Good evening. Thank you for joining us tonight for the AOSSM Fellows webinar titled Hip Preservation Surgery Complex Cases with faculty Dr. Benjamin Dome and Dr. Benton Emblom. Dr. Dome is founder and medical director at the American Hip Institute in Chicago and also chair and fellowship director with the American Hip Institute Research Foundation. Dr. Emblom is orthopedic surgeon and sports medicine specialist at the Andrews Sports Medicine and Orthopedic Center in Birmingham, Alabama, co-founder of the Andrews Hip Center of Excellence and board member of the American Sports Medicine Institute. Dr. Dome and Emblom will present several cases with discussion. To submit a question on the GoToWebinar panel on your screen, click the questions drop down arrow on the right hand side of the panel. This slide shows where you input your question and then click send. I will now turn this over to Dr. Emblom. All right. Good evening. Glad you guys could make it in these rather unique times. We resort to technology to not only get us through this, but to continue our education, which has been nice. I know you guys have all been present or most of you guys have probably listened to the previous presentation by two of the earlier presenters on the basics of hip arthroscopy. I assume they've covered most of the ABCs and one, two, threes of kind of what we do from a hip arthroscopy standpoint and some cases and Dr. Dome and myself are going to go through four, what we consider rather complex cases in terms of management strategy, presentation, et cetera. So just for a little bit of background, I'm going to try and stay away from some of the basics of hip preservation and hip arthroscopy because I assume that's already been done. As we all know, the incidence of hip injuries has increased dramatically over the last decade and that's largely been in part due to better recognition with improved imaging and arthroscopy. When I was a resident back in the early 2000s, I'd never seen a hip arthroscopy procedure, never heard of a labral tear or even thought about the term femorostabular impingement. So a lot has changed in the last 10 to 20 years and it's been largely in part because of MRI technology and arthroscopy. As we know, the incidence of hip injuries in sports has been heavily publicized in the media. We're here in Alabama and I think everybody on this webinar probably knows that there was an Alabama quarterback this year that had a pretty significant hip injury and everybody's aware of that because of the assistance of the media, whether that's good or bad. In addition, our treatment options have expanded over the years with the improvement of biologics, arthroscopy, as I mentioned, and advanced rehabilitation. So in years past, most athletes were essentially resigned to living within the constraints of their symptoms and of the ones that went on to arriving at a proper diagnosis, 60% of those were initially misdiagnosed as an extra articular problem or a strain and this was demonstrated in some of Dr. Bird's work back in 2001. And on average of those patients, it took approximately seven months to move from a incorrect extra articular diagnosis to the accurate intraarticular diagnosis. Most common diagnoses in those cases were found to be labral pathology and or chondral damage. So when we're looking at somebody with a hip problem, I think the goal that we all understand is we need to determine is this an intraarticular problem or an extraarticular problem or maybe even a combination of both. Hip joint pathology can oftentimes coexist with extraarticular snapping hip, athletic pubalgia, lumbar spine disease, et cetera. So it's sometimes considered like a booby trap if you come into a room and see a patient and they first start talking about their buttock pain or their mid groin pain, et cetera. So it's oftentimes in coexistence with hip pathology, so it's important to listen to our patients to help us try and determine what the underlying cause is. In the acute setting, it's much, much easier. As we know, chronic hip joint symptoms can secondarily lead to compensatory extraarticular findings such as gluteal pain, as I mentioned earlier, as well as abductor symptoms, bursitis, et cetera. So when someone presents, we have to consider the history first and foremost. A history of trauma can be variable, whether it's acute or chronic. As we do know that a significant traumatic event does pretend a more favorable prognosis has been demonstrated by Dr. Bird as well in some of his earlier work. Mechanical symptoms such as sharp stabbing pain, catching, locking, or giving way also tends to pretend a better prognosis, and this has been validated as well. Typical characteristic exacerbating features that we'll oftentimes hear without even asking direct questions or the straight plane activities are oftentimes well tolerated. Torsional twisting activities can be more problematic. Prolonged hip flexion, such as sitting in a vehicle, sitting in a chair, or at a desk can oftentimes be uncomfortable. Getting up from that seated position can also elicit pain and sometimes catching or a popping sensation. Inclines tend to be more difficult than level surfaces, and symptoms do tend to be exacerbated with getting in and out of a car, as I mentioned. Typically putting on shoes, socks, hose, etc. So what do you do when you have a patient with evidence of labral damage? Is it significant needs to be the first question you ask because we know there are some cases 20% false positive rates. Some of these cases will become asymptomatic if treated appropriately with conservative measures. It's really important in the athletic population to keep those athletes informed. Not all of these need surgery, particularly acute surgery, and sometimes with an injection the symptoms may resolve and become quiescent. Active rest is always a good place to start. A couple of weeks of that with a reassessment and to maintain communication is critical. If symptoms are manageable, it's perfectly acceptable to go and continue to play that sport. If symptoms persist, we may need to consider the timing of surgery. Likewise, there's no evidence to support acute intervention being better. However, there is more and more studies that have come out most recently in our AJSM journal, I believe last month, showed that the duration of symptoms can oftentimes affect the outcome of surgery. So if someone presents with significant hip pain, an underlying diagnosis of FAI with a labral tear, waiting for five years may be a bad idea. So how long do you wait? As I mentioned, if acute pain resolves, but mechanical symptoms persist, we may need to consider the role of arthroscopy. And as you know, some of the sports specific results, we could go on and on, but relative to the ones that I'm going to talk about, I think it's important to realize, like Chris Larson demonstrated in his 2013 paper, that increasing alpha angle is predictive of athletic related hip and groin pain, particularly in collegiate and national football league prospects. So I'm not suggesting that we forego an echocardiogram or listening to our athletes' hearts at a pre-participation physical, but what I am suggesting is that patients with known cam deformities and elevated alpha angles are at much greater risk for developing hip pain and subsequent symptomatic FAI. As demonstrated by Dr. Philippon and Penjment, in 45 professional athletes was associated with pathologies and returned to sport following arthroscopic decompression. So what that means is that patients identified early, whether they're athletes or non-athletes if treated appropriately, can return to their previous level of sport, even at the professional athletic realm. And demonstrated by Byrd, outcomes after hip arthroscopy and FAI in NFL, the best predictor is the status of the femoral head articular cartilage in the traumatic setting, and early intervention in symptomatic FAI is best, as we alluded to earlier, not necessarily acute treatment, but early intervention. And delayed intervention after instability, pardon that misspell there, may allow better understanding of the prognosis and prevent revision surgery. So the cases I'm going to go over are two cases with some instability associated with them. Case one is a 17-year-old high school basketball player presented with deep bilateral groin pain, the right greater than the left. You can see his AP pelvis up there and his done lateral below. His hip pain had been progressive over the last 18 months. He was unable to pivot and rotate to the right side without pain. He had limited rotation to the left due to stiffness. He had catching, locking in the right hip, and generalized soreness on the left side. You can see on his lateral radiograph he has a substantial cam deformity with a significant alpha angle that was measured at about 78 degrees there. He had a significant cam deformity on his left hip as well, with the same elevation and his alpha angle, and he had complete temporary relief of pain with an intraarticular injection into the right hip, which as I mentioned earlier, was the most notable hip in terms of the symptoms at the time. The MRI showed a large labral tear with a significant labral chondral failure, and we elected to proceed with arthroscopy on the right side in May after basketball season. At the time of surgery, he obviously had a significant labral tear with significant labral chondral failure, underwent labral repair, thermoplasty, and an appropriate capsule closure. He had an uneventful post-op course with a very deliberate rehab progression at the time. He was able to return to play his junior season. Keep in mind we did this in May. In the spring lead, the following season, he had a twisting episode and felt a pop in his left hip, as you can see up there on the screen, and he was unable to bear weight. X-ray CT scan was done at the local ER and an MRI in clinic, and what you can see is he had that persistent cam deformity that we diagnosed or recognized on the initial evaluation of his opposite hip, but he subsequently developed a posterior wall fracture. So we obviously assumed, because I wasn't present at the site of injury, that he had a hip subluxation, likely secondary to his significant cantilevering effect from his femoral acetabular impingement on that side, had associated labral tears, you can see on his MRI. We made him touchdown weight-bearing with posterior hip precautions for six weeks for two reasons. We wanted to confirm that that posterior wall acetabular fracture wasn't going to displace. At its current position, it did need surgery, and from other reports and anecdotal evidence, it's obviously been shown that early intervention in the setting of hip instability, particularly macro instability, may be better served after a delayed period of allowing the hip to calm down before going in and operating on a hot hip. The follow-up CT confirmed healed fragment, and then our subsequent arthroscopy involved a labral repair and femoroplasty, and as I mentioned earlier, there's plenty of studies in the literature that suggest that significant femoral acetabular impingement predisposes us to traumatic hip dislocation or subluxation in this case, and those have been listed here below in the footnotes. Case number two is a similar situation. This is a Division I sophomore linebacker. He had an acute injury when rushing the quarterback and fell onto a knee with a flex tip. He felt a sudden shift in immediate pain and had difficulty bearing weight, and he was unable to return to play. He has a subtle cam deformity that you can see on this post-injury radiograph up on the right side of the screen. This is a video. If you see, I'll put my pointer, I don't know if it demonstrates on the view that you guys are seeing. He's this linebacker right here that's going to come rushing up the middle at the quarterback. You can see him right here. No, excuse me. He's right here. He's coming up the middle, and you'll see right here where he falls down and his left leg jams posteriorly with a hip flex, knee flex position, okay, classic for a hip subluxation and or dislocation mechanism. After reviewing the film, we suspected that he had an impaction injury or subluxation. These were sent to me. I didn't see the kid at the time of injury. He was a couple of states away. The radiographs indicated that he had an elevated alpha angle consistent with cam morphology, which as we mentioned earlier, poses a higher risk for instability, and his MRI at the time was equivocal. So we had a presumed diagnosis of instability, didn't require reduction, didn't have any radiographic findings or CT findings at the time to indicate that he had a posterior wall fracture like our previous case. You can see his MRI here. He's got a pretty significant amount of bone marrow edema in the femoral head, and at this time, his labrum looks decent. Nine months after his injury, he began to experience gradually increasing hip pain and mechanical symptoms. He attempted to play but was unable to. His repeat MRI demonstrated avascular necrosis of the femoral head and a labral tear. The CT scan that we obtained confirmed a cam deformity but no collapse of the subchondral bone, as you can see here. So our diagnosis was a cam deformity with associated femoral isostabular impingement, a presumed hip subluxation with a labral tear, and avascular necrosis of the femoral head. Our plan was arthroscopy, labral repair, femoroplasty, and a femoral head core decompression with backfill of demineralized bone matrix, bone marrow aspirate, and a calcium sulfate void filler. You can see here on the video, this was our initial visualization at the time of arthroscopy. This is his left hip. That's his anterior labrum. You can see he's got a substantial labral tear, and what you'll see next as I peek around the corner, he does have some injury to his ligamentum teres there that we obviously debrided, and you can see this segment of avascular necrosis where he's got a chondral fracture, and at the time, and fortunately thereafter, did not develop any significant collapse of the articular cartilage, but you can see right where the zone of injury is at this point. This is a samurai blade or a beaver-type blade that we used to perform a capsulotomy, and then we're going to sneak in and perform a labral repair like we typically do. You can tell he's still got a fair amount of blood in his hip. His labrum is obviously significantly traumatized, and as you can see, he's got labral chondral failure, so his tear is right at the junction of the labrum and the articular cartilage, which is classic with underlying CAM-type femoralized tabular impingement, so at this point, we're going to stabilize the labral chondral junction. We're going to debride the tear of the ligamentum teres, and we're going to start posteriorly, at about the 2 o'clock position, and start putting in anchors, and sequentially place anchors past and tension our anchors, repairing his labrum. This is a scorpion device that we'll oftentimes use to pass our sutures, and sometimes in these tight hips, you have to kind of turn the scorpion device about 90 degrees to the side to get it to fit in between the labrum and the femoral head. Tried to minimize the amount of traction I pulled on him with his underlying diagnosis of avascular necrosis. He's got a healthy-appearing labrum. It's obviously injured, but he's got good hyperemia and obviously a reasonable blood supply within the acetabular labrum, which does pretend well for him in terms of healing. Anchor number two, I think we ended up putting three or four anchors in this, and then came back in afterwards and stabilized the articular cartilage. So you can see here, the labrum is being repaired. Just for the sake of time, I'm going to move through this. Sometimes in these cases, I'll actually use a radiofrequency ablator and just stabilize the articular cartilage rather than try and place bone marrow aspirate or some type of bone matrix behind that. Oftentimes if it's highly unstable, I'll do a retrograde microfracture or use the curve microfracture picks and pick that articular margin, but his was stable. I didn't feel like that was necessary, and obviously this is our routine thermoplastic correcting the underlying CAM deformity that he had. Once we get through that, we'll obviously reduce the hip and repair the capsule. What we did here is we made him touchdown weight bearing. We braced him for six weeks, followed by a gradual increase in weight bearing to progressive weight bearing and follow up MRI at four months. What you can see on the left is his initial post-op films, that void where we decompressed the avascular necrosis and then the back filled calcium sulfate. You can see on the image on the right, he started to heal that in. So this was his sophomore year. He actually played this year and was the leading tackler for his team. So he fortunately had a relatively uneventful recovery considering how bad the circumstances could have been. Thank you. All right, Dr. Dohm, I'm going to reach over and make you the presenter and let you follow up with your two. Bear with me. Oh goodness, we got you as three people now. So let's see if this works. Hi, Ben. Can you hear me now? I can hear you. Yeah. I just don't see your screen yet. All right. How about now? See my screen now? Yep. Got it. All right. Well, hello everyone. Benjamin Dome here from the American Hip Institute in Chicago. Pleasure to be with all of you virtually. And just to echo some of Dr. Emblem's earlier thoughts, these are certainly strange times that we're in, but if there is a silver lining, it has been that we've all been able to adopt very quickly some of the educational opportunities to online opportunities, which I think are a great vehicle that may actually persist even beyond the COVID crisis as a way for us all to stay in touch and come together for educational purposes. So I'm going to present two cases. And the first one I'm going to start with is one of the most complex cases you'll ever see. So that is the title of our seminar here is complex cases in hip preservation, hip arthroscopy. So this is not a 100 level case. It's not a 200 level case. This is truly a 400 level case, and I hope you'll enjoy it. I think it's a fascinating one. So I've titled the case triple instability. Here's our introductory slide. When all hell broke loose is another way of putting triple instability. So this is a 26 year old male. In 2016, he'd had a right hip arthroscopy with labor repair and ephemeroplasty at another institution. And in November 2019, he slipped on the ice. After that, he had a number of subjective subluxations. And then in December of 2019, he had an actual frank dislocation while lying in bed doing essentially nothing. This required him to go to the emergency room and he was reduced in the ER. He after that continued to have constant instability and pain. On physical exam, he had positive instability tests, positive impingement, and interestingly had a Baton score of 8. Now I'll pause on that for a second because one of the important elements of the physical exam that we teach all our fellows is to do a Baton's test on every patient. I think this is an invaluable series of tests. If you're not familiar with them, please look them up. The Baton's tests give us a sense of the extent of generalized ligamentous laxity in any given patient and really gives us a context for understanding their injury, whether it be to the hip or to any other joint for that matter. Here's his imaging on x-ray. We can see three distinct findings. Firstly, he had an acetabular rim fracture, which you see in the top left here, visible on the false profile view. Secondly, he had residual CAM morphology, so this area here of the femoral neck has a lack of offset. And a third important finding is he certainly doesn't have overcoverage, but he's not particularly undercovered. And this is obviously a gross instability, a macro instability case, so it is important to recognize and acknowledge that he's not overtly dysplastic, because if he were overtly dysplastic, then our clear next line of treatment would have been a periacetabular osteotomy. His MRI demonstrated capsular deficiency and a large anterior osseous fragment. You can see the capsule here is entirely disrupted, and here's that osseous fragment, same one that we saw on the false profile x-ray. And we see that the ligamentum teres is entirely missing here, so absent ligamentum teres. Here's his diagnostic arthroscopy. If I could get good news instead of bad news. Oh, pardon me. Do that again. Here we go, one more time So what you saw there were a number of problems. Firstly, the anterior capsule was essentially absent. This is obviously a big issue with instability. Secondly, he had a badly degenerated and torn labrum, and specifically had a radial tear of the labrum. And then finally, he actually had two acetabular rim fractures. I had only identified it as one based off the pre-op imaging, but there were actually two. One was adjacent to the anterior limb of the TAL, and one was at the 1 o'clock position. So the arrow here is pointing to the one that was adjacent to the anterior attachment of the transverse acetabular ligament. And then he had an absent ligamentum teres, a complete tear of the ligamentum teres, and grade 2 femoral head cartilage damage, probably from the repeated subluxations. So we've got a number of problems here to address. Here's the cartilage damage. In terms of his instability, a number of causes of instability have been identified in previous publications. The x-ray you see here is from one of the first publications by Dean Matsuda on a dislocation after a hip arthroscopy. So Dean and then subsequently many other surgeons thereafter have shown that there can be instability after a hip arthroscopy, which may or may not be iatrogenic, but certainly in a case like this, you see it's quite dramatic where the hip is entirely dislocated. So in this particular case, I felt there were three main causes for instability. From a soft tissue standpoint, at least. The first was labral insufficiency. The second was capsular deficiency with underlying ligamentous laxity. So remember his Baton score was 8. That's 8 out of 9. Anything 4 or more is considered on the spectrum of a ligamentous laxity syndrome. So he had a Baton's of 8 with capsular deficiency. And then he had a complete tear of the ligamentum Now of course it can be debated whether that is a cause of his instability or an effect of his instability, but you can see three major soft tissue stabilizers of the hip are compromised. So we undertook the arthroscopy to stabilize and correct his hip. The first thing I did was the reconstruction of the labrum. So here you see a total labral reconstruction. This goes all the way from 7 o'clock posteriorly around a 5 o'clock anteriorly. So from the posterior attachment of the TAL to the anterior attachment of the TAL. Next, we performed a ligamentum teres reconstruction. So this is the second soft tissue stabilizer. And you can note the attachment location on the acetabular fossa is posterior in the acetabular fossa just superior to the TAL. So it's very important to get low. It has to be just above the transverse acetabular ligament. And you need to stay a little bit posterior because the obturator vessels, which are large vessels, are right on the other side of the quadrilateral plate when you drill through for acetabular fixation. So knowing your anatomy, not just your hip anatomy, but also your intrapelvic anatomy is very critical for performing ligamentum teres reconstruction. Next, we corrected the residual CAM morphology. And Dr. Emblem alluded in his earlier case to the concept of impingement-induced instability, which is definitely an entity and one that we'd want to avoid in this patient. In any case, we don't want him having CAM impingement. We certainly don't want him having impingement-induced instability. And then the final third reconstruction is the capsular reconstruction. So here we used a dermal allograft. We used the residual soft tissue anchors, those being the rectus femoris indirect head on the proximal side, and then on the femoral side the capsular remnant of the zona orbicularis. And we basically bridged that gap with the dermal allograft. We used a Mulberry technique, Mulberry stitches, to parachute the graft into the joint and then to tie the graft to the surrounding soft tissues. So we can see the end result here. So what you're looking at here is the reconstruction of the ligamentum teres. This is the central ligament in the joint that attaches the ball to the socket. A little bit less general rotation there. You can see how it's going to stretch a little bit as you move and it'll hold the ball in the socket. All right, so there you see it tightening as a restraint to the ball in the socket. So now I'm stretching the label. So the entire labrum in the region was just completely shredded and there was also a stabular rim fracture. I removed part of the fractured bone and the other part and I fixated with the anchors here. And again, here you see the completed reconstruction. So what we'll do now, I want to show you the deconstructed capsule. This is the graft that we used to make a new capsule in the area where... So that completes that particular case. I'm going to go into my second case and then we'll have some time for questions after we complete the presentation of these four cases. So let's move into our second case here. All right, Ben, you seeing that okay? Perfect. Great, all right. So this is a case presentation of circumferential labral reconstruction for a calcified labrum. Again, not a 100 level or a 200 level case. The title of this webinar is the complex cases in hip, and this is certainly one. So the chief complaint here was right hip pain. This was a 47 year old female, nine out of 10 pain for nine months, C distribution description. On physical exam, there was a groin pain and limitation of all range of motion, basically pain with every range of motion in any direction. And BMI of 27, which doesn't make anything particularly easier, but hey, this is Chicago, the city of broad shoulders. So x-rays are seen here, and basically this is a case of global overcoverage. And there was calcification of the labrum, which made the overcoverage worse. And you can see a little hint of a double line sign at the lateral edge of the acetabulum. Here we see the done view, and there's not a whole lot of cam morphology, maybe some subtle cam morphology. It's the right hip we're working on. And then here on the false profile view, you can see very significant anterior overcoverage, very elevated anterior center edge angle over 45 degrees. So this makes for a challenging access, and also makes for some challenges with what to do with the labrum and the labral seal. So our diagnosis was FAI and a possible labral tear. It was difficult to actually to see the labral tear because the labrum was calcified. So MRI sometimes doesn't show the labral tear perfectly clearly. So in terms of plan for next steps, we can consider an MRI and MRA or a degenerate MRI, which we use often at our facility to grade the extent or quantify the extent of cartilage damage. Rehab injection are common non-surgical treatments which she had exhausted. And of course, if those are exhausted, then we consider surgery. So she had a degenerate MRI rehab and an injection. The degenerate MRI did show the labral tear. You can see it here, although it's not as obvious as some, but you can see it nonetheless. And the reason it's not as obvious as some is because of the calcification of the labrum again. So after eight weeks of physical therapy, she'd had no relief. She had temporary relief with an intra-articular cortisone injection. We do those in our facility under ultrasound guidance and we re-examine patients 30 minutes after the injection to evaluate if the numbing medication has numbed their pain. That's the diagnostic portion of the injection. And that did in fact confirm the intra-articular origin of her pain. So what options do we have at this point? We could do more cortisone injections, more PT. We could consider biologics, PRP, stem cells, or we could consider surgery. And if we're gonna do a surgery, does she get a scope or does she get a THA? One could argue for a THA. And certainly many skeptics of hip arthroscopy 10 years ago would have said this is an early arthritic hip and there's calcification of the labrum, which is basically an osteophyte. And this is somebody who needs a THA. But today I think the paradigm has changed. And again, not a 100 or a 200 level case, but I think with a well-done hip preserving surgery, hip arthroscopy can help this patient. So diagnostic arthroscopy shows the labrum is calcified and what isn't calcified is totally shredded. So you got basically no significant labral tissue to work with to do a repair in this case. Here we can see the postulateral aspect of it. So when we consider the treatment for this labrum, years ago, this would have been treated with just a debridement because it essentially was irreparable. We can attempt to repair it, but the repair of a labrum like this in my experience is a very unsatisfying, unfulfilling endeavor because there's just not enough tissue to produce a repair that's going to recreate the seal. So then finally, reconstruction. Reconstruction is today our option of choice at American Hip Institute for an irreparable labrum. And then of course, there's the question, should we do a segmental reconstruction versus a circumferential or total labral reconstruction? Well, that's dictated largely by the extent of the damage. So in this case, the extent was very significant. Labrum was calcified essentially circumferentially. So we did a total labral reconstruction. That's the posterior aspect of the reconstruction. This is the anterior aspect of the reconstruction. So we reconstructed it with a six millimeter tibialis posterior graph all the way from seven o'clock at the posterior attachment of the TAL all the way around to five o'clock at the anterior attachment of the TAL. And this gave this patient not only an improvement in range of motion but also a relief of her pain and a well-functioning hip in the years that have ensued since then. So thanks very much once again for joining us on this webinar. And I think at this point, we have gone through our four cases. They're all complex cases and hopefully interesting cases to you. And that leaves us with some time for questions from the audience. And I think Meredith is still with us and may direct some of the questions our way. And I will be able to read through some of them. Benton, is your audio back up? Can you hear me? Yep, you are on. So I'm just gonna read off some questions here. All right, so from the famous Dr. A.J. Lal, what type of graft do you use for labral reconstruction and why? You wanna hit that, Ben? Yeah, I think he knows the answer that you would provide. So when I first started doing labral reconstruction, I used autograft. Typically, I would use a semitendinosus from a knee. And that primarily was an extension of our philosophy for doing ACL reconstruction. However, as labral reconstruction became more accepted and more and more data was borne out, it became obvious that allografts were acceptable and yielded favorable outcomes. As Dr. Dohm alluded to, the tibialis anterior or posterior typically is a perfect graft in terms of its diameter. It tends to mimic the native size of the acetabular labrum. And if you're gonna do a circumferential reconstruction, which is what I typically do every time, it's much more amenable to the technique and makes it easier in terms of using that graft. So I like to use a tibialis anterior allograft. Yeah. And for myself, I've used all of the same grafts that you mentioned at one time or another. Tibialis anterior and tibialis posterior are the ones that I've settled on as the most friendly grafts. They tend to be in the right ballpark of size. They tend to have a good solid tissue. And either a tibialis anterior or a tibialis posterior I find works very well. And I'll just say to the audience again, please do look through your webinar at how you can forward questions. Those questions will be forwarded to me and we'll go through them here as we go. There was an earlier case where there was a question, can you consider this case a shallow acetabulum? Not certain which case that was referring to, but perhaps it was the one I showed with triple instability. For that, so maybe I'll just talk and Benton you can talk about how we decide what's a shallow acetabulum, what's a dysplastic hip. For me, the determination of what is a dysplastic hip is a three-dimensional consideration. So Reinhold Gans often said, I am a friend of no angle. In other words, there's no one angle that sufficiently describes the morphology of a three-dimensional acetabulum. That said, the lateral center edge angle is certainly one good data point and a good starting point. Other angles that we can use include the Sharpe's angle, the Tonus angle, the fear index and the anterior center edge angle. And then there are three-dimensional measures such as three-dimensional surface area coverage of the superior dome femoral head, which is based off three-dimensional imaging. All of those things are useful. I will say that I feel I get 90% of the information that I need on acetabular coverage from an AP pelvis x-ray. If you've stared enough AP pelvis x-rays over the course of your career, you become quite good at identifying the whole line of the anterior acetabular rim and the whole line of the posterior acetabular rim. And you can really start to visualize the entirety of the acetabulum. So it is a three-dimensional determination. And then of course, it needs to be considered in the context of what is the femoral version and what is the state of generalized ligamentous laxity. But I have to say the bottom line for me is in any instability case, the first thought that I have is to do a periacetabular osteotomy. And if I'm gonna do anything other than a PAO, I'm asking myself, why am I going to not do a PAO? There needs to be a good reason why I'm not doing a PAO. So in that triple instability case that I showed, I didn't feel a PAO could make that situation better. There was not enough bony undercoverage to improve the stability with a PAO. The correction would have been either a negligible correction, or if we did more than a negligible correction, it would have created overcoverage. So I'll bounce that over to you, Ben. What do you consider a shallow acetabulum? And when do you think it's too shallow for an arthroscopy? Yeah, so I agree with you. I mean, my principal indices that I tend to hang my hat on are multiple. Like you said, there's not one angle that can give you a strong enough vote of confidence to make a decision. I look at the lateral center edge angle on the AP pelvis. I look at the anterior center edge angle on the false profile. I look at the acetabular index on the AP pelvis. And then generally speaking, if I have anyone that I'm concerned about undercoverage, which is a bony problem, I will typically obtain a three-dimensional CT and utilize those four imaging, basically data points, to determine whether or not I think they have a coverage issue. And when I'm looking at just the center edge angle, typically what's most accepted is less than 20 degrees obviously is considered dysplastic or undercovered on the anterior and the lateral center edge angle. Between 20 and 25 is considered borderline, which in my hands is one that I think may still be a candidate for an arthroscopic procedure, but less than 20, I'm tending to move more towards a bony procedure to begin with. And obviously anything over 25 is considered normal, but greater than 35 may be considered overcoverage and be more of a pincer type mechanism or overcoverage problem. Those are the ones that I typically use in terms of the acetabular index, 10 degrees, or it's kind of what we typically use as our cutoff there. Yeah, I think that's similar in Chicago for us as well. Question from Dr. Ben Mayo, resident. Do you have a specific cutoff for augmentation versus circumferential reconstruction? Ben, you wanna start with that one? Yeah, I think it's really surgeon preference. I would tell you that in the early experience that I had with doing labrum reconstruction, I would generally do a segmental, and a lot of that was because of the graph that I was using. I was using an autographed semitendinosus that would oftentimes have to be doubled over, so a length was somewhat an issue. But as I started to expand the different graph options and kind of settled with the tibialis, graphed material was never an issue. And to be quite honest, I felt like most patients that had a more circumferential labrum reconstruction actually did better. I felt like their pain scores were dramatically improved relative to the segmentals, and I felt like overall, the product that I was able to build at the time of the surgery looked much more like a normal labrum and functioned like a much more normal labrum. Therefore, my go-to procedure is circumferential. Very rarely will I do a segmental unless there's just a chunk of labrum that's missing, and I don't feel like it's a global labral disease or a global labral problem. If I feel like it's an isolated segmental problem, I may consider a segmental reconstruction, but otherwise I think I'm gonna default to a circumferential. Yeah, and for my part, I've lived through a lot of evolution in this field over the last 12 years, and 12 years or so when we started doing reconstructions, they were all segmental, and you mentioned several of the technical limitations back then, and what I've come to understand is that sometimes technical limitations actually affect our clinical understanding, and we could only do a segmental reconstruction, so we didn't look a whole lot further than the area that we knew we could reconstruct. About five, six years ago, we introduced the technique for the knotless pull-through reconstruction with knotless tensionable anchors, which really made the procedure much easier, much more expeditious, I think much more accessible to surgeons around the country and to young surgeons, and it made it easier to do larger reconstructions and to do so in a timely fashion. So we started looking further around and realizing that maybe the labrum wasn't so great even in the posterolateral, even in the inferior posterior quadrants, and so I think there was an evolution over time where the segmental reconstructions became larger and the total reconstructions became more common. On the question of augmentation, augmentation, I think, is a useful technique and can be done with the exact same technique as the knotless pull-through reconstruction technique, the only difference being that we preserve whatever remnant of labrum there is and then place the graft essentially right above the labrum, place the sutures through the chondrolabral junction and then around the graft, so we bundle the graft and the intact labrum together to truly augment the existing labrum. And I think the advantage of a labral reconstruction in my hand, excuse me, a labral augmentation in my hands is that, number one, we preserve the chondrolabral junction, and number two, we preserve the circumferential fibers, whatever circumferential fibers are left, which may contribute to the hoop of the labrum, and that hoop is important. The ability to sustain hoop stresses is important in creating the seal, sealing the femoral head and the socket for stability and also sealing the synovial fluid in the joint for hydrostatic distribution of forces across the cartilage surfaces. So next question from Ben Kunes. For the triple instability case, was the capsule repaired or placated at his initial surgery and what is your general philosophy on capsule repair or placation? So maybe I'll field that one, Benton, specific to the case and then bounce it over to you for your general philosophy on the capsule. So the bottom line is there were no sutures evident in the capsule, and I don't know for sure if any absorbable sutures were placed, but I suspect not. So I think the capsule was left open. Now, to be fair, 10, 12 years ago, there were no capsule repairs. All capsules were left open, or in many cases, a good part of the capsule was shaved out. So I think that the fellows on this webinar probably are growing up in an environment where now closing the capsule has become fairly standard, and I'm really glad of that. I think I and Dr. Emblom have put a lot of work into teaching and publishing research that has contributed in part to making capsular closure the norm, but it wasn't always the norm. So I think in this case, the capsule was left open and probably part of it was shaved out. So when I tried to do a capsular repair or a capsular plication, I could not bring the edges of the capsule together because there was simply a gap. There was missing capsules. So the way that I test that is I bring the hip into extension. And in a revision situation, I bring the hip into extension. I take an alligator grasper and I grasp the femoral side of the capsule and see if I can approximate it in the extended position, approximate it to the acetabular side of the capsule. And in this case, couldn't get anywhere close. There was at least a three or four centimeter gap. So it's not possible to do a capsular closure or a plication in a situation like that. And if you did do it in flexion, it would pull apart as soon as you brought it into extension. Ask me how I know that. So what we did is we did a capsular reconstruction and filled that defect with a graft. As far as my general philosophy on capsular repair or plication, I think I've talked about it a little bit already, but very simply, I think God gave us a capsule for a reason. So unless we have a specific reason to do a capsular release because of an adhesive capsulitis or dramatic stiffness, my routine is to close the capsule. I also evaluate every case for micro instability, which I think is a very real and very common entity, much more common in female hips than in male hips. But in cases of micro instability, I do a capsular plication with an inferior shift, which we've published on in arthroscopy initially back in 2013 and published results on that several times since then. So Benton, can I kick that over to you for your thoughts in general on capsular repair and plication? Yeah, I agree with you completely. When I was a fellow in developing my skillset and in hip arthroscopy, caps for closure was not the standard. And I specifically trained with Dr. Byrd in Nashville, and he was not a closure in terms of what he typically did for his cases and never really had any problem with it. And that was largely his argument for not closing the capsule was that he'd never really had any problems. But Dr. Byrd will be the first to tell you that he's very conservative in his rehab protocols. And if you're conservative enough, even with an open capsule, you could probably get away with it. What I looked at once I developed a significant number of patients to follow is that the patients that had capsular closures tended to have better reported outcomes. I can't really even think off the top of my head, which male patients with traditional femoral establishment impingement had poor outcomes with a capsular closure, but I can tell you which females had poor outcomes without a capsular closure. So when I discovered that, and we're in the process of putting that data together because I've got such a large number of patients that we didn't close the capsule for about five years. When we discovered that trend, my thought was, hey, if I don't know of a single male patient that's had a problem with a capsular closure, but I've got a lot of female patients that potentially had problems, relative problems, not major problems with an open capsule, why not just close everybody? So I'd say over the last five years, we've pretty much closed every capsule. And to this day, I can't tell you of any cases that I've had that I regretted closing the capsule on. I typically use a non-absorbable max braid suture, which is a number two suture. Haven't had any problems with stitch irritation, or I had to go back in and do a capsular release. I've seen a whole lot more patients that have been sent in for problems with capsular insufficiency or instability, micro instability, so to speak, not macro instability due to deficient or ineffective capsules than I have the contrary. So I'm a big fan of closing the capsule and I echo what you said completely. I mean, we don't do an open knee procedure and leave the capsule open likewise with the shoulder. So why should we in the hip? Yep. Question from Nathan Grimm. Do either of you do a T-capsulotomy when you perform a femoroplasty? You wanna start with that one, Ben? Yeah, I don't routinely. And to be quite honest with you, I can't remember the last time I did a T-capsulotomy. I will do one in cases of severe deformity, such as a case with Perthes or some form of significant deformity, maybe even a skiffy case. However, in a routine cam deformity case, which is essentially anything without a major deformity, I feel I can appropriately visualize the femur with a good intra-portal capsulotomy plus, which means beyond the portals and then appropriately placed traction stitches. So I'll routinely place at least three, sometimes four traction stitches in the femoral leaflet and maybe one or two in the acetabular leaflet. And with dynamic visualization, which means taking the hip through different positions at the time of a femoplasty, I can adequately visualize the femur. Now, I will tell you that the area that is most commonly under-resected is gonna be the superior aspect of the femur. Typically, those with an elevated alpha angle on the AP pelvis. What I like to do is take the hip down into extension and even internally rotate it and sometimes pull a little bit of traction, not significant traction where the hip is completely distracted, but just enough to get that residual bit of cam deformity out from under the labrum. And in those cases, I feel like I can see it with those strategies. Yeah, that's great. There was a pair of questions on the ligament of teres. One from Brian Graham, what tissue was used for the ligament of teres reconstruction and how are you determining length tension of the graft? And then from Megan Tranovich, what are your indications for an LT reconstruction? So I've used tibialis anterior and tibialis posterior. The graft that I showed in that case was tibialis posterior, which is my more common graft. And that's a double strand of tibialis posterior. So it makes for about an eight to nine millimeter graft depending on the size of the patient. And the ligament of teres is fairly similar to the ACL in its biomechanical characteristics and also in its thickness. So I've often asked, do we really think that God gave us a ligament as thick as our thumb and as thick as the ACL for no reason at all? Probably not, probably it's there for a reason. And as far as the indications, basically I mostly reserve these for revision cases where there is recurrent micro instability or macro instability with a full thickness tear of the ligament of teres with a few exceptions in primary cases where there is known instability syndrome and a full thickness tear of the ligament of teres. As far as tensioning it, this is an evolving art, but we do essentially an all inside technique, which is a little bit like an all inside ACL reconstruction. We tension it by externally rotating the hip. I've done that both with traction on and with traction off. And having experienced both ways, I prefer to do it with traction on where I'm directly visualizing the actual length of the ligament of teres under stretch. And I have a pretty good feel for what the length should be in order to not over constrict the hip, but to resist translation. And it's at present the only soft tissue restraint other than the labrum, that is the only ligamentous soft tissue restraint to instability both in the anterior and posterior directions. So I primarily reserve this for cases where there is multi-directional instability. And we can assess that on physical exam and find that both anterior drawer and posterior drawer tests of the hip, which we've described in arthroscopy techniques can reproduce pain in the anterior and posterior parts of the hip respectively, or apprehension in the anterior and posterior parts of the hip respectively. Ben, is this an area that you've delved into at all or are you staying away for now? No, we've done a handful of them and most of our indications are very similar to yours. I haven't done any primary reconstructions. And what I mean by that is initial arthroscopy go in and reconstruct the ligament of teres. The ones that I've done are patients that have failed a limited debridement and whether a labrum reconstruction or repair and continue to have pain and some subtle signs of instability, we've gone back in and reconstructed. I think that'll probably shift just like it has with the labrum. I think a primary labrum reconstruction is becoming more and more common in the thought process. And I think the ligament of teres will probably follow. Yeah, and I've been saying for many years, I think this will become the ACL of the hip. And I think the beginnings of that are starting to happen. Question from Dr. David Maldonado, a fellow with us. Should we consider primary labral reconstructions regardless of the native labrum condition or any thoughts on doing a labral reconstruction in every single patient irrespective of the condition of the native labrum? Benton, you wanna start with that one? I mean, I think that's a valid consideration. And there are some across the country that are in favor or more likely to do a primary labrum reconstruction. I will certainly tell you that patients are happy. And those are obviously, and from my experience, the circumferential reconstructions. I think if you've got, like I said, a diseased labrum that obviously has generalized disease, those are the patients that would be more amenable to a circumferential. And I do think that those patients do really well. I just got a alert on my Twitter account, literally about two days ago from a poster presentation that Brian White put together looking at primary labral reconstructions in patients. I think it was women over 40. And they did tend to have significantly improved outcome scores from a Harris HIP score and a HIP outcome score. So I think that is something that we will certainly consider in patients that we think going in probably have a generalized disease labrum. Yeah. I've done several primaries. I've done some on the fly to where I had intentions of doing a repair and got in there and switch gears mid case and did a reconstruction, so. Yeah, and I second that. I'm very much, primary labral reconstruction is very much a part of my arsenal. Primary labral repair remains our first choice. And I think the gold standard when we can repair a labrum and the labrum has sufficient quality of the tissue because we can therefore maintain the integrity of the entire hoop. So from a biomechanical standpoint, I think it has some advantages. Having said that, when the labrum is irreparable or is calcified like in that primary case that I showed where you can't achieve a good labral repair, then a primary labral reconstruction I think is very appropriate. And I think I've often said and other smart people have often said that the more dogmatic we are, the more likely we're wrong. So anytime we say we always do something like we always do a labral reconstruction, we're probably wrong some of the time. So probably we should have a gray scale and be able to appreciate the particulars of any specific case. So I think we're one minute overtime here, Benton, and therefore we should probably cap this off. But I'd like to thank everybody on my behalf and behalf of American Hip Institute for joining. And Benton, if you wanna say any closing words and Meredith, if you have any to close us as well. Thank you very much for the opportunity to do this, Meredith. Yeah, Meredith, I really appreciate the opportunity. Ben, I appreciated the opportunity presenting with you. And the one thing that I would encourage all the fellows, I know we had up to 60 from what I could tell is to take note of the hip. I think it's still a very, very explosive subspecialty within orthopedic surgery and sports medicine for that matter, and it's exciting. And these discussions will be different just a year from now. So I appreciate you guys coming on and being a part of this. Thank you, Drs. Dome and Emblom. Thank you for your preparation and presenting science content. Next Tuesday's webinar is listed here. Orthobiologics, what you need to know, a primary and research update. Registration is now open on the AOSM website for the Athletes Hip webinar series that's taking place on specific times on May 27th and 28th, and also June 3rd and 4th. Note that the fellows will automatically be registered for free for the series, and that will be accessible through the LMS. DME credits will be offered for these. Thank you, everyone. Good night. Thank you. Thank you. Thanks again.

webinar

Hip Preservation Surgery Complex Cases

Dr. Benjamin Dome

Dr. Benton Emblom

American Hip Institute

orthopedic surgeon

sports medicine specialist

arthroscopy

labral reconstructions

femoroplasty procedures