Good evening. Thank you for joining us tonight for the AOSSM Fellows webinar titled Common Practices in Hip Arthroscopy 2020 with faculty Dr. Craig Morrow and Dr. Mark Safran. Dr. Morrow is clinical associate professor of the Department of Orthopedic Surgery at University of Pittsburgh School of Medicine. He is also associate program director at UPMC Orthopedic Sports Medicine Program. Dr. Mark Safran is professor of orthopedic surgery and chief of division of sports medicine and co-director of the orthopedic sports medicine program at Stanford University. This webinar will provide an overview of current techniques and controversies in hip arthroscopy including positioning, portals, capsulotomy, debates, techniques of labral surgery, FAI surgery and management of the capsule. To submit a question on the GoToWebinar panel on your screen, click the questions drop down arrow that's on the right hand side of the panel. This slide will show you where you input your question and click send. I will now turn this over to Dr. Mark Safran. Hi and welcome to the Cinco de Mayo edition of the Common Practices in Hip Arthroscopy 2020. My name is Mark Safran and it's my honor to work with Craig Morrow and the Sports Medicine Fellows webinar series. There we go. As Meredith said, Craig is a clinical associate professor at Pitt and associate program director of their fellowship and he's a team physician for the Pittsburgh Steelers. And these are his potential conflicts of interest that really don't apply directly to what we'll be talking about. I'm a professor and chief of sports medicine here at Stanford and a team physician. And I serve as consultant, I've been the president of ESHA and been a consultant and I'm a consultant for various sports entities. These are my potential conflicts of interest. Again, we get fellowship support and serve as consultant but none of those apply to this talk specifically. So to kind of go over, we're going to try to cover as much as we can in an hour. Ben Dome will be leading a webinar on more advanced techniques in hip arthroscopy. So we'll be talking about positioning or Craig will be talking about positioning. I'll be talking about the portals. Then we'll have our debate on capsulotomy. It's not much, not a huge debate, but we will be discussing whether or not to do capsulotomy. Craig will be talking about issues with doing labral repair. I'll talk a little about how I do labral repair when doing the pincer surgery for FAI, where I take down the labrum and repair it. I'll talk about doing FAI surgery without a capsulotomy. Craig will talk about his pincer without taking down the labrum and also doing a camera section with capsulotomy. And then we'll talk a little about capsular management. So there's a lot that we'll be talking about over the course of the next hour. Just to kind of set the table, when we talk about the hip, we're talking, we generally divide the hip up into different compartments. It's all intra-capsular, but you have your central compartment, which is within the confines of the acetabulum and the peripheral compartment, which is outside of the labrum along the femoral neck. Again, all under the same capsule. When talking about the central compartment, things you can see are the acetabular articular cartilage, the codloid fossa with pulvinar, the ligamentum teres, the acetabular labrum, the transverse acetabular ligament, and the weight-bearing area of the femoral head. The peripheral compartment, basically, you can see the non-articular side of the labrum, but you can't see the labrum from the peripheral compartment. You can see the transverse ligament, the non-weight-bearing portion of the femoral head. You can see the joint capsule, the intrinsic ligaments of the capsule. You can't actually see the specific ligaments, but you can access and either injure or affix them from the peripheral compartment, as well as the zona bicularis. And then you can see along the femoral neck, and particularly, landmarks that are of help include the synovial folds. Some other general considerations. We try to keep our traction as short as possible, definitely with less than two hours of traction at a time to help reduce the risk of neurovascular injury. And the key is that when you perform your capsulotomy or remove the negative intraarticular pressure, that will allow you to lessen the amount of force necessary to maintain a distraction of the joint when dealing in the central compartment. As far as anesthesia, I tend to use general anesthesia with my patients paralyzed. You can do it under spinal anesthesia. As an adjunct, different types of peripheral nerve blocks have been used to help relieve pain. Lumbar plexus block I find to be actually probably the most efficacious, but it is probably one of the hardest blocks to do, and you need an experienced anesthesiologist with blocks to be able to do this block on a regular basis. I tend to do the arthroscopy with a patient under relative hypotension, systolic pressure of around 100. And I don't use a pump. I just use gravity with epinephrine in it. I know most other orthopedic surgeons who do hip arthroscopy do use a pump in relative hypotension. So with that, I'm going to pass it over to Craig, who will be talking about positioning of the patient. So, Craig? Thanks, Mark, and thanks to the OSSM and Meredith for this opportunity. I think this will be a lot of fun and a real pleasure to talk to this group of fellows here tonight. So, did you share with me, Mark, did you share with me the screen? Sorry, I thought I did, but there you go. Sorry, Craig. No problem. Okay. So, can you see me there, Mark? I see you, yeah. It keeps muting mine. Sorry. It keeps muting me. Can you see my screen? You see my positioning? I just wanted to make sure it went over to you. I can see your screen. I can see your positioning. Okay. So, I'm just going to start going through kind of positioning, and I go through this with our fellows. You know, all the parts of the hip and the compartments that we're going to talk about tonight. The first step is positioning, and we really need to make a safe environment for getting into the hip joint, because as you know from boards and as you know from your experience, really the problems with hip arthroscopy oftentimes come with position, come with traction that Mark alluded to, and so really the first step to getting into the joint is successful access. So, this is from John Christopheretti, but I think the point of this is, you know, you really want to have a system as you go into practice of how you want to set up your room. You want to go through a dry run with your OR team, your nurses, and you really want to have a system in place, whether that means writing it down or talking with your scrub techs and having a very specific system. So, we've worked with our anesthesiologist. We want to make sure that the arms are well padded. We use these Velcro straps. We cover them with a bear hugger, and we do all this, you know, as a team prior to set up. I'm very meticulous and very specific about how I want my room to be set up with the hip arthroscopy in particular, and so I have a very specific position of where I want, you know, the clamps, where I want the drapes. My PA, my, the scrub techs in the room get annoyed by me because I'm very particular about where I want anything, but I think it's very important for a hip where time is of the essence. So, just, there's not a right way to do it, but just have your way. I like to have a very simple setup, you know. You don't need very much to get into the hip joint, so we have one tray that we've consolidated from different implants and devices that we need, and I'm very particular. The hip, you may find positioning cords can be all over the place, create a very specific system. I like my cords to be a very specific length for working in the hip, so all these things are important. I like to bring the fluoroscopy in perpendicular to the hip. I think this is important for just ease of access and allows us, when we take the leg out of the boot to get lateral positions, lateral x-rays just fine. I like to have the fluoro screen at the bottom of the bed. We like to have our video monitors. I like to have one at the top, as you can see in this picture, one at the bottom, and allows us to be able to view in both directions. So when we're applying traction, this is my technique. I was using a post for a number of years and then just recently went to a postless system, but when we do a post, I'm sure you all have done this, it's kind of a team approach to applying safe traction. I will do this most oftentimes now after I've prepped and draped in order to save time, but we've actually gone now to a postless system where I actually apply the traction before we prep and drape. So you can do this on any table. This is a standard hip arthroscopy table. You can use Smith & Effie, you can use Arthrex, any of the tables that are out there, and I've gone to using a Trendelenburg with this table. You can see that pink pad, which is a proprietary company has this, but I think you'll see more of this. And what it allows us to do is take our preoperative fluoro images. And in this case, Jonathan, our fellow there is just kind of gently holding the pelvis down and we apply our traction without the post. And I've been amazed. We're in about 20 degrees of Trendelenburg. And basically all cases, you can get traction. You can see our fluoro intensifier there that we've achieved traction without a significant amount of force across the hip joint. So I've become a big believer that this is probably the way the future. Mark and I have talked about this and I'm interested in his take on it, but we really get a good feel of how much laxity there is to the hip joint just by applying traction in this way. I told Mark, we talked a little bit about lateral positioning. I've never done this, but this is certainly one of the original ways the hip was accessed. And there are still a number of people that are accessing the hip and doing hip arthroscopy in a lateral position. Again, if you're trained on this, I would just encourage you to have a system in place, have a setup that's reproducible and you can access the hip this way. Other considerations for me are much of the same. I use low pressure. I have the front pressure usually at 40. I do use a pump, a hypertensive, a paralyzed patient, and we use this multimodal pain control. I don't use any nerve blocks and we've really found that minimal narcotics are needed. So I'm going to turn back over to you, Mark. We'll try to get through some of the meat of this. There we go. All right. So do you see my screen or? Yep, I see it. All right. So once you've got the patient positioned and all, so again, the general superficial portal anatomy, the palpable landmarks, your anterior superior iliac spine, your greater trochanter, and your neurovascular structures to be aware of, the latter from the cutaneous nerve that comes around the ASIS and arborizes in the proximal thigh, the femoral neurovascular structures, which are going to be medial to your ASIS. So you want to try to keep all your entry portals lateral to the ASIS and then your sciatic nerve posteriorly, and we'll talk about how to avoid entry to that with the posterior lateral portal. But if you're not making a posterior lateral portal, that tends to even be in lesser risk unless you're doing more advanced subgluteal space type of surgery. So the first thing I like to do is I try to remove the negative interarticular pressure before we start. So that way my fellows get a lot of reps on identifying the anterior lateral portal. And so what we do is we apply traction, prep the hip with betadine, then bring a spinal needle in. The goal is at the anterior lateral portal, do this under fluoroscopy. We want to stay close to the femoral head so that we're not going through the labrum itself. And I have the long end of the beveled needle away from the femoral head so that we don't skive or gouge the femoral head. And with this, you end up removing the negative interarticular pressure within the joint. You actually, when you take out the trocar, you can actually see the thigh kind of relax. And that'll make it easier to apply traction or maintain the joint space. And once we do this, we take the needle out and then we reduce the femoral head. And then we prep and drape the patient. So here's, this is showing the needle actually just anterior to the head because you can see some of the head and some of the articular cartilage as proximal to the needle itself. And so once we make all our portals, we do, we have a cannulated system and there's multiple cannulated systems in the market. So here we bring a regular needle through between the femoral head to your left and the labrum to the right. And then further to the right is the acetabular articular cartilage. We remove the trocar from the needle and we place a guide wire. We then remove the needle itself, make the incision in the skin and use a blunt trocar and sheath to come through into the joint, taking care not to skive or gouge the femoral head. And generally we leave the cannulas in such that the long end of the cannula is away from the femoral head. And so there's three main portals that I tend to use. I know that a lot of people just use a two portal approach. When you do a two portal approach, most people do an interportal capsulotomy, which again, when we talk about the role of the capsule, I try to stay away from doing that. So I use a three portal approach and I can see all through the hip extremely well from posterior all the way around to anterior and medially. And so you have your standard anterior portal, your interlateral portal, and then your poster lateral portals. And I make all three portals on every case. And so here you see a patient, their head would be to the upper right and their foot to the lower left. You see marked out the ASIS anteriorly. You see the greater trochanter marked out. You see that where the needle had been in the hip and for the interlateral portal and that cross mark there is at the junction ASIS and greater trochanter. So that where some people used to make their straight anterior portal, I don't make my interportal there, but again, using that as a landmark to make sure I don't go medial to that point. So here I'm bringing my trocar over my guide wire for the interlateral portal. And then I brought my arthroscopy camera through the cannula. And so when you go in the interlateral portal, which is my first portal that I make, you penetrate some of the gluteus medius muscle. You're pretty safe from a neurovascular standpoint. The superior gluteal nerve is the closest nerve. It's four and a half centimeters away from that portal and branches posteriorly. So you're pretty safe from that nerve itself. I tend to use both 30 and 70 degree lenses for doing arthroscopy. The majority of what you do in the central compartment is with a 70 degree scope, but the 30 degree does show you centrally better. So you can see the cotyloid fossa and ligamentum teres better. This is a drawing from Michael Deans. The brighter yellow is what you can see with the 70 degree lens from the interlateral portal. The orange is what you would see with the 30 degree lens. And so this is a 70 degree lens looking from the interlateral portal. That's my posterior lateral cannula. There's your head. You can see the posterior articular cartilage, the ligamentum teres here, the anterior articular cartilage and the anterior labrum. You can see my anterior cannula there just at the top at about 1230 o'clock position. So you can get a very good look at the peripheral part of the joint, the entire weight bearing surface of the acetabulum. And here's my 30 degree lens from the same portal. You can still see a little bit of the posterior lateral cannula. You can see some of the articular surface. You just don't see the labrum and the labral chondral area as well. But you can still see a fair amount of the weight bearing surface, central femoral head and cotyloid fossa. Again, I just don't see the labrum quite as well or the labral chondral junction. There's several anterior portals that have been identified, as you can see in this drawing. This is my preferred second portal generally, where a lot of people like to go, was at that junction of the ASIS and the greater trochanter here, and it was well described and worked out by Tom Bird about the angle that you need to use to approach to get in the labrum, get in the central come up from this anterior portal. And so here's showing, and this is a picture that's about 15 years old, using a straight anterior portal. These days, I make more of a, just some people call it a mid-anterior portal. It's about five to seven centimeters anterior medially to the anterior lateral portal. This allows for when people have greater overcoverage anteriorly to the acetabulum, but also it's a better angle of approach when you want to place anterior anchors, drilling is much safer as you're drilling away from the articular cartilage. If you're up in the more standard anterior portal, and you drill straight down, you're likely to violate and penetrate the articular cartilage. The anterior portal tends to be distal to the ASIS, and again, you get an arborization of the lateral from a continuous nerve through there. You are penetrating the sartorius and the rectus, but starting more distally and laterally, you're safe from going through the iliopsoas, which would be more often, when you're doing a more straight anterior portal, I think would be a little bit higher risk. Your pathway is a little bit safer from that standpoint, from the iliopsoas, but you still can go through the rectus and the sartorius. Here you can see the lateral from a continuous nerve in this primal picture anatomy, and again, for straight anterior portal where that yellow dot is, the nerve is a bit lateral to it, but it actually has a variable anatomy, and so it is at high risk. There are a lot of little branches. They tend to be relatively superficial, so you don't want to cut the skin deeply or cut through the skin deeply, because you can cut the nerve, and again, because they use ventricles, they tend to push the nerve off to the side, so moving it laterally doesn't reduce the risk to the lateral from a continuous nerve. You do reduce the risk of lateral from a continuous nerve injury by going medially, but that's where you increase your bigger neurovascular structures, and so we don't do that. Again, don't cut deep, and you want to be careful about using vigorous instrumentation to remove loose bodies or large cannulas there, because that will put a big stretch to the lateral from a continuous nerve. It's not an uncommon thing to see lateral from a continuous nerve injury, but from the anterior portal, it generally is temporary, especially if you're only cutting through the skin. There are certainly a lot of case reports out there and series that describe permanent injury to the lateral from a continuous nerve, but here again, more distally and lateral to the standard anterior portal is where we go. It is closer to the lateral from a continuous nerve arborization, but it is also where it's a bit smaller as it's more distal. The femoral nerve can be tangential to the straight anterior portal. It's about an inch and a half from the straight anterior portal, but again, if you're going distally and laterally to that with the so-called modified anterior portal, you're safer from the femoral nerve vasculature. The lateral from a continuous artery is inferior to the straight anterior portal, but a little bit closer to the mid-anterior portal, and so the key is not trying to skive off the neck down low and come up into the joint. If you're actually entering towards the joint, you should be very safe from the lateral from a continuous, or from the lateral from a circumflex vessels, and again, because you can sometimes see overhang like you see on this 3D CT scan of this patient, it can be very hard to use a more straight anterior portal to get access to the central compartment, so starting more distally, you can get under these acetabular osteophytes much more easily, and again, it's a better approach for drilling and placing your anchors. So when you're making your portal, regardless if you're doing a straight anterior portal or a mid-anterior portal, you want to cut the skin only because of the risk of the lateral from a continuous nerve. Again, in yellow, here's what you can see with a 70-degree lens, and it's very hard to see right near where your portal comes in, and it also is hard to see posterior and posterior medially from the anterior portal because of the curvature of the femoral head, and the 30-degree lens, you can see centrally quite well, but the 70 to see more peripherally. So again, the key is when you make whichever of the anterior portals you make, you want to stay lateral to the ASIS, and when you enter the capsule, you want to stay lateral to the iliopsoas as well. Don't aim distally to avoid the lateral from a continuous artery. So this is from the anterior portal. This was a case actually I did today. You can see my anterior lateral and posterior lateral portals there. There's the posterior lateral and the anterior lateral with the 70-degree lens, and you can see all along the anterior labrum, you can see the femoral head. You can see the articular surface of pretty much the anterior two-thirds of the hip. You can see even way medially in some patients, or inferiorly on the acetabulum there where it meets the transverse ligament. And this is with the 30-degree. Again, I can see the cotyloid fossa very well. I can see some of the posterior articular surface. That's my posterior lateral and anterior lateral cannulas. But you can't see the most posterior inferior joint, just like Michael Dean showed in the drawing. Then my last portal, but this tends to be my working portal when I do arthroscopy. I make a posterior lateral portal. And for this, you want to basically make it in line, relatively in line with your anterior lateral portal, but posterior to the greater trochanter. You want to make sure the leg is in neutral rotation. So there's my posterior lateral portal with the yellow arrow. And again, that's my posterior lateral portal. You see my scopes in the anterior lateral portal. And with this one, you're going through, that's your portal. You're going through the gluteus medius and minimus at your superior anterior piriformis. So you're relatively safe from the piriformis standpoint, as well as the sciatic nerve. The sciatic nerve, though, is closest at the level of the capsule. It's about just under three centimeters from your portal. And so if this is your direction of your portal, you can see your sciatic nerve. If you have the hip externally rotated or internally rotated, you do increase the risk of injury to the sciatic nerve, as well as if you have the hip flexed. If you have the hip flexed, the sciatic nerve is more adjacent to the capsule. This is a drawing from Tom Bird showing that as you look at the solid line for the greater trochanter neutral rotation, you're going along the posterior aspect of the greater trochanter. You enter the joint, and you're at a safe distance from the sciatic nerve. But if you're externally rotated, your margin of safety relative to the sciatic nerve is lessened, and so you have a higher risk of injuring the sciatic nerve if you are externally rotated. And again, if you're internally rotated, you are bringing the sciatic nerve closer to the joint, as well. So neutral rotation is the key. The superior gluteal nerve is also at risk, but again, this is about four and a half centimeters away and branches posteriorly, but it's more proximal than where you normally would have this posterior lateral portal. And so again, this is a schematic from Michael Deans to what you can see with a 70 in yellow and in orange with a 30-degree lens. So here's with a 70. You can see that whole posterior inferior labrum going all the way down almost to the transverse ligament. You can see a little bit of the cotyloid fossa here as an anterior and anterolateral portals. You can see labral chondral separation straight anteriorly, but you can see the labrum or labral chondral junction all the way around as I'm rotating the lens, the 70-degree lens around. So you get a very good view of everything. I tend to keep my scope in this portal and do most of my work because most of the pathology is the anterior and anterolateral portals and go between those two portals. Here's the 30-degree lens. I can see a bit of the labrum here, but again, it's mostly the articular surface and the cotyloid fossa. You don't get to see as well peripherally anterior, straight lateral or posterior laterally, but you can still see some anteriorly. So normal variance. Normally we talk about the labrum being in continuity with the articular cartilage. Sometimes you can have a more medial insertion and so you can have a cleft that sometimes on MRI is read as a tear, but that's not a tear, it's a cleft. You see the normal articular cartilage going over the edge of it, similar to what you might see with a slap. You can see a tri-irradiate cartilage. Those things will close upwards into the 20-year age range. This is a supraacetabular fossa, a keyhole-shaped cotyloid fossa, again, a normal variant. And then sometimes you'll see the stellate crease, which is also a normal variant. We don't know of any consequence of seeing these creases on the weight-bearing surface of the acetabulum. For the peripheral compartment, you need to take the traction off to relax the capsule. If you flex the hip up, that'll also relax the anterior capsule. A lot of people will make a distal-anterior lateral portal to access the joint and have both in the peripheral compartment, below the head and neck junction, if you will. So flexing the hip to relax the anterior capsule, as you see here, about 15 to 30 degrees. And so here's your anterior lateral portal. That's your mid-anterior portal. This is more straight anterior portal. That's a proximal anterior portal that some people will make. And this is your proximal anterolateral and distal-anterior lateral portals that can access the peripheral compartment. And that would be the portal that you'd make for an iliopsoas lengthening. And so here you can have sometimes multiple portals. That's your anterolateral portal. That's your mid-anterior portal. That's your posterolateral portal. That's an accessory anterior portal that we use sometimes to take down the labrum. And then this is a distal-anterior lateral portal. So you can have a lot of different portals in there as opposed to doing the capsulotomy. But here's your anterolateral and proximal anterolateral portals for doing camera section. You can see that here, reflection of the labrum from the peripheral compartment, you see the head, the seal of the labrum on the head and the reflection of the capsule. Here's the, you can see the, down below, the medial synovial fold. You see the zone orbicularis above. And that's just a synovial reflection at the head-neck junction. And my probe is pushing on the iliopsoas. So if you made a capsulotomy, you get to the iliopsoas there through the peripheral compartment. And then I'm just going to actually, why I don't do a capsulotomy, if this is your iliofemoral ligament anatomically, that's your anterolateral portal and your straight anterior portal where they'd come in. So at about the 1 o'clock and 3 o'clock positions, the iliofemoral ligament is basically between those two portals. So if you do make an incision to join those two portals, you're cutting the entire iliofemoral ligament, which is the biggest, strongest ligament in the body. And in my mind, it doesn't make sense to cut that ligament, even if you're going to repair it at the end. So Craig, off to you. Okay. Thanks, Mark. So I'm going to talk about why I do a capsulotomy and then why I repair it. So we'll talk about that at the end. But for me, doing the capsulotomy really is about visualization. So I primarily, just as a segue, use, in almost all cases, a three-portal system as well. But I use a traditional anterolateral portal for access. I use a mid-anterior portal, which I actually view through for a lot of the case. And then I use a distal anterolateral portal for drilling, much the same reason Mark talked about with access to the angle into the S-tabinum. So I do an interportal capsulotomy. So this is viewing from the anterolateral portal. And then the blade is coming in the mid-anterior portal. This is done in cases where I'm going to do ephemeroplasty. I do this at the very start of the case. This case, I usually do it dry, if we have a good view, so you can start there. I then reposition my hands. So this shows now my camera is in the mid-anterior portal, and the instrument is in the anterolateral portal, and I actually spend a fair amount of time during the case in this configuration. So as you can see, between the two of us, there's many different ways of looking at the hip joint and accessing the joint. So then I move toward, now I'm viewing from an anterior portal and looking posteriorly. So we're looking at the posterior wall there, we're kind of taking a bird's eye view down on the joint. I've connected my two portals there with a blade. The reason I do a capsulotomy, for me, it's all about visualization and ease of access and instrumentation. So this is a view from a mid-anterior portal after we've done a capsulotomy, which shows the bird's eye view down, I like for a lot of the case, and it shows the labrum in the middle of the screen there, and I don't know if you can see my pointer, but our ostabular rim where we're going to do some work. So for example, I've done a capsulotomy here, and now I'm viewing from a mid-anterior portal, and I have a lot of ease of access. I can rotate my hand, I can look in the central compartment, I can come back out, I can look at the labrum from the rim side. And so it just gives me a lot more flexibility and movement to safely move around the hip joint. We'll talk about this a little bit more in the CAM section, but doing a T-capsulotomy for me allows me to visualize the entirety of the proximal femur. I can take the hip through a range of motions, this, for example, is the camera in the mid-anterior portal and instruments coming in from a distal-anterolateral portal, and it really gives us a bird's-eye view down the femoral neck, and we can take the hip through range of motion, we can access the entirety of the CAM lesion through a T-capsulotomy. So for me, you know, this has come out, this is an example of a case where an outside surgeon performed a femoroplasty. You can see this is just completely inadequate, just, it's a very proximal femoroplasty, and the patient still had ongoing CAM impingement. The very distal neck is sclerotic, there's really no work done distally. And when you do a revision arthroscopy in this case, you can see where the previous capsulotomy was done, it was interportal capsulotomy, and you can really see just the extent, at least in my hands, of the proximal femur that you can access through the interportal capsulotomy. So in this case, we did a more formal T-capsulotomy, I was able to look down the femoral neck, we can take the hip through range of motion, we can fully access and understand where this residual CAM lesion is, and then we can do a revision femoroplasty through this capsulotomy. So for me, it's all about access, you can see I'm using fluoro to help me work all the way down the femoral neck where there was some, the continuation of this CAM lesion, and we're able to create an adequate femoroplasty for this patient. So for me, it's all about access, and we'll talk a little bit more about repair of that capsule. But I think, you know, it really is important for me to be able to see the entire joint to be able to access it. So that's why I do a capsulotomy. I'm going to turn it back over to Mark for the next session. Correct? No, it's you. It's you still, Craig. It's me. Okay. So we'll talk about the labrum. So in this section... Actually, Craig? Yeah. Craig? Yeah. Hold on a sec. Dr. Moore, do you use traction sutures with your capsulotomy to reflect the capsulotomy limbs? Yeah. So I will show a video of that. I do, I think in the capsule management or in the CAM section, I have a video. I use, and I'll talk about that, but I do use traction sutures, which I think are very helpful. Okay. Good question. Yeah. No, there's several techniques for that, and we'll talk about that a little bit later. So just being aware of time, we're about halfway through here. The labrum, you could spend a whole day talking about, but I think the long story short, I'm not going to really talk about literature, but as you all know from your experience with the hip, there are many different ways of repairing the labrum. You can do... This is an article that Ben Dome and Tim Jackson wrote. You can do pierced labral base repairs. You can do circumferential stitches. But the concern is, are you restoring the labral position and the seal that the labrum potentially creates? I bring this literature out because it seems that really, I know Mark and I both do a base fixation technique, but I think you're justified in doing either circumferential or a base repair technique in whatever the situation presents. The literature supports that. Again, this paper from Tim Jackson and Ben Dome, a paper from Mark Pilipon, all really show no difference in outcomes, whether you do a base fixation or whether you do a looped repair. So I think either are justified, and sometimes it depends on the type of tissue you have available to you. And we'll talk a little bit more about that. We'll also get into the topic of whether to detach the labrum or not. I think Mark and I may have a subtly different take on this. And again, you're justified with the literature in either direction that taking the labrum off and repairing it after you do your acetabuloplasty versus just doing more of a peel back, either have good support in the literature. When it comes to labral repair versus debridement, I think we all know the papers, you know, there's very good support that patients have better outcomes with labral repair than with debridement. I think, you know, you need to really understand what patient and what pathology you're treating. But in general, we're very well supported with our labral repair literature. So there are many different techniques of doing this. You can use tape suture that's shown in this in a simple fashion. This again is kind of a bird's eye view down on that tape repair, which is my preferred technique. You know, sometimes you get in there and you have a very macerated or a smaller labrum and you may want to consider a looped suture like this. So in certain situations, I do use a simple loop suture, although my preferred technique that I'll show here is more for a base fixation technique. This is a suture base fixation with tying knots. And so, you know, I think it's dealer's choice whether you tie knots or whether you like a knotless technique. My preference is for a knotless technique, but this is a technique with a base fixation with the knotted. I'll just show a few slides of my technique. So my first step for doing the labral repair really is to kind of understand the pathology, understand the labrum. You know, you do your diagnostic scope that Mark really showed elegantly. For me doing a knotless repair, I really take time to make sure that I expose the rim in a way that I preserve the capsule. So you can see that top picture, I've kind of exposed the rim there. And then I take an understanding of the bed. Is this a labrum that I can do a repair and a base fixation, or is this labrum compromised? Is there a lot of intrasubstance tearing that I may want to do a loop suture? So in this case, I'm going to show an older technique that I did with a base fixation. But in this case, I'm passing a wire through the chondral labral junction. And in this case, it's severely compromised. In general, I leave this compromised tissue until I'm done. Because once you start debriding here, it kind of never stops. So I'll pass a wire here, and then I'll use that to pass a tape. In this scenario, it was a labral tape, which I don't routinely use anymore. And then in this case, I'm using a base fixation. So I'm, again, piercing through the labrum in order to achieve just tissue at the base of the labrum. So this can be done using a penetrator. You can use any number of instruments that are available on the market. But the goal is to achieve that pierced type of construct so that you don't have all that suture material in the joint. I, again, as we mentioned, use a distal-anterolateral portal for this very reason. So when you have an anterior portal or a mid-anterior portal, your trajectory into the joint can leave you in a position where you might be compromising the cartilage. So that dial-up portal really gives you a better angle into the, for me at least, into the acetabulum. This is what you want to avoid. I came across this a couple of years ago in a revision arthroscopy patient at persistent pain after arthroscopy. And these anchors were obviously placed from just a much more, a very proximal portal, as Dr. Safran is alluding to. This is what you really want to avoid. So move distal, either if you're using your mid-anterior portal or if you're using a distal-anterolateral portal, that gives you a much better trajectory. So I'll shuttle these sutures to a distal portal. And then I'll drill, this I'm viewing from a mid-anterior portal. And I'm drilling from a distal-anterolateral portal. And that just gives me that bird's eye view down on the rim. Again, this is kind of a knotless technique. But again, this can be done with a knotted suture very similarly. I'll place my anchor. And for me, part of the issue with a knotless technique is that you oftentimes can't get that same tension. So I use another instrument to maintain my tension exactly where I want when I'm doing the repair, so you don't over-tension the labrum. I use fluoro to confirm I'm in the right position. We're cutting our sutures. And then what we're trying to achieve is this labral seal. So my current technique, and again, this just shows you a different instrument that you can use. This is a capsule closure device. Again, you can use a penetrator. I like this device because even though it's made for a capsule, I think it gives me a nice angle to pass the suture. In this case, I'm using a polyester suture tape. And again, passing the suture, doing a base fixation. And in that case, you could see that you almost pull up that chondrolabral junction when you do the base fixation. Again, we're using a knotless technique here with kind of a bird's eye view down on the rim. So I'm going to shift over to you, Mark, to I think your next talk is... The pinstick FAI. The FAI talk that we'll move into. Yeah, so do you see me? Oh no, here we go. No, I just switched, you should come up there. There you go. Okay, so there's a question here about, by the way, when accessing the hip, when do you turn on the water flow? And I know some people, when they remove negative pressure, will go ahead and just inject some saline to help distract the joint. I don't like to put any saline in until I have an inflow and an outflow. Otherwise, if you get a little bit of fluid mixed with some blood, then you can't see anything. And I want to always make sure that after I make my first portal, that I can watch my second and third portals under arthroscopic visualization to make sure that I'm going in with the needle through the capsule and not damaging the labrum. So I turn on the water after I have my two portals. Craig, are you doing the same thing? Yeah, I'm the same way, Mark. I actually try to go as long as I can dry. I mean, it's amazing. And you can take this to other joints too, but you get a great view dry. So I'll do everything you said for accessing and getting your suction, you vented. And I'll put the camera in. If you have a great view dry, I'll put my second cannula in and then I'll start making my capsulotomy dry. And then I do my whole capsulotomy if I can dry because it's just a great view. Then you'll start to get some bleeding and that's when I turn the water on usually. Okay. So most people know the pathophysiology, obviously, of FAA at this point. The pincers with the acetabular overcoverage and normal femoral head-neck junction, which you'd get more often is the crushing of the labrum as opposed to labral control separation. You'll see oftentimes notching on the femoral head-neck junction from the labral hitting up against the acetabulum, the femoral neck against acetabulum. Then you get this contracoup injury. So not just where you're getting the hitting of the femoral head-neck junction against the acetabulum, but then you'll get the levering and you'll get a contracoup type of injury. Whereas the CAM, you have that loss of the femoral head-neck junction. And so initially your labrum is actually spared and you're damaged at the labral chondral junction. Craig showed a great case when he was showing his labral repair about how the articular cartilage was delaminated, as you would see here, the so-called carpet phenomenon where the labrum is initially spared, but it's a labral chondral junctional injury. And then the articular cartilage delaminates. And then ultimately later on, you can get some damage, intrasubstance damage within the labrum itself. So with isolated CAM, you'll see anterolateral pathology with labral chondral separation and chondral delamination. And I address this, when you deal with FAI, you have to address the intraarticular pathology, the chondral pathology, the labral pathology, which we've ideally shown you. I tend to do the acetabuloplasty with the traction on while looking for the posterior compartment and shave down some of the bone on the acetabular side and then repair the labrum if the labrum was intact and or repairable. And then I take the traction off so that you have relaxation of the capsule. And even if you can flex the hip some, I like to not do it in flexion so that you don't get disoriented anatomy-wise. And you can shave down and restore the femoral head and neck offset using your enter, you can switch between your portals and you can rotate around the hip so that you can see and access the different areas of the proximal femur. So when I do the pincer, and if the labrum is for the most part intact, I'll take down the labrum and I want to feel along the acetabular rim. So here's a case, I'm looking for the posterior lateral portal. You can see the femoral head to the right. You can see the articular cartilage of the acetabulum. My probe is pushing, showing that this is actually a combined FAI case. There's some delamination of the articular cartilage off the acetabulum. This is a female water polo player. And then what I'll do is I'll take an arthroscopic knife, come behind the labrum. So I'm feeling along the acetabular rim, I come behind the labrum, and then I actually make sure that I complete this labral chondral separation, first with an arthroscopic knife, and then I use an elevator to complete it. I don't like to use the knife all the way through because you can prematurely amputate the labrum, which would be a problem. And then I can come from behind the labrum. I find it's a lot easier to do a chondroplasty coming from behind the labrum, depending on the radius of curvature of your acetabulum itself. So here you can see there's the labrum, and you can see my curette coming from behind the labrum itself to do a chondroplasty of this acetabulum. And then if need be, you can do a microfracture through there. And then I tend to use, here the labrum is detached. You can see the edge of the acetabulum all through here in purple. And then I've got a probe, and this probe is laser etched at five millimeters, so I can measure how much exposed bone you have. The key is that you don't want to remove too much bone. You don't want to make the patient dysplastic. Do realize that when you're looking at a lateral center edge angle, and most people will use, so Mark Philippon came up with an algorithm that was roughly two degrees per millimeter for up to about five millimeters. But the key is that that's the lateral portion. That's not necessarily the anterior portion. And so if you have some anterior acetabular under coverage, if you're not getting a false profile view to measure your anterior center edge angle, you don't just assume that since somebody's center edge angle is maybe 30, and you can take away three millimeters from there and feel safe about it, that if you do that anteriorly, you may actually make them dysplastic. So you want to get a three-dimensional view of what's going on from the acetabulum. And then again, you can use a laser etched probe to help give you an idea of how much acetabulum is exposed and how much you're removing, trying not to make the patient dysplastic. So here's another patient. This is actually another, this is a collegiate football player. And you can see we've removed a fair amount of delaminated articular cartilage. This person has about 15 millimeters of exposed bone from the acetabular rim interlaterally. And so here we're doing a microfracture for that because it's a large amount of exposed bone. And so here's another example. This is a power lifter that was having hip pain at combined FAI. You can see, looking from the posterior lateral portal, you see the head to the right. You can see anteriorly, the labrum is pretty beat up anteriorly. You can see the articular cartilage next to it is also beat up. You can see as I scan more towards the interlateral and lateral aspect, got chondroflaps, a delamination phenomenon, which you'd see again with the CAM type of anatomy. So here we did a chondroplasty, removing the damaged articular cartilage because when we've looked at this under the microscope, those cells are essentially dead even if they're full thickness. And you can see that there's this much exposed bone and based on where this laser etching is, it's about five to six millimeters of exposed bone from the acetabular rim. Can do an acetabuloplasty. I know how big diameter burr I'm using, but here you can see as I was coming along that I had been removing about three millimeters of acetabular bone from this more anterior area. And as we recontoured along, now you can see there's about three millimeters of exposed bone, two and a half millimeters of exposed bone. So I removed about three millimeters of exposed bone in this individual. Here you can see my drill guide to place my anchors. Here I've placed my three anchors. I haven't tied down yet for my base fixation as Craig was talking about. And then this is your repair. And again, I try to do a base fixation whenever I can to leave the free end of the labrum free so that it still can function like a seal. There's still about a millimeter or two of exposed bone from the acetabular rim, which I don't consider a big issue. The portals for the CAM. Again, I take the traction off. I have my standard anti-lateral and proximal anti-lateral portals. I tend to use fluoro. I push right down with my shaver down onto the femoral head at the site of maximal loss of offset, if you will. And then I start to, under arthroscopic visualization, I know the only thing there is the capsule and then the bone. So I'll do a little partial capsulectomy. Here I've done a little bit of a partial capsulectomy. You can see this femoral head loss of offset, and you can even see some wear on this lateral aspect of the femoral head. Here you can see from anterior impingement from the acetabulum, there's this even notching of the anterior lateral femoral head neck junction from the impingement. I can look and see and make sure I've restored my labral seal from this little capsulotomy laterally. And this capsulotomy is lateral to the iliofemoral ligament and anterior to the ischiofemoral ligament. So it's this, what I call the rotator interval of the hip, if you will, where there is no ligamentous structures in that 40% of the capsule doesn't have ligamentous structures. So here you can see I've done my camera section. I've restored some concavity to this femoral head neck offset, both anteriorly and I can see it laterally. And I use fluoro. And we also take the foot out when we do this. And so this was a case from last, actually a couple of weeks ago, my fellow, with my scope in place, we're flexing the hip, we're adducting and internally rotating to make sure that I have eliminated the impingement. We'll also do that with fluoro. We'll also move it around with fluoro to make sure we restore the offset. But we also do this dynamic with the scope in place. Here you can see with my scope in place, we're flexing the hip up. And then we're adducting and internally rotating and making sure that there's no further impingement. And it pushes it so far up at about 120 degrees that it starts to push my camera out. So here's an illustrative case. This is a collegiate basketball player. Has some combined FAI with actually a low AIS and a large CAM lesion on the right. And so here you can see at the lateral with the loss of offset on the anterior femoral head-neck junction. Here's the fluoroscopic view before, both in AP and frog lateral. And then here's the AP and after I've done a resection and the lateral and after I've done the resection on the lateral. So now I'll pass it off to Craig for his approach to this. But I've lost, let me see here. I've lost how to send this back to you, Craig. So here it is sharing. There you go. Gotcha. Okay. So yeah, I think this is a nice juxtaposition here just because I have a slightly different approach and kind of shows us kind of what we can see and what we can't see and what the limitations of my technique and maybe some of the benefits. So I have, you know, illustrative case. This is a woman who has primarily a pincer type impingement with some calcification in her superior labrum. She's overcovered. She's superiorly retroverted. And so I use intra-op fluoro to help identify where I am. But again, this, you can see on the bottom right here, I've taken a bird's eye view down. So I'm approaching the rim from a slightly different view where I'm looking down on the rim. And you can see the labrum has kind of been peeled back, which I'll show in a video here coming up. So I try to access this basically from the backside of the labrum. And in this case, you can see the fluoroscopy pre and post that show us kind of what we've achieved with working behind the labrum. And it's actually, you know, pretty dramatic how much of a resection in the region that doesn't involve the cartilage you can do and change the way the fluoro looks pre and post. This is, you know, her labrum after we've repaired it. And for me, she had a very small, thin labrum after it was destabilized. So I did a simple stitch repair in this situation. And you can achieve going by working behind the labrum, the similar type of appearance to the rim. So for me, I use more of a peel back technique. So again, you're viewing here. I'm gonna go back just to orient you. Let me see if I can pause it. So again, we're viewing mid-anterior. I'll let it run a couple of times. And I'm bringing a burr in from an anterolateral portal. So I'm working all approximately. I'm not using the distal anterolateral portal here. And I'm basically kind of peeling back the labrum from the acetabular rim. Certainly compromising that attachment, but that's part of the goal. Some, you know, I don't completely take it off though. And so for me, I'm using whatever the natural kind of biologic attachments that are still there and trying to maintain those while at the same time, using fluoro and using kind of the bone and my assessment with my templating of how much I wanna take on the rim. So, you know, as we showed before, I kind of then assess what type of labor repair I wanna do. I can assess the position of the labrum. In this case, this was not a significant pincer lesion. This was more of that cam appearance. This is the, you know, the type of case where I'm going to wanna access the rim. I'll have to say, I probably more of a femoral based resection advocate, but in this case, you know, you're gonna wanna access both sides. And so when we look in, we see that kind of macerated pincer type look to the labrum. And so this again, is this mid anterior view down on the labrum. So it's a very different perspective than the one that Mark has shown and gives you a different feel. So you just need to understand, you know, the labrum is now kind of peeled off. I'm looking down on the pincer rim here, which I'm showing with my arrow. And I'm, and on the capsule is on the right side of the image there, where we've made an interportal capsule on me, but we're taking, you know, a significant caution and care not to remove that capsule on the acetabular side. So I've done my resection here. I've repaired my labrum. And in this case, you can kind of see that mixed appearance of resected on both sides and you achieve what you're trying to achieve with the bony resection in these scenarios. So I think I'm gonna, now it's still me to talk about the CAM. So I, for me, you know, I talked about this a little bit earlier, accessing and understanding the CAM both preoperatively and then intraoperatively, I think is probably the most important part of the visualization. So I, for me, the capsulotomy and my work on the CAM, it's all about visualization. And so we do our preoperative template and we certainly have an idea of where we expect to see the CAM, whether it's a superior CAM, an anterior CAM, or kind of a classic anterolateral CAM, or even ones that extend posteriorly that we see on the AP images. For me, I do use a T-capsulotomy and this goes to the earlier question. So I'll let this run here, but I, you can see the labrum on the left side of the screen there. I'm bringing a knife in through, a beaver blade in through a distal portal here, and I'm basically cutting in line with the femoral neck. And so I'm viewing again from this, and you can view it probably from an anterior lateral, but I'm viewing from a mid anterior portal here. And this goes back to the traction stitch here. We can show this one more time and I'll go to this point with the traction stitch. So what I'm doing, and I'm bringing in a stitch, again, you can use a penetrator, you can use a lasso with a wire and then pass the stitch, but I'm passing a stitch in this case through the superior or the kind of anterior leaflet of the T. And so for me, that allows me to then pull traction and we'll, I think we'll see on the next video. So I'm pulling traction here. I've got my camera in the mid anterior portal. I've got a, whether it's a burr or radio frequency ablator through a distal portal, and I'm pulling traction or having my assistant, usually the scrub tech next to me, pulling traction from the anterior lateral portal. And what that allows me to do is lift up the capsule and really view down the neck. And for me, one of the most important things is to make sure where you think you are with the resection is actually what's matching up with the fluoro. So we'll use intra-fluoro to confirm, okay, this is where we wanna be. And then again, we're kind of lifting the capsule with our traction stitches. And then I'm really trying to define the entirety of the CAM lesion. So that for me starts with distally, especially if it's a younger patient, they've still got some healthy periosteal tissue. I like to remove this with an ablator. I think the burr kind of binds up in the thick tissue, the thick synovium. I'll look and confirm where the retinacular vessels are. So in this case, this is a left tip. We're kind of looking over the top, maybe a little backwards if you're not used to this view. You can see the zona obricularis there, but you just wanna confirm, you know exactly where the vessels are. You understand the extent superiorly of the CAM lesion. I almost always bring the burr in through the distal portal. So again, I'm viewing from this skyline view, kind of the mid anterior view. I'm using rotation to understand how proximal is the lesion. If I wanna get to a more distal lesion down the neck, I'll flex the hip up more. If the lesion is more superior and something we see on an AP view, we're gonna have to bring the hip into more extension and internal rotation. And then probably use the burr through the anterolateral portal or through the mid anterior portal to get more proximally. But I usually start distally and I outline my CAM lesion. I don't wanna go for the low hanging fruit. I kind of let the fellow that gets to do that part. I like to first outline the periphery of where I think the lesion is. And then oftentimes you're left with the mid portion of the CAM lesion where most of the impingement's going on. What we're trying to avoid is this, which is, for me, just kind of an inappropriately placed resection that isn't contoured right. I just don't, this may achieve some functional improvement, but I just don't like the way that looks. So for me, I like to have a nice, well-contoured CAM lesion, CAM resection, both with direct visualization and on my fluoro. I also take the hip through a range of motion, but I actually don't find my dynamic exam, Introp, as valuable as some of the fluoro I use and some of the intraoperative assessment of kind of where the CAM is. For me, it's more important than my impingement test. Sometimes you'll find that sclerotic bone or there's little cystic changes. They're a good Introp clue for you is if there's where the CAM lesion is and how much more bone may need to be taken. So I'll use my pre and post and we'll put it at several different angles and confirm our resection. And we showed that earlier. So I think we'll try to tie it up here in a few minutes on capsule management. I don't have much more here. We talked a little bit about this, but much has been written about this and Dr. Safran eloquently talked about where we need to be concerned. We may be compromising the stability of the hip as we cut through these ligament complexes. And I think this is probably the most important part of the hip, the surgery is the capsule repair. If you're going to take an approach like I've shown, you can do the most beautiful camera section label repair, but if you leave the hip fillet open like I've just done, the patient's gonna be miserable a lot of the time. So I repair every capsule I do a capsulotomy on in almost all cases. You can do a more limited repair as shown in this schematic where maybe only the bottom of the T is repaired or a portion of the inner portal is repaired. For me, I do the bottom right, which is usually five or six stitches, which we'll talk about. So I use a number two absorbable stitch. I think that's debatable whether you use an absorbable or a non-absorbable fiber wire type of stitch. I don't really want a big knot stack living there forever. So I use an absorbable number two stitch, a bicryl type of stitch. This is a picture of the stitch going across the distal T capsulotomy. This is a picture of the stitch, and I'll show this in a video going across that inner portal capsulotomy. But as you can see, these are fairly large bites. And I actually take a pretty large bite when I do this. This shows the start of it. So I'm at the bottom of the T capsulotomy there and I've passed the stitch. And it's a fairly large bite. You can use, again, a penetrator. I'm using a capsule closure device, which for me is a nice device to be able to pass a stitch. And then through the same portal, go and retrieve the stitch. So in this case, I've passed the stitch through the more medial leaflet of the T and then gone and retrieved it from the more superior leaflet. And then using any type of arthroscopic knot tying technique. I don't think there's any right or wrong here. You wanna get a kind of watertight seal for me. So I close usually the bottom with three stitches and then the top part of the capsulotomy with two additional stitches from kind of distal up to proximal. Sometimes that takes three to get that kind of anatomic repair. And I once upon a time was quite cautious with my rehab and used a brace and thought this was something that was very tenuous. I think that if you get good bites and get a good capsule repair, it actually affords you the opportunity then to be a little bit more aggressive with your rehab. And I've gone away from using braces. We're quite active early on with external rotation, internal rotation because of the bites. And I think because of the capsule repair that we can achieve with current techniques. So, in summary to the capsule, I think the most important thing is to, and I didn't really talk about this. I would tailor your capsulotomy and your capsule management to what you're doing in the patient. So if I'm doing a femoroplasty, I start my capsulotomy from the beginning with an internal portal capsulotomy. If I'm going in to do a simple debridement or maybe a more limited repair, I don't do a full capsulotomy and I'll maybe take a more of an approach like Dr. Safran has talked about. So I think you really wanna think about your capsule for what you're trying to achieve. In cases where I'm doing a big repair and a femoroplasty, for me, it's a big capsulotomy and a big repair. You really wanna avoid these capsule defects. In my mind, I see a lot of patients who have had surgery elsewhere and they continue to have pain in their hip. And as Dr. Safran has taught us all, this really can be from instability or micro instability to their hip, which I think this bottom right picture shows a revision arthroscopy where we look in and there's just a big hole in the hip. And patients really, in my experience, don't tolerate not having their capsule repaired, especially if they have any underlying laxity to their hip. So I would encourage, if you're going to do these large capsulotomies, you really need to repair them anatomically to avoid iatrogenic instability. Craig, that's great. Craig, you said that you repair all. I mean, if you've got a 45-year-old, 200-pound steelworker who's got a big CAM lesion and maybe some mild degenerative change and you're taking down his CAM, are you actually closing that capsule? Because I find that those guys get stiff and they don't like stiff. I close it, yeah. I would, the cases that I don't close it, Mark, are cases where there's, if I'm doing a debridement case where I'm just doing, maybe I'm extending my portals a little bit. If there's some arthritis in the hip, I'll close the bottom of the capsulotomy in all cases. So if I cut, make a T down the neck, even in that steelworker, I will close that. But I probably won't be as meticulous with the inner portal closure. So I may just kind of tack it with one loose stitch up there just because I don't want it to sag down the neck and leave him with a hole. But I almost always close the bottom portion of the T. Okay, there was a question. I think you did answer it. It says, do you use absorbable and non-absorbable suture for your repair? You said you use absorbable sutures for your capsule, right? I do, I use a number two absorbable suture. Yeah, and so I use a non-absorbable suture. But again, I think the people that I know that have had problems with the sutures causing irritation with the iliopsoas are those more anterior inner portal capsulotomies. And since I'm more lateral when I'm doing my flication, if you will, I don't, the iliopsoas isn't rubbing over it. So I tend to use the permanence because I want to maintain the strength for a longer period of time. So there's it, that's that question. And somebody asked if I use a brace post-op, because Craig, you don't. You said, and we did some basic science work on the labrum and the strains on the labrum. And depending on the hip position, you can stress different parts of the labrum. So I do use a brace post-op. Generally for those anterior and anterolateral labral injuries, I basically let them get from zero degrees of extension to about 90 degrees of flexion with slight abduction. And then I try to limit the external rotation for only two weeks, and then I get rid of it. I use it on those high risk patients. I will use it, Mark, someone who has a connective tissue disorder or a revision case where I'm doing a capsule flication or someone I don't really trust, you know, a knucklehead, I'll put them in a brace for that very reason too. Okay, Meredith, do we still have time for those last three questions? I hope. Yes, we do. Okay, great. All right, Craig, here's a question for you. For fellows that will be doing hip arthroscopy next year, what advice would you give to becoming proficient and comfortable with the surgery? Yeah, so I think that's a good question. And it also kind of goes into kind of what kind of case do you do as your first case? I would start with that case that you've described there, Mark, that 35-year-old steelworker. I wouldn't start with the teenage lax girl that wants to go back to gymnastics. It's gonna be hard to get her better. That 35-year-old male steelworker who has a hard time sitting in his car, he can't drive to and from work, he wants to go outside and play with the kids, he doesn't have arthritis, but he's got a little bit of a hip that might be more forgiving. I would start with hips like those. I would stick to what you've learned. And for me, and for you, Mark, with the different portals, I use this kind of mid-anterior viewing, and I encourage my fellows, just stick to it. When you start out, it may take you a little longer, but stick to the techniques and the principles that you've learned during your training, and it will come. It just takes a little bit longer than the shoulder and the knee, because we've done a million of those. I would book the case for longer than you think so that the OR doesn't think you're really slow. So start, say it's gonna take you three hours, or tell them it's gonna take you all morning. And then when it takes you less, you look like you're moving quickly. So just take your time with them. You can take, especially when you're out of traction, you can take time on that femoroplasty. Now, don't hesitate to go back to courses in your first year and go back and revisit it. Go visit another surgeon who you've trained with or who you've wanted to see how they work. I think that's always helpful. And you may pick up something, oh, I see what they're seeing from that portal. I learned a lot from you here tonight, Mark. And I think that's really helpful just to see how other people approach the same problem. Yeah, no, that's, you know, it's funny. When I went back and looked at it, I mean, I've been in Tom Sampson's OR, Tom Bird's OR, Chris Larson's OR, John O'Donnell's OR, Ernest Schilder's OR. I've been in a lot of other people's ORs and you always pick up different tricks as we're still trying to evolve this. There's no question. But I think it's reps. It's all about reps. Go to, do cadaver courses, go to industry-related things where you can go and practice on the cadavers. It's all about getting used to the three-dimensional, working at a longer working length, working with the 70-degree scopes. It's all about reps. It's interesting. I agreed with Craig. I used to always say you want to do that 45-year-old mildly arthritic hip because you couldn't, you know, because one of the biggest risks is causing some iatrogenic articular cartilage or labral damage. But Ricky Villar had a different approach to it. His thought was you want to do the young person that's easily distractible because they'll distract so much that you're less likely to ding up the cartilage and be able to move around. But I think some of the techniques are more advanced in those younger kids. And I, you know, I would tend to be more like Craig when you're with the first cases. And don't, you don't want to pick up that first case that has a huge osteoacetabuli that you need to fix or somebody that's got Ehlers-Danlos syndrome or dysplasia that has an irreparable labral tear that you have to do a labral reconstruction, AIS takedown and so forth. So you want to start straightforward, simple and easy and work your way up. But you want to take care of all the pathology. And it is, there's no question there's a learning curve that is a prolonged learning curve with hip arthroscopy. Here's a case, here's two questions from the same individual. The first one is thoughts on primary labral reconstruction, Craig. I do primary labral reconstruction rarely. I think I actually, so I, you know, I think there are people that are big believers and huge advocates of the role of the labrum. There are others that don't think the labrum is that important. And then there are those of us, probably the bulk kind of in between. I think you need to think about what role the labrum is playing in some of these hips. I mean, if you've got a hip that maybe had the hip already has a little bit of early arthritis, they've got CAM morphology, the hips, the labrum is pretty beaten up. I wouldn't repair them, but I wouldn't also hesitate. And I didn't really talk about this much to do a limited debridement and do their bony work and get them rehabbing. They're going to do very well with that. I don't feel like you have to recreate a labrum in every case, just because it has some tearing, especially in that 35 year old steelworker that we've talked about. That being said, there are cases, whether it's a big unstable OS or a large calcified labrum. And you know, when you get in there, I showed that one case where you kind of do a peel back or you do a takedown and you're just not left with anything or the hip is, the person already has some underlying instability. I think there are some cases you want to be prepared. And for me, it's usually the case where I've seen that the labrum is already calcified quite a bit. And it's not someone I just want to do a big debridement of their calcified labrum and leave them with nothing. So I am very rarely, but sometimes prepared to do a primary labral reconstruction. But I just, I wouldn't feel like you have to. And I certainly wouldn't do that early. I wouldn't be chomping at the bit to do that early in your practice. My thoughts are that, first of all, the labrum, when somebody has a normal depth acetabulum, I'm not so sure they use the labrum that much, at least from a stability standpoint. And I'm not entirely sure that when we do a labral repair that we restore some of the labral function that's a barrier to the extrusion of fluid from the articular cartilage. So in all reality, when you have a patient that has 40 degree center edge angle or 35 degree center edge angle and they got a totally beat up labrum, I'm generally not doing a labral reconstruction there and doing a debridement. And actually people can regrow labral-like tissue. That's been clearly shown. So when I do a primary reconstruction is if I've got an irreparable tear in a dysplastic patient or patient that has an irreparable tear and they're clearly ligamentously lax and I think the labrum is playing a stability role in those two situations, it is uncommon for me to do a primary labral reconstruction. In revision cases, I might do it more often, but again, usually in borderline dysplastics or instability patients, but that's kind of about it. The same person asked, do you do capsuplication in borderline dysplastic and lax patients? And the answer for me in my practice is almost always yes. But particularly I look at how easy it is to distract the hip and Craig and I talked about that. We've figured out how much, how easy, based on the number of turns on our fracture table. Today, I just did a case that just with body weight, we brought the fluoroscopy in and the patient was already 12 millimeters distracted just with body weight without fine tuning. No question there. But I also did a patient today that had a CAM lesion, but it was only about 57 degrees alpha angle. But again, his center edge angle was 24, his tonus angle was 12. And so that guy, I'm closing the capsule so that he doesn't become unstable, even though it took 11 turns on our table to get him. So I tend to be more inclined to address those. And it sounds like Craig, you close those people on a regular basis anyways, right? Yeah, I closed to varying degrees of tightness. Again, that steel worker who's a little bit stiff as it is, I just kind of tack it together. But the patient who my goal is to achieve some stability, which isn't that often, I think we've gone to collaboratively treating these patients and if their problem is instability, I involve my open hip colleagues much more quickly than I probably did early in my career. I'm in those cases, I'm quite meticulous with the capsular closure to the point of, probably tightening and placating a bit, but I think it's hard to... Capsular placation is tough. It's a tough primary. And Dr. Safran has taught us all a lot about this micro instability of the hip. But I think if the bony coverage isn't there, it's tough to make up ground with capsular placation. And so you really wanna pick those patients carefully. And to the point that was made earlier, I also use the pre-op exam, basically the traction exam to help me understand how unstable is this hip that I'm about to go into. If it pops right out with or without a post, and I've actually found the postless, and Mark and I talked about this offline previous, I found the postless to give me a little bit better understanding of how loose the hip is because it's much like a shoulder you're putting in the lateral position. You just kind of have a little bit better feeling of how much I had to pull on that hip to get it out for me. And then you maybe treat the capsule a little bit differently if it's a very unstable hip. Last two questions. What is the distance between each stitch? I think that came up during the labral thing. I put my stitches, I use a 1.8 millimeter anchor and I tend with the 1.3 millimeter drill hole and I tend to put it about every eight millimeters. Craig, how far are you putting your labral stitches? I think it depends for me whether it's a case like you've shown where the labrum is completely unstable and kind of either totally peeled off or detached where I may put them a little bit closer together. But if it has some inherent stability, if I either haven't done an acetabuloplasty or I've done a peel back and still some stability, I may space them a little bit more. And just for me, it's kind of more of a feel at that point. They can be a centimeter or a centimeter and a half and it's a kind of a feel thing. Interrupt. Now, last question. Well, second to last question. Are you using a 70 degree scope throughout the entire case? So I tend to use a 70 degree through the central compartment and sometimes I'll use a 30 for some central areas of the central compartment around the fovea and the central head. And then I tend to use a 30 degree almost exclusively in the peripheral compartment. Craig, what about you? I use a 70 basically exclusively through the central compartment, through the peripheral compartment. I think my thing that takes getting used to for our trainees is that just the perspective, kind of looking at it from both sides, looking at it from that bird's eye view down, which for me, the 70 is real helpful for. I use a 30 if I'm doing peritochonteric work, I find that to be helpful. If I'm doing a glute repair, sometimes that 70 can be just, it just gives you too much angle and you're better served doing it like a rotator cuff of the shoulder with a 30 degree scope. Last question, are the Steelers going to play this year or not? Good question. It's a whole new world. I'm guessing we're going to play without fans, but who knows? Well, I want to thank Meredith for putting up with Dr. Morrow and I and the AOSSM for asking us to present and hopefully you found this beneficial and useful. And Craig, I certainly did. I enjoyed seeing your videos and learning from you and I appreciate working with you on this. So thank you very much. Thanks, Mark, you too. Thanks, Meredith. It was a great pleasure. Thank you. Thank you, Drs. Morrow and Saffron for your time and preparation for this and presenting tonight's content. Next week's webinar is listed here, the preservation surgery in complex cases. Registration is now open for the AOSSM webinar series, the Athletes' Hip that's taking place at the end of May, the last week of May, and also the beginning of June. CME credits will be offered for these webinars. Thank you again for participating. Have a good night. Thank you, Meredith. Thank you. Thanks, thanks, Craig. See you, Mark. See ya.

Common Practices in Hip Arthroscopy 2020

Dr. Craig Morrow

Dr. Mark Safran

hip arthroscopy techniques

labral repair techniques

capsule preservation

knotless technique

orthopedic surgeons

femoroplasty

surgical planning

surgical technique