Welcome to the Multi-Institutional Sports Medicine Fellows Conference. Please keep your computers muted for now. This is being recorded and will be transferred to the OSSM playbook on the website and will be on the learning management system and available next week. If you have any questions, submit on the chat function and I'll ask at the end and also for faculty, I'll unmute you at the end. We had a last minute change in lectures for today and unfortunately Dr. Spindler was unable to make it. So I'm going to go ahead and give my talk which was scheduled for May 27th and Dr. Spindler will be giving his talk on May 27th instead. So if you were here to learn about registries in your practice, come back on May 27th for that. Instead you'll hear about hip arthroscopy and hip instability and hopefully you'll get something from this. So I'm going to be talking about the evaluation management of hip instability. Particularly it's kind of much more common I think than most people recognize or realize but I think the more you look for it, the more I think you'll see it. As far as information, basically a lot of what I'm going to be talking about came out in January of last year in the Yellow Journal. I wrote a review on the micro instability of the hip gaining acceptance and a lot of this stuff will be there but here we'll be able to show you some videos and some other information. So first the issue is how do we define instability about the hip and so certainly when you have individuals that are loose jointed like this, you know, they're loose but are not necessarily symptomatic. So just like in the shoulder, we talked about laxity and we talked about symptomatic laxity and instability is really symptomatic laxity. And again, hip micro instability is being recognized more and more frequently. More recently I think it's been identified as really a true cause of hip pain and originally I started identifying this by looking at people that had normal bony anatomy but still were having symptoms that was really with intraarticular injection with anesthetic. And if we looked at this more and more and looked at these individuals in the operating room, we started to identify patterns and when you look back at the original research about people with labral tears that were symptomatic, about 87% have bony abnormalities like dysplasia or FAI. So where's that other 13% and I think a lot of those people have micro instability. And so the key to being able to treat hip instability is being able to make the diagnosis. And so I'm going to review the latest clinical and imaging clues for hip instability, discuss some of the arthroscopic findings that we seem to correlate with hip instability that help you recognize it if you didn't recognize it ahead of time that you'd recognize in the operating room and then talk a little about management and what we found. Now the first thing to understand is that I'm not talking about dislocations and it used to be said that you couldn't have hip instability if you didn't have dislocation and the same thing was said in the shoulder but that's not really not true. And so the key first for people that have when you're seeing somebody with hip instability, oftentimes they don't have a history of injury though we have seen about a third of patients have will have had some sort of traumatic episode that might have set it off but minor. But certainly if they're diagnosed with something like Ehlers-Danlos syndrome or benign hypermobility syndrome or dysplasia certainly those would be some clues of people that might have soft tissue related instability again with or without dysplasia. Rarely do the people with instability actually complain of instability. They generally complain of hip pain and so when you evaluate them we generally do Baton signs to see about their generalized ligamentous laxity but just like in the shoulder the Baton signs don't seem to correlate with instability. You'll have a lot of individuals that have positive Baton signs that usually we use five out of nine as our cutoff but that doesn't seem to correlate with whether or not somebody has hip instability. A lot of people like to use the so-called Faber test where they're in the flexion abduction external rotation but when you look at this guy the question is is his left hip tight or is his right hip loose? Certainly the thing we look for is asymmetry and again trying to figure out if one is looser or tighter is hard to know but one of the things that I get a clue on when I examine people with doing the Faber test is if their lateral joint line of the knee is less than one fist from the table itself. So when you look at this young lady here her left hip in the Faber position or left knee in the Faber position is more than one of my fist heights from the table whereas on the other side or symptomatic side you can see she goes down further closer to the joint line itself. Sorry let me get out of the sound here for a second. Excuse me for one second and trying to not have the sound for this but so some people talk about the log roll test and in the log roll test you lay the patient supine you let you bring the foot internally rotate and you watch it roll outwards. Here again that was a young lady with her Faber being different between her left and her right leg you can see both her feet tend to externally rotate pretty significantly the right one more so than left and that's a sign of the iliofemoral ligament being a little bit more lax on her right hip than on the left. Also what you see with the Faber position. A test that Carlos Guanche showed me is the abduction extension external rotation test where he abducts the hip he extends it he externally rotates and puts an anteriorly directed force on the greater trochanter to push the hip forward and individuals that have pain will have pain anteriorly. In a study that we did with Daniel Hoppe who was a fellow here we looked at sensitivity and specificity of the different tests for instability and what we found that this was the most accurate test. The sensitivity was 81% and the specificity was 89%. The prone external rotation test Ben Dohm describes the patient is prone their hip is externally rotated he puts an anteriorly directed force on the greater trochanter here. Again if this causes pain anteriorly you'd suspect that they might have some anterior instability as well. This test was very low sensitivity but very high specificity if patients had this test positive they're very likely to have intraoperative diagnosis of laxity of the hip. Then the hyperextension external rotation test the patient's at the very end of the table and I would really stress that they really need to be at the far end so that their thigh is allowed to extend beyond the end of the table. They use the other leg to help lock the pelvis in place and then you externally rotate. I'll run this again they're locking the pelvis in place the hip is at the far end they're extended and then you externally rotate. If that causes pain anteriorly that is also suggestive of some anterior instability. If they have pain posteriorly they might have some posterior impingement. When we looked at ours this was number two in sensitivity and specificity with a specificity of up to 85%. Some people have talked about like an apprehension relocation maneuver where somebody else will put a posteriorly directed force on the humeral head when you're externally rotating the leg to see if that relieves the pain but I haven't found that to be particularly useful. What we did find though is that if we run this video, the video is not running, basically if all three tests are positive patients had greater than 95% likelihood of intraoperative diagnosis of instability and actually if two of the tests were positive they had a 93% likelihood of having an intraoperative diagnosis of instability. The key is that when you externally rotate the humeral head comes forward when you extend the humeral head comes forward and then if you apply an anteriorly directed force the head will come forward. So any of those things are causing some anteriorly directed force which is what we see with micro instability. Steve Aoki talks about his axial distraction test that he does in clinic and here the patient is supine you can see my knee is under his ischium trying to help stabilize the pelvis if you will. The hip is flexed a bit it's slightly abducted and an anteriorly directed force in the proximal tibia is applied to basically kind of shuck the hip or distract the hip and you will feel some laxity and patients may complain of some discomfort and instability as well and this is his go-to test. Certainly I also do a posterior apprehension test though most of my athletes that have instability don't really have much posterior apprehension it tends to be more of an anterior apprehension that they have but you do the posterior apprehension test as described with and how people would normally dislocate the hip so you flex you adduct you internally rotate and you put a posteriorly directed force on the hip and again their pain should be felt more posteriorly. This is also the obviously flexion adduction internal rotation is the position of impingement of the hip so anterior pain I don't think is necessarily an issue here. And then recently Costas Economopoulos in Arizona talks about what he called the pull test and we kind of talked about doing a similar thing in the operating room but basically he's quantified it where he has the patient asleep on the operating room table he applies a axial force and found that a distraction length of more than 1.3 centimeters with just using body weight traction had a sensitivity of 94% specificity of 96% of instability so that it's positive predictive value was 97, 91% negative predictive value 97%. So again laxity in the operating room when the patient was asleep is consistent with patients with instability as well. Radiographically I think there's a lot of clues that you can get for having instability of the hip. Obviously you want to look for dysplasia and so most people use the cut off of 25 degrees on the center of jangle where you have a true AP of the pelvis. I think getting a Lecunier viewed for looking at anterior under coverage is also important and then a high tonus angle greater than 10 degrees is consistent with instability and so this is the problem is it and McGlinchey is shown very nicely in some work as well this is a three-dimensional problem it's not a two-dimensional problem so just looking at an AP pelvis at just center edge angle or even a tonus angle are probably not enough to really assess true dysplasia and where I've seen a lot of people get in trouble is seeing they'll see a cam lesion on the femoral head not recognize that there may be a high tonus angle or low center edge angle or even more is that they'll see a regular center edge angle but the anterior wall is deficient and they do a bit of an acetabuloplasty and the patient becomes unstable and dislocates post-operatively. Some of the other things that we see is excessive femoral and acetabular anteversion so seeing a high anterior wall if you see here and this is a cut down view of an AP pelvis but you can see there's the anterior wall here just barely covering over the femoral head and that would be very much a concern. Excessive coxa velga, a narrow iliac wing and wide obturator foramen are all signs that you may be dealing with other other degrees of dysplasia. We describe the so-called cliff sign and this was published in 2018 where we look if you look at the femoral head it comes out around and these are people that haven't had surgery before and so we describe it as a cliff sign because it comes around and drops off like a cliff and we don't know why it comes off as a cliff. If you look at sorry the here we go here's some more examples of the cliff sign where the ball comes out around and just drops right off and here you can even see on this patient this is not a post-operative patient you look at this lateral cross table lateral view and again the femoral head just drops right off like a cliff. We tried different ways to quantify cliff signs and did not find those to be useful but when you see it you know it and so when we looked at cliff signs versus and went back and looking at patients that I operated on with and without instability that had cliff signs the ones that had a cliff sign 89% had instability diagnosed intraoperatively those that had cliffs and 27% of those that had cliff sign had no evidence of instability intraoperatively. When you look at instability in patients with and without cliff sign again 74% of patients that had instability intraoperatively had a cliff sign whereas only 7% of those that had instability had no cliff sign. So what we found particularly useful is women under the age of 32 all of them that were under the age of 32 with cliff signs had capsular laxity or easily distractible in surgery. The inter-observer reliability is we had several fellows and residents look at this we had three and in this one study we did 96 patients we had three raters so all three of the fellows the presence of a cliff sign was agreed upon in 0.81 so a high correlation and high inter-observer reliability. As I said when we looked at different ways to measure this we didn't really find any one way was best but Jonathan Packer who was our fellow at the time that was leading this project looked at patients and tried to quantify what he called the cliff angle so he drew a sphere around the femoral head a best fit sphere and looked at where the cliff or where the ball came out of round inside the sphere and then went back to it and that angle the so-called cliff angle he found that a cliff angle of greater than 45 what was more likely to have instability but again it was just a small number of patients. Other clues looking for distal sclerosis further down than what you normally would expect with impingement that this could be hypermobility impingement and also potentially related to impingement along the AIIS so trying to differentiate between low AIIS causing impingement and hypermobility impingement so you'll see this sometimes in your dancers figure skaters and synchronized swimmers who may be loose relatively loose jointed and are able to do the splits and cause impingement in that way. Josh Harris described the so-called splits radiograph where he has the patients doing the splits while taking an AP pelvis x-ray while they're sitting upright they're doing the splits their legs are in external rotation so this shows that actually an internal rotation but he also has an external rotation and he found that they can impinge the greater trochanter on the posterior acetabular rim in this position and what he found is that a fair number of these people will have femoral head subluxation or also what he describes as a vacuum sign which is like you'd see when you're applying traction on patients before you relieve the negative intra-articular pressure and so this is from Josh Harris's paper and you can show see the patient regular AP pelvis and then doing the splits and what they found was you have the vacuum sign well you see the subluxation of the femoral head relative to the acetabular so the wide medial clear space as well as the vacuum looking at 47 professional ballet dancers 89% had femoral head subluxation 36% had the vacuum sign and that those that had an increased alpha angle particularly had the vacuum sign and the subluxation and men had an increase of this displacement and the positive signs of instability when they had associated dysplasia. Their average subluxation in these asymptomatic dancers was 1.4 millimeters and so when we published research back in presented research back in 2008 talking about how the femoral head moves relative to the acetabulum when we're told well that doesn't generally happen in asymptomatic individuals and that the femoral head is a ball and socket joint this work by Josh shows that clearly that the femoral head can sublux and same thing with the work done by Jacques Menetre in Switzerland looking at professional ballet dancers where they showed if you do splits forward splits compared to a supine MRI that the femoral head can sublux almost two millimeters relative to the acetabulum. John Sakia's group at the University of Michigan looked at patients with instability and they looked at a couple of particular signs on MRI to help give clues to instability. One was what they call the wide anterior hip joint recess and this is on an axial MRI cut looking at the this area lateral to the zona obicularis that's pointed out here with the with the arrow. What they did with their arthrogram was they'd inject fluid until the patients felt uncomfortable. On average it was about 15 cc's of fluid. They also looked at the thinning of the capsule in that same area and they found that if the capsule is less than three millimeters or if the joint recess was greater than five that that was consistent with instability and so we tried to replicate that study and but we only give about 11 cc's of fluid on a regular basis and so that may be different for somebody who's 4'11 versus somebody who's 6'5 and so it doesn't stress the capsule or the joint as much as they did and so to no surprise we didn't find that that area recess was consistent with the instability but this paper did just get accepted by the Journal of Hip Preservation Surgery that we found that with women that had laxity 85 percent had a capsule thickness of less than three millimeters of the women that didn't have laxity 40 only 45 percent so just less than half had capsular thickness of less than three millimeters and if you take it from the other standpoint if you're looking at a capsule that's less than three three millimeters thick 82 percent of the women had laxity and if it was more than three three millimeters thick 40 percent of the women had laxity. We didn't find that this correlated for men just with the women. Some other clues you can get that somebody might have some instability so this is a post-op patient of somebody that had a capsulotomy to add with that was not repaired for a hip arthroscopy and you can see capsular defect may be a clue this obviously is more in the lateral zone of the of the hip where you don't have the autonomous areas for the hip capsular ligaments but certainly it will and we'll talk about this if you do an interportal capsulotomy you cut right through the iliofemoral ligament and if that's and you'll see that on on your sagittal views or your axial views where the where your defect is more in the anterior part of the hip and so that can be a clue but here this is just on this one cut you can see clearly the capsular defect. The other clue on patients that may not have had surgery is that oftentimes the ligament materials will also be torn in instability patients as well. Martin Beck described the so-called fear index and what he looked at the FE stands for femoral epiphysis or basically the ficial scar in the femoral epiphysis and he looks at the acetabular roof AR is the acetabular roof at an angle between the line up for the acetabular roof or tonus angle or the line that you'd make for the tonus angle or looking at your roof angle versus the ficial angle and so he's looking at acetabular inclination versus the ficial scar and he used the MRI as where you'd see an accumulation of gadolinium in the posterior joint as being patients that have instability and he was doing this in patients with borderline dysplasia to see which had hip impingement type of pain versus hip instability pain. They also used extrusion of the femoral head on radiographs and broken shenton's lines as signs of instability as well and so what they did is they drew this line of the acetabular roof and joined it to the line of the femoral epiphysis and would identify this angle and basically if it was a positive angle you could expect the roof is steeper and might be more likely to have instability and so when they compared when they looked at the lateral center jangle and the acetabular inclination they found that there was a high inter and intra-observable reliability and that they found that if you have a fear index of less than five that's a flatter roof then you had a 79% probability of correctly assigning the hips as being stable and therefore greater than five they considered consistent with instability. So if you had a painful hip with a center edge angle of less than 25 and a fear index of less than five that you can think that they're that you can think that they're more likely to be stable. So we actually confirmed this study and published this last year in AJSM, looking at patients with instability, whether or not they had dysplasia or not, and also found that the fear index does seem to correlate for those that have instability versus stability, when you compare it to patients with FAI that don't have instability or patients have other causes of hip pain. But we didn't – the 5 degrees was not our cutoff, but it does seem to have a correlation with the higher degrees of the fear index being more associated with instability. So our management of hip instability, you have operative and non-operative. Similar to shoulder instability, we start off with non-operative management. We try to strengthen periarticular musculature, particularly the hip and the core, and activity modification. And we looked at a series of 64 patients, 63 of which were females that had instability. Their average age was 18 to – was 32 – they were 18 to 53. The one male was a professional ballet dancer. Seventy percent of these individuals complained of insidious onset of hip pain, so no trauma. The symptoms, on average, were just about 2 years before coming to see me. We sent them for formal physical therapy and a home exercise program for a minimum of 6 weeks, working on hip and core strengthening, and a follow-up of a minimum of 2 years. On average, the follow-up was close to 4 years. And we've submitted this for publication, but what we found is that 35 percent basically said they had marked improvement and basically were asymptomatic, 16 percent had partial improvement, 19 percent said they didn't really improve but they weren't bad enough to want to undergo surgery, and 30 percent actually underwent surgery for capsular placation. What we found is that if you're an athlete, you're more likely to have surgery for instability compared to the non-athletes. But surprisingly, then, 70 percent were able to avoid surgery with rehab, and in all reality, a bit more than half definitely had improvement, though. As far as how else to manage instability of the hip, it really depends on what the cause is, and you want to address the root cause. It's not just one stop shop, one operation to take care of all the different causes of instability. And so if they have a bony problem, like market dysplasia or market femoral aversion problems, those are managed with bony operations. If they have atraumatic micro-instability, that's a different matter altogether, and if it's iatrogenic, then you want to manage the capsular defect. And so, again, it comes down to identifying what the underlying cause is, and this comes from Josh Harris's paper in 2016, looking at all the different contributors to micro-instability. And again, you want to make sure with your checklist to identify all the different potential causes so that you can try to manage it appropriately. And so, again, if the problem is a bony deficiency, like market dysplasia, then a PAO is the answer. If it's an excessive femoral aversion problem, then we'll do a femoral osteotomy, derotational osteotomy. So then if you look at the other causes, if you had somebody that had an acute injury, the things that you're going to see arthroscopically that correlate with it, you'll sometimes see chondral damage on the central aspect of the femoral head. You'll oftentimes see a Bankart equivalent, if you will, or even sometimes a bony Bankart equivalent. So sometimes you'll see some bone off the posterior acetabular rim. And what you'll see anteriorly is the iliofemoral ligament can be torn. So your head is going to be bouncing off the back of the acetabulum. So this is, again, with more of an acute type of injury. You'll see the bony Bankart, or just a Bankart type of equivalent. The ligamentaries will be torn, and there's your iliofemoral ligament. The types of people that I see this in, I've got a series of patients where they were trying to stop short while running. I've had a couple tennis players, but oftentimes people wearing cleats, their legs in front of them, they're extended, they're trying to stop short, their flex at the hip, and then they feel something go in their hip a little bit. But not a true dislocation. I've had some that came to me after two, three months of persistent symptoms after an acute episode like this. And so arthroscopically, sorry, my video's not running, arthroscopically, you'll see chondral damage of the central aspect of the femoral head, as I mentioned, as well as the posterior labrum. I'll see if I can show this video when we're done. You may see the anatomy of FAI with this, and this comes from several papers, and Brian Kelly was first to kind of alert me of this, where basically we talk about the pincer anatomy being where the femoral head and neck junction will lever against the acetabulum and cause a contra-coup injury, but the CAM lesion can also lever against the acetabulum, and that can also produce subluxation or dislocation. And when you look at elite athletes that had a subluxation or dislocation, they frequently will have CAM or pincer lesions, and you look in the literature, it's between 64% and 82% of the time in the series that I've published on this. As far as what is the outcomes for traumatic subluxation in athletes and surgical management, there's really no data on this. This is actually, looking from a posterior lateral portal, the femoral head is up here, this is the acetabulum, and you can see the tearing of the posterior lateral labrum from the edge of the acetabulum, and this was actually a collegiate tennis player that came to me after trying to stop short so he didn't run into the net, and then we did, this is looking from the anterior lateral portal, looking down, and we were able to do a primary repair of this labral injury to the posterior lateral acetabulum. Capsular laxity, this is probably the most common scenario of instability patients that have. They tend to be individuals that are involved in laxity types of activities or sports. Again, you can have individuals that have underlying collagen disorders, either true Ehlers-Danlos or benign hypermobility, but it can come from repetitive microtrauma. Your dancers are always trying to get increased turnout, if you want to call it that, which stresses the iliofemoral ligament, so the repetitive microtrauma can lead to stretching out of the iliofemoral ligament. You can get at the residuals of dislocation, somebody who's injured the iliofemoral ligament in a dislocation, an anterior dislocation that healed in a stressed position, and again, you can see it in dysplasia, so you can get some laxity with the bony deficiencies. You put more stress on the soft tissues and they stretch out over time. What I find intraoperatively, these individuals are really easy to distract. It depends on the table you use. The tables that I have used over the last 15 years, it's been 10 or 11 turns on the table to get more than 8 millimeters of distraction of the femoral head relative to the acetabulum. Here's a woman that came to me with, again, relatively normal bony anatomy, put her to sleep on the fracture table, we pulled on her leg to make sure that her perineum was down against the perineal post, brought the fluoroscopy in to center it before we started to apply fine traction, and you can already see that her femoral head is subluxed a little bit away from the acetabulum, about 2-3 millimeters of space. Then as we remove the negative intraarticular pressure, just a practice for the fellows to get access to the standard anterior lateral portal, we did here, you can see the arthrogram, then what we do is we generally take the traction off, so here she's got just with body weight, here the next one is with the traction applied, after I move the arthrogram, and then you look at the far right, now we've taken off the traction, the fine traction, and you can see the femoral head is really subluxated still laterally, and that's another clue that they may have some excessive laxity. The issue is that with repetitive motion of the femoral head relative to the acetabulum, you start to get this breakdown at the labral chondral junction, and you'll get some wearing of the acetabular articular cartilage at the rim, and it's more of an inside-out wear pattern as opposed to an impingement type where you're getting the delamination from the femoral head-neck junction abutting against the acetabulum. And so what you see arthroscopically, you have a labral tear at the labral chondral junction, generally it's at straight anterior, so this is the so-called psoas-u here, and you can see just lateral to the psoas-u, this is looking for my pustular portal, you can see clear damage of the labrum straight anteriorly between 2 and 3 o'clock. You can also, when you clear that away, there's inside-out wear pattern on the acetabular rim also about 3 o'clock, or straight laterally at 12 o'clock. So this is another kid, this was a baseball player that was having some hip pain, they actually had a slightly high tonus angle, about 12 degrees, and so this is looking from the posterior lateral portal, this cannula is at the anterior lateral portal, that's my probe, and you can see this inside-out just wearing down of the articular cartilage straight laterally at about 12 o'clock. We can see on the femoral head the chondral damage at the central area of the femoral head, so this was a former collegiate gymnast, and you can see the wear at the central femoral head, oftentimes some pulling off with the ligamentum teres and near the ligament teres, and this was actually just the torn ligamentum teres, more of an acute type of tear of the ligamentum teres in actually another gymnast. So how do you manage this? You know, in the old days, people would try to do thermal capsulography, and you can see this is a very capacious peripheral compartment, and I'm just using a thermal wand, this is from 2001, but you can see how this just tightens down the capsule, and as opposed to painting the entire capsule like you did in the shoulder, like some people used to do in the shoulder, this here, we did it in stripes, with the capsule being thicker as well, I don't think you had as much of the necrosis like you had in the shoulder, but because of the concern of thermal entry to the capsule, we went to plication. Here Mark Filippondo first talked about thermal tightening of the hip, but then Bendome published his work on what he called the inferior capsular shift, where he took his interportal capsulotomy and tightened up the capsule and tightened up the ligaments for this, and then Chris Larson published his series as well of Ehlers-Danlos patients, where he basically closed and tightened the capsule to help with the instability. So interestingly, Filippondo's papers, we don't have as much data on the patients, there was just a handful of patients, Bendome had a pretty good number of patients, but about 40% had some bony work done with the plication, and Chris Larson, so about 96% of his patients had CAM work in addition, and bony work in addition to the capsular plication, so it's hard to know whether it's just the capsular plication or some of the other stuff that is why the patients did well, but overall, greater than 80% good, excellent results in all these different series of capsular tightening. Mike Calzart, who was one of our fellows a number of years ago, and I had talked about publishing my data on capsular plication, and I was reluctant to do so initially, and after we agreed that we would do it, it still took three to four years to get it published, because a lot of people had a hard time accepting the fact that instability of the hip can occur without dislocation, but we had 32 patients, all were women, the average age was 27, these patients just had plication and labral work, no bony work done, 29% had center of jangle of less than 25, and 45% had a tonus angle of greater than 10, so depending on how you wanted to define borderline dysplasia, it was somewhere between a third and nearly half. All the patients had improved, there were no reoperations, no increased symptoms, no loss of motion, and I bring that point up because in Bendome series, the patients had loss of external rotation of about 10 degrees, and for your dancers, if you lose 10 degrees of external rotation, I think that can be a big issue, and so what we did was we worked in an area, what I call the rotator interval of the hip itself, between the ilio-initio-femoral ligament, it's straight lateral, and it kind of tightens them both up, and what we found is that all our athletes were able to return to college and professional sports, even those with the mild dysplasia, and so here, what we did was we took out a piece of the capsule between the ilio-femoral ligament and ischio-femoral ligament, and then we basically just tightened up and closed up that interval, tightening both of the ischio- and ilio-femoral ligaments, and then the last cause of instability I see frequently in my practice is the itrogenic. When you look at people who do inter-portal capsulotomies or T-capsulotomies, when you join the anterior and anterolateral portals, you have to cut the ilio-femoral ligament if you're joining them completely, and you can do a T-capsulotomy, go down the ilio-femoral ligament further as well, but what we show, this is with Jessica Talaria, who was a medical student here, that if you look at the acetabulum on the left is schematic, on the right is actually from one of the cadavers, 6 o'clock position being straight down, 12 o'clock straight lateral, 3 o'clock straight anterior, what we found is that these needles would be where the anterolateral and straight anterior portals would be coming in in the hip, and between them is the ilio-femoral ligament, as seen outlined here, and that's where the ischio-femoral ligament is, between the posterolateral portal and all the way posterior medially, and then there's your pubofemoral ligament, and if you cut the ilio-femoral ligament by joining between the anterior and anterolateral portals, you have to essentially cut the entire ilio-femoral ligament, and so here's a case that I took care of of a patient that was having pain after having had a hip scope somewhere else, you can see there's the labrum, there's the femoral head, there's the capsule, that's the iliopsoas, not a normal view of the iliopsoas from the posterolateral portal, and that's because the capsule defect, the trans-portal or inter-portal capsulotomy did not heal, and so again, you see these in various cases, and when you look, though, from Shane Ngo's series, they look at patients that have failed arthroscopic surgery, Shane Ngo found that 70% of his patients on MRI had some capsular defects and ilio-femoral ligament defects, so Alex Weber looked at another series of Shane Ngo's patients, and they were FAI patients with T-capsulotomies that did undergo routine capsular closure, and these individuals that he operated on still had some symptoms, and about 7.5% had a capsular defect in spite of him closing them at the time of surgery. I think that partly depends on how aggressive you are with your motion and what position, post-operatively, in what position you close the capsule. So this actually, none of my videos are running, so I apologize, but this basically was that patient with the capsular defect from the inter-portal capsulotomy, and I put a couple of anchors in the supracetabular region to repair the capsule back down, not repairing it to the labrum, you want to keep the labrum separate from the capsule itself. And then finally, Steve Aoki looked at his series of 1,100 patients, 33 of his patients developed some instability post-op, including two dislocations, and these are all people that he did inter-portal capsulotomies on, but did not repair initially. So he went back, did a revision arthroscopy, did a capsular closure, and all his patients approved of the revision, regardless of whether or not he did additional procedures to the capsular repair or not. And I think if you have an irreparable capsular defect, I think capsular reconstruction is the way to go. Mark Philippon talks about using an IT band allograft, I tend to use a dermal allograft, but in Mark's study in the lab in Vail, it showed improved distraction stability when you do a reconstruction of the capsule to fill the defect. I think clinically he tends to use autograft, and again, I tend to use dermal allograft. So this is a professional tennis player that had had several hip arthroscopies, and one prior to her seeing me, she had had a revision with a dermal allograft and capsular reconstruction, and you can see that this didn't heal at the suture line, so there's her femoral head, that's the native capsule, that's the allograft capsule. And so we went ahead and closed that up. So I think hip microstability is real, we're better able to, I think, diagnose these people and this problem preoperatively by examination. I think radiographs are giving us more and more clues, MRIs, more clues, and I think that just people can have instability without having dysplasia, or at least down low syndromes, though we see it in that group as well. So you just got to be alert to it. The vast majority tend to be in women. The issue about managing them is if you want to treat the underlying cause, start with rehab. All the capsular placation studies report excellent results of greater than 80%, but we still need more data to identify how loose they are preoperatively, how tight we're making them intraoperatively, and how tight they are postoperatively, and what are the best techniques to placate. And I thank you all for your attention, and I'm sorry this isn't the registry talk. So I'm going to unmute some folks here. Hold on, there's, let me, I'm having trouble with, there we go. So I'm going to unmute folks, and if you guys have any questions, please don't hesitate to ask. Let's see, Latul, you're unmuted, I think. Yeah. Mark, that was a phenomenal talk, and it amazes me, because I think back to my residency, which I started in 2002, and there was like no mention of like hip pathology at all. And the amount of knowledge that we've gained in the past, you know, 20 years on this joint is absolutely amazing. I definitely think this is a real thing. I see these in a lot of my patients who, I'm also seeing for patellofemoral instability, because I think they have a lot of the same issues with respect to joint laxity, and we're seeing, you know, a subset of patients who are subsequently being seen for hip pathology after I've seen them for their knee pathology, so I think there's definitely a lot of links to that, and I think you gave us some tools to kind of identify, you know, some of these things in our efforts and our patients. Yeah, I think the hip, you know, I always joke that the hip is, the shoulder's just a really just plastic hip, so we take a lot of what we learned in the shoulder, and we apply it to the hip, but as Ben Ma sitting there kind of just wondering about that one, we're going to ponder that. Winston, you have some thoughts about instability of the hip, and again, if there's any questions. Yeah, Mark, that was awesome. You know, I think that every time I cut the ortho-roling, when I think about you, and I think about what you tell me about you cut the ACL when you do a knee scope, and I'm like, well, no, but I think for me getting that view, but I also think that you can utilize interpol cut to get some tightening of the capsule, or even making a T-cut to get some tightening of the capsule, sort of the way you showed that in the capsule ortho. But I still think that, when I trained with Dr. Bird, and when we were doing these back in 2012, we were making a pretty large capsule, it was a capsulectomy, and I certainly think the evolution in the past five years has been to protect the capsule at all costs, especially with these people with instability. I think that's the cause of hip pain. No, and it's funny, because when I was, you know, I saw some videos from Tom Sampson and Jim Glick back, you know, in the late 1990s, early 2000, and they were very aggressive about doing capsular resection, and then I ended up having a patient that had some symptoms from that, had some symptoms that we thought was related to instability, and Tom Bird and I and some others spoke about it, and found that, you know, it's probably instability, the capsule generally will heal in, but it's the more we look into it, I think it's a bigger and bigger issue, and it's one of those things, if you don't look for it, you don't see it. As they say, the eyes don't see what the mind doesn't know, and I think we're starting to be more and more respectful, I think, of the capsule, and again, I think it's a bigger problem than what we realized, and the thing I don't know is that what's going to happen down the road 20 years from now with the excessive femoral head motion relative to the acetabulum, I'm not, I'm still not, and I know I'm clearly in the minority about not doing interportal capsulotomies, I think 95% of people who do hip arthroscopy do interportal capsulotomies, and do a two-portal approach, and it's easier for them to see, but I always think about it, I kind of joke that, you know, for a meniscal root repair, a lot of times when you're doing a meniscal root repair, you're struggling to, you know, because the ACL's in your way, and so do you cut the ACL to get to the root repair, do your root repair, because it's much easier that way, and then repair the ACL again? We know that doesn't work. So my brother would suggest that you cut the MCL. Well, that's another thing. The question is, why would you cut the iliofemoral ligament, which may or may not heal, and even if it does heal, will it restore its function? And so, I've gone to the point where I just, I try not to touch it if I can avoid it, but again, I know I'm clearly in the minority about it, so. I think that interporeal cut, I think a lot of times it doesn't heal, you know, I think people try to justify doing the interporeal cut saying that it heals, but holy smokes, how many MRIs have you seen with that big capsular defect, with someone who clearly has instability-type symptoms, and you go in there and you close that defect, and they do just fine, so I think that it is a big, big part of it, and I think iatrogenic micro-instability is probably the biggest, the biggest bad actor here, so I'm always careful with it. Yeah, I don't know if the, you know, when I see people that have instability, and they said, oh, well, you know, they had surgery, they had their hip scope, and they're no better, and when I examined them, they were having instability, the question is, was the instability there before, or was it just that they're now, now their hip pain is related to instability before it was impingement, I don't know, you know, I, but that's what gets me always concerned, if you will. My question for you, Mark, is, doing those capsuloraphys, in these instability situations, you know, in this borderline dysplastic, do you think that soft tissue work can, can solve a, basically a bony problem, or, or a, you know, bony instability? Yeah, so, I think there's a couple ways to look at it, I, I don't, you know, I think I have an upper limit, if the tonus angle is greater than 16, if the acetabular inclination is greater than 16, I can't make that better, that is a bad biomechanical environment, if the center of jingles less than 17, or less than 18, rather, 17 or less, again, I, I worry that I can't make that better, but what I was, you know, it's interesting, when I first started out doing borderline dysplastic patients, it was mostly because Ben Ma's partner over there, Mohammed Diab, every time I'd send him somebody for a PAO with the center of jingles of 22, he'd say, oh, that's, that's not bad enough to require PAO, you could do something with the scope, and then I'd do something with the scope, and then it would be 20 degrees, and he kept pushing me, but there comes a point where I said, I just can't do that anymore, I can't risk that, and we found that the results from 17 to 25 were actually the same as the other people, and when we looked at it, we've been looking at our five-year results, and they've held up over five years, because I worry that, you know, will they stretch out? I don't know what the long-term is, but you offer to the patients, hey, I, you know, I don't know how long this will last, and, and, you know, it's a 20-year-old female, they'd rather have a scope plication than a, than a PAO, and more often than not, so I think there's, you know, dysplasia is a complex three-dimensional problem, and it's not just about lateral center of jingle, and it's not just about a tonus angle, the anterior coverage, you know, the volumetric, you know, the volume of the acetabulum itself, all those things, I think we're going to get smarter about how to classify dysplasia, and, and true support, and, and from that, we'll probably be able to be better about figuring out who we should not even bother doing a scope on, and be doing, doing a more definitive bony operation, so. Alexander Brown, Dr. Stafford, thank you for your talk. What tactic do, do you suggest for creating working space in the hip if you don't cut the ilioformer ligament with an interportal capsulotomy? So that's a great question, and so I do a couple things a little bit different, Alexander. I, first of all, I don't do the, my peripheral compartment work inflection, which also takes some, opens up the anterior peripheral compartment, because I think when we're doing CAM work, I find it's easier to keep the femur parallel to the ground, and that way you're not, my fellows and the residents aren't getting as disoriented dealing with divergent rays from the, from the fluoroscopy, and then now, you know, dealing with obliquity of the femur relative to the ground, but what I do do is, as I was talking about, I take, I take out a part of the capsule straight laterally, and that's where I do my placation. I take it out straight laterally between the ilio-initio-femoral ligament, and from that, I can use my, my shaver and my burr to lift up the, and see the whole anterior femoral neck, and what we do then is, if I'm going to be doing like a camera section in that, we, I will have the fellow or resident, once we've done most of the basic work for the camera section, take the foot out of traction, flex the hip up externally and internally rotate so I can get to the whole femoral neck, watch for dynamic assessment for impingement itself, and then, and then when we're done, if I need to, I close that capsule up right there, and again, I don't worry about losing motion because it's not directly tightening up that ligament itself, and it does seem to help tighten up more in the rotator interval, so that's how I've done it. The other thing you can do, there's a nifty device that Mike Gerhardt came up with that a company called Medacta just released in this country, and basically, it's a percutaneous type of device that punctures essentially into the, through the skin down into the capsule, and then it's got this like flip switch on it, and it, and outside the skin, it's got this plastic kind of star-shaped device, and it ratchets up so that you can pull the capsule up away from the femoral neck towards the skin and hold it there without it being in your way, so that's another way, if you need it to have access and increase space in the peripheral compartment, that you can do that without doing, and it's kind of, I think he did that as an alternative to putting in some traction stitches in the capsule itself to help keep it out of the way. There any other questions? Ben, oh, sorry, Ben, I thought you were on mute, you're unmuted. Did you mute yourself? No, there you go. I muted myself over there, so, well, I have to say that I learned a lot, you know, about the hip over there, even though I don't do any hip surgeries, you know, I do mostly, you know, shoulder and knee surgery, but it's always kind of fun to hear about this, so, so Mark, you know, I, you know, I think I, as you mentioned earlier, the hip and shoulder are very similar, instability is something that is very common in shoulder, and the same with rotator cuff tendon injury, in the hip right now, there's some, you know, muscle injuries also, you know, some of our partners are doing these label reconstruction, also capsule reconstruction, maybe share with us your thoughts about these, you know, tissue you bring in, how do they remodel, how do they get vascularized, because obviously in the shoulder world, we try to do a lot of, you know, capsule reconstruction in the shoulder with, you know, allograft tissue, it just doesn't work that well, what are your thoughts about those? Yeah. Yeah, so there's not enough volume, I don't think people have done enough capsule reconstructions, unfortunately, for us to really have any long-term, you know, outcomes, as I said though, you know, I've only done a couple of capsule reconstructions, and we had that one particularly that had, that was done elsewhere that hadn't healed along one of its suture lines that I had to try to repair, but it does seem that the label reconstructions do tend to revascularize and do tend to heal, Mark Philippon's had some second looks, some biopsies that he's shown with that, and so, you know, I don't, I think the whole thing about labor reconstruction is a whole other topic, I mean, I do it in patients that have borderline dysplasia that are, or have dysplasia that are unstable and an irreparable labral tear, so if they have an irreparable labral tear, rather than me sewing that back up, I think the labrum probably plays an important role for them, and I will do a labral reconstruction, but if somebody has a normal center edge angle, I generally won't do a labral reconstruction, but there's some that, there's some people that prefer, there's a guy in Colorado that prefers to do labral reconstructions, circumferential labral reconstructions, and he thinks they're better than primary labral repairs, but, you know, I'm not that aggressive about it, I don't know, I'm, Rosnick was on, I don't know if he still is, but Winston, are you doing labral reconstructions? I am, using the revision setting, but there's some primary scenarios in which I'll do a labral reconstruction, but I certainly agree the labral functions are being really critical, especially against stability, and so, if I have an irreparable labrum, then I think a graph could probably be better than a repair. I tend to do circumferential, but I'll, I've done a few segmental as well. Do you, how about the labral capsule reconstructions? I haven't done, I haven't done one of those yet. I've had a couple that I've considered for, and I haven't, I've been able to repair it primarily. If I have a really bad capsular problem, I'm pretty close to Chad Mather down at Duke, and he's done some really nifty things with capsular reconstructions. James Rosnick says he's there if you want to unmute him. Is he there? I didn't see him. He was hiding. I'm, I'll take a look. Here we go. Hey, sorry about that. Please. No, no, no, no great wisdom here. I'm along the same long lines of what Winston said, only in the revision situation. I've done a couple primaries, but had to talk myself into it on the reconstruction pathway, and Chris Larson talks about, after a labral debridement, evaluating the actual suction seal, and if that's still present, then patient necessarily doesn't need one if that's what you're trying to restore. Yeah, I mean, I think there's a lot of functions of the labrum, and, you know, we, the seal is certainly one of the things, but I think one of the important functions of the labrum I look at is that it tries, that it's a block to the extrusion of fluid from within the articular cartilage, and I don't know that we ever restore that, but I do think that it helps in the depth of the acetabulum for people that have borderline dysplasia or instability, so I, that's really been my role of doing a labral reconstruction. Again, mostly revision, some primary, the only time primary has been in the borderline is plastics that are having irreparable, irreparable tear. And Dr. Brown said, what suture do you use, absorbable or non-absorbable suture for capture or closure? So, I tend to use a non-absorbable because it tends to, the absorbable ones tend to lose most of their strength in the first couple of weeks, but I think a lot of people, especially when they're doing the interportal capsulotomies or the T-capsulotomies, have gone to using absorbables because sometimes the non-absorbables will irritate as the ileosolis is rubbing right over it, whereas, you know, when I'm doing, where I'm doing it straight off to the side, you know, that's, the ileosolis is not rubbing against it, so I haven't seen any issues with that, but Winston and Jim, you guys want to comment? Or actually, Will Workman's on too. Will wants to comment too. Yeah, I use a non-absorbable. I think it's easier to tie, more reproducible. I usually use number two orthochorum. I'm using some tape lately that I've been happy with, tieable tape. Hey, Mark. Hey, Will. I've been spending the day doing interportal capsulotomies and leaving them open. You're killing me. You're killing me. You know what? Can you hand out my card as they're leaving the recovery room? Well, I know I have you just a few miles away to take care of my problem, so it's not a big deal. I thought it might be helpful for the fellows to get kind of the community guy that does hip scope perspective on things, and, you know, I always learn a ton from you, and instability is kind of a frontier for me, to be honest. I've seen, and I was thinking about, you know, I think your patient population might be a little bit different. I think it's, you probably would see it more in younger athletes, I would say, than, you know, I see kind of more middle-aged. Like the two I had today is a guy, you know, he's probably 45. I did his other hip a few years ago, you know, straight FAI, and then an older woman that had FAI. I haven't had a problem leaving the capsules open, as far as I know. You know, there's the, all the patients don't do great. Some of them still have some anterior hip pain, and I'm not sure why that is, but I do, you know, I do the physical exam test that you showed me. I've closed a couple, you know, I've seen people with instability, closed them, and they've done well, but I've also had problems closing capsules on, like, my FAI patients, and I felt like they had more pain and more tightness, so I'm still not there yet. I don't know. My patients seem to do decently well with leaving the capsule open so far, and I do the interportal capsulotomy. The other thing I want to say is with the labral reconstruction, I have not done one yet. It's not because I don't want to or I'm afraid to. It's kind of the consent thing for me so far. I haven't figured out how to work that in. I don't think I'm really good at evaluating the labrum on MRI when I go in and know whether it's repairable or trashed, and I kind of go back to even when you talked about, back in the old days when you weren't sure about repairing labrums because you weren't sure how to protect them, and the literature that shows that, you know, labrums can heal a little bit, maybe regenerate, so in the cases where they're trashed so far, I've just debrided them and told them that I've had to debride it and see what happens, and then we go back and do a reconstruction later if they need to, and I haven't had to do that yet, but I'd be curious. I think the consent part is part of it for me for labral reconstruction. I'd be curious to know what the faculty thinks about that. Yeah, actually, you brought up a good point. I don't know, and I should be clear, and we can poll, you know, everybody here is about it, is I don't know that every interportal capsulotomy needs to be closed, right? There's a lot of people that have had it with interportal capsulotomy, never had any problems. I don't close all the capsules when I do my capsulotomy, you know, straight laterally. I think people, you know, when you're dealing with your 45-year-old, 200-plus-pound guy with FAI and maybe some mild arthritic change, that person probably doesn't need to be closed because I think they will be made tight, so I think, you know, I don't know, but Winston and Rosnick, do you guys routinely close your interportal capsulotomies? Are you selective, and if you are selective, who are you selecting them on? So I had the fortune of being with Dr. Byrd when he was kind of going through his transition, and he, you know, he would tell me early when I was with him, he was like, look, Winston, for 15 years, I never closed one capsule, people were doing fine, and I was like, I'm starting to close capsulotomy just so I can, like, you know, feel good on the podium sometimes, you know, but he's now doing it a lot more frequently, but what I've been doing is I start off my practice closing maybe half of them. I pretty much close almost 100% of them now. I can't really remember the last one I didn't close except for what Dr. Work was describing, you know, that older patient who I worry about capsular stiffness, and I always think a capsular release in that patient might be kind of part of the therapeutic value of the surgery, just kind of, it's almost like a tight shoulder or something like that, you know, you release that really tight capsule, and you can see their motion improve, and I think that actually could be therapeutic, so that's one that I probably wouldn't close, would be the 45 to 55 year old guy with, you know, a big camera for me that's kind of tight. Dr. Rosnick, do you want to comment on that? He's muted still. Are you still muted, Jeff? There you go. No, there you go. Yeah, so I, it's, yeah, I'm interportal, no T, and I don't ever see the psoas, so I don't really go that far medial, but I am still, I'm closing using UltraBraid number two, and I agree with Winston. I was going to ask you, Mark, when should we not close the capsule, and I think the patient he describes is that, at least that's the decision making I use, kind of that maybe early chondral changes, big cam, but yeah, I can't think of a patient, I mean, I think I maybe didn't close one in the last four months before we went on the COVID hiatus. Yeah, I'm going to close the capsule and stay How many cases have you done in the last six weeks? Zero. I got two on Friday. The thaw is coming. Yeah, I mean, I would, so I, you know, again, I, my approach is a little bit different since I'm not cutting the iliofemoral ligament, but the issue comes down to when do I close my capsulotomy, straight lateral capsulotomy, and when do I close my ulnar ligament, and I think that's a really good question. Yeah, I think that's a really good question. Yeah, but the issue comes down to when do I close my capsulotomy, straight lateral capsulotomy, and I do that in people that if they're not unstable, I'll still close in people that I think might be at risk. So people that have easy distractibility, they may not be unstable, but they have some, you know, borderline dysplasia with a large femoral head, you know, I'll probably, when I do their cam, I'll close that capsule back up so that I don't make them unstable, but, you know, so in my mind, it's, there's got to be a reason to close the capsulotomy as opposed to, you know, I close everybody, and I have to find a reason not to close, but, you know, what it really comes down to, I think you're, Will, you bring up a great point. I think you can make somebody unstable, but, and I think you can also make somebody who's not unstable stiff, and so it's trying to find, like I said, I'll tell you, 90, when we look back at our numbers, it's got, it's 90 plus, like 95 percent plus tend to be female of my instability patients. Yeah. So, you know, and then again, when I'm examining them, if they have that really, you know, the Faber where they can, they can, their knee, their lateral joint line, their knee is really close to the table, you know, that's a, you know, a clue where when we were trying to look at hip range of motion, we didn't find that there was any range of motion that actually was a big predictor, but, you know, somebody's flexing their hip up to 160 degrees when you're testing them supine, they got, you know, 80 degrees of external rotation and 60 degrees of internal rotation, you know, they're just kind of loose jointed, and they got five out of nine or seven out of nine baiting signs. I mean, that's when my, that's when the hair on my neck starts to kind of sit up a bit, and I start to get a little concerned about it, and then when we're in the operating room, how easy is it to distract? And this would be a very interesting thing, because there are guys that are going to postless, you know, type of hip arthroscopy. When you're going postless, I don't know how well you can tell how easy it is to maybe distract. I, you know, I don't know, but for me on my fracture table, I can tell, you know, if I'm just pulling body weight to get them set against the perineal post, and they're already distracted, you know, that tells me this is somebody that I need to be careful of. If I've got somebody that takes 25 turns on my traction table, and I'm worried about the boom on my traction table starting to bend, but that's how much it's taking to distract their hip, I'm not closing that guy up. That's not going to, you know, there doesn't seem to be a need. And again, if they have, you know, we showed that you can have labral regrowth, as we were talking about, and you mentioned earlier, Will, if you, there are people that have labral regrowth, and I think the labrum plays a bigger function in people with a shallower acetabulum than somebody that has, you know, a center edge angle of 40. And if you have a center edge angle of 40, I got to think that that the labrum is not playing a huge role, and I'm less likely to do a labral reconstruction in those individuals if they have an irreparable tear. So that kind of. That may be why I'm getting away with it, because it's more of the, you know, again, it's more the FAI with a, with a, not quite Petrugio, but definitely a deeper, deeper socket. Yeah, I think that that's probably it. I think as we get, as we get more and more savvy about this stuff, we'll be able to be able to identify more, who we should be or shouldn't be. But right now, you know, based on experience, but, and it's, you know, as they say, experience is based on good judgment. Good judgment was based on bad judgment. Amen. Dr. Rothnick, any other last clues of wisdom from, from you? No, I just, one comment about the post list, post list, post list, excuse me, which I've recently gone to, you do not get the same feel that you're describing. Like you, like you said, with the post in terms of the ease of distractibility, at least I haven't figured out that deal yet, but maybe to come. All right, Winston, you got any other words of wisdom? I try post list man, post list is good. I've been doing it, you know, it's young and use like this special table, you can just use a regular table with a pink pad, just put some tree tileboard on. But I do think that all the fellows out there who are watching the capsule and this concept of micro instability is what I was missing my first three years in practice. And I, if I look back on my, my less than optimal outcomes, I think it was missed my grants and building. I really forget. I think it was either voting or hooks. Great. Like what's the deal? It's this concept that the hips still can toggle within the acetabulum. And if you're not seeing that as seeing you, I can promise you that. So good talk, Mark. Yeah, great talk. And I would echo what Winston said. And I would add five years to what he said to his three in terms of the things that you know, your patients that aren't doing well from an open capsule out of me, it probably was seeing me a lot more than I was seeing it. You got some words to the tool. Well, thank you all for, for being patient and staying on for me. I know, but not, not quite Kurt's talk, but you'll hear Kurt's talk on May, May 27th. So thank you all very much. Appreciate you all. Have a good evening. Take care. Awesome.

hip instability

hip microinstability

clinical clues

imaging clues

surgical management

non-surgical management

rehabilitation

labrum preservation

capsule preservation

hip arthroscopy