Welcome to the Athletes' Hip, New Trends, Controversies, and Contemporary Surgical Management webinar series. Before we get started, we'd like to review a few items. First, if you need to adjust your audio, please refer to the Audio tab in User Devices Audio Settings. To submit questions throughout the evening, please click the Questions tab, type in your question, and click Send or hit Enter. Next, a special thanks to our course chairs, Drs. Gwathmey, Huskone, and Ngo, for their work on this online educational opportunity. And lastly, here are AOSSM's upcoming meetings, which include the AOSSM AAOS Orthopedic Sports Medicine Review Course, Baseball 2020, Youth to the Big Leagues, Managing the Developing Player, and the Advanced Team Physicians Course. With that, we'll get started with this evening's program. Thank you all so much for joining us. Welcome to the second webinar on the Athletes' Hip, New Trends, Controversies, and Contemporary Surgical Management. Tonight, we will be discussing and we'll have some interesting debates surrounding intraarticular techniques, which Dr. Ngo and Gwathmey will be refereeing. I would like to again thank AOSSM leadership for supporting this virtual endeavor. Remember, please type in questions for the debate and also the question and answer portions during the webinar. Okay, this is Steve Aoki. I'm going to go over hip arthroscopy on the setup, access, and diagnostic arthroscopy. Here are my disclosures. So the first step is to evaluate your surroundings. There's a lot of equipment associated with a hip arthroscopy, so you need to be able to have a room large enough to accommodate. You need to know what type of distraction table you have available, whether it be a hip arthroscopy-specific table or a trauma fracture table. You need to know how to use it. There's a lot of specialized equipment associated with hip arthroscopy, so make sure that you talk to your hospital, your staff, and your reps to make sure it's all there. And I would recommend to use fluoroscopy initially at least to make sure that you can check your work and make sure that you're doing a good job from a standpoint of the bony work. Now I'm going to go through two ways of approaching a hip scope with a setup. We're going to go over the post type of table first. I would make sure that you pad the heel, that you really secure that foot, and test your distraction prior to draping and make sure that you're not getting any slippage. One of the nice things about the time that we live in is that there are endless resources for us to be able to help us with our profession. There are numerous technical guides out there that can be really helpful that include really detailed videos. I'll touch base on one of our videos that we put together, the one in the yellow here a little bit later. Now these are the typical portals that I use. This is the anterior lateral portal for visualization. My modified anterior portal is my main working portal. And then I use the dollop portal for placing my labral stitches, and I also use it for placing my retraction stitch. So this is my initial distraction when I use a post table. I will abduct the leg first and then pull gross traction, lock the table in position. It'll get me some distraction typically, and then I'll slowly adduct the leg, and that gets me the rest of my distraction so I don't have to use the fine crank. So we're going to get started with just first drawing out our anatomic landmarks. You got greater troch, anterior posterior femur, and mark out my anterior superior lac spine, draw a line straight down from there. This is just marking out to give you an idea of where I'm going to put my anterior lateral portal and the modified anterior portal, which is just lateral and distal of a classic portal. I like to first line up my spinal needle, and I want to have it so that it's lined up. I take a floral spot, and I check the floral spot to just get a general idea of the direction that I'm headed. I want to overlap the femoral head, and that allows me when I'm placing my spinal to be in that anterior quadrant in that larger triangle region that allows me to get in between the femoral head and the labrum. So this is popping through the capsule, and I want to place my guide wire so that when it comes in straight and goes right into the medial wall and overlaps that femoral head. So why aim for the femoral side? This is a schematic showing you the acetabulum and the femoral head. When you're looking at the clear space, you're effectively looking at that distance between that front of that acetabulum and the femoral head on the superior surface. Now if you're placing that spinal needle into the clear space, you can be anterior, middle, posterior. They all look the same on a two-dimensional fluoroscopy view. As you drift a little bit more posterior, you're more likely to get into that labrum. I like aiming in that area overlapping the femoral head because it helps keep me in front anterior to all of that tissue, and it minimizes my chance of getting into the labrum. So when I'm coming in with my spinal needle, I want it to come in and overlap that femoral head. I want that bevel towards the head and the tip turned away from the head so I'm not scraping the cartilage surface. When I'm inserting my guide wire, if I'm coming in and it's bouncing off the femoral head, it probably means that I'm aimed too far posterior and I need to adjust my needle. So then you can adjust it a little bit more anterior, and that gives you that straighter shot into the joint. Now this is an old video of mine where I used to take the spinal needle and play around with different positions and then check what it looked like on fluoroscopy. So this is just placing it in that kind of the widest area between femoral head and labrum. You can see that the corresponding fluoroscopy view has it overlapping the femoral head. Now I'm going to take and I'm going to switch that spinal needle and then I'm going to place it into the soft tissue into an area where I'm going to pierce through the labrum, and then you can see the corresponding view on fluoroscopy where I'm going to the clear space. Now I'm not saying that you can't get into the joint safely by using the clear space. You just have to be aware that if you're aiming for the clear space, it can allow you to drift posteriorly and get into that labrum, and you have to know that feel. So now we have our anterior lateral portal set up, and now we got to set up the anterior portal. If you ever have a difficult time trying to triangulate and get into the joint, there's an easy technique that allows you to get into the joint by using fluoroscopy. So you take your spinal needle, you go down until you hit capsule, and if you take a fluoro spot and you're aimed a little bit more lateral, then you adjust and you got to aim more medial. And I want you to aim for that area right below where you see your scope tip. And so adjust, bring it back down, hit capsule. You have to be on capsule in order for this technique to work. Once you're down into that zone right below your scope, then you can switch and look at your arthroscopic view on your screen, and then you can look for the tenting of the capsule and then make minor adjustments in order to get into the joint. So here's an example. Once you've got it in the right place, then you can watch that tenting of that capsule and you can bring that needle in. I like to make sure that that bevel edge is turned on the femoral side so that you're not scraping with that tip of the spinal and causing iatrogenic damage. So we're going to switch gears a little bit. We're going to talk about a post-free distraction table. This is using Trenlenberg position, using the body weight as counter traction in order to get the distraction at the hip joint. So for a basic setup for a post-free distraction table, I have the feet right at about shoulder level. I have the hip at my working hand height. I set up two mayo trays. I like my first mayo tray to be the one that holds all of my cords so that I can reach and grab. And that's sort of my space when I'm operating. And then I have another tray which holds all the instruments. And then the scrub tech adjusts the instruments that are on that tray according to what steps we're on. And then I adjust the fluoro so that it's tilted to match up with the Trenlenberg position. So let me back up a little bit. I always test the foot before I do any draping to make sure that I'm getting distraction because there's nothing like having to re-drape because your foot starts slipping. I like using a C-arm drape on the controls because that allows me to do all the manipulating of the lower extremity myself. And particularly because I like doing an interportal capsulotomy that I need to be able to move that leg and put it right where I want it in order to visualize in that peripheral compartment. If you're ever struggling to get the hip to distract, then I would recommend that you vent and just put a spinal needle down on the neck of the femur and then do an air orthogram and break that seal of the vacuum. And that can help get that distraction. So setting up the anterior lateral and anterior portals are similar to what I showed previously with the post table. I'm going to show you the dala portal now. This is just triangulating between my other two portals. And then I use a blunt switching stick to slide over the top of the capsule. And I find this to be a lot easier than using a spinal needle where you can pretty much put that needle anywhere. I can do it bluntly. I slide my sled and then I put my guide over that sled and then I'm ready to go for placing my labral sutures. And so this is that blunt switching stick sliding over the capsule. I switch it out with the sled and then I bring in my guide so that I'm ready to start doing my drilling. And here's that guide. So let's talk diagnostic scope. Let's start with the central compartment. I'm going to go into the hip joint. We're going to start by first using that 70 degree scope to visualize the labrum. And I really make minimal movements with my hand and it's all moving that scope cord. 70 degree scope looking all the way around the periphery, drop in a little bit further so I can see the cartilage of the acetabulum, see ligamentum, go over to the femoral side, swing around and use that 70 degree scope to essentially scan the entire area of both cartilage surfaces and the central compartment in its entirety. The next is in the peripheral compartment. I drop medially. This is looking down at the medial synovial fold by the lateral retinacular vessels. You can see zona obicularis. I want to see all the way down that neck. I want to be able to see the cam lesion and you can drop your scope and get behind and then you can visualize your medial circumflex vessels oftentimes on the backside. And then I'm going to go ahead and Hello, Benjamin Dome here from the American Hip Institute in Chicago. This talk is on rim and subspine resection. My disclosures are listed with the AOS. Now under resection and over resection can both be problematic in treating the rim and the subspine. As Victor Hugo said, to put everything in balance is good. To put everything in harmony is better. And this is particularly critical in addressing the rim. So pincer type impingement can cause injury to the labrum. This is a primary labral injury with mucoid degeneration or intrasubstance tearing, sometimes with calcification. It can also cause damage to the periphery of the cartilage. And if we under resect a pincer impinging hip, this may lead to further damage. On the other hand, an over resection can lead to worse problems, such as iatrogenic dysplasia as seen in the x-rays on the right, which led to a rapid onset of arthritis. Now there's global overcoverage and there is relative overcoverage. And these are two somewhat different animals, which need to be treated differently. On the left, you can see the crossover sign indicating the retroversion of the acetabulum, which is essentially relative overcoverage of the anterolateral rim compared to the posterolateral rim. Other signs of retroversion include the ischial spine sign and the posterior wall sign. Whereas on the right side, we see global overcoverage, where the acetabulum is simply deep and it's overcovered almost throughout. Preoperative planning is absolutely paramount in importance for rim resections. So we start with our drawing of the anterior and posterior walls on the x-ray. And remember that an x-ray is a two-dimensional visualization of a three-dimensional object, but we can actually learn most of what we need to know based on the AP pelvis x-ray. So the white dots on the left trace the anterior rim and the black dots trace the posterior rim. On the right side of the screen, you see the technique that we'd published in arthroscopy techniques for templating. So we draw this blue line, which is essentially the ideal or optimal anterior acetabular rim. Then we measure the distance between the actual rim and the optimal rim at each position on the clock face. So here we've shown this at 12 o'clock, 1 o'clock, 2 o'clock, and 3 o'clock, and we've templated the maximal amount of resection at each of those positions on the clock face. Now we'll never trim more than that maximal resection that we've pre-templated, but sometimes we might trim less. If we find there's pathology at the position we templated, then we trim the templated amount. However, if we find an absence of pathology, then we may trim less or not even trim none at all at a particular position on the clock face. Now, acetabuloplasty without labral detachment was developed in the early 2010s. This was a paper that we published in 2015 on the technique, and prior to this, labral detachment was typically performed before performing an acetabuloplasty. So we'd detach the labrum, trim the rim, and then refixate the labrum, and that's how labral repair got the name labral refixation at that time. However, we demonstrated that we could successfully trim the rim without labral detachment, hence preserving the chondrolabral junction in this paper here. One of the keys to this technique of acetabuloplasty without labral detachment is the views, and the upper deck view is what's shown here in the bottom left. So here we have the scope between the labrum and the capsule. So we're looking at acetabular rim here. The burr is on the rim. That's the labrum. That's the capsule. This is an alternate view, which is the bird's eye view, where we look from outside the joint back in on the labrum, the acetabular rim, and the capsule. And using the combination of these views, we can very successfully visualize the acetabuloplasty without doing a detachment of the labrum. The upper deck view decreases the chance of the upper resection due to the 92% likelihood of a residual beak of bone if the view is not used during rim trimming. Now iatrogenic overresection can be a huge problem. This study by Josh Harris and company demonstrated 11 cases of dislocation have been published in the literature, and numerous others, innumerable others, have occurred and not been published. Of these, five had postoperative acetabular undercoverage, six underwent rim trimming, three reported overresection. Now probably an even more common complication than dislocation is dysplasia after rim trimming. So iatrogenic dysplasia caused by an excessive rim trimming or rim trimming in a hip that was not particularly overcovered in the first place. This iatrogenic dysplasia can lead to the rapid onset of arthritis, as you see in these x-rays here. Fortunately, we are able to do a PAO, a periacetabular osteotomy, as a salvage in cases of iatrogenic dysplasia if we catch them early enough before they become arthritic like this. Acetabular retroversion was traditionally treated with an antiverting PAO, and this is a very powerful procedure. And the reason that we performed antiverting PAOs for these was because the focal anterior overcoverage is accompanied by a posterior undercoverage, or posterolateral undercoverage. So the concern is that if you trim the rim anteriorly, you could actually lead to global undercoverage because you're already starting out undercovered posteriorly, and now you trim the rim anteriorly. Having said that, in most cases of focal retroversion, we've shown in this paper back in 2016 that we're able to treat them successfully arthroscopically with a conservative rim trimming of the anterolateral rim and preservation of the capsule with a capsuloraphy or a capsular plication to preserve stability. This is a case of global overcoverage, and this presents a particular challenge both clinically and surgically, technically. This is not a 100-level or even a 200-level case. It's really a 400-level case in the arthroscopic world. This can be done through a surgical dislocation. An open surgical dislocation is a very powerful approach for a case like this, and we can trim the rim circumferentially. But arthroscopically, we've also developed the techniques to be able to address the rim circumferentially from 7 o'clock at the posterior attachment of the TAL all the way around to 5 o'clock at the anterior attachment of the TAL. So you see the pre-op on the left and the post-op on the right, and we've done a circumferential rim resection. Now, how did we do that? How did we get into this joint? This can be a very challenging joint to enter. We entered this using a peripheral compartment first access technique where we can perform the capsulotomy under direct visualization. This is a very valuable technique. You can laterally extend the capsule here on the left, and on the right, you'll see we complete the capsulotomy. Once we complete the capsulotomy, then we can gain enough distraction to be able to actually enter the joint with the scope and do so in a safe fashion. Subspine impingement. Classification has been described by Hastroni et al. Type 1 is an AIS above the joint line, type 2 is at the joint line, and type 3 dips below the joint line. This can be congenital or post-traumatic. Clinically, it may manifest as pain in deep hip flexion with or without limited adduction or internal rotation. Indications for surgical treatment are type 2 or 3 subspine impingement with symptoms with straight flexion. Capsular management can be challenging. The anatomical group looked at the anatomy of damage to the capsule and stabilizers during subspine decompression and found that there is, in fact, damage to the anterior capsule, which is important to understand. Based on other anatomic studies, we've tackled this using three windows at American Hip Institute. The first is between the labrum and the capsule, the second between the capsule and the rectus, and the third working superiorly to the rectus. Using all three of these windows, we can minimize the amount of damage done to the attachments of both the capsule and the rectus femoris. The capsular window is shown here as well in Larson's study, which demonstrated excellent outcomes after subspine decompression in their later clinical study as well. This is an interesting case of subspine impingement after an AIS avulsion. You see this very large avulsion fragment. This makes for a very difficult arthroscopic access, so the way we approach this is to do the open procedure first, and through a DA approach, remove that fragment of bone. We have to detach the rectus femoris to do it. Then we did the arthroscopy, so we can pack the wound and do the whole arthroscopic procedure including the labral repair. On the left, you see here the rectus femoris is repaired through the open window with multiple anchor repair. Pre-op on the left here and post-op on the right, you can see a dramatic difference. In summary, everything in nature is about balance. When approaching the rim and the subspine, we have to strike that balance, and we have to make sure to avoid over-resection while still addressing the source of the impingement. Thank you very much. Thanks, Ben. I greatly appreciate that. Next is Marc Philippon, one of my favorite Canadians. He's the orthopedic surgeon and managing partner at the Steadman Clinic. Thanks, Marc. Hi, everybody. Today, I'll talk to you about the treatment algorithm for the labrum that we use. These are my disclosures. We know that the labrum has multiple functions. It really helps in the creation of a hip fluid seal. It reduces stress and consolidation, provides us with stability, and it absorbs about 1-2% of the load across the hip joint and increase the contact area of the hip joint and decrease the cartilage contact pressure. Unlike microscopy, you can see here the external zone and the internal zone, and in the middle, the transitional zone. Internal zone face the femoral head, and the external zone face the capsule. Scanning it through microscopy, we can look at it three layers. Layer one, superficial, is a network of randomly arranged fibrils. Layer two, we have interstitial fibrils at various angles. And layer three, the majority of the collagen fibrils have circumferential orientation. We can still debride the labrum and have a great outcome. Most of the time now, I believe most surgeons will repair the labrum. They have adequate tissue. If it is not adequate volume, reconstruction, augmentation are options as well to help our patient. So the algorithm we use, if we have a tear with a healthy volume, I'll repair the labrum with 2-3 sutures. If there's a defect with the labrum, it's degenerated with decreased volume, I'll augment it with IT band autograph. And if there's a segment that's calcified or absent, we'll do segmental reconstruction with IT band autograph. So you can see here at the top how we fix the labrum with suture anchor, loop suture, or intra-substance suture, depending on the position where we want the labrum. We want to preserve the convalescent junction and stabilize the junction. It's very, very important. And then, obviously, when we repair the labrum, the end point is that we want to restore the seal. You can see here the traction has been released and the labrum has a great seal. So outcome of labral repair versus debridement. We know that selective debridement in female patient versus labral repair, a good study done by Dr. Coleman and others, showed labral repair having superiority. We recently published also a follow-up on 10 years on our patient, and we found that depending on the circumstances, also very good result with debridement in comparison to labral repair. So I think both options are available depending on the situation. The labrum is an important structure. We try to preserve it. And again, if we can't preserve it, we will reconstruct it or augment it. Again, I think it's important to understand its role. And it also has proper receptors, inertial receptors. So here you can see on this video, sanguineous extravasation of a central compartment because the labrum has been captured by a capsule, capsule labral adhesion. You can see that clearly there. So I think in this situation, in this video, the labrum appears to have adequate volume. So releasing the adhesions might be sufficient, but we've evolved to include augmentation and spacer if we feel it's going to have a reoccurrence. Segmental reconstruction, you can see here this patient has almost no labrum, very inflamed tissue. So this is a great candidate for a segmental reconstruction. So why do we reconstruct it? Well, we want to reproduce the seal and provide stability to the femoral head acetabular complex. We have good literature that has been published. Dr. Nipple, when he was here in Vail, did very good studies on this, on the cataract model. We here have a patient who's had previous surgery with the baseline tissue that appeared to be viable and has remnant of labral circumferential fibers. So we feel in that position, in that situation, we feel that augmentation is appropriate. This is looking at a segmental reconstruction. We feel that augmentation is appropriate. This is looking at time zero, the native labrum on top, the graph inferiorly or approximately. You can see how we like to place it. So if we look here, this is a case report we published a few years back in the GBJS, a seven and a half year follow-up. You can see the augmentation at time zero. And then at seven and a half year post-op, we can see the augmentation, greater incorporation. But also we can see the seal that has been preserved. You can see the head and neck junction coming approximately in contact with our labrum. And very good seal has been preserved. Took a biopsy. This is how it looks. A good fibrocartilage with cerebral cell tissue. And again, in augmentation, sometimes I'll use my graph as a spacer to prevent reoccurrence of adhesion to the labrum. Conclusion, I think it's important to pick the correct technique for every situation to restore the labral function. A good joint environment will certainly improve the health of the joint long-term. And we have good outcome studies with cadaveric study that showed that labral reconstruction improved the joint biomechanics. And preservation of the native labrum through augmentation has shown improved clinical outcome without increasing pain. And with proper technique, I think our patient can expect very good results and return to their activities. Thank you. Thank you, Mark. Next up is Dr. Shane Ngo. I'm very fortunate to have him as a co-chair of this course. Coming from the Hip Preservation Center at Rush. Shane will be talking about optimizing the CAM correction. I want to welcome and thank all the virtual attendees to the AOSSM Hip Arthroscopy course. My name is Dr. Shane Ngo from Rush University Medical Center. And I am one of the course directors along with Dr. Brian Busconi and Dr. Winston Gwathney. My topic today is on optimizing the CAM correction. My disclosures can be found on the Academy website. I am a consultant and receive royalties from Stryker Endoscopy and Sports Medicine. The most common reason for a failed hip arthroscopy is a lack of correction or the incomplete correction of the underlying femoral acetabular impingement morphology. Satanovich and colleagues recently published a systematic review in 2016. And they cited that 81% of all cases of failed hip arthroscopy were due to residual FAI. We also know that residual FAI morphology leads to a high failure rate and an inferior clinical outcome. However, we do not understand the biomechanical basis of the CAM effect on the hip joint. So we want to answer the question, what is the biomechanical effect of a CAM deformity, partial CAM resection, and complete CAM resection using contact pressure testing and three-dimensional morphologic analysis? We selected cadaveric specimens with a CAM deformity. We perform an open partial CAM resection. And in the same specimen, we performed a complete CAM resection. And we perform contact pressure testing between each intervention. Using a tech scan, we obtained contact pressure, contact area, and peak force. This is a characteristic heat map comparing CAM deformity, partial CAM resection, and complete CAM resection. And you can see that when you go to a complete CAM resection, there are very few red spots, which indicates lower contact pressure compared to the other groups. Interestingly, we found that peak force was highest in the partial CAM resection group. So now that we understand the biomechanical and clinical basis for CAM resection, how do we optimize our CAM correction? I think this starts with three different phases. First is planning, second is access, and last is execution. In the office, I obtained plain x-rays as a workhorse for my workup for any patient with hip pain in a young adult and non-arthritic case. I like to obtain an AP pelvis, a false profile, and a 90-degree done lateral view. If I'm concerned about a complex CAM deformity, I have a low threshold for obtaining a CT scan with three-dimensional reconstruction. This will allow me to understand the personality of this specific CAM deformity. In addition, there are now available software programs that will help to quantitate your CAM deformity. In this particular patient, you can see that while the majority of the CAM deformity resides within the 12 o'clock to 3 o'clock location, there is a significant lateral extension between the 12 o'clock and the 11 o'clock position that must be visualized and must be addressed in order to comprehensively correct this CAM deformity. In terms of access, there are basically two most common reasons or common ways to access the joint. One is through an interportal capsulotomy, and the second one is through a T-capsulotomy. Both have their merits, but depending on which capsulotomy you may employ, this will dictate the amount of flexion, extension, rotation that might be required in order to obtain the harder-to-reach areas. The interportal capsulotomy is a capsulotomy that is performed connecting the interlateral and the interportal. I like to do this with a beaver blade, and I like nice perpendicular capsular incisions. I'll then use a traction stitch to help retract the S-tabular side of the capsulotomy so I can access the pincer deformity as well as perform my labor repair. Once the central compartment work is done, we will turn our attention to the peripheral compartment. In this case, we will debride the pericapsular fat tissue, and I would implore you to do this completely so that not only can you visualize the anterior capsular tissue, but it will facilitate visualization at the conclusion of the case when you have to repair the capsule. Here, we'll go ahead and place one traction stitch to the medial liftlet, and a second traction stitch to the lateral liftlet. At this point, we'll use a hemostat to then pull maximum amount of traction so that we're able to retract the capsular tissue to give us full access to the entire peripheral compartment and the majority of the CAM deformity. In terms of execution, you want to understand what positions of the leg will allow you to see which areas of the CAM deformity. 1145 requires that the leg is in extension and the foot is in interrotation. 1230 is with the foot in neutral, and 1 o'clock is with the foot in extrarotation. Next, if you flex the hip up to 50 degrees, this will show you the 1145. If you actually rotate to 40 degrees, this will show you 1215. If you actually rotate to 40 degrees, this will show you 245. I like to begin, generally speaking, with the leg flexed at 30 degrees. At this point, I'll then mark my proximal extent. In addition, I'll also try to connect the medial extent, and I will follow the labrum so that I can have a decent idea as far as where my deformity lies. In order to obtain that far lateral area, especially beyond the 1230 position, you want to flex and internally rotate the foot. Again, I'll use fluoroscopic imaging to determine how proximal I need to go. Remember, in this particular patient, he has a far lateral extension. In some cases, when patients might have to go beyond that 12 o'clock position, distracting the hip can be very helpful. Here, we have the hip distracted. This will allow you to access really that 12 to 1130 to 11 o'clock position. We can obtain fluoroscopic imaging to simulate our morphology. We'll go ahead and continue our resection until we're happy with the amount of correction that we are able to see. In order to access the medial cam, we'll go ahead and flex the hip up to 40 degrees, and in some cases, we'll externally rotate as well. We want to follow this all the way to the 6 o'clock position, and we want to have nice broad strokes to continue between the medial cam, the mid cam, and the lateral cam. We also want to ensure that we've removed all our periosteum, and that we can see the medial synovial fold so that we are as medial as we need to get. So our pre-resection alpha angles compared to our post-resection alpha angles at 1145, 1230, and 1 o'clock show that there's excellent correction from pre- to post-op. And when we carry this over to 145, 215, and 245, we're able to comprehensively correct the alpha angle to less than 42 degrees, Our x-rays show that on the left, preoperatively, we can see that there's a large lateral cam extension. And on the right, our post-operative view with a patient in the office, you can see that we've corrected that lateral view, so that he's got a nice spherical femoral head. Likewise, on the lateral view, you can see that while there is a flattening or a loss of offset, we've corrected that lateral view, so that he's got a nice spherical femoral head. Likewise, on the lateral view, you can see that while there is a flattening or a loss of offset, we have restored that offset in the post-operative view. So in conclusion, residual FAI may result in clinical failure after hip arthroscopy. Cam impingement can increase contact area and contact pressure. Understanding the three-dimensional path morphology with CT scan can be very helpful to understand the personality of the cam deformity. Use multiple fluoroscopic views to optimize your cam corrections so that you can execute what your surgical plan is. Thank you very much, and we appreciate your attendance. Thank you, Shane. Next up is Josh Harris from the Houston Methodist Academic Institute. He'll be talking to us about capsular management, and we'll be having a debate later on regarding this. The title of this presentation is Capsular Management, and I'm Joshua Harris. I'd like to thank AOSSM for the opportunity to present during the athlete's hip. Here are my disclosures. And so 10 years ago, we would routinely leave the interportal capsulotomy open during most arthroscopic hip preservation procedures. Now the pendulum has swung, and now we routinely completely close the capsule with most hip arthroscopies. Competence for capsular management and routine closure has significantly increased over the past two decades, and now even some authors are questioning, what were we thinking with not closing the capsule? The reason for this, as you can see here, is the possibility for anterior hip instability and frank dislocation if the capsule is left open or if the repair is disrupted. Fortunately, this is a very rare complication. We studied this a few years ago in which we published a systematic review, and only 11 dislocations were reported in the literature. Only two of those capsules were closed, and interestingly, they were all interportals. No T-capsulotomies were performed. However, a more interesting topic is that of micro-instability. Micro-instability is a subject that is growing in popularity, and micro-instability has been published by Dr. Mark Safran. We have looked at this as well. The role of micro-instability is a very nebulous concept, and it falls on the stability spectrum with most patients complaining primarily of pain but also of instability symptoms with apprehension, their hip feeling loose, or even internal or external snapping. There are many ways to go about managing the capsule, and at the start of the case, there are many ways to expose your central and peripheral compartments, and Steve Aoki described this very, very well. In trying to drive from Denver to Salt Lake, you can go about it multiple different ways, and the same concept applies with hip arthroscopy. As Dr. Aoki reports here, he prefers the interportal. I'm more of a T-capsulotomy surgeon. As you can see here, there's a very big difference in visualization. With the interportal shown here on the left, the interportal capsulotomy perpendicularly cuts your iliofemoral ligament fibers, whereas the T-capsulotomy also adds a vertical extension. However, this is parallel to your iliofemoral ligament fibers down the anterior femoral neck. The T-capsulotomy does provide significantly increased visualization, and if you can't see it, you can't treat it. You certainly wouldn't drive down the highway without your windshield wipers on, as you can see here, and I think that the same concept applies with the peripheral compartment. By using a T-capsulotomy, it really affords you the best visualization to really adequately see what you're trying to treat. However, a caveat with this is make your cut big enough to see, but no bigger. An alternative is just bring the pathology to the window that you're viewing and not make the window bigger to see the pathology. This concept is really your suture suspension technique. This is a very, very nice way to place some capsular suspension stitches to really provide the best visualization of your peripheral compartment, as you can see here. In my practice, not all capsules are closed, but most are. Greater than 95% of my cases are nondisplastic, nonarthritic, and those are the cases that I'm routinely going to close. I typically do not close tight hips, male more than female, older patients, or any with minimal arthritis. A caveat with capsular closure is do not use a capsular repair, placation, or shift to treat structural instability. That is a situation in which a PAO is the right surgical choice. Same for Ehlers-Danlos. Is this really the MDI of the hip? Time will tell. There are limited publications showing short-term and mid-term results can achieve good or excellent outcomes. However, this does require a significant skill in watertight closing your capsule. Remember, the capsule is a ligament. This is the iliofemoral ligament. In many ways, it's very similar to that anterior cruciate ligament, your ACL, as you can see here. If we recall back to how ACL repairs did, we're essentially doing the same thing with capsulotomies and capsular repair. We're cutting a ligament and then repairing it during the same case. More and more literature is needed to really evaluate how our capsules heal with routine closure. We've studied this in the lab. We know what happens when you cut it open and then when you repair it. The capsule is an important structure for hip stability. After the break in your suction seal, the capsule is the single most important structure that resists hip distraction, as Dr. Philippon's study recently has shown. There are many ways to go about closing the capsule. I will routinely perform a side-to-side repair. You can also perform a capsular subtraction, where you move a small amount of capsule and then side-to-side repair it. You can also use suture anchors in your acetabulum. You can also perform an inferior capsular shift, or even augment or reconstruct your capsule. A very important part of managing your capsule is before the actual surgery has even begun. This is with a good examination under anesthesia. You can see with very easy resistance to distraction, this is an Ehlers-Danlos hip in a revision setting. Similarly, resistance to lateral vector force. You can see with capsular deficiency, the femoral head is grossly unstable in the acetabulum. A very, very important key is preserving proximal capsule. This is all at the start of your case, and so make sure that you leave yourself something to close at the end. I routinely leave at least 10 to 12 millimeters on the proximal side, so you can place between 2 and 4 sutures on that proximal part of your capsule to do your capsular repair. Another important point is for surgeons that use a T-capsulotomy, avoid cutting the zona. The further distal you go with your T vertical extension, the more you may disrupt the zona. Even with a repair, it may not restore that normal biomechanics and the resistance to axial distraction. I prefer tape rather than suture for both the T and interportal limbs. We've shown in the lab with our group that the tape does a significantly better, stronger repair than suture. And the rehab is just as important as the surgery itself. A perfect capsular repair can be completely disrupted if the patient is aggressive in extension and externalization early on in their postoperative rehabilitation. Part of the capsule is also, it's a piece of interposition tissue, and it goes between the joint and the overlying soft tissue musculotendinous structures, specifically your rectus and your iliopsoas. And if you don't have that interposition, muscle can herniate into the joint, causing both pain and snapping. And in revision settings, primarily, you have to be prepared to potentially either augment or reconstruct your capsule if the capsule is significantly deficient and you cannot perform a primary repair. A new concept that is significantly growing is the role of capsulolabral adhesions and their role in postoperative pain. This can be medically managed following the primary arthroscopy with an anti-TGF1 beta medication, Losartan, which is primarily used for blood pressure, but does significantly reduce adhesion formation. And this can hopefully reduce the rate of capsulolabral scar after hip arthroscopy. So in conclusion, capsular management is a very critical part of a successful arthroscopic hip preservation program, and with good patient selection and meticulous technique, you can optimize your outcomes. Most cases now involve routine capsular closure, and postoperative rehabilitation is just as important as the surgery itself. Thank you. Thanks, Josh. So we're going to change up a little bit right now. So we're going into a debate format now, and we're going to talk a little bit more about the capsule. We're going to have some fun. The first debate is going to be on capsulotomy technique. Dr. Mark Saffron is going to champion the periportal capsulotomy, whereas Steve Aoki will champion the interportal capsulotomy, and Dr. Chad Mather from Duke will talk about the T-cut capsulotomy. And we'll have some discussion. I would like to thank the AOSSM and Drs. Biscone, Guatemi, and Ngo for allowing me to participate in this debate. By stance, don't cut the capsule. Our lab has shown that the femoral head moves 3.5 millimeters in the medial lateral direction and 1.5 millimeters in the anterior, posterior, and proximal distal directions with hip range of motion in a cadaver. Shock metatrainers group showed by MRI that the femoral head can sublux on average 2 millimeters in asymptomatic ballet dancers when scanned doing the splits when compared to standard supine scanning. And even our own Dr. Aoki has shown more elaborately with biplanar fluoroscopy that there's femoral head motion relative to the acetabulum with hip range of motion. When surgeons do an interportal capsulotomy, they have to cut the iliofemoral ligament. And when they add the longitudinal arm of the T-capsulotomy, they may also cut the zona obicularis. We've shown that when you join the anterior and anterior lateral portals, you must cut the iliofemoral ligament. Here you can see schematically and with the cadaver specimen that if you do an interportal capsulotomy, you must cut the iliofemoral ligament. And if you do a longitudinal T-capsulotomy, you may also cut the zona obicularis. We've shown that the zona obicularis is the most important capsular ligamentous structure resisting distraction displacement. So the question is, will cutting the iliofemoral ligament and or zona obicularis function normally, if at all, after you cut it with or without repairing it? My esteemed colleagues have posed this question before. Dr. Aoki has reported that 33 of his patients developed hip instability after interportal capsulotomy and required a second operation for this instability. While Dr. Mather showed the bigger the capsulotomy for hip arthroscopy access, the more unstable the hip becomes, though they could restore the stability at time zero. However, this makes about as much sense as cutting the anterior cruciate ligament to allow easier access for the posterior cruciate ligament reconstruction and then suturing the ACL back expecting normal ACL function. We've known since the 1970s that suture repair of the ACL does not work. So if you cut the iliofemoral ligament, will it heal? Shano has shown that it does most of the time. Does it function normally? If not, is there increased femoral head translation that may result in instability or osteoarthritis? These cases are uncommon, but not rare. We do see instability and osteoarthritis and even large symptomatic cysts resulting from these capsulotomies. So Steve and Chad, why cut the capsule? Remember your oath. First do no harm. Awesome, Mark. Thank you so much. So Steve Aoki will talk about interportal capsulotomy. Thank you so much, Steve. All right. Thank you. My name is Steve Aoki. I'm going to be giving the interportal capsulotomy side of this debate. Here are my disclosures. You're going to hear three different approaches for capsular management of the hip arthroscopy today. No capsulotomy, Mark Safran, T-cut by Chad Mather, and interportal capsulotomy by me. I really think of this as a balance between visualization and disrupting the capsular integrity. And I'm here to argue that the interportal capsulotomy is the most balanced of the three procedures. Now, one of the technical aspects that you have to understand in order to work effectively through an interportal capsulotomy is that you have to be able to be comfortable with mobilizing the lower extremity so that you can visualize the whole area of the hip. You have to be able to visualize the whole area of the cam lesion. In extension, I typically am able to see up in the pistol grip deformity and the medial aspect of the cam, and then I have to flex the leg in order to get down the neck as well as down inferiorly. Ultimately, the goal is to obtain the visualization needed to do a good osteochondroplasty in the peripheral compartment but also minimize disruption to the capsule. Now, this is a typical interportal capsulotomy for me through a right hip viewing through the AL portal. The AL portal holds my retraction stitch, which lifts the capsule up to protect it during the case. With more experience and with techniques like retraction stitches, it's allowed me to be able to effectively shrink down my interportal capsulotomy over time. So, once we're done with doing our work in the central and peripheral compartments, then we're ready to close the capsule. This is starting on the medial side of the leaflet, passing my first stitch through the S-tabular side, and then I'll reach and I'll grab on my femoral side for my second pass because it's just technically easier because that tissue on the femoral side is more mobile. Then I'll take that same stitch and I'll pass it through on the S-tabular side once again, go over to the femoral side, and grab that same stitch so that there's effectively four passes for one stitch. And by doing a figure-of-eight pattern, I can put my stitches right next to each other and get a watertight seal and so there's no gapping between the stitches. So, I've placed three stitches in this patient that's just pulling it up tight. I will fix and tie my stitches with the leg in neutral so I don't over-tighten. So, I do an interportal capsulotomy. It's easy, it's reproducible, and it really goes back to the concepts that we learned back when we were a child. Going back to the Goldilocks and the Three Bears, we've got the no capsulotomy, that bed is too firm. The T-cut, that bed's too soft. That interportal capsulotomy bed, that's just right. If you do it well, you'll be able to go to bed and sleep well at night. Thank you. Thanks a lot, Steve. Chad Mather from Duke will now be speaking on T-cut capsulotomy. So, thank you, Chad. Well, good evening, everybody. Since I've only got two minutes, I'm going to jump right into it. Here are my disclosures. Why do a T-cut capsulotomy? Well, because seeing is believing. This is the view you get with a T-cut capsulotomy with full suspension, and you can drive a truck through this exposure. The other reason is because this is how I like to move it when I'm in the hip. In a T-cut capsulotomy, Ford's U.S. Lane says it's wide lanes, it's so luxurious. That's often how I feel when I'm in the T-cut capsulotomy. On the other hand, interportal is a little bit more like when I visited Damien Griffin in the countryside of England, driving through those narrow streets. Well, periportal capsulotomy, this picture says it all. Why else do a T-cut capsulotomy? Well, to get the job done. So, we're there to treat the FAI and the other pathology, and you can see what great exposure you get. It's hard to miss it with a T-cut capsulotomy. Much like analogous to doing a minimally invasive arthroplasty, you don't want to put the implants wrong because the incision is too small. Learn to do a T and be able to do the job that you're there to do. Why else? Well, let me share some facts about T-cut capsulotomy. Shane Noah showed that it does lead, as expected, to better visualization. Confirm that. But also, he showed that instability comes more from the interportal cut, not from the descending limb of the T-cut capsulotomy. But last of all, most importantly, so you can be a T-man. I mean, look at these definitions, number one, number three. Who wouldn't want to be a T-man like Mr. T? So, now that everybody on this webinar wants to be a T-man, let's get to the technique. So, to start with here, we place our suspension sutures into the distal portion of the capsule. I use different colored sutures so that we can then better organize our cells for retraction and repair later. These are being placed through the anterior, lateral, and the dilaperal here with this last one. These two sutures create essentially a target for our T-capsulotomy and then also provide retraction later. So, you can see how this allows you to have a nice, clean, controlled, fine cut. And as they retract, it allows you to assess your exposure so that you can achieve only and cut only the amount of capsule that's necessary to see what you need to see. We'll sometimes put an additional traction stitch in to be able to fully access the CAM morphology and the femoral neck. And here you can see what that view looks like prior to the femoral osteochondroplasty. We'll then remove the periosteum over the CAM morphology. And the other thing that's often not mentioned about T-capsulotomy is the ease of movement. It's not just the visualization, it's the ability to move the instruments cleanly. And here's that, again, that final image. So, I'd say more about this, but I'm out of time. And I look forward to more in the discussion. Thank you. Awesome, Chad. Thank you so much. So, Mark, Steve, and Chad, if you could show me your webcams. And so, I'm just going to ask some questions and please, if the audience has any questions, ask too. Question for Mark, are you jealous of that view that Chad just showed? Do you ever get that kind of view with your literary portals? In the peripheral compartment, yeah. I mean, the peripheral compartment, I actually make what somebody called my interportal capsulotomy is between the anterior lateral and posterior lateral portals. It's in that zone where there's no iliofemoral ligament. So, I can actually see quite well there. I flex the hip and rotate around. Maybe not so good as that whole Mr. T thing, but I started to think about this Mr. T capsulotomy there. He had such a wonderful view. I thought, that's almost like trying to do a meniscectomy through a transfemoral amputation incision. Just cut the whole leg off, move the pedal out of the way and I can get to that meniscus. I mean, that was a great view, but I'm worried about all that other damage that's going on there. So, Mark, do you ever find places you can't get to with the peripheral capsulotomy or the places you feel like you can't get to? No, but again, I use a third portal always for my central compartment. And then I actually make a fourth portal when I'm going to go ahead and do my peripheral compartment work. So, I'm making more skin incisions than Chad and everybody else are. But again, the goal in my mind is leave the ligaments intact. And so, 60% of the capsule is covered by ligament. 40% is not. If I can go in the area that's not affected by ligament, then I can feel a lot safer that I'm not going to affect the biomechanics of the hip. I don't know for a fact that I'm not affecting, but I got to think it's a lot better than the ligament itself. Hey, Mark. So, quick question. When you're doing your portals, you kind of have to dilate on the undersurface of the synovium and partially, I see sometimes when people are doing through the portals, they're getting into the undersurface of the capsule. Do you think that that's an issue? When I'm doing the synovectomy you're talking about? Yeah, you kind of get into the synovium and you get into the undersurface of part of the capsule? Yeah. Do you feel like you get into the undersurface of the capsule or violate the undersurface? No. So, I have a different view. You guys are always looking from the top and the back. You know, Ben Dohm showed very nicely looking at the top and the back when he's doing his AIS. I'm actually, most of my visualizations in the central compartment is from the posterolateral portal. And then I can also look from the anterolateral portal as well. But most of the time, I'm just working from the posterolateral. When I'm doing my peripheral compartment work, I've got my scope in the anterolateral portal and then I make a proximal or a distal, usually more often, a proximal anterolateral portal. And then I, you know, use that. It's along the anterior portion of the femoral neck. And I can, you know, see as far medially as I want along the femoral neck and go down the neck itself without cutting the zona and without cutting the iliofemoral ligament. So, I think you can. You know, for people who do lift up a little bit of the capsule, the capsular insertion is pretty broad. We published a study on the capsular insertions on the acetabulum and on the femur. Jessica Talaria, who is the same medical student who helped me with the ligament study, we digitized, using a microscribe, the anatomy of the insertions. And actually, it's fairly broad. The iliofemoral ligament insertion is fairly broad on the acetabulum. So, I think you could take a millimeter or two of it and certainly not disrupt the bulk of the capsular insertion. So, Chad, do you T-cut everybody or are there ever capsules you don't feel the need to T-cut, hyperlaxity patients, things like that? You know, I do T-cut most everybody and try to really minimize my interportal and those types of patients. As Shane showed well, the instability comes from the interportal cut. So, if anything, I just try to minimize my interportal. So, how do you address the central compartment with a small interportal? I'll move my portals around to make sure they're just over the central compartment pathology. So, I'll often take a look when I first get in and then readjust the portals and only make my interportal capsulotomy only big enough to address the central compartment. So, Steve, how do you get down the neck with your interportal? How do you get way proximal? From the standpoint of the interportal capsulotomy, I really think if you need to for visualization, you really have to be able to move the leg. And so, it comes down to when the leg is in extension, you tend to be able to see more towards the ascetabular side. You can get most of the front of the CAM lesion. You really have to flex the leg internally, externally, rotate in order to get down the neck. Got it. So, one of the audience members wants to know what you close your capsule with. Absorbable, non-absorbable tape? How do you guys close capsule when you close it? Non-absorbable and about usually about three figure-eight stitches. So, for me, I use non-absorbable stitches. I do figure of eights. I do typically three stitches in the interportal capsulotomy area. I typically look at the issue of anytime you cut something, it heals with scar. Scars never as strong as the initial tissue. So, I like to have something that's non-absorbable. Got it. I use non-absorbable as well, but I know some people talk about the problem with using the absorbable or not non-absorbable, especially when you do the interportal is the potential irritation with the iliopsoas, but I'm off way lateral and I don't end up worrying about that because the iliopsoas is not around there. For your typical interportal, the knots are more underneath your rectus, not your iliopsoas. Right. So, Mark, do you routinely close your periportal capsulotomy or are you just talking about application? Yeah, no. I'm just talking about when I when I'm doing my peripheral compartment work and I do my, again, a variation, not the true interportal capsulotomy that's described between the anterior and anterolateral. What I'll do is if somebody is tight or a big guy or mildly arthritic, I don't close those guys. They'll be unhappy. But the people who are easily distractible, those I'll close back up so I don't make them unstable. Got it. So, Steve, how has your capsulotomy changed over the years? Are you making the same one you made 10 years ago? It's smaller now. I think there's a couple things that have changed over the time period from when I first started to now. Number one, there's more issues associated with capsular instability associated with the capsule not healing. So I think I'm a little bit more aware of that. That capsula has shrunk over time and I think there's a couple things that have improved that. It's me doing the movements. To me, it's a struggle. If I have to have a nurse or someone move the leg, I want to be able to move it right where I want to be able to put the leg so that I can get to where I want to be. For me to be efficient, I prep out the leg so that I can do all the movement myself. That's shrunk down my capsulotomy. Traction stitches have been helpful because it helps elevate that capsule and keeps it away so that it's easier to teach and it's easier to get around and see the area of the CAM lesion. That's shrunk down my inner portal capsulotomy. I think from the standpoint of what I've done from a repair, initially there was no repair. I had two of those dislocations that are in those papers that I've published to show my complications. After those, I started with one stitch to repair my inner portal capsulotomy. Then I went to two. Then three. Then four. Then five. Then six. Then I started doing the figure of eight just so I can get a better watertight seal on that capsule. One more minute. Chad, can you over-tighten a capsule by closing it? I think if you don't preserve the native edges and that's where the I like to call the suspension technique just as much a capsule preservation technique. When you capture those edges and maintain those native edges, you typically don't over-tighten it. Also, we often, when we get into the capsulotomy recess, we're elevating the iliophobic ligament a little bit. I think they can get scarred and heel tight, but I don't think we over-tighten them. I do think you can over-tighten. I would not flex the hip up to 40, 50 degrees and try to close it. You have a tight closure at 40 degrees because the minute you go out into extension, it's going to pop. You got to be able to close it in a neutral position. I always extend it to full extension before I leave the OR to make sure it's re-approximated. Guys, we're out of time. That was awesome. Thank you guys so much. We're going to move on to the next debate. I think Shane's going to take over. I want to be a T-man, Chad. You got me convinced. Right. Knew it. Hey Shane, you're muted, so let's unmute Shane. Can you hear me? Yes. Okay. Good evening, and welcome to the AOSSM Athlete SIP. This is the second debate of tonight's webinar, and we'll be talking about the management of the label tear. The rules are similar to the first debate. Each speaker will have two minutes to state their case for each technique for the management of label tears. We'll start with Ben Dome, who'll talk about defending the primary label repair. Mark Philippon will discuss label augmentation, and Annie Wolfe will take the position of circumferential label reconstruction. So without further ado, we'll have Ben start us off. Thank you. Hello, Dr. Benjamin Dome here from the American Hip Institute in Chicago, taking the stance that label repair is the gold standard. My disclosures are listed with the AOS. Label tear treatment involves restoring the anatomy and function. Why restore? Biomechanical evidence tells us the labrum is critical to the function of the hip. Clinical evidence tells us we get better results with label restoration than with debridement. And of course, common sense, the hip was made with a labrum for a reason. At present, long-term evidence is available only for repair, not for reconstruction or augmentation. Since the advent of label repair, significant progress has been made in the technique. Where early repairs sometimes failed to achieve the suction seal, techniques like label-based refixation were developed to restore this seal with consistency and reliability. We've published the five-year minimum clinical outcomes of label-based repair in the hip and showed significant improvement in all of the patient-reported outcomes, and that the improvement in the PROs was sustained from two years to five years follow-up. Importantly, at two years and five years, the survivorship rates were 97% and 91%, respectively. A subsequent iteration of the technique is the controlled tension anatomic label repair technique, or a CTA technique. This takes advantage of inserter-out-selective tensioning technology of the repair stitches in order to achieve a consistent seal of the labrum against the femoral head. At present, one of the best pieces of evidence we have from our database is the five-year outcomes comparing reconstruction to repairs. We showed comparable improvement in PROs, comparable survivorship and secondary operation rates, and that label repair yielded higher patient satisfaction. As a result, our protocol at present holds primary repair as our gold standard. If we are encountering a defect, or a calcified, or irreparable labral tear, or non-viable tissue, then we perform a reconstruction or an augmentation. However, if we have good viable tissue, label repair remains the way to go. Thank you very much. Next up, we'll have Mark Philippon talk about labral augmentation. Hi everybody, I'll discuss now the labral tear treatment with segmental augmentation. So the logic behind it, we want to preserve the native tissue in the augmentation situation. When we have enough circumferential fibers, enough tissue, I think it's important to preserve it and just incorporate these fibers into your graft. That will increase the labral volume to re-establish the seal. So we've looked at our result comparing labral augmentation to labral reconstruction. We had two groups, one of 33 in the augmentation group, one of 66 in the recon group. Pretty much the same distribution between augmentation and reconstruction as far as alpha, tonus, joint space. Then, if we look at our procedure performed in both groups, pretty much the same procedures were performed. And then at our outcomes, if we look at the modified RSF score, HUS-ADL and HUS-SPOR, it looks like, if we look at the percentage MCID, better results were seen in the labral augmentation group with a significant P value. So again, the goal is to restore a good labral seal. We like to perform a dynamic assessment, inflection, abduction, and rotation just to make sure that the seal is appropriate. And it's important to look for a range of motion without impingement as well. So if we look at augment versus recon, the reconstruction, restore the seal mechanism in case of severely hypertrophic and poor quality labrum with the augmentation, we do the same thing with the remaining viable circumferential fibers. I think the labral reconstruction also goal is to restore the native anatomical and biomechanical relationship of the structure composing the femoral acetabular complex and restoration of the native anatomy, but also preservation of the vascularization, if possible, of the host labrum is helpful, we believe, in the case of augmentation. Thank you. Thank you, Mark. And next we'll have Andy Wolfe take the position of the circumferential labral reconstruction. Thanks, Andy. Hi, my name's Andy Wolfe from Washington Ophiudics and Supports Medicine. I'm giving the talk on Complete Labral Reconstruction and Treatment of Labral Tears. These are my disclosures. As previous speakers have mentioned, the labrum we've come to appreciate biomechanically for multiple reasons. There is, it is a fibrocartilaginous structure akin to the meniscus of the knee, and we all have learned to appreciate that saving it and preserving it where possible is better than cutting it out. We really want to repair the labrum sometimes, but it just looks like it's too damaged and maybe a persistent pain generator, and we know that we don't repair any chronically damaged fibrocartilaginous structures elsewhere in the body, and we know that this is, most labral tears are chronic injuries, so we would not repair a meniscus that looks like this. Similarly, we know that the acetabular labrum has pain fibers in it, and so what we want to do is offer a standardized solution to a common problem such as hip replacement does for hip osteoarthritis. So if we have a labrum that looks like this, which is torn throughout, we can replace it with a graft that goes from the transverse acetabular ligament in the front to the transverse acetabular ligament in the back, and can restore good tension, good suction seal, very reproducibly every time using my Ligma technique. We can get this good seal, and this translates into good clinical results, so we're offering a standardized solution to a common problem, and we don't need to repair tissue that has limited healing capacity and is a pain generator. Additionally, with a complete reconstruction, we can eliminate weak junction points between the graft and the labrum. We can increase our certainty that we're eliminating pain-generating tissue, not missing hidden lesions of the acetabulum. Additionally, we can address cocciprofundal lesions, which are more circumferential, and this is a reproducible and reliable procedure, as we've shown in our clinical studies where we compared our repair results to our reconstruction results and found, despite much more unfavorable characteristics in our patients undergoing reconstruction, that we can achieve essentially indistinguishable results in terms of our IHAT-12 improvements. So the take-home messages are that the labrum is important for hip health in most patients, and can also be a pain generator. We don't want to repair chronically damaged tissue elsewhere in the body. We shouldn't necessarily do it in the hip, and that complete labor reconstruction offers a standardized solution to a common problem with reproducible results. Thank you. So I'm going to ask Ben, Mark, and Andy to go ahead and turn on your cameras. Andy Wolf? Yeah. So I guess while we're waiting for Andy, I'll go ahead and start asking questions. Ben, what is your preferred anchor and why? Maybe take us through your decision-making as far as what you like and what you've used in the past. Sure. I'll try and steer clear of commercial interests in answering that as best I can. But I use predominantly knotless anchors. In comparison between knotted and knotless, I think the obvious advantage is that we avoid a knot stack, which might be irritating or might cause a mass effect or be a nidus for scar tissue. One of the disadvantages in the past was inferior control of the tension. Some of the more recent technologies in knotless anchors have allowed for controlled tension repairs, which I think negated that difference. And then between hard body and suture anchors, all suture anchors, I've tended toward all suture anchors. So I would say that my primary anchor of choice is a knotless, tensionable, all suture anchor. Great. Thanks, Ben. So, Marc, I think some people may be interested as far as why did you decide to transition from a reconstruction to an augmentation as your primary tool when dealing with irreparable labral tears? Well, you know, I still perform segmental reconstruction. What I found is, if we go back in analyzing the weight-bearing mechanics of the hip joint, we know that when we weight-bear, the column expands, the anterior and posterior column. And there's an old paper from Dr. Gruen showing that the base of the labrum acts as a secondary stabilizer for expansion of the columns. If it stays in continuity with the transverse acetabular ligament. So based on that, when I was doing my revisions, if I had enough 2 to 3 millimeters of circular fibers, I felt it was worthwhile, instead of transecting them, even if they're not really truly functional, per se, as far as the seal, because it's very diminutive, I felt that if we could augment it, preserving the fibers, the circular fibers preserving the circle, it would be beneficial. So that's how we evolved to that. And what we found over time, Shane, is that for some reason, clinically, our patients are doing slightly better. It's actually significant. If I compare it to my recon patient, they do better. So that's in my hands. I mean, that's how we evolved to do this. Do you think it's more that you find that clinically that they're better? Or is it something at the time of surgery that you like as far as maybe the suction seal, for example? Or is there something technically at the time of surgery that you feel provides a better result? Well, one thing that if you have an intact chondral base label junction, I think it makes sense if you can preserve it and just place stuff, your graft behind it, so you can have healing to the host tissue. And at the same time, you don't really rely on secondary intention healing from your graft to the cartilage, because you already have a healing segment there between the cartilage and the base of the host tissue. Now, you've got to make sure you have enough fiber. So I like to have 2 to 3 millimeter remnant at the base. Otherwise, I'll resect it. I mean, this week, I'll give you an example. This week, I did a calcified labrum. So I had a young guy, 28, who's a primary, had to resect the segment, did a recon, segment reconstruction. And this afternoon, I just did the augmentation. The patient I previously had, actually, a large label recon, which actually was done very well technically. But unfortunately, part of the graft didn't do well, kind of air ball sutures because of the graft is integrated. So we just resected part of the graft. I used the graft tissue that was placed in the first couple surgeries. And then I reconstructed using a combination of segmental and augment on that patient. So one doesn't exclude the other. I just look at the remnant tissue that's there, that's healthy. And I try to save it if I can. So Andy, I'll give Andy a chance to respond. Mark is saying that the condor label junction is important to preserve when he's considering reconstruction or augmentation. How do you reconcile that with the circumferential label reconstruction? Yeah, it's a good question, Shane. And by the way, thank you for doing this. And thanks to Winston and Brian for setting this up in AOSSM. I think the deal in my experience is that I think that the condor label junction a lot of times is compromised in these patients. And like Mark was pointing out, like the patient with the ossified labrum, there's no real way that you can augment that. And so I think in my hands, I think the most reproducible thing is to restore the suction with the circumferential graph that you can get the tension and the seal right every time and leave your junction points in areas if you have, there's going to be a junction at some point. And if they're in areas where they're relatively low stress, like down by the post, the transverse S-tabular ligament, I think you're probably going to be in better shape. And I think the other thing is that I think sometimes we sort of presume where we know where the pain generating tissue is. And we sort of say, oh, well, it's anterior superior. And more often than not, that's true. But sometimes I think we miss. And I think you can get a reliable result with a circumferential reconstruction pretty much every time if you can get it right. So I think that's why I sort of have that as part of my armamentarium. And so that's sort of my rationale for that. So it would seem to me that the anastomosis between the native tissue and the graft is an important part. Maybe each of you guys can maybe discuss what happens if you can't get a suction seal? What happens if you feel like, how do you bail yourself out if you feel like your seal is not as robust as you'd like it to be? Well, I can answer that. I just had a case a couple hours ago. As I said, I was combining segmental augment. And my posterior anastomosis, I wasn't happy with it. So what I did, I augmented my anastomosis with a segment of the rectus. So I used my beaver blade, made a small one centimeter segment, and I beefed it up with vical suture at that segment. And I had an excellent seal after that. Before that, my anastomosis, I had some leakage. So I augmented it with the local adjacent rectus tendon. And it's a small segment. When you do that, just make sure you release that indirect head because you don't want to have traction there. So that's what I did in that situation. Great. How about Andy and Ben? Any pearls that you guys have for us? I think that if you're using a small anchor and you're getting it on the rim and you've sort of practiced this technique, I think that it's been my experience that suction seal is really not a problem. I think that there is always going to be some sort of a weak point between native tissue and the labrum. I think the natural point for that is at the transverse S-type of ligament where it comes together with the labrum in the front and in the back. I think down in that same area I think is going to be another natural area where you're going to have a weak point. You're going to sort of hide it there a little bit. I think that putting them in areas of high stress is not ideal. That's been my approach to it. We've got a question from the audience. Do you guys want to just talk about what graphs you like to use? Start with Marc and then Ben and then Andy. For me, I know it's more time in the OR, but I still use the autologous IT band. Today, for example, I had a large segment I had to beef up. It was large. It was seven. No, it was not seven. It was five centimeters. I still use the IT band autograph. That's my graph of choice. Sometimes if I just do an augment, I'll use IT band allograft. For my primary young patient, recon or augment, most of the time I'll use the autograph IT. For me, tibialis posterior has mostly been the allograft of choice. I've used tibialis anterior as well. Just to address your previous question about the anastomosis, Jane, you've done some great work on the biomechanics of the seal, whether you do a segmental or a total label reconstruction. I think pointed out that in either case, you have two anastomosis between the labrum and the graft, or in the case of a total reconstruction between the TAL and the graft. The TAL is really an extension of that circle. My two pearls on that point are we need structural contact and we need biologic healing at those anastomosis. For structural contact, I try to overlap the graft with the native tissue by placing the end anchor essentially above the native tissue, almost through it. For biology, we need to have a bleeding bed of bone right up to that site in order to hope to have the biology to heal the anastomosis. Andy, your graft choice? I use an IT band allograft. We found that that is the most reproducible graft that we can get. I think doing that and tubularizing it with non-absorbable 2-O suture, I think, in my hands, has worked by far the most reproducibly. Let's see. We've got one other question here. I guess this goes to probably the debate of primary labor repair. What are each of your indications to do a primary labor repair? I'm sorry, a primary labor reconstruction. Maybe each of you guys can kind of give your algorithm for that. Yeah. I mean, for me, like I said yesterday, I did a patient who had a young guy, 28, primary hit mountain rock climber, very good athlete, but his labrum was ossified. Like Dr. Wolfe said, couldn't do an augment on this. I resected the segment that was ossified and did a primary labor reconstruction, 5 centimeter. But that's my indication for me when I have no tissue to repair. And I couldn't debride that segment, obviously. I still want to say a word about labor debridement. If you look at our published 10-year result in GPGS, medium patient satisfaction at 10 years was 10 out of 10. And in that group, we had labeled debridement and labeled repair. And if you look statistically, when we selected the debridement properly versus repair, there was almost no difference, except if you had to do an acetabular microfracture. So I believe that sometime we can do labeled debridement if you have a small flap. But again, yesterday, the guy was ossified, the patient was ossified, so I had to do a primary segmental reconstruction. And before Ben goes on, maybe each of you guys can just describe like percent of repair versus debridement versus reconstruction as well in your own practice. Most of the time I repair the labrum. It's very rare to debride now. That cord I was talking about was back in 2005, 2006. But now I would say at least 98% repair. Yeah. So in my practice, my algorithm is basically if it's repairable and I think it's going to be able to heal, I think that I would repair. And I end up doing that probably 60%, 70% of the time. I probably debride, you know, if there's really nothing there that's actually a problem, I think, you know, you sort of chalk it up to a debridement when you're really not really doing much of anything with the labrum because that's not the primary issue. Or that's not the pain generator in that situation. That's probably, you know, 2 to 5%. And then the reconstructions I will do in a situation where I deem the labrum to be irreparable. And like Mark pointed out, I think the labral acidification is a clear indication for that. And that typically does extend, you know, the length of the acetabulum posteriorly. I will also favor it in a revision situation where they failed a previous repair and don't have any other obvious reason for their failure. And then I'll do it in a primary situation where their labrum is just, you know, in bad shape. So that sort of that intrasubstance synovitis type of issue, which you'll often see on the MRI, you'll get a clue for that, where you'll see, you know, big intralabral and paralabral cystic changes. You get in there and that, you know, you start getting into that labrum, you're looking at a totally intrasubstance synovitic type of situation. And, you know, I think wrapping sutures around and through that is probably a somewhat of a futile exercise. And so that's that's been my approach. And, you know, I think that, you know, we have a we have a article coming out on arthroscopy that that shows really, really good return to sport with these. So I don't think that it's only a salvage procedure. We have, you know, 30 patients and 29 of them would have gotten back to sport with their with the with the hip that we fixed. And the biggest reason for failure with with them, we had 86 percent return to sport and three of the four that didn't return to sport is because their other hip had the same problem. And so I think I think that it's I think it's a good procedure and that it's and that it's here to stay and that. But I don't think that it's it definitely doesn't need to be for everyone. And there's definitely labrum that can be repaired or debrided with very good success as we've seen, you know, for years in the literature for from guys like Dr. Philippon and Dr. Bird have had excellent long term results with debridement and repair. And so I think it's just an important part to have of your armamentarium. And for me, I would say in my primary situation, it's about 80 percent repair, 20 percent reconstruction, maybe a few percent selective debridements in there. And in revisions, it's almost 80 20 the other way, 80 percent reconstruction and 20 percent re-repair. I think it really all comes down to the viability of the labrum and each of us is looking through our own lens, trying to figure out what is or is not viable labrum. I think we all probably agree that a calcified labrum doesn't function as a labrum. And if we need to resect the calcification, then that leaves them without a labrum. Probably we mostly agree that most cases of failed labor repair, there's some biological problem with the labrum where or a structural problem to where it's insufficient. So probably we need either to replace the tissue or to add tissue to it as in an augmentation. But I think fundamentally, the viability is is what we need to evaluate. And the last thing I'd say on this, just to echo Mark's thought on simplicity, there is still a place for selective debridement. There's certainly still a place for labor repairs. And I think each of us needs to know where we are in our own learning curves and abilities and skill sets. To do a total labor reconstruction is a wonderful procedure and can be a great reproducible procedure. But it can also be a very difficult and high risk procedure when you're putting in 12 anchors. If you misfire anchors 10 percent of the time, you've got a whole lot higher chance of misfiring an anchor in a 12 anchor labor reconstruction than you do in a two anchor labor repair. So, on the other hand, if you are further along in your learning curve and you only misfire an anchor one in a thousand, then it's probably not a problem to put in a 12 anchor labor reconstruction. So I think each of us knowing our own hands and where we are helps us choose the right procedure for us in that patient. All right. Thanks, guys. We're going to end the session and turn it over to Brian to head up our Q&A. Thanks, everybody. Oh, hey, Mark, by the way, as a 23-year retired colonel from the military, I've never felt more American than by looking at your jacket and the flag in the background. As a Canadian citizen, thank you very much. I'm feeling good. All right. I'm going to ask some specific questions. So if you guys could come on and off the webcams, I'll ask them. The first up is to Steve, if you could come on. Chad, come on. And Manny, Ben, don't stay on. Mark, what's the deal with post free traction? Are you guys using it all the time? Are you using it sometimes? When do you use it? When don't you use it? Steve, I would use it all the time if I could. There's one hospital that I that I'm at that doesn't allow us to have the tables yet. So I just it's it's to me, it's so much easier to do post free traction because it's you know, I know that people talk about like the post giving you distraction and lateral lateralization of the hip. I don't think lateralization of the hip is helpful. I like I like a pure axial distraction. OK, Ben, I would just add to that. I think you can do postless distraction at all your facilities because any bed can serve very well for postless distraction. If you put a little Trendelenburg in it and we tend to use the post, but we use Trendelenburg so that the post is just a belt and suspenders to prevent the patient from falling off the table. And in the severest cases, if we needed more traction and need a secondary restraint. The other thing to consider in Trendelenburg is remember, we're flowing a whole lot of water through the hip joint and some of that in a Trendelenburg position can track north. So we there is some emerging data to suggest that may increase the risk of abdominal intravisation or even of tracking of fluid to the lungs. So I think we should be measured in how much Trendelenburg we apply, knowing that the Trendelenburg will give us most of the counter traction that we need. Chad. Yeah, I use it exclusively and agree with what Steve said, that there are a lot of technical benefits beyond the patient safety aspects of it. One nice thing is that often once you establish your capsulotomy, you don't need much Trendelenburg. I discovered that accidentally in a patient that couldn't go to Trendelenburg and found out that as much as Trendelenburg is the contact with the bed. And the hardest patients to distract are the small frame patients. You don't have much bed contact. So I think you can work without the Trendelenburg still being a post-free system. And I've gone to now where if I feel like I can't get enough distraction, I'll go to an outside-in approach because I see that I don't know. I'm not sure that much traction is safe even with or without a post if it's at a high enough level. Can I request Josh Harris's opinion on this? Yeah. So, hey, Josh, come on here for a second. Maybe he can tell about how the average arthroscopist can go post-free. Yeah, so I've been doing post-free for about two years now, probably close to 800 cases. And I've been able to successfully get it 100 percent of the time. I've not had to add a post once yet. I think one of the big advantages that we don't really talk about a whole lot is the advantage of less pain. We presented this at ISHA last year. It's submitted for publication right now. The post, whether this is just pressure in the perineum or on the medial thigh, patients have a lot more soft tissue pain around that area post-op. And we found about three points on the VAS score difference within the first 10 days. And so patients are going to take fewer opioids and probably recover a little bit better. The motion didn't really change, but there were much fewer opioids. And with the opioid crisis in this country, I think that makes a big difference. And so I love it. I'm a big advocate for it. I'm obviously, you know, number one safety first. And so Ben brought up a really good point about safety and having, you know, as much security as you can. I do very little Trendelenburg. My patient is on the bed secure. We've not had any safety concerns. And so obviously with a new technique, you want to make sure safety number one. Great. And if we could bring Mark Safran on, Josh, if Chad and Ben could go off for a second. Mark, stay on. You know, Josh, where'd Josh go? Get up here, Josh. Don't you go away. All right. So, you know, we talked about these capsular repairs and we talked about the suspensory sutures. Do you utilize your suspensory sutures to primary close or do you use a separate set of sutures to close your capsulotomy? So for my T, I put one capsular suspension suture medially, one laterally, and it's usually right at the apex with the inner portal. And so because I like to close from distal to proximal, I will remove those suspension stitches and then place new ones. And I usually do three or four in the vertical T limb. Mark, what about you? How are you closing? What do you use for your capsular incision, Mark? What's your portal type? We looked at that. I do a small interportal capsulotomy. It's about 22 millimeters and I use two number two vical suture to close it. And we have trained fellows here. So we sometimes some of my fellows are more challenging to teach. I'll put a retraction suture distally and that helps them a lot. And I don't use that suture to close at the end, actually, because I use a capexity slider to close my portals. So I need to do one pass, double number two wire loop. And that's how I close them. So two number two vical suture, capexity slider knot. Mark, I don't use a stitch to hold back on the capsule. So I just when I'm done and I want to close the capsule, I pass. I just pass sutures regularly. And as I said, not absorbable sutures. I use a arthroscopic suture passer kind of device. Steve. So typically for my interportal capsulotomy, I will do two to three figure of eight stitches. So each stitch is passed four times to the capsule just so that I can place stitches right next to each other so I can get a watertight seal. Great. All right. If we could have Ben and Chad come on up again and Josh and Steve, if you could go off. You know, we talked about pincer resections, Ben. You know, what fluoroscopic views do you use in the OR to get your reception techniques? And Mark and both the marks and Chad, what are you using intraoperatively to make sure that you're resecting the appropriate amount of bone on the acetabulum? Ben first. I my workhorse is an anterior posterior view and my secondary view is a false profile view. But I have to inject a big dose of caution in using fluoroscopy to measure your pincer resection. I think I've seen more errant pincer resections because of the use of fluoroscopy than because of the lack of it. We can be easily deceived if our fluoro image is just a little bit off. So I do spend some time right before I'm about to start any resection. I spent some time making sure that my image is perfectly matched to the AP pelvis that I'm looking at on the wall so that whatever I've templated in the resection, I can correlate to what I'm seeing fluoroscopically just as inlet or outlet. It's not rotated left or right. But even then, I'm still using fluoro primarily to locate where I am on the rim and to confirm that I'm at nine o'clock or twelve o'clock or two o'clock. And then I'm more than anything, using the width of the burr to gauge how much I'm resecting at any given point. Mark, same with you. So which mark? Go ahead, Mark. Oh, that's right, Mark. That's right. Go for it. So for me, I use my landmark. I use the psoas U. I use the subspinal region. Still a crease. And like Ben just said, I use the width of my burr to gauge. But truly, based on what we measure pre-op, I'll kind of quantify how much I'm going to resect at the crossover. And I also use the formula that Dr. Wolfe developed when he was here with us. I use that formula for every millimeter of resection, roughly two degrees of center edge reduction. So I always keep that in mind. I shoot now from my end point. I try not to go below 25 degrees ever. So I'm very more of a conservative on the rim. And then I follow the rectus fibers up in the subspinal region. And I spend more time on the subspinal region because I really believe dynamic impingement is an issue. And if we can clear that a little bit more in most patients, I think it's helpful. So I minimize my rim trimming and I spend more time on the subspinal region. And we found that that's been clinically – that's been good for the patients. Mark Safran? Yeah. So, I mean, I base it a lot on pre-op x-rays. Like Mark, I don't want to go below 25 degrees. And, again, realize his – I tend to use some degree, two degrees for every millimeter. But that's straight lateral. The problem is most of what we're taking down is anterolateral and a bit anterior. And so I think you need to look at your anterior center edge angle as well. And that needs to be determined pre-op. The problem about correlating an intra-op fluoro where the center of your beam is centered at the hip versus an AP pelvis where the center of the beam is the center of the pelvis and the beams are diverging, they're not exactly the same views. And I don't think you can rely on that entirely intra-op. So maybe if – you know, when we're working with the residents and they want to – or fellows and they want to know where they are, we use the fluoro to tell us where we are. But I don't use the amount of resection based on the intra-operative fluoro. Because I've got my camera in the posterior lateral portal, I tend to remove where the damage in the articular cartilage is. And I measure with my probe how much exposed bone I have. And then I know based on the width of the burr how far down I'm going onto the articular face. So that's one of the advantages of looking from posterior lateral and working and seeing anteriorly. I think when you work from behind, sometimes you can get a little bit confused about how much you're really removing of articular cartilage. But I end up, like Ben and Mark have talked about, using the width of the burr. But I also use a probe. And, again, the goal is not to make them dysplastic at any cost. And I tend to use, again – it's a little bit of an overestimate, but one millimeter per two degrees. Great. Perfect. And, Chad, I've got one last question here. When you're doing your camera section, how often – what is your working portal for your camera section? And how often are you going back and forth between the mid-anterior and anterior lateral portals? I view through the mid-anterior portal and work through the dowel for the anterior lateral portal. Generally, for the lateral half or the 1145 to 130 position, I'll do that through the anterior lateral portal. And then the medial half will be through the dowel portal. Perfect. All right, guys. Well, listen, thank everybody very much, all the faculty members. Thank you for the webinar attendees. Alexander, if you'd finish it off first, that would be great. Thanks for the invite. Thanks, guys. Thanks very much. Thanks, everybody. Yep. On behalf of AOSSM and ISSACAS, thank you to our course chairs, our speakers, and all of you for joining us this evening. For more information on AOSSM, please visit sportsmed.org. To complete this educational activity and access your CME, please visit education.sportsmed.org. And if you have any questions regarding tonight's webinar, please feel free to email me, Alexandra Campbell, at alexandra.aossm.org. We look forward to next week and hope that you'll join us for both webinars, both on Wednesday and Thursday. They will both start at 7 p.m. Central. On behalf of AOSSM and ISSACAS, thank you again for joining us and have a great night.

capsulotomy techniques

hip arthroscopy

hip capsule

stability

complications

interportal capsulotomy

visualization

T-cut capsulotomy

labral tears

primary labral repair

labral augmentation

graft

circumferential labral reconstruction

weak junction points