We'll start with the future of hip arthroscopy. In my opinion is the extra-articular side. We're going to talk about endoscopic abductor and hamstring repair. Again, I could probably talk about each of these topics for hours, but I got ten minutes and we lost about five. So disclosures available on the Academy of Orthopedic Surgeons websites. So this is just a brief differential. This is what I see in clinic. You'll every now and again see an external snapping hip. All you have to do is see one, and as Dr. Bird famously told us, you can see it from across the room. Well, you'll see bursitis and tendonitis. This is pretty easily distinguishable by excellent strength overall. And if you look at the bottom left, that video is actually a case of calcific tendonitis of the gluteal tendons. But what we're going to focus on here is gluteal tendon tears, both partial thickness and full thickness. I won't belabor history in physical examination. I will tell you a pearl on history is injections will dictate whether or not that tendon's torn. What I mean by that, if you inject somebody and it lasts five days, they've got a tear. So tuck that in the back of your mind and they'll also tell you just like a rotator cuff, they're unable to sleep on the affected side. Abduction strength is important on physical examination. Be aware of past external rotation of the foot and beware of a large 4-5 disc. I recently incorporated the resisted internal rotation test. That seems to be pretty accurate. And then I'll ask them about ambulating up and down stairs. I've got a set of stairs at the end of my hallway and I'll have them go up and if they're grabbing the banister and pulling themselves up the stairs, dead giveaway that they have a tear. So what about chronic bursitis? I saw a lady, I was her 11th surgeon that she saw and she was diagnosed with chronic bursitis. Well if you look, over 20 years ago the radiology literature was on to the fact that if people failed PT and non-operative management, they have nearly a 50% chance of having a tear of the abductors. MRI is very important. I interpret all my own MRIs and I review them all the night before for office. If you look, we see bright T2 fluid signal here, underneath the tendon. That's a dead giveaway for a partial thickness tear. Ben Dome wrote a really nice technique paper looking at this and it's a good paper to read if you want to get more into this and you want to help educate your local radiologists with it. Full thickness tear, even the naive radiologists will pick up on this. You can see a massive retracted tear here, over four centimeters retracted. And then the next question is, why should we repair this endoscopically? You look at the literature and a systematic review showed excellent outcomes, equivalent to open, but just like nobody does open rotator cuff repair, we shouldn't do open glute repair anymore, unless it's a really massive one. And again, we're looking at fewer overall complications doing this through the scope. So when I first started, I used what Dr. Kelly and Dr. Bird taught me, which was an IT band sparing approach, 70 degree arthroscope, and it just didn't make sense to me. The portals didn't line up. They didn't make sense. The repair was difficult. It took me two hours to do a glute tendon tear. Well, what did I do when I was a resident? I fixed a lot of rotator cuff tears. And so we basically changed the portals so that they would mimic a rotator cuff. So instead of a 70 degree, we use a 30 degree arthroscope from a proximal anterior lateral portal in line with a femur, and that gives us this beautiful 50-yard line view. And then the second portal I make is a dollop portal, and I make sure that that's in line with the lateral facet so I can slide an integrated suture passer and be efficient. So once you clean up the bursa, you want to evaluate your tear pattern. This is a great example of a full thickness tear of the minimus with some partial thickness tearing of the medius. And what I'm looking at, I'm probing, I'm looking at lines of tension. Where am I gonna place my anchors? Do I need to go single row? Do I need to go double row? What do I need to do to anatomically repair this back down to bone? You can actually use a couple outside-the-box techniques. So this is actually a label repair device. We're using this in a retrograde fashion to pass sutures efficiently. You can see my assistant passing them there. And I like to do a mason alley. I tend to be biased towards single row because we tend to do a lot of allograft augmentation of these. So for the dollop portal, this is where my residents get to go nuts. Basically they hold the scope in an integrated suture passer. They'll slide right underneath and you can see, very simple, very easy. I'll retrieve it on the other side. We start from anterior and work our way posterior, retrieving through that anterior portal. And what that allows you to do is be very efficient. So we can do just a primary glute repair in 20 to 30 minutes using the new portals. I like to tie these down using an SMC, followed by reverse alternating half hitches on alternating posts. And really what I want is to make sure that I have excellent fixation in that tendon. And the entire time I'm passing, I'm judging what is the thickness and caliber of that tendon and do I need to do anything to reinforce it. So here we can see a completed primary repair, mason allen configuration of sutures, and a nice anatomic reduction here. This is one that we left alone because tendon tissue quality was good and it was a younger patient in their 50s. So what about retear rate? You look at the literature, the orthopedic literature, and they'll tell you the retear rate is low, but if you delve into the radiology literature, it's somewhere between 16 to 35 percent, perhaps higher. And I'll tell you, I got sick of seeing this over and over when I got into practice over 10 years ago. And this was a five anchor, all endoscopic repair, triple loaded, and this failed and failed miserably. So because of that, we came up with this concept of allograft augmentation, and we do this all endoscopically. And really, it's treating the quintessential lesion. This is from JBJS 2019 out of Japan, and there are portions of that medius and minimus tendon that are less than a millimeter thick in some patients. And so what we need to do to really affixate these well is to add tissue to that tendon. This is the simplified shuttle technique. We published this back in 2018. Basically, I wanted a simple way to get a graft into whatever joint I wanted or whatever space I wanted, so we created a railroad track. No risk of entanglement. It's basically two sutures and two sutures only, and you can see that slide into position. The second thing it allows us to do is in-situ tensioning of the graft. How many times have you done an allograft augmentation, and you've measured, and you've placed your anchors, and you've shuttled, and it's loose? There's no worse feeling this. What in-situ tensioning allows you to do is you pull that with a ring suture retriever. You know where to place your anchor, and the ring suture retriever will leave a mark on the graft so that your resident knows where to fire that suture through. And here we can see a completed allograft augmentation. This was a 30 by 40 millimeter revision that we did, and you can see it's really acting as a biologic double row. It's compressing the primary repair and making sure that that will bioincorporate over time. So does it bioincorporate? So here's a great example. Full thickness tear retracted. We did three triple loaded anchors, and I've been here before. I know this is gonna fail because all my big ones failed before, just like my big cuffs did. So we did add a graft to this, and I went through a phase where I was closing the IT band. I do a small IT band split, and I caused about 20 iatrogenic cases of snapping IT band. And Robbie Westerman and I published this on this, and it seems to have better patient report outcome scores to split it. But you can see this is a year-out bioincorporation of the graft. You can see excellent vascularity around. No re-tear, just a pure case of snapping IT band. So we're gonna switch gears now. So we've talked about lateral or paratriarchal tear compartment. We're gonna go to posterior hip compartment. The key takeaway here is it is not the piriformis. It is not the piriformis. It is not the piriformis. I've tried to get in a verbal shouting match with Hal about this, and he always seems to kind of wiggle out. He's a good boxer. But I will tell you that by far and away, hamstring tears have been the number one pathology I've seen in the posterior hip. Issue of femoral impingement has also been the number two pathology. And if you look in your bottom right, another interesting case of calcific tendonitis of the hamstring. That's the proximal ischium. You can see us poke it with the needle. And just like you would see on a cuff, toothpaste spills out of there. So when I think of these tears, I think of them in two different varieties. The full thickness tears we all know. Partial, excuse me, hip flexion with dramatic knee extension, dramatic echemosis. The partial thickness ones are degenerative. These are the ones that get lumped into deep gluteal space or deep gluteal syndrome. And they're likely related to IFI. In certain people, more minor trauma. Both will present with inability to sit in a chair. Both can have sciatic nerve symptoms. So MRI imaging, the same as looking at gluteal tendons. We're looking for bright T2 fluid signal. These are 2-2 coronal fat sats. You can see bright T2 fluid. That's a high-grade partial tear. And the full thickness tear is more easily identified. Again, I changed the portals. Carlos Guanchi taught me this years ago. And we switched them up and kind of moved things a little bit. We invented a suture management portal. I'll show you another portal that we came up with about four months ago. And the other big pearl here is to understand the biomechanics of the issue of femoral space. If you look right here, that's what the leg in neutral rotation adduction. The sciatic nerve lies right next to the hamstring origin. When you abduct, you can see the sciatic nerve dynamically move away. And that protects it and makes the approach easier. This is the point at which most people will freak out in the case. So we use fluoro to do this. This is the subgluteal bursa. You can see this red, bloody, inflamed mess. You don't know quite where you are. This is where fluoro can keep you safe. We start from medial and work our way lateral. Mid-central portal to view, medial to work. And we try to do that parallel to the ischial angle. Once you have the bursa cleaned out, the next step is sciatic nerve identification. And you can see we're just kind of bluntly dissecting. You can see there's our sciatic nerve moving from superior on your screen to distal. And you'll watch as we retract the scope with the abduction technique, how much further away that is from the proximal hamstring origins. It will keep you safe. Just that little pearl. There are variants and you have to be aware of these. This is a true bi-fit sciatic. I use a technique that I like to call resident neural monitoring. And that's where we have a resident put their hand on the back of the hamstring and calf. And we poke both those branches and both cause twitches in the muscle. So there are a tremendous amount of variation back there. And you have to be really careful. For a partial thickness tear, you'll be required to split the tendons in line with the fiber here. We can see a bubble wave sign there laterally. This was an ischiofemoral related tear. And what you'll need to do is split those in line with the fibers. This is actually a partial thickness tear that was a revision. You can see we've split it. You can see the old anchors there. And you can see where this tendon had a biologic non-union. For two tendon tears, this was an interesting case. This was an anesthesiologist's wife who was playing kickball with their kiddo and felt a snap. So classic two tendon tear. Medial aspect of the hamstrings intact. We can see our stump sitting right there. And what you want to do is mobilize it and be able to control it and anatomically reduce it. This is my personal best. So this is a 10 centimeter retracted tear. And you can see this is now scarred to the sciatic nerve. You'll look as we look laterally. That sheath of tissue there is the sciatic. This is actually the tendon adductor magnus. And then way up there is the ischium. And so I will tell you the future is limitless when it comes to hamstrings. And I'll kind of show you what we did with that at the end. Understand there are two big tigers that are back there. One besides the nerves. One is the medial femoral circumflex artery that comes off the superior border of the quadratus. This is the first perforator from profunda femoris. And that comes off the inferior border. And I thought this was just peristaltic flow from the pump. That was actually the artery itself. And we're fortunate to identify and protect it. So for a partial thickness tear suture passing, again I like to be an outside-the-box thinker. You can see an integrated suture passer here in order to be efficient. As I pass that to my assistant and they start to take the slack out and sort the sutures out. What you can do is come in immediately with a labor repair device. And basically use it as a retrograde stab and grab. So what you'll see is we'll come in with basically a crescent device. We'll poke. Get a full thickness bite of that tendon. Gently work our way under. Deploy the hook and retrieve. And you can really be efficient with these and work back and forth and repair them in a rather expedient fashion. I like for full thickness tears to do a Mason-Allen configuration of sutures. Like we talked about with the glute. You can see our vertical. I'm passing now my horizontal through that two-tendon tear. And then this is an example of a three-tendon tear. So this is three triple loaded anchors. This is retracted about five centimeters. And the key is to stay organized. Because you can see with 18 sutures back there, it can become rather daunting. But as long as you work systematically, you can keep all these sorted out and make sure that you don't get into trouble. This is our reduction. This is that three-tendon tear that I just showed. I want to make sure this is an anatomic reduction. I want to make sure that everything's keyed in. There's the quadratus. There's the artery. You can see their superior board of the quadratus. And I want to assess, is this enough fixation? We're going to flex and extend that knee and make sure that this is anatomically reduced. That there's not there's not undue tension there. This is that 10 centimeter retracted tear there that you see. We had to mobilize it. We used a pulley technique. We did a lysis of adhesions and sciatic neural lysis laterally. We're able to free that up. Able to get that keyed back into the ischium again with several triple loaded anchors. So what cannot be repaired endoscopically? Chronicity is key. Four to five weeks from injury, it gets really, really bad. Retraction, 10 centimeters is has been my limit. And after looking at netters for a long time and grays, this is the new inferior medial portal. That's what allowed us to get 10 centimeters down here below the scope to be able to repair that. So what is the future? In my opinion, extra articular hip pathology. That is, I think, the bigger more growing portion of it. You can really help yourself by critically assessing your MRI, taking a great H&P, and utilizing the portals and patient positioning pearls that we showed. That was supposed to be a pic of my wife and kids, but didn't show up. Thanks guys. Thanks Jovan.

hip arthroscopy

endoscopic abductor repair

hamstring repair

external snapping hip

gluteal tendon tears