lectures here. This is a HIP series that we're doing right now. We'd like to welcome Dr. Winston Gwathmey from the University of Virginia. He's associate professor there. He is their HIP stud, which basically means he can say what he wants because none of the rest of the jokers at UVA know anything about the HIP, and he'll be the first one to tell you that. I think that's probably true. When I was up there as visiting professor, I think they were still looking for a HIP stud, so it's great to have you Winston. I appreciate you doing it. As always, please mute your lines if they're not already muted for you, and submit questions through the chat box, and I will ask them of Winston. If any of the faculty want to jump on or ask any questions, please don't hesitate to unmute yourself or send me a text. So with that, I'll hand it over to Winston, and we'll talk to you in a bit. Jeff, thanks man. I just want to say thanks to Mark Stafford. I know he's on the OR right now, but for putting this together, I think this is a crazy time we're in, and I'm so happy that we're utilizing it to be constructive and try to do as much as we can. So I'm going to be talking about HIP labral tears, which is kind of a... HIP itself is... HIP labral tear is obviously associated by other conditions, and so I try to make it as comprehensive as possible during this talk, but also try to make it as interesting as possible. I tell my fellows, I don't want to bludgeon you with HIPs, and so if you don't have an interest in the HIP, that's fine. I'm just going to try and make this as sort of universal as possible, and I got a lot of pictures and things like that. So I really have no disclosures on the fact that, you know, as a HIP arthroscopist, that might be a little bit crazy, and so just be aware that I do like the HIP. Ironically, I didn't think I'd like it when they made me a HIP specialist, but I do like it, and I'll try to convey that appreciation I have with HIP during this talk. So the polls... I was going to put a poll up to see how many people are doing HIPs in their fellowship and whatnot, and we can talk about at the end, like, how many HIPs do you think you'd be doing during your fellowship in order to be comfortable doing them in practice? And that's a good question, I think, to ask and kind of figure out what you want to do going forward, and so since the poll question's out, we don't have the poll option. I'll just skip through these. So this is what we've been doing for our sports conferencing. This is a Zoom conference for all the different sports talks at UVA and all our fellows who are alumni. So this is... I made a Zoom conference for laboral terrorists as well, because laboral terrorists have a lot of different faces, and I think what I'll try to get through as far as is, during this talk, is that no two laboral terrorists are really created equal. So let's talk about what the labrum is, okay? So, you know, in my clinic, the labrum gets all the press, you know? I have a labral terror. Oh my god, I can't tell you how many runners and athletes have basically, you know, came to me crying because they have a labral terror, and so it does get a lot of press in the HIP clinic, and so I'm gonna try and go through that. Like I tell my patients, you have to have a spiel for all this different stuff, you know? It's like a gasket seal for the hip joint. It's a liner, you know? It helps to seal the joint. You have to have some way to explain it to patients, but I think for this forum, I think it's probably appropriate to dig a little bit deeper, okay? So, talking about the anatomy of the labrum, it's a fibrocartilaginous ring, just like the labrum in the shoulder, the meniscus in the knee, as far as what it's actually made of. It has a little bit different function that we'll talk about. Inferiorly, it's contiguous with the transverse acetabular ligament, so it creates a complete, you know, 360-degree circle around the hip joint. It helps to seal the joint, okay? So, you take the cross-section of the labrum, you can see that it ranges from about four to eight millimeters in size. It's thickest superiorly, but widest inferiorly, and the thing about the hip labrum, which I think is really important, is just the variability as far as the morphology of both the hip and the labrum. You can see some massively hyperplastic labrums, or hypertrophic labrums, and pages with dysplasia, and you can see some very small labrums, and so there's a lot of variability to it, which makes trying to figure out the function of it even that much more challenging. It's contiguous or continuous with the articular surface. Sometimes it's hard to see where the cartilage stops and the labrum starts, okay? Which makes it a little bit different in the shoulder, because, you know, it creates more of a sealing function in the hip than it does in the shoulder, in my opinion. The blood supply is from the periphery, much like the meniscus. It actually has a fairly robust blood supply, which helps when you do, which helps with healing. As far as the function, I think there's a lot of important function of the labrum. It distributes the load within the hip, okay? So what does that mean? It actually increases the acetabular volume by about one-third, so in the shoulder, in the bumper, in the shoulder, the labrum, the hip actually increases the volume within the, within the acetabulum, and it seals the joint. And I think that's really a neat thing about the labrum is it creates this interface between the articular cartilage of the femur and the labrum, where the intra-articular fluid, which is this here in purple, is pressurized within the joint and creates a micro layer of separation between your articular surfaces. And because of that, it's a weight-bearing joint, your cartilage is actually, has a little fluid separation to it. The best I can describe it, it's kind of like an air hockey table, where the air hockey puck is sitting off of the, off the table by that little layer of air. This is really critical because when the labrum starts to have dysfunction and you have breakdown of that, of that interface, that's when you have arthritis, and that's why labral tears can cause arthritis, because you sort of lose that biomechanics. And so the fluid sort of pumps through the joint and then out ethereally through the fossa and the transverse octagonal ligament into the periphery and creates a constant flow of articular fluid, which I think is really interesting and neat. I hope this video plays. Sanjeev Bhatia is a friend who put this video into the, and I hope this plays well. It's a great video of just showing you how it creates basically a suction cup. In a functional labrum, it's pretty hard to distract the hip joint because of the suction cup that it creates, you know. So if you strip all the meat off your pelvis and just put the ball into the socket, the hip is pretty well sealed because of how that function works, okay. Also really important for proprioception. So why does a labrum tear? Okay, so here's a labrum tear. And Homer Simpson would say that it's, it ends up being the soft interface between these two hard structures, the femur and the acetabulum. And so the tear is because of the repetitive stress or strain on the labrum over time. Unlike a shoulder labrum, and I'll keep referring to the shoulder to keep Jeff at least paying attention, which sometimes a dislocation or even, you know, if a posterior labrum tear on the shoulder, it might be repetitive, but it usually is more of a traumatic situation. The labrum and the hip tends to be more repetitive or attritional or cumulative kind of situation. And so it can either be pinched between two hard surfaces, like this poor lamb stuck between these two rocks, but also can be ripped by repetitive shear, meaning if the hip is loose or unstable over time, the labrum can start to fail, like this loose-fitting pair of shoes. Or sometimes it just frankly wears out over time, just like a lot of different joints in your body, the articular surface and the labrum, the structures can start to wear out. So why does it hurt? So looking at the innervation of the hip, it's like the biceps anchoring the shoulder, it's highly innervated with a concentration of nerve fibers, particularly the anterior superior to posterior superior aspect of it, which gives you the ability to fill your hip in space, but also gives you the ability to feel pain. And so that's why these superior and anterior superior labral tears can really hurt. And plus, and I hope these videos kind of, I know that Zoom can sometimes be tough for videos. So I didn't put as many videos as I normally would. But you can see how these unstable labrums, which are, you know, inflamed and engorged, can possibly be uncomfortable. So are all torn labrums painful? And I, this is one of my favorite studies that Mark Philippon put out a couple of years ago, because you can utilize it for a variety of reasons. But when someone comes into your clinic and says they have a labral tear on their MRI, and they're grabbing their back, or they're grabbing their, the outside of their hip or something like that, you can say, well, you know, MRIs often show labral tears in asymptomatic patients. And so it's very possible you can have a labral tear in your hip. There's not a cause of symptoms or maybe even a natural process of the hip aging. And, you know, further studies that sort of play that out where, you know, the MRI showing a labral tear doesn't always mean everything. And so it's important to realize, you know, MRI documented labral tear does not always mean that person needs to have a labral repair, or even the labrum itself is causing, causing pain. So the question, you have to ask the question, if you tear your labrum and you don't MRI it, it's kind of like if a tree falls in the forest and nobody's around, is it really a problem? So, so be aware that it's very common to have labral tears that don't cause problems. This is a video I took of Beth Potts over at Thomas Bird's clinic doing an intra-articular injection. This ends up being a really helpful adjunct to your clinical diagnosis of a labral tear. And Thomas Bird utilizes this pretty frequently as far as trying to elicit a response to, or a decrease in pain after an injection. It can be very helpful to sort of determine whether that MRI showing a labral tear is actually the source of pain. So I do utilize this in my clinic, not infrequently, but I'm trying to tease out if the labrum is in fact the source of pain. When it comes to classifying labral tears, as you can see here, they all look different, you know, and it doesn't really have a great classification system like, you know, meniscus tear in the knee might have, or something like that, because you're dealing with such a, such a heterogeneous group of both morphology and pathology. You know, early on, you know, this is 1996 when they came up with an orthoscopic classification, they basically looked at it and tried to describe it. But you have to realize this, this came out before even the concept of FAI was out, so it's hard to know kind of how repeatable these types of things are. I do think that when Salady's put together his documentation of labral tears back in 2001, he was on to something, because we still utilize this classification pretty commonly. And what you'll see is you'll see these patterns with different types of joint pathology, with a Salady's type 1 being a chondralabral separation, and a type 2 being more of a cleavage or intrasubstance tear. So you'll see the one sort of with that shearing, shearing effect from either dysplasia or CAM type impingement, where the type 2 is normally a crushing type kind of phenomenon with pincer type impingement. The HIPP research group probably put out the most comprehensive classification system, because they utilized both the morphology of the latent to describe the morphology, then the chondralabral junction, you know, as far as if they're partial, complete, or flap tear. They also talked about the actual intrasubstance changes, and so I think if you're trying to classify your labral tears intraoperatively, utilizing a classification system that's more comprehensive might be more reproducible as far as trying to describe this or document this. So as far as localizing the tear, I still use a clock face, and I'm weird because I always put three o'clock anterior, whether it's anterior or posterior. So the majority of tears are going to be located anteriorly or anteriorly superiorly, which can be, and where does a clock face start? It was described as starting at six o'clock was a transverse acetabular ligament, and the entire clock was built off of that. The recent research, including this paper by Dr. Philippon, proposed the iliopsoas recess or the iliopsoas U could be your anterior mark at the three or three thirty o'clock position. Sometimes people use this stellate crease here at the twelve thirty o'clock position, but ultimately three o'clock ends up being anterior, twelve o'clock being it ends up being superior or lateral, and nine o'clock ends up being posterior. And again, most injuries are going to occur kind of in this twelve to three o'clock range, with the vast majority occurring in what we call a subspine region, sort of a twelve thirty one o'clock to two o'clock range, which is helpful because that's probably the easiest place to repair a labrum. As far as imaging goes, I'm not sure if they're doing it out in Alabama, but here at UVA we're doubling up our MRIs. We know we're trying to make up that eighty five million dollars a month we're losing because of COVID, so we're doubling up on all this stuff. You see they're wearing masks. I kind of enhanced this cartoon a little bit. But the MRI of the hip is really challenging, mainly because the labrum is circular and it's oblique in its orientation, and so it's hard to get these cross-sectional images to really describe the labrum, and that's why labral tears can be hard to pick up. And so really when you're looking at hip MRIs, it's important to look at each sequence and try to figure out what that sequence is going to tell you, okay? And so again, I spend a lot of time on this middle sequence, this sagittal sequence, and sort of trace out the anterior part of the joint. The reason why I do that is if you look at that clock face, you know, the far anterior aspect might be best shown on those axial cuts, those axial obliques cuts, but those sagittal cuts are really well showed, really really show the sort of anterior superior aspect, the subspine region quite well, which is where the majority of the labral tears will occur. The coronal will give you that superior, that lateral aspect, where the posterior, for me at least, is going to be also seen on the axial sequence. I really think that as a fellow, you guys should be looking at your MRIs closely and trying to correlate that to your MRI, to your arthroscopic findings, because you're going to be looking at these hip MRIs all day long and just looking at signal and trying to figure it out, and Thomas Byrne would drive me nuts because he can look at an MRI, which looks stone cold, I don't know what I mean, and really be able to tease out what was happening inside that hip. So just a couple correlations here. Here's the anterior superior labral tear. These are the actual MRIs showing the actual arthroscopic correlation. You know, here's a coronal image showing this sort of anterior lateral labral tear. It's a big labrum. Look how big that labrum is. It's big and triangular, and this one here is also a large labrum, but you can see the intersubstance signal of this anterior lateral complex tear with this flap involved as well and chondral labral separation. You know, sometimes the labrum MRI will look pretty darn small. Like in this scenario, we had this sort of small bruised pincer type labrum where you can see the labrum on the MRI is pretty hypoplastic or hypotrophic, and you can see on the arthroscopic picture it's pretty small as well. It's nice knowing that when you go in because it might change your attitude toward that labrum once you get in there based on the size once you get in there. Look for these cysts. If you see a paralabral cyst, that's the most pathogenic for a labral tear. It's like that posterior paralabral cyst in the shoulder, Jeff, that will get the, you know, suprascapular nerve. So again, I'm going to try and correlate the shoulder just to keep, you know, Jeff paying attention. So yeah, this can be just like that labral tear in the shoulder. So there's no way for that fluid to accumulate outside of the central compartment unless there's a labral tear and some egress of intraocular fluid of that cyst. The chondral wave is almost ubiquitous with FAI, and so sometimes you can sort of pick up how the labrum will take a little piece of cartilage with it, and there's no chondral labral separation, but the entire labrum is coming off with the cartilage as well. Be aware there's a couple variants, again, like the Buford complex or a sublabeled fragment in the shoulder. There's a couple things that are pretty much normal that can be read as tears, especially low anteriorly and low posteriorly, especially when you're getting closer to the transverse acetabular ligament. You can have these sulcuses or these separations, which are actually just normal variants, and so it's probably okay to repair these, but these aren't really true tears, and I wouldn't repair them normally. Much more common posteriorly, these posterior labral sulcuses are very common, and be aware of a posterior labral tear read in isolation on MRI, because a lot of times that's just a normal posterior labral sulcus. So what about the plain radiographs? This is a common hip patient. I don't need x-rays. I already have an MRI. I know I have a tear. Like, what's the point of x-rays? They always, you know, it's almost like kind of a know-it-all kind of concept. You got to get x-rays. Why? I call the MRI like the Google Maps street view. So here's a view of the hospital, but you have no idea kind of where that is in the state. An x-ray gives you a larger map, a more global, a bigger screen picture of the situation, and so when you see an MRI of a labral tear, you have to kind of know what hip that labral tear lives in. So this tear occurs in a dysplastic hip, which is going to be a much different situation than a labral tear that would occur in impingement type hip. So the x-rays provide context. So the MRI ends up telling an incomplete story. These are all MRI reads you might get coming into your clinic, and you're reviewing your charts, and you see all these different reads, and you realize these are four very, very different labral tears. The reason why they're so different is because these are the x-rays that are associated with them, and the one in green is probably more of a dysplastic case. You know, the one in blue, clear impingement. You know, the one in red is this tiny little labrum, but this person actually has hip instability, and the one in the kind of the yellow ochre is more of an earlier arthritic type picture. So each of these labrums and x-rays has a patient attached to it. These are just kind of, you know, these are just pictures you might see these patients in, but in order to appropriately manage that pathology, you need to understand the etiology of the labral damage in these patients. I'm not going to belabor, you know, FAI and dysplasia too much, but I think it's important to realize that hips come in all shapes and sizes. The socket can be either shallow or deep, and the ball can either be round or not round, again this is a gross generalization, and knowing that these come in different shapes and sizes, you have to realize this is just morphological variations, okay, and so there's really ends up being two ends of the spectrum, your hip can be either too loose or too tight, and so in general dysplasia or under coverage would be considered too loose, or potentially too tight, but really that spectrum is way too simplistic, and there's a lot of sort of subsets within these two sides, and there's actually even some crossover, because you can see some patients who have both impingement and dysplasia, and so it makes it kind of confusing to treat some of these patients, and so I think you have to look at each x-ray really critically, and try to let the x-ray tell you the story, let the patient tell you the story, otherwise if you treat all labral tears the same, you'll find you'll have really outcomes that are not very reproducible. So talking instability versus impingement, these are just two kind of generic x-rays, you can see how the impingement hip is just a different hip than the instability hip, and so as you could imagine how that labrum might tear, the instability hip's going to tear because of sheer forces or sheer strain on the labrum, whereas the impingement hip's going to tear because of constant repetitive pitching. So here's a schematic that I kind of made showing a shallow socket, the labrum ends up, you know, kind of finishing up the sore seal here, and so as that person does athletic activity, and the ball tries to slide out, you'll see a tear at that chondrolabral interface. These are frequently going to be lateral tears, or tears that start laterally and extend anteriorly, especially with lateral undercoverage, okay, and you can see on the MRI here just how big and hyperplastic that labrum is, and that's really going to be, I think, when you see a big, big, big labrum, think instability, that could be a compensatory developmental situation for that hip. So when you look at the foundation of that hip, it really leads to instability, kind of like this house positioned on this, on this cliff here, you realize that's not a good situation for anybody. If you go into this hip orthoscopically, you'll find it's going to be very hard to give that patient a good outcome. So why did this lady tear her labrum? It really ends up being inadequate bony support, leading to increased strain on the bone-labrum interface, really untreatable with a soft tissue procedure, and so this scenario, this athlete, with this left hip, which is too shallow, clearly the treatment of choice is going to end up being a bony treatment for this, and don't get me wrong, there's some borderline dysplasia and some subtle dysplasia that I think you can do a good job with orthoscopically, but for this, but for the moderately or severely dysplastic, you know, you've got to change the bone. So that brings me to FAI. So Femoral Astabular Impingement, which is a mouthful, I have to say it about a thousand times in clinic, but at the end of the day, I feel like I'm talking marbles. It really is the reason why hip arthroscopics were put on this earth, in my opinion. So ironically, this didn't even exist, you know, before 2002, 2003. In fact, Thomas Berg told me, you know, the first 10 years of his practice, he was just debriding labrums without really any concept of how FAI worked, and so it's interesting how things have evolved. So like two basic types, I mean, the nuances of FAI, it could be an entire talk by itself, but really it's either a rim problem, or it's a femoral sided problem, or a combination of both. And so the rim sided problem ends up being kind of low clearance in the front, so it's kind of like this truck that can't quite fit through. With this overhanging rim, as the athlete or the patient brings their hip into flexion, what ends up happening is the femoral neck will collide with the rim, and over time will crush the labrum, give you contracute damage in the back of the joint, in these herniation pits, or these sclerotic focuses of damage on the femoral neck. And so it can be pretty dramatic. These labrums are pretty badly bruised, these are the so-called Salvi's type 2 labral tears, interstitial damage, and the culprit is going to be behind the labrum. The cam type mechanism is a little bit different, kind of more common in men and some of these athletes, and I love this this jiff or gif, we're going to call it, but it kind of gives you a sense of how the cam might work. The thing rolls around, and it lifts up the the duck's wing. This is how it looks like in the actual hip joint. So you can imagine that if this cam deformity, as you can see right here, goes in the flexion, you can see the ball levering out of the socket, and you just know that everything in between these two balls is going to be crunched, or crushed, or sheared, and so that's a problem. And so when you start seeing these cam deformities, when the ball is not round, as that area gets into the joint, it can start to carve away the cartilage pretty dramatically, and cause that shearing type labral damage, the Salvi's type 1 type tear, and it can be pretty dramatic even in young people. A lot of people, including Thomas Berg, calls this a silent killer of the hip because the cartilage, when you start to slough it off, you don't necessarily feel it. It's not only until the labrum tears that you start, you really feel it. And so here's just an example of what a cam type, or actually this is more of a mixed type if you look at it closely, because there's some femoral side and some mastabular side problems. But once you get into this hip, you realize this cam is just giving you this dramatic tear, and you can see this this caudal labral separation with a pincer deformity behind it, this large cam deformity. And clearly the treatment for this is going to be correcting the impingement. And if you had to give me only one thing I could do in this hip, it'd be taking down that cam, I'd leave the labrum and everything else alone, because if you just fix the labrum and leave the cam there, you know, that's going to be an incomplete surgery. Taking that cam out is really going to be critical. And so why did he tear his labrum? This is these repetitive collisions between the femoral neck and the rim, and over time it leads to cumulative damage and tearing. And again, it starts with the cartilage first, the labrum tears over time, and a lot of times these people will actually become symptomatic when the labrum tears, and that's when their symptoms will start to appear. There's a t-bone state without any meat on it, so it's important to realize that it's not just the bone, the soft tissue is critical. Again, this is an MDI of the shoulder, Dr. Dugas, and so you see folks like this, who are all bendy and twisty, and dancers and ballet dancers and gymnasts. It's possible for your hip to have micro-instability. The capsule isn't always that tight. You can have some some subtle dysplasia, and the hip joint itself can start to become loose. And so this is a picture of a girl's shoulder, and this is a video that I really enjoy doing. I don't like watching her do this. This is a, I did not operate on the shoulder by the way, but you can see if someone can spin their hand around 360 degrees, you have to imagine what the soft tissue inside that shoulder is trying to do to stabilize that joint, and so over time the hip joint can become compromised by this as well. And here's a video of me just basically pulling a lady's hip out with two fingers and traction, and if that scenario is existing in that hip, you have to realize that the soft tissue is a bigger problem than you think, and you have to correct that as well. You do some type of capsular flication. So this person, the instability patient here, Abram, ends up being the repetitive excess micro-motion within the hip joint, which leads to accumulation of chondrolabral shear and progressive micro-trauma. So you've diagnosed a tear. I made, I actually changed, I'm such a nerd when it comes to PowerPoint, sorry guys. I actually put a labral tear on that operation guy. You've determined the labral tear is symptomatic. I'm trying to keep the non-hip people involved. You figured out what tore the labrum, and now you got to fix it, and so that's what's going to be kind of the second half of this talk, is fixing labral tears, okay, which is really one of my favorite things in the world to do. So you got a big toolbox of different tools, of things you can do in it. In my toolbox, the hammer, no question is repair. You know, you can resect the labrum, you can take it out, you can augment it, you can replace it, but ultimately for me, repair is going to be the main thing in my treatment algorithm, unless there's a reason not to repair it, okay. So Ben Doan put out a great Gilligan article back about three years ago, where he has this beautiful algorithm and all these wonderful pictures, and I would encourage you guys to read as many things you possibly can about these algorithms. There's a reason why people like Ben and Tom Byrd and Chris Larson put these algorithms out, because they developed these algorithms over years and years and years and years of experience, okay. So and the evidence is starting to back up these types of experiential type tales. Dr. Byrd would always tell me, experience is me learning that I've made this mistake before, and so just this has been a lifetime of putting together these types of algorithms, okay. But ultimately, repair has great long-term outcomes, and I think that if you're, if you have repair in your toolbox, you're going to be in pretty good shape, okay. So basically, all the repair outcomes are going to be kind of hidden inside FAI kind of papers and plication papers, but almost all of these papers will be a high preponderance of labor repairs in these patients as well. So what about debridement? You know, debridement is a pretty easy thing to do. It's like a meniscus debridement, but honestly, the biomechanics really don't support it. You know, like I showed you that picture of the labrum sealing the joint, when you start resecting the labrum, you start to lose that, the sealing effect of labrum and the structural functional labrum. So you really want to preserve the labrum at all costs, in my opinion. There's only a few scenarios where I think a partial resection is appropriate. So clinical results also really don't bear it out. This Espinoza paper that he put together with Dr. Gons and Dr. Lunig and Marty Beck is one that's commonly cited in the debridement versus refixation kinds of things. These are shingled dislocations, and he saw much better results in the good, in the refixation group versus the resection group. This really plays out in all the literature. This is a Chris Larson-written paper as well, and really much better results with, with refixation. This is refixation after a pincer takedown or even a repair, but much better results in the debridement group, so just keep that in mind. If you read literature recently, there's been a lot of push toward primary reconstructions, right? So Brian White over in Denver is probably the biggest proponent for this, and he's, he's a guy who really likes to reconstruct everybody because he thinks the labrum itself is a pain generator, and he thinks it's more reproducible and predictable to reconstruct these labrums. I encourage all of you to read this controversial article that he put together as far as comparing these primary labral appearance reconstruction groups. There's a lot you can talk about that article, but he, he, this is an important thing for him. He really does believe labral reconstruction for being a primary surgery for people. So Andy Wolfe in D.C. is, is, is also showing really similar kinds of results. Now he's got a, his algorithm is a little bit different than Dr. White's algorithm, that he utilizes repair much more commonly, but he's also seeing good results of primary reconstruction, and so I think it is a useful tool, especially in these, these hypoplastic hips where, you know, the, the labrum itself, this is a primary hip we got into, and the labrum just looked pretty trashed, you know. The labrum that becomes ossified over time, you know, there's really not much you can repair if you take that ossification nucleus out, or those irreparable labrums, you know, so it's nice to have that in your, in your, in your bag of tricks for, if you get into the hip and you see this kind of scenario. Mark Philippon has really been a proponent for labral augmentation, and so he does, he takes native labrum, and he'll put a graph behind it to kind of buff it up a little bit, and his results have been really good. His results are always good, he's Mark Philippon, but his results have been really good as far as doing labral augmentation, even comparing it to segmental labral reconstruction. Now note this is a revision group, but he's been applying this in the primary setting as well for those hypoplastic-type labrums, so be aware that if you have a hypoplastic or irreparable labrum, you can augment it with a graph with decent results, you know, it's not the easiest thing to do, but you can do it, but I like this, this algorithm because it shows just how big the circle is for repair. This is Chad Mather, who put this into a recent Current Reviews article that basically gives you a sense of who's appropriate for repair, who's appropriate for reconstruction, who's appropriate for debridement and augmentation. You can see the debridement and reconstruction groups are pretty small in this overall Venn diagram. So what are the goals of labral treatment? First off, you have to correct the deformity. You've got to remove whatever is stressing that labrum out. You've got to eradicate the labrum as being the source of pain, so wherever the tear is, you've got to, you've got to fix it. You've got to give it a repair that's going to heal. You can't just throw a single stitch and expect it to heal. You've got to make sure it's a robust repair with a good bed to work the heal to, and it's important to restore that anatomy and function. Finally, you want to really cause minimal iatrogenic damage. You don't want to take the entire capsule out. You don't want to cause a bunch of scuffing on the cartilage because you want to make the hip better than when you got in there, okay? So what are some technical considerations? So the portal, so every single case you go into, you have to have an algorithm, right? You're going to do it. What portals are you going to use? What kind of capsulon you're going to use? How are you going to prep your rim? What type of anchors? Where are you going to put the anchors? How are you going to put the anchors, and how are you going to put your sutures? And so just have that sort of checklist in your mind. This is an article Brian Kelly put out with Will Robertson back in 2008, showing kind of the safe spot for portals. I tend to use these three portals almost in all my cases. Sometimes I don't use the dollop portal if I'm using curved guides, but, and very rarely do I use a posterior lateral portal. But, you know, these are pretty much the same in all my cases for most repairs, and so a lot of people cheat their anterior portal a bit more to the side, a little distantly, both to protect the LFCN and to get a better angle on your labral repair. So that's kind of what I use. So as far as rim prep, you need to correct the pincer if it's there. I don't think pincer, you know, I think you can do a lot more, have a lot more effect on the overall impingement of the hip if you do it on the femoral side, but if there's a big pincer deform in there, of course you want to take that down. Take down any ossis tabuli if you need to, but there probably is a trend away from just doing a routine acetabuloplasty, kind of like an acromioplasty in the shoulder. You know, I address the labrum when it needs to be, excuse me, I address the acetabulum when it needs to be addressed, but I don't just make it a routine part of the case. There's also a trend away from labral detachment. So it used to be you take the entire labrum off, you take the rim down, and then you'd reattach the labrum. We find this probably pretty important to maintain that interface between the cartilage and the labrum, and so what I tend to do is I'll tend to roughen the labral base, but I'm also trying to preserve the blood supply, and so I want a healing bed, kind of like you're doing a bankart repair in the shoulder, where you want to kind of, you know, put something in there to give the labrum to heal to, but you don't want to be too rough with the, with the rim. There's a bunch of different types of anchors you can use in the hip. In general, they're small and hard. A lot of peak anchors are used. These, you know, some of these anchors are as small as 1.4 millimeters, okay. You can use a knotted anchor, a knotless anchor, or an all suture anchor. This Q-Fix is a very popular anchor for the hip. It's a wonderful anchor you can use. It's pretty low profile. What a knotted repair looks like, I don't know, again, if this video plays real well, but you place the anchor first, and then you pass the suture second. It's a great technique, and I utilize it a lot if I can't see the rim. So if I do a pretty good rim prep, and I can see the rim well enough to put knotless anchors in, I might use knotless anchors more often, but sometimes you try to put a knotless anchor in, and you can't see the rim. It's hard to find that hole again. You do tie knots in these. I tend not to tie slide knots, but you do tie knots with these, and those knot stacks can be kind of proud. There are a couple areas where you're really careful. One is right beneath the iliopsoas tendon. A big high knot stack there can be a problem, so just be aware of that when you're tying these, and you want to tie low profile. Hold on, we're working on it. Am I in trouble? Jeff? Hey, Jeff. I think you're good. I think you just, you may be on a call. Okay, okay. My apologies, that's all. I just didn't know. People got so excited about my knotted repair. So the knotless repair, again, it's nice to be able to see the rim. In order to do these, you drill the anchor hole first, and in fact, I'll drill all my anchor holes first, you know, three or four at a time, then pass this ditch. This is a really fast repair. I'm using a loop technique here, as opposed to a mattress technique, and then you place the anchor here, and this is a great anchor, because after you place the anchor, it's still tensionable, so you can actually dial the tension in on the labrum, and so you can actually kind of roll the labrum back and forth, and sort of find that raffae you like to be kind of your interface, and your seal for the joint. So again, you can utilize these different types of repairs in the hip. So again, knotless versus knotted, you'll see that you want to keep the knot stack off of the femur. You don't want to have this thing abrading the femur. The knotless is a little bit lower profile. I think overall, these knotted anchors are probably a little bit more, I can't find the word, I've been talking too much. They're more, you can use them in more different places. They're more versatile, there's the word. So when you place anchors, I think this is the one thing about the hip that really, really ends up being important. You want to get it close to the articular surface, but you don't want to create these grooves in the hip joint. You got to be really careful, because especially anteriorly, the actual S-tab was like a knife blade, so it can be really hard to find that central spot. So when you drill the anchor, you're gonna be pretty close to the articular surface. You wanna be one or two millimeters off the articular surface because you don't want to evert the labrum too much. But as you place this anchor in, you wanna make sure that you direct it in such a way that it's gonna go right down the pipe. And I always watch the surface when I put these anchors in to make sure I'm not causing something in the actual hip joint itself. There's been plenty of kind of various things about kind of which direction you wanna go, but be aware that you can have two places you can penetrate, your articular surface or into the internal basically wall of the pelvis, okay? And so if you don't direct your drill guide basically approximately enough, you can actually have articular surface perforation. And it can be really problematic in these chondral wave cases where the anchor can be hidden beneath the chondral wave sign. And so again, you gotta be a little careful with how you direct these anchors when you put them in and watch the articular surface because nobody wants to see an anchor here during an origin situation. Conversely, you can also cut the medial side if you're not careful and you'll put an anchor proud. This could be right in the iliopsoas and sometimes can be an irritant in the iliopsoas tendon. The last thing you want after a hip scope is irritable iliopsoas tendon. That can be a real harbinger for a bad result. So yeah, psoas tunnel perforation I think is a much bigger complication than we make it out to be. So you don't want to overdo it. So you got to find that fine balance between the two sides. This is a great article that Mark Philippon put out. She's showing you kind of that knife edge, okay? And so as you get closer to that three o'clock position anteriorly, you get to see in this red area, it drops down precipitously. So your actual angle, your safety angle is much, much, much lower. As you get superiorly, you can see you have a little bit better angle, especially that sub-spine region. But then posteriorly, you can get a little bit of trouble with that posterior wall as well. So just be aware that the rim is different in different places. It's not like the shoulder where the entire rim is pretty much the same. It can be problematic, especially anteriorly. So use caution when placing these really anterior anchors. Curved guides can make it more helpful to get into these spots. I tend to use a curved guide anteriorly in a smaller anchor. I'll use a 1-4 or an all-center anchor anteriorly. I'm going to be putting this in my mid-anterior portal. So that's kind of where I put those. The sub-spine region, it gives you a lot more forgiveness. And so between 12 o'clock and two o'clock, that's pretty much where you have a lot more, I think, room for error. So I tend to use larger anchors here. I'll use a straight guide to a Della portal. And I love Nautilus anchors here, just love them. And then posteriorly, I'll tend to go back to a smaller anchor, use a curved guide, so I can kind of use that guide to direct it to the posterior wall. And generally, these will be to an anterior-lateral portal, very rarely to a posterior-lateral portal. The three o'clock anchor, a lot of times I'll put on, and again, this is gonna look like a shorter labrum THF, so I'll put it on the articular side and direct the drill guide almost back toward the hip, so I can watch it go in. That way, I know that it's not inter-articular, and I also know that I'm gonna be as close to the subchondral bone as possible. And so that can be a really nice trick to get really far anterior. And so that's a little schematic of kind of how I come to the articular side. As far as repairing constructs, you really have two main ones. You have a simple or looped construct, where the suture wraps around the entire labral substance. You get the entire limb with this, but you are worried that sometimes you can disrupt the suction seal. And Ben Dome, he wrote a lot of papers about this, and he really is a proponent of this labral base fixation, this mattress-type technique, where you actually will penetrate the actual substance of the labrum, and just try to get the base of the labrum repaired. And so it gives you kind of a cleaner interface and maintains that triangular shape of the labrum. The problem is you worry that maybe you're not gonna be able to get the entire labrum involved, or you're also, the actual process of sticking the labrum can cause injury. As far as what the survey would say, biomechanically, labral base fixation probably creates a more biomechanical repair that's more like the intact labrum, but really there's no clinical difference between the two. I used to do a lot more labral base than I do now. I find the labral loop, the loop suture ends up, to me, just giving me more confidence in my repair. So again, we talked about the different goals of labral treatment, you know, correcting deformity. Again, that ends up being, I think, the number one goal. You wanna remove the thing that's bashing the labrum. You wanna take away the pain generator. But ultimately, you wanna create this nice labral seal. You don't want the labrum up off the ball. You don't want the labrum everted. You don't want it inverted. You're trying to basically make it the way that it's supposed to be made. So it can be kind of challenging, but if you can get this picture and this beautiful seal, I think you're gonna have a happier hip. So, love Mike Tyson. Everybody has a plan until they get punched in the face. You go into your toolbox and your hammer, you got a labral repair planned, and you got some destroyed labrum that you can't fix. Yeah, primary reconstruction, I think, is an option. And this is a reconstruction talk, but I can kind of give you just my two cents on it. You know, Brian White and Andy Wolfe and Mark Falpone, they love fashion a lot of this IT band. Andy and Brian will use an allograft. Mark likes to use autograft for it, which makes a great graft. I've been using tibialis anterior. It already comes tubularized, but these are the kind of graft options you can use. You don't wanna make it too big. There's two types. There's segmental, where you're gonna basically be making a small, you're basically replacing a small part of the labrum in the injury area. Very similar to augmentation. You're gonna remove those painful fibers. It's a lot easier than a short-cut parenteral. You're gonna be using a smaller graft. It's gonna be much less challenging, but you worry about discontinuity of the ring. You know, it's like a radial repair of a meniscus. You know, it's gonna give you that hoop stress you need for this to be a normal functioning labrum again. And will there be irregularity of the anastomosis? Alternatively, the circumferential or complete labrum reconstruction, which is really what Dr. White and Dr. Wolf like to talk about mostly. It gets the entire labrum out. It's very challenging. It's gonna be a long graft. It's a long day. It might cost a little bit more. It's a much, much higher learning curve. That's, it's nice in that it takes the entire labrum out and you have a continuous graft that restores the seal quite nicely. So this is kind of my order of events. You know, your diagnostic arthroscopy will kind of be the first thing you do. Kind of looking at that labrum. You want to remove the labrum and prep the rim. I'll usually do this on traction just so I can see the whole thing. And then you want to complete all your peripheral work off traction. And so you got to make your femuroplasty perfect, you know, because that's gonna be, otherwise you're gonna have a labral graft in there with the femur that's gonna jeopardize the overall integrity of that graft. You know, while I'm doing this, while the fellow's doing this, you know, you can prep the graft and it takes about 15 minutes or so to prep a good graft. Prep it tight. You want a nice clean graft. And then what you can do is you can start, I usually place all the anchors first, you know, before I actually put the graft in and you're gonna show the graft in place. I show it to the most anterior anchor first and then sort of fix it in the back. Secure it anteriorly and then secure the posterior and cut off the access. And then it ends up being kind of a labral pair at that point or, you know, and so these videos you'll watch on YouTube will make it seem like, oh, this is so easy. It's really, really hard guys. And so don't make this your first step. I can tell you that. In fact, the last one I just did on Friday, I felt like I was a complete moron trying to do it. Just some pearls, practice, practice, practice. Go to the lab, go to the courses. You know, these courses are great that AOSSM offers, Anna offers, you know, different, you know, a striker, you know, arthritics that you'll offer. Practice, practice, practice. Really important for meticulous rim work. Capillary management ends up being really important. Spend some time on the graft. You know, you wanna place the anchors as close as you can to your articular surface. So you don't want that graft to be off the surface. And that's the mastomoses. So you figured out how to fix the labrum. So hopefully that was helpful. Now comes the hard part. You actually treat hip patients. And I think most of you guys realize that hip patients are not exactly Rubik's cubes. I guess they are Rubik's cubes. It's nice if they just, you know, you could just turn the sides and get a nice clean fix. You know, you'll see an ACL in your clinic and three minutes later you have surgery ready and it's easy. But hip patients require a lot more thought, nuance, algorithm. So what you gotta do, or what I did, was go to the masters. And so I'm not saying I'm a master, but these are pictures I took in the OR. I went and saw Scott Martin, Thomas Bird, Andy Wolfe, Shane Ngo, Chad Mather, Brian White, Chris Varson. I just went into their ORs, picked their brains, looked at their setup, took pictures, asked them questions, talked about their philosophy, and just tried to, I mean, if you're gonna be a hip arthroscopist, I think you gotta own it. You gotta really immerse yourself in it. I think dabbling can be problematic. And so these are the masters. And I would encourage you that all of these, the hip world is such a great world because everybody is so welcoming of students, of fellows, and then even of surgeons early in practice can learn how to do it. And so I encourage you to learn everything you possibly can. So a shout out to my current fellows and past fellows who've had to struggle through so many of my diatribes while scoping a hip. Ephemeroplasty is a, you learn a lot about somebody during ephemeroplasty. So just keep that in mind. But it is so worth it. Becoming a hip arthroscopist was one of the best things that happened to me in my career. And I hope that I can inspire one of you guys to become a hip arthroscopist with this. So I'll leave it at that. If you have any questions, I'm happy to answer them. I got to hang out with the red panda, by the way. That's like my favorite picture that I have with my former fellow, John. I held our bowls. All right. Hey, Winston, thanks for that, man. Really appreciate it. I see Latul on there and we'll take any questions. I see that picture there with Tom Bird. I'm sure you'd agree. He's a gentleman among gentlemen and one of the true giants, not just physically, but professionally, he is a gentleman among men. Yeah, well, I think that when you're a fellow, you look to people like that to kind of fashion your personality around, because the way he treats people is just so awesome. And so I did my best to kind of take everything I possibly could. And just like your partner, Jim Andrews, I mean, the same kind of thing, that kind of person makes a big difference. And these hip people, they need that kind of person in order to get used to these scenarios. Well, he was a fellow years before me with Andrews and Tom called him at the end of his fellowship and said, Dr. Andrews, what do you think I can do to make a mark in this world of what we do? And Dr. Andrews, in his typical way of thinking, he was thinking about it for two seconds and said, I don't know, figure out how to put a scope in the hip. He tells that story. He tells a lot of great stories, but he loves talking about how he got into hips and he just kind of wandered into it. And now he's the godfather of hip arthroscopy in this country. So find yourself a Thomas Byrd out there and you'll be very happy. So I must profess that I haven't seen the hip in 20 years. So I'm gonna have to count on Alex Johnson and all the rest of my fellows. I think Alex is on Benton's rotation right now. So AJ and the rest of you guys that are out there, if you have questions, speak up. That was a really good talk Winston just gave. So if you have any questions about this stuff, we don't have any way of knowing which programs or which fellows are on specifically, but if there's specific questions you have, don't hesitate to reach out. So my email is here and I have these forums. I know people, I guess on seven o'clock, people are like, I don't want to belabor this anymore. Be careful. I'll talk about hips really all night long as we've learned in the past. And so, but please email me if you want to come check out my practice. You know, one thing I want to do through the OSSM, I'm not sure if you remember this, Dr. Dukas a couple of years ago, but Atul Gawande was talking about surgeon coaching. And I've offered to my fellows coming to their ORs. It's a big learning curve in shoulders and knees. You know, your OR already knows how to do it. But like, what table do you need and what tools do you need? And so I think that all of us have to share in our experience in order to make this something, so. All right, we got two questions here. At least my people are paying attention. I'm proud of my people. So Alex Johnson or Alex Brown rather says, what table are you using for these label repairs? Any postless attempts? Yeah, so I do do postless. And so I did the Stryker kind of guardian table for a trial. It's like a hundred and some thousand dollars. It requires a little bit of overhead expenditure, but you can take a regular traction table and put the pink pad that OBGYN uses and take the post off and put it in 12 regions in Delaware. It works great, A. And B, if it doesn't work, you can put a post in pretty easily. It ends up being less expensive, less trauma on the perineum. Do I use a post routinely? Yes, I use a post normally because one, that's what my staff is used to. I think teaching fellows in a post is a little bit easier. My traction times are rarely over 45 to 55 minutes, and I haven't really had any issues with the post, but I think the trend will be toward postless going forward. And, you know, I think during the caps or management talk, they can talk about how the postless can work, but once you get like a joint that's vented and open, the postless ends up being pretty reproducible. Even for, the one that I don't use on Alex is skinny women, which makes no sense, but the skinnier you are, the less friction you can create in that pink pad. So, you know, a larger woman's probably a better scenario there. So I'm reading Megan Flynn's question. For hip reconstructions, how do you attach your first anchor with the graft? So I'll use at the four o'clock or four 30 o'clock position as close as I can get to the TAL. I'll use a curved anchor with a, it's a suture anchor, and I'll shuttle it. So I'll actually, I don't tie it to the graft. I pass it three times through. Once through, then around, then around the other side, then around the whole thing again. So it doesn't really slide, but there's not a knot there. Really important is to bring the stitch through one side and out the other side. Otherwise when you tie it, it will make a big bunch right there. So you want to tie it as close as you can make it until labor will repair. The lower you make it, the more bone you have, and the better your knot stack will be against the iliopsoas. So that's how I tied my first one. And I think Jordan is on here somewhere. It could be a complete thrash regardless, but it's a, I usually tie the first one and then the second one, and then I'll tie one up top and one in the back. But each one ends up being a little bit different. I'm not quite as reproducible as Dr. White. Cool. All right. There's one. Dr. Pullen, toss me. Thanks for- I remember all these, when you guys interviewed, it was great. So thanks for a great talk. Can you talk about your approach to contravene delamination, cartilage wave that occurs with labral tears. Given the congruity of the joint, is there a point where it needs to be addressed if you're doing adequate decompression labral stabilization? I 100% agree that the number one thing to do to treat cartilage damage is to address the whatever's causing the cartilage damage, okay? So I will leave a wave sign alone. I don't typically take it down and go behind it and microfracture it or put fiber and glue or anything like that behind it. If the flap is loose and there's a loose flap, I'll take the flap down. If the area is small enough, I tend not, I'm not a huge microfracture fan. I just feel like the hip is like five to 10 years behind all the other literature when it comes to cartilage repair. And obviously microfracture hasn't had a great track record for me. I have microfracture and I will microfracture, but I don't routinely do it. I'll do an abrasion chondroplasty, take out whatever is loose. But a lot of times I'll leave cartilage alone because if I address the deformity, then the cartilage will be under less strain and it won't be as big of a problem. I don't like to leave a completely ebernated hip joint, I can tell you that. So I like to leave as much cartilage in there as possible. But there's definitely a lot of new things, de novo, ACI, you know, things like that, biologics from the hip that we're trying. Chad matters in a lot with osteochondral grafts. So it's a great, great area for advancements. Cool. So again, that was awesome. I really appreciate you guys giving me this forum. I hope you guys liked it. I put a lot of effort into it because I want to make it interesting and inspire people. But if you're into hips, I mean, the hip chooses you, okay? So you'll find that you getting a job, a lot more appealing if you're a hip enthusiast because nobody else wants to scope hips out there. Cool. I don't see Jeff's going. Absolutely. And Winston, really appreciate you. Great talk. Thanks, everybody. Please, we'll see you tomorrow night and keep going. I think the hip stuff continues. So anyway, Winston, thanks for the time, man. Really appreciate it. Tell my friends at UVA I said hello. All right, you all have a wonderful night. Okay, bye. Thanks, Winston. We'll see you. Night, everybody.

Dr. Winston Gwathmey

hip labral tears

treatment

deformities

source of pain

labral repairs

labral augmentation

grafts

surgical techniques