So welcome to the Multi-Institutional Sports Medicine Fellows Conference. We're going to put everybody's computer on mute except for Dr. Philippons, of course, and then we'll unmute for the faculty for questions. And if you have questions, please go ahead and put them on the chat. This is being recorded and will be transferred to the AOSSM playbook on their website, and it will be on the learning management system and available starting next week. Again, if you have questions, please submit on the chat function, and we'll ask at the end. And, again, we'll have the faculty also ask questions as they come up. It's very much my honor today to present our next speaker, Mark Philippon, who really requires no real introduction. He is the managing partner of the Stedman Clinic, and he's the co-chairman and co-director of the Sports Medicine Fellowship at the Stedman-Philippon Research Institute. He has really blazed the trail for hip arthroscopy, advancing things from just a diagnostic tool and just doing some resection to where so much of what we do is attributed to his trailblazing and foresight. So in his next area of development, as he's taken us from labral repairs to reconstructions, now dealing with capsular reconstructions, something that few have much experience with, Mark is, again, trailblazed and trying to sort this out and get us to solve some of these difficult problems of irreparable capsular destruction. So really, without further ado, it's really my pleasure to introduce Mark Philippon, live from Vail, Colorado. Thank you, Dr. Safran. First of all, thanks for including me in these sessions. I give you kudos, Mark, because during this difficult time putting this together, it's outstanding. I've had feedback from our fellows. Kudos to you, Mark, for putting this together, and thanks for inviting me. So today, as Dr. Safran said, I'll talk about capsular reconstruction. So necessity is the mother of invention. As we were doing revision surgeries, more and more we're seeing patients with deficient capsules. And over time, we develop a technique that's helpful to our patients for this difficult problem, and I'll share that with you. So these are my disclosures. So first of all, the capsule, I mean, we pay a lot of attention to caps on the shoulder, but the hip capsule is very important. And truly, to make it simple, we have reinforcement of our capsule by three main ligaments. And the ligament of bigelow of the iliofemoral ligament is the strongest ligament in the body, actually. And it's a very important thing for capsular function and health of the joint. We also have our pupal femoral and ischial femoral ligament, also important. But truly, when we talk about capsular reconstruction, most of the defects I see are interior around the iliofemoral ligament. And of course, we have the zona obliquilaris, which is the circular fibers around the, like a leash around the distal joint. And that also is important because it certainly plays a role in synovial fluid circulation, but also in stability, in helping with the congruency of the femoral head with the acetabulum. Now, the zona obliquilaris, there's a good MRI study, I would refer you to that. Richard Field did a lot of work on that. And truly, again, you can see on this picture, you see our ligament, a right break, menial cerebral fold, but right on top, you see the zona obliquilaris. And you can see inferiorly, it probably plays a role, again, in fluid, synovial fluid circulation, but also in stability. Now, a few years back, we looked at the capsular thickness, where it's the thickest, because obviously, that area, because it's thick, we should probably try to preserve it. And it's thickest between one and two o'clock, according to our study. And the maximum thickness at two o'clock correspond to our ilioformal ligament. And from the edge of the labrum, the thickness was greatest at nine to three o'clock. So, most of us now, I think we've evolved. And in the past, when I started doing this, I did my portals, and we didn't really need extension of our portals to do our work. But now, with what we do, labral repair and osteoplasty, most of us do a capsulotomy. And I think it's important now, I believe we all understand that most of the time, it's important to close a capsule, unless we have to deal with arthritic patient, where releasing the capsule becomes part of treatment. So, for us, we do an interportal capsulotomy. And I use, now, 2-number-2-vicral suture to close it. Our capsule is about, capsulotomy is about 25 millimeter in length, parallel to the labrum. And again, with 2-number-2-vicral, we have the same resistance to, we did a biomechanical study, and we have good resistance to failure, the same as 3. So, now, most of the time, we use two sutures. So, when this capsule failure, actually, I just saw a patient, who had some, unfortunately, had an open hip surgery, because of a fracture that he had. And this patient, actually, has some residual capsular issue, actually, from the injury, but also, probably, from the surgery. But we know that the iliofemoral ligament restrict hip extension, exploitation, and also allows us to stand on the upright position, you know, as a point of stability to prevent persistent muscle contraction. One thing I want to add, next to the iliofemoral ligament, we have our psoas tendon. And I see the psoas tendon, almost, as a supplement to our capsule iliofemoral ligament complex, because it's a dynamic stabilizer. So, you can see, if you have instability in the front of your hip, you'll have a tight psoas, and create a flexible fracture. So, sometimes, that's difficult to treat. But if you have a good closure of your iliofemoral ligament, good stability there, usually, it helps relaxing your psoas. The, you know, unfortunately, when we repair a labrum, medially, often, we have to incise a capsule, and by doing this, we incise the iliofemoral ligament. So, I think it's important to close it, especially in an athlete. And sometimes, what we've seen is, on our revision surgery, especially a patient with flexion contraction, we see a hole right at the psoas level. So, why the capsule fails? Well, of course, you have trauma, you have hip dislocation, prior open surgery, and also prior hip arthroscopy without capsule closure. You see, these are different variants. But a common denominator there is that most of what I see in capsule failures is in the front, just underneath the psoas muscle mass. So, when we have a deficient capsule, again, you'll have increased rotation, especially with the iliofemoral ligament, you have no end point external rotation. And that will lead to micro-instability. And again, if you have a deficient labrum, a deficient capsule, it might progress from micro-instability to micro-instability in extreme cases. So, this is an example, a rotational sport, a golfer who does a golf swing. You can see the forces anterior to posterior, but also anterior to external. And again, you can imagine if you have an iliofemoral ligament deficiency, you won't have that stability, primary stability during this motion. So, again, what we've seen over the years, and I would refer you to an old paper I wrote back in 2000 about, actually, it was called monocapsulography of the hip. And at that time, we described the anatomy of the capsule, and we put already, this was back in 2000, we put the emphasis on the iliofemoral ligament, and we felt it was important for this patient with rotational sport. So, you have a baseball player at bat, same thing. A watch when he hits, a lot of force, anterior, posterior, and internal, external rotation. Same thing with the quarterback throwing to the sideline. Not as big, but you can see when he rotates, he puts a lot of stress in his back leg. Tae Kwon Do, probably the worst. Look at that axial distraction, in addition to rotational control needed. So, if we have a deficient capsule, what can we do? We can try to close it with the primary closure, but in my hands, anyway, it's very, very difficult to do, especially if the tissue has been removed. So, that's how we came up with a capsule reconstruction. So, these are examples of patients where you can see, on the top left here, you can see, it's a, this is a left hip, you can see the hole there, the psoas level, and you can see the really irritated and inflamed soft tissue. And again, these patients, when they sit, they have pain, when they extend, they have pain, so it's pretty, pretty, pretty classic, actually, and when they stand, sometimes they tell you they have difficulty with their stability. Often, these capsular adhesions are present, and that compounds the problem of the capsular deficiency. So, why should we spend time reconstructing a capsule? Look at that picture at the top there. That's an angry psoas. Look at that, there's no support. So, in that case, you've got to put something, I see that almost as a hernia. Not only the psoas is herniating in the joint, but the muscle. So, the idea, when we reconstruct a capsule, there's a different philosophy here. For me, the primary reason is I want to plug the hole to prevent the herniation, but also, there's a secondary instability issue. And, you know, but I really feel that once you plug the hole, the capsule will heal, and the stability will come back. So, we look at the effect of the capsular reconstruction with the IT banalograph. We just did a biomechanical study, but we found that if you do a good reconstruction, the distraction forces were not significantly different from the intact state. This was done by Lorenzo, published in AGSM. So, how do we do that technique? So, first step here, I'm getting in, and we look at the defect. What you're seeing there is a femoral head at the bottom, top, you saw the subspinal region. First step, we want to measure the defect. You know, in my hands, I've seen as big as 5 by 5, 50 by 50 millimeters, but on average, I'd say it's more like 3 by 2 or 4 by 2. So, after we measure the defect, we'll prepare our graft, and we want to have about 4 millimeter thickness. You don't want to make it too thick. In the past, I've used the dermal allograft, but now we've evolved and we went back to the IT banalograph for our donor tissue. So, this is how we prepare it. We fold it. I'm a big fan of vicryl suture. We package it with vicryl. And again, you want to make sure your graft is 30 and about 4 millimeter thick. What you're seeing there in the corners, this is the old way I used to do it. These are non-absorbable sutures for the corner stitch. When I used to manipulate the graft inside and do the intra-articular anastomosis using a relay technique, now we have an instrument that allows us to do it in one step and I don't put the loops anymore. So, the graft insertion, we'll start proximally, put the anchors into the subspinal region where the defect is. Usually, it's around the psoas tube. And then we'll deliver our graft there. And then we'll make sure it's stable. You can see here, the graft has been delivered. And now I'm using a mini-pass suture to pass the vicryl suture. I'm sorry, this was an anchor approximately. So, putting the anchor and then I'm stabilizing the graft proximally. At the top, you can see the psoas mass there. So again, the graft has been delivered. This is the thickness you can see. And I have delivered a graft and we're getting ready to do the anastomosis distally. So, now the host capsule. Some people were asking me, do you use anchor distally? No, I attach the graft to the residual host tissue. And you can see here, the graft is being pulled and attached to the host tissue. And this is done without traction. Now, again, look, this is the mini-pass. Getting my vicryl stitch number two through the graft. And then I'm advancing our host capsule to the graft distally. And I start medial and then I work myself laterally. Good. This is before we... Now, I'll use a suture lasso. So, I use both technique. I use the mini-pass and the suture lasso, depending on the position. Sometimes it's difficult to reach, especially medially, it's hard to reach. So, I'll use a suture-related technique. I'm just now maneuvering the... Now, what you're seeing here is sometime I will use a flexible tool. To help me with the suture management. When it's hard to reach with our straight instrument. So, for me, I've learned that I like to use the IT band autograft as my source of graft. I use... I start proximally, I work myself distally and medially first and then work ourselves laterally. And then one thing I've learned, I like to deliver my graft through the lateral portal, not the anterior portal. It's much easier, less soft tissue to negotiate. That's a pearl I would give you. So, the post-op rehab is... You know, I like to keep them flat foot with bearing at 20 pounds for about three weeks. We, again, protect the excessive exhalation to about 40 degrees and avoid hyperextension. We don't want to have a flexion contracture, so we're very careful about the flex position. And I like to use a CPM and I get them on the bike also rapidly to get the active motion going as well. So, we also do the circumduction. I think it's important to prevent adhesion because this is a big procedure, so you want to avoid adhesions. And then we do the functional rehab. This is a kicker, NFL football kicker playing soccer. But we like to, around six, seven weeks, we like to get our athletes on whatever sport they do, just easy reps to get their muscle memory back. So, here, if we compare the CPM and the CPM, we found a better result with the IT band, especially the Haas ADL score. So, this is preliminary midterm results. These are difficult patients, so we have to be patient. We have to be patient. preliminary midterm results. These are difficult patients, so we have to accept these are good results. There's room for improvement, but I think midterm results are encouraging. We have a minimum of three-year follow-up. 10% of those were converted to hip replacement. They had multiple surgery. Cartilage status was the main culprit for those. And 15% of that cohort required revision surgery, mainly for adhesions. That's why I put a lot of emphasis after that procedure, you got to move them and make sure you don't get stiff, especially at the flexion level. So we had improvement for the modified IRIS-HEP score, 51 to 75. HUS-ADL and HUS support also improved, and these were all in the WOMAC and SF12 as well. So I think the results are encouraging, and it's a tool we have now to treat this complex patient. Sometime I'll use, I've done also capsular augmentation. These are, this is a technique that I've used only a few times where a patient have a very attenuated capsule. I use the Regenit and Xenograft as a patch with the PDS staple to augment the tissue. Early results are promising for this. So in conclusion, I think it's important that if you're going in for revision hypertroscopy, most of the time you'll definitely see your defect on the MRI. And if you have a large defect, I recommend to really consider this technique. It's going to, you'll be surprised. And usually the patient do really well early post-op. They don't feel that pinch anymore. And if you have an attenuated capsule, instead of going the full capsular reconstruction route, augmentation is a new tool now that has been promising. Now, I'll give you a case study. This is an example of a patient who had the procedure, a 30-year-old male MLB baseball pitcher, had a scope before, had a complaint of instability and pain, and had a positive dial test. Fever on the left was 22 versus 26 on the right. And then this is what we saw in the imaging. That's what I was mentioning earlier. Usually you'll see these defects. They're pretty obvious. So on the coronals, you can see that very well. And you can see anteriorly there, that's pretty deficient. And on that last picture, you can see herniation and muscle mass. And I really think that's a big pain generator. So I think these patients get pain, and they get secondary instability from the pain. Yeah, you can see the left versus the right here. Intact capsule versus non-intact capsule. So time of surgery, there was a defect. It was addressed with the trick thing we just discussed. I also did a recon on that patient with an autograph. And I used an IT band autograph for the capsule. So the defect was 3 by 3 centimeter in a capsule. I'll show you the video here. We're placing the anchor in the subspinal region. Again, it's pretty standard that we start medially. This is a 2.3 anchor. And again, the graph has been delivered. I have the loop suture on this one. And back then, I was using the relay technique, which worked really well, actually. And then we just do our anastomosis side to side. Now, you can see at the top, it's subspinal region. We start with the anchors approximately, and then we do side to side anastomosis with VICO. I used a loop as a point of fixation. And then we attach the graph to the host capsule utilizing a Quebec City slider knot. Again, this is a shuttle technique. You just want to, sometime, as I was saying earlier, going medially is difficult. So you, and we normally just use two portals for this. Most of the work is done through the lateral portal as far as, and the cameras and the interior, mid-interior portal. And then, I was mentioning earlier, the E-flex is used to deliver the suture sometime when it's hard to maneuver to get there. And that's a trick that has been very helpful for me over the years. And then I do my side to side here, anastomosis. So, and then we test it after we do our capsular reconstruction. We're done. And we do a flexion extension test to regularization to make sure there's not too much tension on our graft. So this guy went back to pitching at one year, he's 96, and his host ADL, 97 host support, two years, 96, 97. Modified iris, went from 85 to 100. So he's doing really well. So this was our early experience with capsular reconstruction. Good tool to have in our bag if you see revision. And again, I see that as a good solution to a difficult problem. And of course, I think over the years, we'll improve our technique. But right now, I feel that it's a good solution to a difficult problem. Thank you very much. That's awesome. Again, you know, you're to be congratulated for all the creative stuff you've added to us to be able to do stuff in hip arthroscopy. So that was awesome. And for those of us that have encountered it, and then we sit there and see one that you can't get closed primarily, you sit there and kind of go, now what? And you feel like you're stuck with your pants down in the operating room. Yeah. Yeah. Yeah. So Winston had a question for you. Yeah, I'm going to unmute Winston here, I think. There you go. To start, and again, if anybody has questions, I've got certainly a bunch. But yeah, go for it, Winston. So Mark, I was just going to ask you about visualization of pericapsular space. Visualization of pericapsular space, how do you get those beautiful views you had? Yeah. So that's a good question. So we, you've got to, we, of course, we control the blood pressure. And because you have a hole, you have a good point of fluid extravasate. So you've just got to make sure you have good, I do a spinal epidural on my patient, low blood pressure. And then I put my pump, usually I keep my pump at 50, I flush it frequently. And, you know, sometimes in these patients, in males, I'll be more aggressive with my pump pressure. But in females, because of the, I found that sometime with the fluid tract, the psoas, and go in the retroviral space, females are more symptomatic than males. So I'm very careful. I keep my pump at 50 millimeters of mercury. And I keep the mean pressure as low as possible. And that helps a lot. And I quite relate to small vessels. But good blood pressure control is really helpful. And I use two portals only. I feel if I use too many portals, it might be easier to go in certain position. But I keep most of these procedures at two portals. And how about, how do you find the natal capsule? I mean, do you have tips? Because sometimes there's a big scar ball up there. Like how you dissect the muscle off? How do you find the edges? And how do you freshen them up? And. That's a good question. So, you know, we have defects. But we can't forget, sometimes our muscles, our pericapsular muscles on the outside get stuck. So I dissect, often I'll go from outside in. I'll dissect with the motorized shaver, the muscle from the capsule. And I create the plane. And you'd be surprised how much flexibility you have with your distal limb when you do that. And then, you know, I use a grasper just to freshen, to stretch it a little bit. And also to make sure we have good quality tissue to repair. Proximally, usually, though, there's not much there. So I'll put, you know, as I said, I put the graft right in the subspinal region there underneath the rectus. And, but going from outside in first, freeing up the pericarticular muscle is really helpful. So, Mark, I have a couple of questions for you. So starting off with, you know, you talked about starting with the brace and a limited weight bearing post-op. But, you know, you're talking about trying to prevent flexion contracture. And how long do you limit hyperextension? Because most of these, you know, most of these defects are anterior, anterior, lateral. So how long are you limiting that hyperextension? So I, the brace is there for the, so what I do is I put them to neutral extension. It's just like, and when I test them in the operating room before we leave, sometime I'll get an hyperextension to see if we have flexibility to get them to 10 degrees of past extension. But I use a brace. Now, as you know, a brace, the brace we use are low profile. So they're not super precise with limiting the range of motion. But I block them around five degrees of flexion for the first couple weeks. But I'm very careful. We check them because if they start getting tight, I'll move, I'll eliminate that extension restriction right away. Because you don't want to have another problem with, again, the graft getting stuck in the front. But so far, with two weeks of, two to three weeks, 17 days, let's say, of hyperextension limitation, zero neutral, early on has been safe and effective in preventing these flexion contracture. And what do you tell the patients? I mean, I understand these tend to be more salvaged than your standard primary. As you said, they're difficult cases. If you're a pro baseball pitcher who comes back, or let's not make it a pro athlete, let's say, you know, you're a high level recreational athlete that has one of these, that what do you tell them when they say, how long until I can get back to sports? You know, what are you telling them? How much longer? Yeah, that's a good question, Mark, because we found that this patient takes about 10 months before they turn the corner, 10 months. They have good pain relief early on, but truly, before they become functional, it takes about 10 months. That's what I find in the scores. They start turning the corner around 10 months. And what do you think is the difference that's taking them longer? Are you just slowing your rehab down because, yeah, they're feeling better, but you're just being conservative about the capsule, or what? Yeah, yeah, I want to prevent tendinitis. So the muscle weakness is the limiting factor, I think. We don't rebalance the muscle as fast as a normal surgery because we don't have the support from the capsule. So we, yeah, I think it's an issue with, we're taking a little slower as far as rebalancing our muscle, especially the glute max and the flexor. We don't want to start straining our flexor too early because it's going to put too much stress on our capsule repair. Yeah, it's interesting. I've had one patient that I operated on that had had a dermal allograft that this lateral suture line hadn't healed, but a lot of their symptoms were ileososis because they had scarring of the ileososis to the dermal allograft. And so, again, it is that fine balance between the two, I think, you're trying to find. Yeah, the dermal allograft, I don't want to say anything negative about it, but in my hands, I found more of a reaction to it. So I don't use it anymore. Well, I was going to ask you why, that was my next question, and all reality is written here, so don't worry about that. It says, why is the IT band better than the dermal allograft? Yeah. Yeah, I mean, we found that, and I, you know, I thought the dermal would be good, but skin in the joint, for that purpose, looks like we had more of a reaction there. So are you seeing any reaction with the Regenitin? Because, I mean, that's. No, no, hey, Mark, no, actually, I've used it in a capsule, but I've used it in the medias, too. No, I mean, I'm impressed with that product, actually. I use absorbable staples. So far, we've been pleasantly surprised with that one. Yeah. So let me ask you that. So I recently had a capsular reconstruction to do versus repair, and we, you know, so we had the Regenitin available, but based on the data that, obviously, in the shoulder, Buddy Savoie's data on the shoulder looks outstanding for the rotator cuff, but have you had the opportunity to image those patients with the Regenitin at the capsule augmentation, and what are you seeing, if you are doing that? Not yet, Mark. I haven't. That's too early. I don't have a full year yet to follow up on that, yet. On the capsule, yeah. On the capsule? Are you, so to put this into perspective for the fellows, you, first of all, but how many capsular, how many patients are you operating on a year, or what percentage of patients are you operating on a year that you find that have capsular defects? So the percentage of your revisions, would you say, that you're doing that have capsular defects, and what percentage of those are you able to repair, primarily, versus doing a capsular reconstruction on? So we'll kind of get into the problem. In our revision cases, most of them are lysis of adhesions, and sometimes reshaping the neck. I would say one out of four revisions will do a capsular recon. One out of four. One out of four capsular defects you're doing, or one out of four revisions? No, in a revision situation, let's say I have four revisions, probably one of them I'll have to do a recon of the capsule, because of a defect. Wow. Okay. So, I mean, in my practice, I see a lot of, of the revision hip arthroscopies, I'm seeing a lot of micro instability, either that may have preexisted and wasn't addressed, or maybe was made by a capsulotomy that wasn't closed. But sometimes, if there's some capsular defects, but I'd probably say 80, 90% of the time, I'm able to get a, get a primary repair of the capsule, either repairing the capsule directly, or putting anchors into the acetabulum and suturing it back to the acetabulum. Winston, what are you seeing from your revision practice? Yeah, exactly as you say, I had a revision the other day, I put anchors in, into the subspine region, I was able to get the distal limb back up. I don't have the same experience with the reconstructions, but obviously after watching Dr. Philippon's work, it'd be nice to recreate what he can do. But it's pretty, it's a tough procedure, Mark, I mean, it's tough. Yeah, it's just, yeah, it's just what happened. I know what you're saying, like, medially, usually that's where the hole is. I've done primary repair, which I'm happy with, but sometimes there's a little tension on it. So, my threshold now to put, even a small patch, I'll put a small patch, one by two centimeter, just strategically where the psoas glides. So, instead of having too much tension, that, my threshold is lower than you guys' probably, because a small patch is much easier than a big one. And that's, it's probably, it's, in many ways, it's easier than doing a primary repair, because these primary repairs sometimes are really hard to do. Yeah, let me put, let me put that in perspective. Let me put that in perspective, Mark. That's like saying, you know, a 20-foot jump off a cliff is much, much easier than a 40-foot jump off a cliff. Yeah. Mark, what are you using for your patches, Mark? The patches? Yeah. Yeah, I use the IT band allograft. That's what I use primarily. Now, it's, I wish I could use the Regeniton, you know, but it's not, sometimes with these defects, it's not, I don't have any tissue there. I don't, I don't think it's strong enough. It's not strong enough. Yeah. It's an augmentation device. It's not a bridging device. Yeah, yeah, yeah. So, I would agree. And if you didn't have IT band allograft, and I know you, I know you're a big fan of the IT band auto. What's your, what would be your fallback from there? Would it be, yeah, what would be your fallback from there? Well, I mean, we use a dermal, but, you know, right now, to be honest, I, if I don't have the IT band allograft, I would use, you can use it, you can use, you can use a tendon, Achilles tendon, because they're pretty thick. Yeah, that's what, I mean, I thought you, before you told me you'd used Achilles, right? And early on, you'd used Achilles. It's thick, and I'm not sure, and, you know, you remember these patients, when they sit, you've got to make sure it's pliable enough, and I thought the tendon was too stiff. And from when you look back at your people that you're doing these on that have the defects, are they people that were unrepaired capsulotomies, were they T or interportal, and or were they, well, so were they T or interportals, and were they repairs that failed, or just people that didn't get them, didn't get a repair, that were just left? Or were they in their mind, and I just removed the capsule? No, a lot of them, what happened is, what I see is, you can tell is you know, they have a difficult anchor to put in And they'll shave the capsule um And you know, unfortunately when you shave medially, it's hard to repair afterward. Um, you know, sometimes it's better. Um, To get exposure to put your anchor and repair your labrum and then sacrifice a capsule Sometime the capsule will fill in no problem So in my hands what i've seen is mainly the these capsular resection. Um Yeah and and mixed with adhesions So most so most of the years are people there were people that had capsular resection not necessarily in a portal capsulotomy And certainly not those that were closed. Yeah those I mean, uh You know, sometimes we have revision patient close a capsule and those actually Especially the t the t the distal limb is well closed. Sometimes i've seen proximally when they close it There's enough tissue. So there's a hole there Uh, but most capsular closure i've seen They look pretty good at the time of revision So mark, I know you make like an air portal kind of a laterally based air portal How do you what's your what's your trick for getting to those medial spots in the acetabulum and not resecting more capsule? Yeah, so, um, okay, so The capsulotomy we do is laterally based. Um, and I use a lot of curve instrument now Like for the medial anchor i'll use a curve delivery system curve burrs, for example, um Uh the flexible tools so I I do a lot of my work laterally based and I don't violate that medial sleeve our fellows probably don't Most of them probably don't like it because it's much easier to shape to extend a capsulotomy But I teach them how to do that because at the end of the day when we rehab them I really think it makes a big difference because when you don't violate that sleeve there so that the trick is I do a mid interior portal slightly cheating interiorly lateral portal And I I put uh my camera Mid interior and do all my work from the side. And again, what's helpful is you're flexing the hip or um Sometime what i'll do is i'll put my anchors in traction But in some instance when we have to go very far medial below four o'clock I'll do it in flexion with a curve delivery system uh And and from the side so in my hands anyway flexing the hip a little bit no traction gives you access to the Five o'clock four o'clock position and you can see really well where your anchor goes So these are Good tricks that I have learned I I use I mean, of course my medial anchor I'd like to use my mid interior for more often extending it but I really try not to violate that male capsule if I don't have to I think that's critical because you also have to worry about the pubofemoral ligament there. Exactly, right? Yes. Yeah I've learned that over the years. I mean once you cut it, first of all, it's hard to repair it Yeah, I mean I I've I've been there and I that's why over the years I've evolved it's more difficult maybe for the Time, you know when you do your surgery, but at long term, I really believe they do better our patient do better I I agree with you. Um, and again, I and you know me i'm even more conservative because I I try not to do the interportal capsulotomy. I try to leave the Native iliofemoral ligament so that the it doesn't upset the iliopsoas as well. Um, yeah going. Yeah, I think it's a great strategy mark Um, yeah, it's a very good. I think it's really and your rehab must be much faster and easier less than unitis Less less not not a lot of tendonitis, but I don't know if I go as fast as you anyways from the rehab um, so one of the tips I I was trying to get to to see if you if I could get you to To comment, you know where where some people who do the interportal capsulotomy have have an issue they put the stitches in but if they if their proximal sleeve or the or what they take from Closest to the acetabulum where they cut if they cut too close to the acetabulum that there's not much tissue there It's thick but there's not much of it and it's not really forgiving And so I find if you if you put stitches in there for that I think and you and especially if you put it in when they're inflection I think it's going to rip out and I think you're going to get your if it doesn't heal in um You know that some people do clearly heal in I think that's where you're going to get your defects from is that kind of your experience? Oh, no for sure. I mean when we see the effects, that's where they That's where usually the capsulotomy is very proximal there's not much left to repair so we can repair it So I don't see how I guess sometimes you can put the anchors and advance the distal sleeve but You know, you have to have a lot of mobility. So At time zero, I think you can do it. But when it's a revision case, there's a some contracture tissue there more viable tissue that's why we have we've evolved with that that that technique because It was frustrating when you pull on the distal limb and then it doesn't once we cycle it doesn't hold so And so that brings up another question I mean your technique that you showed is that you're you're putting in the anchors up off the acetabulum and so That brings up the question when you're doing capsular reconstructions Yeah You know Are you actually or how often would you say you are dealing with just putting it in as a defect in the capsule? proximally distally medially laterally So it's all that you're sewing this graph to capsule only versus that it's really proximal And the problem is that you need to put it into the acetabulum and distally to the to the capsule Yeah, most of the time actually Um You know your lateral anastomosis will be um Maybe around for left around 10 o'clock Most of the crucial part I find is it is that? So as you region and I do proximal with anchors Medial with side to side anastomosis distal side to side anastomosis and lateral um side to side anastomosis But proximally I always use anchors. There's nothing there's Most of the time I don't see any Any tissue left? Yeah, so I mean that's that's the issue that it tends to be It's not like where they end up with a defect. It's not usually in the middle of the capsule It's usually off of the acetabulum and you're and how far down you go is dependent on how much was removed Yeah, yeah, but you know to be most of the time though the shaving that's done is is the upper third so You have enough sleep. You have enough tissue distally mark to To grab it uh, but crucially, I mean honestly you got to put Most all the one i've done i've been with proximal anchors from my point of fixation is I haven't had any and you have to be careful because sometime I use an all suture anchor immediately because you don't have much bone. So sometimes you you actually will see your your uh you know, you'll see when you drill that you perf the the wall there, but you know luckily with the all suture you just pull on it and it just grabbed the bone and It's it's irrelevant if you use a biocomposite anchor or peak anchor Those you I don't think you can leave them proud there Right, they'll get some solace irritation. And then if they break off, you know, i've i've to have a case of somebody came to me Who had a failed? Uh labor repair and their uh anchor that you could see on mri was next to the outer wall of the bladder um Really? It had migrated down, you know to the to the bladder. So But you know, this is yeah, I can see that happening. Yeah Yeah, that means they can breach the cortex You tried to not enter the joint but they they're in that wall at three o'clock Which you've shown is such a small wall. It's easy to breach the other way. Yeah, I use all suture anchor for that. Yeah Yeah that purpose. Yeah I I think I don't know if this Talk was at such a high level or so thorough or just that none of the fellows have seen any i've not seen any This may be the first time in the five weeks. We've not had any fellow questions Any fellows out there? Maybe they're sleeping mark. Just give them some espresso Mark philip on you use loose arm on your post-ops for these I beg your pardon, please Oh, yeah. Yeah, I use uh now it's standard practice for us. We use four weeks of lasaurin Yeah, 25 milligram a day Yeah, when you know, hey winston when i'm doing capsule reconstructions i'm taking lasartan too to keep my blood pressure down Hey, i'm on it guys i'm on it I got converted I take it every day now No No, I guys we have we have uh, we're doing a project right now with the nih we got the fda actually Gave us exemption to uh, we're studying it. Um I'm pretty big. I really believe in lasartan that you got to be careful with teenagers so they don't drop their blood pressure, but really there's something there and And I think it helps with our minimizing the adhesions So some work, yeah, I don't know, you know winston and I were aware of it, but why don't you tell the The the fellows I mean, I know you're using lasartan to reduce um scar tissue and all what you want you kind of If you will help by educate at um, what what you guys are doing and what what you found you and johnny Yeah, and your group have found now so what we found is johnny actually started working on lasartan when he was in pittsburgh and uh, when he moved to vail I was always interested in scarring and and uh revision and you know fibrosis in the muscle and the joint so we had a You know, we started looking into it start to use it clinically off label I had a guy a player that uh had a surgery before a lot of scar prone We put him on we had johnny talked dr Hewitt talked to him put him on it for four weeks had great result and from then we started using judith you know in high-risk patients and from there we um So clinically we we have we reduce our revision rate from adhesion from four percent to less than one percent with the lasartan But then we also use lasartan now in microfracture uh We did an animal model look at the microfracture with with lasartan without lasartan on a rabbit model And we found that actually in the lasartan model. We had less fibrosis ninety percent Highland college versus forty percent in the in the microfracture group so We also use lasartan now for our microfracture patient and we're doing actually a trial uh Uh the from uh, we got funding from uh, the department of defense We're doing a trial with microfracture lasartan now in a clinical trial. So we know the animal model. We have better Microfracture bed with lasartan, but now we're doing the clinical trial in humans and hopefully it's going to show the same. Hopefully it's going to Small animal model to human and we'll have positive results there Well, I think that mark would agree that when I go in my revisions of things that I see are sometimes just dense adhesions Oh, yeah, and I always wonder if that's the source of pain There can be so many of a reason why a post-op pivot can be painful Those adhesions really look painful No, no, uh these adhesions especially when they trap your the capsule traps, uh the adhesion between the Capsule and the labrum. It's like having a chronic skin pinch. That's the way I tell my patients like you've been your skin Is being pinched all the time when you move? so, uh I think definitely it's a pain a big pain generator for these patients Yeah, I mean, I think the key is you know, the capsule moves independently from the labrum I mean that you know unlike the shoulder The capsule inserts into the acetabulum directly and the labrum moves independently and if you if you put those together then the capsule is going to tug on the on the labrum whenever you do any Any motion and you're and you've got the nerve fibers in the labrum. I think that's that's a significant source of pain from the adhesion So I think it violates the seal. So I think the capsule pulls the labrum off the femoral head Yeah, and so suddenly your seal that you thought looked good at the time of surgery is no longer there. That's true I think that's what you see. Yep, exactly. I use your labral augmentation technique to I think that's a good trick to To keep those adhesions from forming too. Yep. Yeah. No, it's it's exactly what happened It just pulls your labrum off and you have no seal so you have that micro instability in addition to that that uh that that pinch I think and and you know, I think the the micro instability that Non-seal hip is is really painful for these these patients I agree That's it it's all solved no no fellow questions today my goodness guys, that's Yeah Hey, how many fellows do we you you have at your lectures mark usually? Roughly it's hard. It's hard for me to know exactly how many are fellows and how many? are we have some physical therapists and some trainers and some residents and Okay, so we get we get a variety of uh, yeah and then we and then every now and then we get some faculty members like winston, you know, and and the tool who the tool secretly wants to get out of the patella femoral joint and do real surgery, but uh, Oh, he's unmuted now beware Yeah, no and then I see a talk like this and just realize how ill-equipped I am to take care of a real joint Well, can I ask a question that I think will be helpful for the fellows mark dr Philippon, I mean you've been doing this for so long. What has been your uh, I guess your evolution as far as capsule I mean were you doing 2.5 million centimeter capsulotomy when you're getting started and and like what has been your evolution? No, my evolution when I started doing the osteoplasty I was making a bigger i've always been conservative as far as the capsulotomy because of the ligament, but My my capsulotomy were way bigger. Oh, yeah way bigger and they were literally based sometimes I violated the iliopremal ligament Especially for the osteoplasty when I was getting started so, uh, it evolved I mean after realized you can't do that and you gotta minimize the uh, Resection so but at the beginning when I You know when I was in pittsburgh, I used to do larger capsulotomy for sure Yeah, but you're still getting excellent results back then I feel like and so I mean have you seen a have you seen improving the Results, but you know, you can ask my my old fellows. Um, we used to see more in pittsburgh more flexor tendonitis erectus inflammation and now uh as we evolve it's it's almost gone, but uh That's the evolution i've seen that of course eventually the capsules stabilize and most of them close and that goes away But I I realized that I was dealing with a lot of unnecessary Tendonitis because of my capsulotomy. That's that's what I think was happening Well, there are two things though, right mark? I mean if I remember correctly and you and I had spoken a lot about it You also move your portal more distally that add to your portal more distally to also help avoid the iliopsoas, right exactly, right? Yes. Yep. Yep. I did that and that was very helpful Yep. Yeah I mean, I think yeah combination of things but I think we're I think you know from when I started as well We we are so much more cognizant of the of the importance of the capsule and and and not uh, Uh haphazardly Whacking away at the capsule. I'm just thinking that it's all bony support that the capsule does have some uh, important contributions to uh function of the hip and and pain Yeah, so when do you what on the on the post-op patient is having trouble like when do you pull the trigger on? Say the cat might still heal. I mean, are you six months out? Are you still trying to give them more time 10? I mean, how do you how do you guide them through this difficult time? I I really like to wait a year yeah wait a year, um because I see patient turn the corner at a year and now we know our patient get better for two up to two years after surgery but sometimes it'll get stuck like sometime that you can get the muscle strain back and You know, there's muscle uh contraction inhibition from the pain uh So those patients i'll i'll intervene before one year when I know You know, but sometimes post-op mri won't tell you the story. So I'll give you know around six months to 12 months. That's where i'll more be i'll be more critical to Make sure we're not missing anything and do a diagnostic scope Uh, but truly most of the time I will wait one year before I reintervene um You know and to be honest, you know what goes along with that is that i've seen now a couple patients that Had mris at six months that had um a capsular defect And then when they come to see me and we get a new mri at a year And I caps with an arthrogram and that capsular defect has filled in so I think it can I think it can fill in usually what you would expect it to fill in sooner, but Um, sometimes they can fill in. Uh, you know in that six months to one year period of time So the question is what does it fill in with? You know, is that a capsule or is that? tissue that's going to be as You know stiff as the iliothermal ligament, so it's hard to know Yeah The answer is I I don't know mark. Have you biopsied that stuff? Uh, yeah, uh, actually we've biopsied some adhesions and um, the capsule and revision surgery, uh, and we found a lot of them at high concentration of Estrogen receptors and mmps Yeah, and uh, we don't know but we we're looking at that right now actually We look we biopsy and we're in cases the labrum the capsule that has regrown and the adhesions And we're trying to figure out like exactly what you're asking what kind of tissue quality we have I think that's going to be critical. I think that'll be great stuff when it comes out Yep, we just we start we have dr. Payne. Ashley Payne. She's working on that right now for the past year Well, I want to mark thank you so much for taking the time to share this stuff with us, this is great It's always a pleasure to talk with you. Thanks for inviting me. I'm happy That's great stuff. The fellows love it. So thanks for taking the lead on that mark My pleasure, thank you and winston, thanks for your contribution and the tool even for your two cents. Yeah Thanks a lot. Thanks Take care. Be safe Take care. Take care. Thank you very much. Bye. Bye. See you soon Thanks, winston, yeah

capsular reconstruction

hip arthroscopy

hip capsule

stability

capsular defects

IT band autograft

allograft

subspine region

acetabulum