but some patients it does. I think that's the same thing with the capsule repairs. Initially, we thought, look, we don't have to do it because patients don't see that difference. But now when you look at it critically, capsule repair is really important. We actually see a difference in them. And I think the same thing with cam. We're going in there with the intention to do cam less than 55 degrees, or 50 degrees depending on who you want to talk to, in all the different planes because it's a ball and socket joint. So we intend to do that. I think what our goal is, we should really try to do that. And I think with the data coming out, like with Shane's paper now, it just really says, if you don't get it fully resected, you know, long term, you do see a difference. And if we follow patients longer, we actually will see even more differences. Thank you. I got one, Shane, if you. Yeah. One of my residents is high and back, they're a former resident, but one of the things I noticed early on was I was not getting that inferior and more lateral, almost that hidden area. And like you did, I lied to myself, they'll never get that deep. This guy's, you know, 250 pound linebacker. So I do all my camera sections starting from the base of the cam and then working my way back up. I don't know why, but that just seems to make a more spherical femoral head. And I do the same thing as you. I outline and I tell the residents, stay inside the lines. And we start at the base and start to get our offset and work our way up. And I'll check on fluoro to make sure, okay, this is what I preoperatively planned on my x-rays to stop here. And then it's about contouring it up and matching that curve rather than the tendency is, if you start at the top, you tend to cut down on it a little bit more. So it's just, it's like anything, it's just repetition, repetition, repetition. That's a little pearl for you. Absolutely. Great. Oh, we have a question. Oh, we have a question. Yeah. So, great talk. How, like, do you guys own a 3D printer or do you, like, send this out, like, and how expensive is that? Absolutely. So I forgot. That's, that's common questions. So it started off, you know, I got three young kids, took them to the library. And in the library, they literally have a 3D printer there for kids to, you know, little press a button. And they get a little widget for a dollar and then they can take it home. And it's a MakerBot, is what it is in our library. And they provide it. I was like, you can get this little widget for a dollar? And I was like, look, can you print my hip? So I brought a thing to the library and say, look, this is for my kid. And they printed it. And they go, yeah, looking down the price chart, they, yeah, $5. I'm like, $5? Okay. So that's where I started on. So I bought a 3D printer. And it's 2000. Sorry. Then it was $3,000. So it costs about, for a hip, it costs about $7, $7 to $8 for the filament to print. For a shoulder, I do a lot of shoulders too. That costs $5. Mainly because we're actually trying to expand the cortices just so it doesn't collapse on itself and you can, you know, you can see it. It takes about 20 minutes to format. You get your CT, you get DICOM images. Literally it's a free program. It comes with a 3D printer. You hit convert to an STL image. And then you hit print and you got to wait 20 hours to print it. So I actually have four 3D printers so I can cycle in. So this is the problem is once you start using a 3D print, I saw somebody had a 3D print here or a bunch of people did. You really realize when you don't have it and I miss it. And so that's why I bought four 3D printers because it makes you a better surgeon. I pay for it. But then again, I think my patients are happier and, you know, doing a lot of revision cases now because that's what, you know, my referral pattern changes to have the failures. It really helps to make sure because I don't want to do another surgery afterwards to have them missing because I can say the resections are better when I have that. So you're getting CT scans for all your patients, David? Yeah. So we try to do that low dose CT protocol. I do a CT scan for all of them. We don't have an ability to convert from MRI or I asked our MRI technologist to see if they can have it. Apparently you have to buy software and our hospital refuses to buy anything. So I do a CT scan for all our patients. I really like it. There's certain things I like too. You know, I get a better idea of how much arthritis they have with a subchronical cyst. I see it better on that than I do, I find, than I did on our MRIs. It just gave me a very quick, it also is faster for us to get in Canada because MRIs take upwards of a year. Our system's a little bit different. And then the other part is because they scan the hip, they actually scan the other side simultaneously. So a lot of these things are bilateral. I don't have to get another CT scan afterwards for their other hip. I already have a good idea what we have to do. So it tells me a lot of different things. So Dr. Wong, I'm from Sioux Falls, South Dakota, and we kind of came into a similar process. We created our own print farm as well for this, but we've reached a point now where we're struggling with the workflow. Do you do all of those own prints or do you have your radiology service help you with that? Yeah, so workflow becomes a pressure. So we came to the same problem, which is why instead of my one printer, now I have four. So on average, I do four to five hips a day, and I get three days of OR. And so what I do is I cycle them through. So I have a research team, and I actually built this into our research study. So we're trying to figure out how we do it. So my research team, so after I learned how to do it, I taught my researchers. They're literally coming right out of university. It's not hard to do. It's just a tedious process. So the workflow goes. The day when we're getting ready for surgery, about a week before, they take the CT. They just cycle it through so that they have prints running every evening so that no one gets bothered by it, and it's done in the morning. So then they have to process it. You have to peel off the PLA to make sure the process is round. And so I don't get someone else to do it because it goes by their time frame. When I get my own staff to do it, and it really doesn't take that much time, and it doesn't take that much training, it makes it quite easy. And then I'm sure there's a business case to do it. I'm not a great business guy. I just like a 3D print. I have two questions. One in the second view. What do you do with all the printouts after you're done with them? Do you have hundreds of printouts? Yeah, so that becomes a problem. I get to take a lot of pictures like this for conferences. So that's one thing. And it's usually my suitcase. I try to take some. And you notice if you watch the videos, they're pictures of these carpet. I have no carpet. They're always hotel rooms because I'm like, oh, I should have shown it that way. Because I'll tell you, I've had a really hard time trying to describe why I like it. And it's really hard to design a study to show the benefit of it. Because studies only happen when a question is designed well. And so I think right now the study is really on how good an alpha angle is. And I think later on we'll be able to show the clinical improvements. Now, the rest of them I give to the patients. And they love it. They put it on the mantles. I see it on Twitter. I see it on Instagram. They love these things. And then when I don't have one because either the machine – because they're not perfect. You hit run at night. If the thread just falls over one bit, that print's ruined. And you only find out the morning of. So if you didn't print it a day before, you won't have one for the OR. Because it takes 20 hours. It goes a tenth of a millimeter by a tenth of a millimeter. It's pretty impressive, the quality, for the cheap price relatively. Thank you very much. Javon, can any girls get those views? I mean, your views are very gorgeous. How do we get that view, especially endoscopic view, and repair it? How do you figure out the first step and see the tendency? Yeah, so I think the biggest thing is that over-the-top view is achieved through a proximal anterolateral portal. And so most people, I don't think, use fluoroscopy for a glute, right? So I do just to establish those first two portals. So I don't want the sutures in my eyeline either. So this one goes, if the femur's sitting like this, this one goes slightly anterior, and this one's directly central with the femur. And so step one is make a little incision in the IT band, you know, a couple centimeters. And then we get into the bursa. And I'm heavy on the cautery wand with this. In addition, you know, Poiseuille's Law is a great way to think of fluid management. Resistance to flow in a tube is radius to the fourth. So I actually use a 6-5 cannula for my scope. I think one of the more brilliant things I realized years ago was, you know, seeing Dr. Bird's early videos in the 90s and the brilliance of putting in a posterior lateral portal and attaching that to a pump, as well as having a pump attached to the scope. So if you can get good fluid management skills, you become friends with anesthesia, perhaps buy them lunch every now and then. Like Diamond Deli goes a long way in getting the anesthesia to like you. And ultimately, if you can have them run systolic around 100, you've got good inflow. And again, I just switched. Why use a 4-5 scope sheath? There's no reason to. And again, lining these up, that's the critical point to it. And once you can see, you can do really anything with this that you want. That's great. Yeah, for me, I've evolved over the years. But now at 10 days, they're full weight-bearing. And I really feel one thing about the neck resection. We know that if you over-resect the neck also by 5%, it's going to affect your outcomes. You have to be very precise. That's why we do the dynamic analysis. And when, depending on the amount of resection I'll do, I'll modify my weight-bearing. But now most of my patient, it's 10 days or less, 20-pound flat foot. And we're very aggressive with the motion. Circumduction, clockwise and counterclockwise, is a big benefit for the patient. We show that we went from 4% to 1% or less adhesions in our hands. And I think restoring the muscle balance, adductor, abductors, flexor extensors. As you know, most of our patients are hamstring dominant because the glute shuts down. So they all have, most of them have a little bit of flexor tightness, rectus and flexor. So we really spend a lot of time activating the glute max after surgery. But weight-bearing, I'm trying to push it even to start even earlier, but 10 days or less. Yeah, I'm pretty much the same as Mark. I probably, at 2-4 weeks, 20 pounds foot flat and then progress at 2 weeks to be off crutches by 4 weeks. Yeah, I'd say the same. 2 weeks foot flat touchdown. I do do a CPM, which is interesting. You know, I read Mark's study years ago. We do circumduction immediately. We teach family how to do that. CPM for 6 hours a day, starting at 0-50 and having them move up to the goal of 120. And then I'll see them in the office, 50% weight-bearing week 3 and then full weight-bearing after that. Yeah, I've started them full weight-bearing right away. So I tried to follow the same principles as Mark right at the beginning. What I found was our therapists, at least in Canada, they were very timid because they didn't see many hip arthroscopies. So they actually, with a partial weight-bearing, they'd just lay in bed and they got so stiff and so many adhesions. I really had a difficult time with outpatient physio. So we just got them weight-bearing as tolerated. And if they were pained, just not really full weight-bearing. I found it was better to prevent the adhesions. But again, it was just because communication was more of an issue. Bring your therapist to surgery. Let them watch and see what you're doing. Let them understand the principles. And that'll help them tremendously kind of get what you want to achieve with this. Great. I have a question for Dr. Philippot. You know, you taught me to do certain types of exercises like a decade ago. I always ask, like, clockwise, counterclockwise? And I always just tell them it doesn't matter. Just get the head moving, right? Yeah, that's... Why do you think it matters? No, I think... I just feel like these are circular fibers we're addressing. So I think you have to address them in both direction. So I do it... Also, you know, I just want to make sure they stay focused. So I tell them do it two minutes one direction, two minutes the other direction. Truly, I don't have any scientific explanation for it. But I just feel you got to do it in both ways. Like when we do the CPM, it's flexion, extension. So both direction. So I just feel it's a conduction. We should try to do it both direction. I don't have a proof that it makes a difference yet. It might not be, but just do it. I'm just trying to figure out... Oh, yeah. So we may be just at the end of time. If there's one more question, we can go. If not, just a little reminder to fill out your evaluations when you get in an email. I already forget where the snacks are. Level two and four. I'd like to thank our panelists. Again, outstanding group. I'm honored to work with. So thank you very much. Thank you.

3D printing

dynamic analysis

surgical techniques

hip arthroscopy

surgical planning