Welcome to the Athlete's 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 name, and click Send or hit Enter. Next, a special thanks to our course chairs, Drs. Gwathmey, Buscone, 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. Good evening, my name is Dr. Winston Gwathmey from UVA, and I just want to say thank you to the AOSSM for allowing us to put this on. My co-chair is Brian Buscone from the University of Massachusetts, and Shane Ngo from Chicago, from Rush. And I just also want to say thank you to all the faculty who've come out for this. This is our fourth out of four sessions. We're going to focus tonight on really two areas, one endoscopic versus open glial tendon repair, as well as endoscopic versus open hamstring repair. Then we've got a couple of really cool debates about osteoarthritis and whether or not a scope's worthwhile for a versatile hip replacement, and then mild dysplasia using either a PAO versus a hip scope for it. So very excited about our group tonight. And again, thank you for everybody for being here, and I think we'll have some fun tonight. So our first speaker really needs no introduction. Dr. Thomas Bird from Nashville, Tennessee, is going to be speaking on endoscopic glial tendon repair. And I just, you know, again, he's one of my mentors and one of the godfathers of hip arthroscopy, so thank you, Dr. Bird, for coming out tonight. My charge is to highlight for you the endoscopic approach to glial or abductor repair. My disclosures are available on the AOSSM website. Most symptomatic abductor tendon tears that have failed conservative treatment are amenable to an endoscopic repair. Keep in mind that there are many people with imaging evidence of abductor tendon damage that may not be clinically relevant. And even though you can address these endoscopically, it's the rehab that's onerous. It ain't the surgery, it's the rehabilitation. I tell people that it takes four months for the tendon to heal, and my nurse, Kay, who's been with me forever, says, don't ever mention the word four months to anybody. Tell them it's going to take at least six months before they begin to think that the surgery is worthwhile going through. In my mind, it's hard to envision a role for an acute repair, because most of these occur in older people, and regardless of the suddenness and the onset of symptoms, it's usually a chronic process. Now, you may ask, what about an acute tear in a young person? I think that's a possibility, but I've never seen an acute tear where the tendon has come off the emphasis. Most tears that we see in young people occur at the myotendinous junction, and these heal uneventfully without surgery. There are some large retracted tears that are better served with an open approach. On MRI, fatty infiltration alone is not a contraindication, because sometimes that can kind of overestimate the disease of the tendon. The advantages of the endoscopic approach include that there is a lower complication rate compared to an open repair. You can do this on an outpatient basis, and perhaps most important is the ability to assess and address any associated intraarticular pathology that is commonly present. I used to run the other way from laterally based hip pain, because I felt like there were older people, they were miserable, and they were hard to sort out. Over time, I figured out that only two of these things were true. They were an older population, and they were severely disabled, but they're really not that difficult to sort out. Two things that are true are MRI evidence of abductor tendinopathy is often an incidental age-related change, and symptomatic abductor lesions often masquerade as recalcitrant trochanteric bursitis, and that led to the term greater trochanteric pain syndrome, which, although less specific, is probably more accurate at defining the constellation of things that can present as laterally based hip pain. Ultrasound-guided injections can be the deal sealer on establishing the clinical relevance of abductor lesions and also exhausting conservative treatment. This was the very first abductor repair I ever did, a 63-year-old gal who was incapacitated by this laterally based hip pain, where she was really miserable. She was sent to me by her orthopedic surgeon, who I'd operated on, she had this significant abductor lesion. I used to try to punt these, I'd try to send them to Brian Kelly in New York, and her surgeon said, you'll operate on me, why won't you operate on my patient? So he sort of embarrassed me to tackling this. I remember telling her, going, lady, if you just won't fuss at me, I'll try. This is the tear that we encountered, the first one I did, and basically just using the techniques like we'd learned for rotator cuff repair in the shoulder, we used the double row technique, and the bottom line is it worked, and she ended up being an extremely happy patient. We have identified the rotator cuff tears of the hip. I prefer an IT band sparing approach. We'll place two anteriorly based portals to develop the paratrochanteric space. I believe if the underlying abductors are compromised, and they're probably relying on their IT band more, so I prefer not to violate it any more than I have to. This is a 45-year-old gal for two lumbar spine fusions that failed to solve for laterally based hip pain. She had significant abductor tendon damage that had failed numerous injections. Having developed the paratrochanteric space from anterior, we'll place a viewing portal just posterior to the vastus ridge, which is comparable to your posterior subacromial portal. A working portal is placed just distal to the ridge, which is comparable to your lateral subacromial portal in rotator cuff repair in the shoulder. We're identifying the extent of the tear, which is more of a longitudinally or vertically oriented tear in the gluteus medius. We're freshening up the underlying footprint. We'll then place the anchors percutaneously. We'll place the anchors in a longitudinal configuration. We'll position the more proximal anchor first. This is a triply loaded anchor, and we'll pass one limb of the suture through the posterior leaf and one through the anterior leaf of the tear. We'll sequentially pass all of the sutures, and we can dock these out anteriorly for suture management as we're placing the anchors and passing the suture. We've placed the more proximal anchor. Now we'll place the more distal anchor working towards the arthroscope. Once the anchor has been seated, we'll then pass all three pairs of sutures distally. Then we'll come back and sequentially tie the sutures. We'll tie these from distal to proximal, working away from the arthroscope. As we tie down the last sutures, we'll then inspect the integrity of the repair because we keep people on crutches for six to eight weeks. Which is it? Six or eight weeks? Well, it just depends on how confident I am in the repair site. If it's really secure, we'll let them start to wean off at six weeks. If in doubt, we'll keep them on for eight weeks. This is just another example of a 68-year-old gal with abductor tendon damage that had failed ultrasound guided injections. It has more of a complete sleeve avulsion of the gluteus medius. This is the type of tear that is ideally suited for double row fixation. We'll place two or three transversely oriented double-loaded anchors. In this case, we're going to use two. We'll place the more anterior anchor first past the sutures. Then we'll seat the more posterior anchor, placing our anchors from anterior to posterior working towards the arthroscope. Once we've passed all the suture limbs, we'll then tie these down and we'll retain one limb from each knot and incorporate these into our distal row fixation where we'll use one distal row knotless anchor matched with each proximal row anchor. Once we've completed the process, we'll put a couple of absorbable sutures into the origin of the bassus lateralis just to make it look better because if it looks better, it must be a better repair. When we looked at our experience in endoscopic abductor repair with minimum two-year follow-up, we found that these patients were more than 20 years older than our average FAI patients. The vast majority were female. Their preoperative baseline modified Harris-Hipps scores were more than 20 points worse than our FAI patients, so these patients were severely disabled. But their amount of improvement, their delta, was double that of what we encountered with FAI. So it dispels the myth that older patients can't do well with endoscopic procedures and it also dispels the myth that poor preoperative scores are an indicator of poor results because these tend to be some of the happiest patients that you'll encounter. Now this is not entirely an old person's disease. This is a 22-year-old cross-country runner from one of our colleges who had recalcitrant laterally based pain and evidence of a partial tear of her abductor. She's failed two cortisone injections, two PRP injections. At this point, she's not running. She just can't walk across campus without discomfort. As we probe it, we see this is a partial thickness tear. The superior fibers are intact. We have to make a longitudinal incision in the superior fibers and identify the damaged portion underneath it. Again, it's more of a longitudinally oriented tear. We'll use two doubly loaded anchors in a longitudinal orientation, passing all the suture limbs and tying these down. She had a very successful outcome with pain relief. She's subsequently gotten married and having kids. So in conclusion, when surgery is needed, most abductor tears can be repaired endoscopically. Certainly for large retracted tears, these are probably better served with an open repair where you've also got the option for reconstruction. Persistently symptomatic partial thickness tears are successfully treated with an endoscopic repair. The results are excellent. But we're still looking for better solutions because it's not the surgery, it's the owner's rehab process for these partial thickness tears. There's just a big gap between failed cortisone injections and surgery, and that's where we're looking more closely at orthobiologic solutions as well as other techniques and technology that can stimulate healing of these partial tears. Greetings from Nashville, and everyone be safe. Thank you, Dr. Bird, you make that look easy. Our next talker will be Dr. Shane Ngo, our co-host, talking about open gluteal repair. I want to thank all of our attendees to the virtual AOSSM hip arthroscopy course. My name is Dr. Shane Ngo, and I am one of the course directors along with Dr. Winston Guathme and Dr. Brian Busconi. My topic today is on my decision making for scope versus open gluteus medius and minimus repair, and I will focus on open gluteal repairs. My disclosures can be found on the Academy website. Gluteus medius and minimus tears are also known as the rotator cuff tear of the hip. It's thought to occur in about 10 to 25% of the general population and has been reported to occur in about 20% of cases of total hip replacement surgery, incidentally. Patients with gluteus medius and minimus tears are generally middle age, between 50 and 70 years old. They describe lateral sided hip pain that's worse with abductor use. This would entail either prolonged standing, walking, or going upstairs. Many patients will also describe pain in a lateral decubitus position, as well as night pain. In severe cases, some patients might require the use of assisted device for ambulation. My decision making for the surgical treatment of abductor tendon tears relies on four major factors. One is, which tendon is involved? Second is, is it partial or full thickness? Third, what is the degree of retraction? And fourth, how much fatty infiltration can we identify? The gluteus medius muscle and tendon originates from the iliacus and inserts on the greater trochanter. You can see that the footprint comprises the lateral and the superior posterior footprint and is much more posterior compared to the gluteus minimus. The gluteus minimus is smaller, deeper, and also originates from the iliacus and inserts on the anterior aspect of the greater trochanter. You can see that this is located much more anterior to the gluteus medius and is easily seen through the arthroscope. The thickness can be used also as far as your decision making. On the left, you can see a partial thickness gluteus medius minimus tear. While the tear is hard to identify, with inspection, palpation, and rotation of the foot, you are able to identify the location of this tear. And you can see that with simple debridement, you are then able to debride the superficial capillary tissue left and then enter the tendon tear itself. In contrast, on the right, you can see a large full thickness tear, which is massive, retracted, and entails both the gluteus medius and minimus. This is hard to mistake upon just entry within the peritrochanteric space. The amount of retraction may vary from surgeon to surgeon. In general, I will use 2 centimeters as my cutoff. If less than 2 centimeters, I will treat endoscopically. If greater than 2 centimeters, I will treat with an open approach. Fatty atropy has also been shown to have an effect on the patient's outcomes after gluteus medius repair. We published a recent paper describing the relationship between the Goutelier-Fuchs classification and their clinical outcome and found that there was a correlation. The classification scheme involves a four-stage classification, with stage 0 indicating no fatty infiltration and stage 4 indicating that there was significant fatty infiltration. My treatment algorithm is as follows. First, I want to identify is this a gluteus medius or a gluteus minimus tendon tear. Next, I want to identify the amount of retraction. Is it less than 2 centimeters or greater than 2 centimeters? For gluteus minimus tears, I want to know is this partial or full thickness tear. For gluteus medius tears that are less than 2 centimeters, the endoscopic approach is highly successful. For gluteus medius tears greater than 2 centimeters, it depends on the degree of fatty atrophy. If minimal, a direct open repair is recommended. If there is a significant amount of fatty atrophy, then a superior gluteal reconstruction may be preferred. With gluteus minimus tears, in general, most can be amenable to arthroscopic repair. Here's an example of an open gluteus medius tear that is repaired. Here you can see we're placing one anchor. You can see this large tear. This tear is located between the lateral and the superior foster footprint. And you can see that with the direct visualization, direct approach, that you can provide an excellent anatomic repair with an open approach. This is a case example of a patient who underwent a failed prior gluteus medius repair. You can see the patient has significant loss of range of motion, significant weakness, especially with abduction strength. When obtaining the MRI, you can see that with the T2-weighted images, there is significant inflammation, as well as a significant tear involving gluteus medius with retraction. On the axial view, you can also see that not only is the medius involved, but there is an extension to the minimus as well. The T1-weighted images demonstrate a stage four gluteal classification in terms of fatty atrophy. In this particular case, the patient was indicated for an open gluteus medius and minimus repair with superior gluteal reconstruction. I like to use a lateral-based incision centered over the greater trochanter. Given that this was a revision case, there was a significant amount of scar tissue and adhesions to dissect. This can be very challenging, as the iliotibial band may not be very visible. Once you're able to identify the gluteus medius and minimus tendon, at this point, you can then determine to what extent the tear is and try to understand the significant amount of involvement of this tear. Here, we will use an Alice clamp to help with retraction. Then, we will use an ethabond stitch for mobilization. Once we're able to separate out what is tendinous tissue, what is bursal tissue, what is IT band, and what is surrounding other muscular tissue, at this point, we can go ahead and start to proceed in terms of our planned reconstruction. We do want to mobilize the gluteus medius tendon, and we will do so by performing interval slides. Again, once we're able to retract our gluteus medius and minimus, we're able to identify where there's fatty tissue planes that can be resected as well as scar tissue that can be removed so that we're able to mobilize it as best as possible so that we're able to fully cover the greater trochanter. Here, we're placing a series of additional ethabond stitches to help with our retraction. And again, we're trying to dissect out what is gluteus medius, what is IT band, and what is the surrounding normal tissue. At this point, given that the patient had significant fatty atrophy, we had already decided to perform a superior gluteal reconstruction using an acellular dermal allograft, which is three millimeters in width. We'll go ahead and plan our size of graft. We want to cover not only the repair site, but we also want to extend it all the way down to the greater trochanter. This is a schematic showing our planned procedure. We will go ahead and place provisional fixation with vicral stitches. We've already placed our three suture anchors to make our medial row construct. At this point, we'll go ahead and pass our stitches not only through the gluteus medius and the minimus tendon, but also through the acellular dermal graft itself. Here, we will then use our Allis clamp to help mobilize and distalize the gluteus medius and minimus tear. Once all the stitches have been passed in a mattress configuration, we'll go ahead and tie our medial row stitches incorporating, again, the gluteus medius, the gluteus minimus, and our acellular dermal graft as well. Once the medial row has been completely tied, we will go ahead and incorporate them into a lateral row. In this particular construct, this requires one, an initial anchor, and second, a backup anchor to provide interference fixation of the lateral row stitches themselves. Here, we are tensioning the sutures so we get an excellent and stable construct. For our final repair, incorporate not just the gluteus medius and minimus, but also the graft tissue itself. In conclusion, patients with recalcitrant lateral-sided hip pain likely have evidence of gluteus medius and or gluteus minimus tear. Be familiar with the MRI to detect gluteus medius and minimus tear, not only to determine the size of the tear, but also the amount of retraction and the degree of fatty infiltration. Endoscopic or open repairs can yield excellent clinical outcomes, and superior gluteal reconstruction may be a promising option for massive gluteus medius and minimus repairs. Thank you. Thank you, Shane. We are going to go to Prune now. Dr. Chad Mather from Duke is going to be talking about endoscopic hamstring repair. Thank you, Chad. It's good to be back with everybody again tonight to talk about the technical side of proximal hamstring repair, and I'll be covering the endoscopic technique. My disclosures. This is an overview from last week. Again, we're talking about a spectrum of proximal hamstring pathology, and it's important to cover this as it will clarify where we primarily use the endoscopic technique. Again, we've got our tendinopathies. We've got our chronic partial thickness tears that look a lot like those rotator cuff tears. We've got our full thickness with minimal retraction, the full thickness retracted acute tears, and then our full thickness retracted chronic tears. So I primarily utilize the endoscopic technique for the tendinopathies that we do operate on, and most of them, unfortunately, we don't have to. The chronic partial thickness tendon tears, the minimally retracted full thickness tendon tears, and then some of the retracted acute tears, and for those patients, I utilize more of an endoscopic-assisted technique where we'll place the anchors endoscopically and then open it up and then place the sutures through the tendon discly. We utilize the open repair for some of the minimally retracted full thickness tears. The majority of the retracted full thickness tears, really virtually all of them, and some of the chronic tears, although most of the chronic tears, I will utilize a graft for. So here's my endoscopic technique. This was just published in Arthroscopy Techniques. We start in the prone position with the hip and the knee flexed. We drape off the perineum and then the disc aspect of the leg. So I utilize four or two, even five incisions. Three of those would be in the gluteal crease, and we'll primarily start with the middle two, both the more proximal and the more distal one that are in line with the side nerve. So here we are viewing through that more distal, working through that more proximal portal, both in line with the nerve and the tendon. This is about two minutes into the case, and we're just bluntly dissecting in line with the nerve and primarily working to identify the neurovascular structures in the tendon. We'll go ahead and gently stimulate the nerve to ensure that we are getting stimulation. We'll then examine the tendon. Here you can see the typical detachment underneath with almost normal perineal outside appearance. There, down into the right, you'll see the posterior femoripectaneous nerve, and I think the ability to see that does help decrease the incidence of sensory disturbance. Well, then it's important to mobilize the nerve and expose the tendon all the way around the anterior aspect of the ischium to the short external rotators, and that's what we've done here. We will utilize a tracheostasis crossing between the portals, and you should utilize a couple of those to retract the gluteus maximus. Remember, your hamstring pathology includes two primary tendons, and there is a distinct interval. So we'll then go down and identify that interval, just distal to the ischium. Here's the fatty interval and that fatty stripe there, that's very identifiable as part of it. Then we'll then gently work that out with a radiofrequency device. Here I'll palpate that line to ensure that we still have the two distinct tendons. And then it tends to wrap up a bit more posterior with the seven membranous, just taking up a larger portion of the, this lateral portion of the proximal footprint. Here you'll see we are confirming where the detachment is, and then lifting up, you can see the near-complete detachment underneath. We'll then release as much of the interval distal as is necessary to fully access the tear and the ischium for repair. You can still see the side of nerve down in the lower part of the screen. And that unfortunately typically remains out of the working way most of the time, we'll typically use a switching stick to run the accessory portals just to ensure that it is retracted safely out of the field. Then use standard tendon repair techniques utilizing typically four anchors, two in each of the footprints of the two tendons. Usually with a combination of mattress stitches and typically in a rip-stop type fashion. Here's the final repair. You can see this achieves a nice anatomic repair, minimal disruption of any of the normal muscle and tendon while safely protecting the sciatic nerve and the posterior femoric cutaneous nerve. So when do we do endoscopic repair? So as I mentioned, that is primarily with our chronic partial thickness tendon tears, which is what we showed there in the video. Again, with our full thickness minimally retracted tear, so I would typically use endoscopic repair for those, but occasionally open repair if it's very early and needs a little bit more time to repair. And then we'll do the endoscopic repair for the posterior femoric cutaneous nerve. And again, we'll do the endoscopic repair for the posterior femoric cutaneous nerve. And then I'll typically also use an endoscopic repair technique to place the anchors even for my full thickness retracted acute tears. I find it easier and better when you're working under the gluteus maximus to do that endoscopically. And if you need to work down in the leg because the retracted tendon tear, that's best to unopen. And so we'll typically use a combined endoscopic assisted approach for those tears. So therefore the factors favoring endoscopic repair for me would be location of the tendon. If the tendon is near the ischium or under the gluteus maximus, they will be more likely to use endoscopic technique because that allows us to access that portion of the body better. Tendon is retracted down below the gluteus maximus at a minimum where you are going to do endoscopic assisted approach if not fully open. Patient size is another factor. So larger patients I think actually are better treated through the endoscopic technique. And these would primarily be patients in that full thickness retract area where it may be harder to work up under the gluteus maximus due to the body habitus. It's easier to place those anchors and then open up to get down to the tendon. For smaller patients, this is less of an issue. And so for those, we may do the entire thing open, again, for these patients more to the right. History of acute injury, if they do not have history of acute injury, they are therefore much less likely to have scar around the sciatic nerve. And that can make the endoscopic approach difficult and lengthy. And so if they do not have history of acute injury, I would more likely favor that. If they do, we may still take a look, but often we'll end up converting that to an open repair if the sciatic nerve cannot be safely identified as that is a key aspect of performing an effective and safe endoscopic repair. And so in summary, and we showed this from our talk yesterday on the outcomes, endoscopic repair, that you have better access for a large portion of the tears. I think you can get a better repair for the chronic partial thickness tears where you can see that you're zoomed in seven times magnification with a scope. I think you can get a better, more anatomical repair. We've shown in our series that it's safer regarding infection and injury to the posterior femoral cutaneous nerve. And I think there's also oftentimes less muscle injury. Now, these are all many of the same reasons we've used for years to do an endoscopic rotator cuff repair. And I think we'll find that over time as we get more comfortable with the endoscopic cancer repair technique, that it will become the dominant technique for these set of injuries, much like arthroscopic rotator cuff repair has for the majority of rotator cuff tears. Thank you. So now we're gonna have Dr. Brian Busconi, my co-chair, talk about open hamstring repair. Thanks, Brian. Welcome and thank you for attending the last talk in the fourth session of The Athlete's Hip. As a co-chair, I would like to thank the AOSSM leadership, the AOSSM Education Committee, and my co-chairs, Dr. Gwathley, Dr. Ngo, and all of our speakers for their hard work and collaboration to put together this virtual educational opportunity. Tonight, I'm going to be speaking about open proximal hamstring repair. We've heard from Dr. Mather about the really sleek and slick endoscopic repair. Well, for a 57-year-old physician who's a little bit older and needs to see everything a little bit clearer, I'm gonna talk about my open proximal repairs. I've already discussed my disclosures. And as Dr. Mather has already indicated, hamstring injuries account for up to 29% of all injuries in multiple different types of sports. In fact, in the NFL literature, it is the second most common injury. There are multiple biomechanical factors that can be involved, as Dr. Mather already talked about, but it's most common to have these injuries during the last 25% of swing phase in which these hamstring tendons are at their maximal length and have their highest eccentric load. Multiple other risk factors can be found, but what's important are the non-modifiable risk factors, which include age, and in many sports include previous injury. As Dr. Mather talked about in the anatomy of the proximal hamstring, it's really important to understand the semitendinosus and biceps have a common proximal insertion, which is what I call the medial footprint, and the semimembranosus inserts more laterally in the lateral footprint. And that was already eloquently discussed. And again, important point in the anatomy is the recognition as to where the sciatic nerve is, and that becomes very, very important endoscopically and also open. In my practice, it's important to, when patients come in, to try to differentiate whether this is a proximal, mid, or distal tear. The proximal tears oftentimes will have this tearing sensation and will have a significantly altered stiff-legged gait. It's very different than my other mid or distal tears. They'll have a lot of tenderness at the ischial tuberosities, and oftentimes they have difficulty sitting on that side. My mid-substance tears are more on the posterior aspect of the hamstring area, and oftentimes these go away very quickly. My distal injuries are oftentimes in the popliteal area, so these are really three different clinical presentations. When you're doing your physical examination, as Dr. Mather indicated, you want to evaluate walking, standing, sitting, supine, and prone, and there are a lot of special tests that you can do, but what's important is knee flexion as well as, and Dr. Steve Cohen gave me these pictures, I like the bridging tests because if you have a lot of weakness to your hamstrings, you really can't do that, as well as the standing heel drag. That is oftentimes very positive with people with proximal ruptures. Plane radiographs don't really do a lot for me in my practice. It's rare that I have an abulsion injury. Ultrasound is very important in my practice. It allows me to see whether or not a patient has a tear. However, MRI is really my go-to imaging as it really helps me determine whether there's a single, a double tear, three tendons, and distance as well. So multiple different ways with which we could grade these, grade one, twos, and threes, as well as pathological appearance. But what's important is understanding the distance that the tendons have traveled and which tendons are torn. MR and ultrasound are considered equally in identifying injury. However, MR is better for me for deep injury and recurrent injury. Non-operative management, general consensus says partial injuries, mid-substance injuries, complete single tendon, proximal injuries, or two tendon proximal injuries with two sonometers or less for traction are usually commonly referred to for non-operative. However, I would like to put a caveat in that a lot of people are quite debilitated by the two tendon ruptures and that you may wanna think about doing operative intervention if they fail conservative care. Again, non-operative care, you wanna allow this to heal and then return to sport when they're able to feel comfortable doing those things. Platelet-rich plasma is part of my practice, especially for proximal and mid-injuries. However, this is in tendon tears with which I do not feel that they are going to have surgery. So these are not in lieu of surgical patients. Operative management of these tendons are for more significant injuries, two tendon abulsions with greater than two sonometers of retraction, three tendon tears, and also partial injuries with which I've failed conservative management. The goals, again, as Dr. Mather indicated, were to restore muscular and osseous attachments. For me, this is much easier done in an open environment. It allows me to get in there acutely. I can really do a good job of cleaning out the hematoma and it allows me to feel safe with doing my sciatic nerve neuralysis. I do these patients in a prone position. I like to have a little bump under the heel. A transverse decision allows better cosmesis and allows me to see the avulsed tendons well. I go down through the gluteal fascia, make sure that you don't affect the posterior cutaneous nerve as that could give them sitting pain. The gluteus maximus is then identified and elevated. The hamstring fascia is identified in size and looked for a hematoma. You wanna make sure you debolt the scar around the tendons. Utilize a headlight loops if needed. The sciatic nerve is always identified by palpation, is protected and you wanna make sure you move it out of the way during your repair. Use a periosteal ovary, a curette for the footprint area. Don't use a burr. I like to use suture anchors and in fact I've moved towards now all suture anchors for these repairs. Remember that the semitendinosus and the biceps share a common footprint origin. I usually use two double loaded all suture anchors and I plate them in the appropriate anatomic footprint and I do a opposite limb pull tendon to reduce them. I'm reducing it down to bone. However, many other techniques are out there and Steve Cohen and Jim Bradley like to use a five anchor technique. It doesn't matter which technique you utilize. What matters is being able to reproduce the anatomy and footprint attachment. The fascia is enclosed and the wound is enclosed in layers with monocryl and dermal bond. Again, I like to use a hinge knee brace locked at 30 degrees for two weeks. Weight bearing with crutches, foot flat and then at the end of two weeks, I keep the leg straight and then I slowly start motion in the knee. Jogging can be permitted at four to five months. Partial tears have also been talked about in the literature, operative management for these, especially if they've failed, conservative management can be very successful. Chronic tears usually require, in my practice, a longitudinal incision and you may have to consider doing allograft tissue augmentation. Okay, here's my longitudinal incision showing the large hamstring tear and then me utilizing Achilles allograft to get this back down to bone. There have been some studies looking at a meta-analysis and systematic review in AJSM 2017, 24 studies were looked at and interesting enough, the complete tears did very well with good satisfaction, hamstring strength and lower extremity scores but their complication rate was high. So be very wary that you're very meticulous about this. Acute versus chronic repair. Again, acute repairs did better than the chronic repairs and complete versus partial tears, actually patient satisfaction and pain were decreased with the partial tear. However, they were able to return to their sports and they had lower complication rates. So in general, what they concluded really was that acute repairs have higher satisfaction, less pain, return to strength and higher functional scores. Recent publication at KSSTA in April showed that patients, they looked at 94 patients, which was quite a large study, the complication rate was low and the outcomes were both excellent in partial and complete tears. So I thank you very much, Dr. Mather. I'd love to learn how to do it endoscopically but I do not feel that it's necessary in my practice. I'd like to be able to see, visualize and return the footprints back to their anatomic positions. One last thing prior to me leaving is that I would like to thank Julie Ducey and Alexandra Campbell for all their hard work in terms of organizing this virtual conference. I can't thank you guys enough for everything you've done. Thank you. We are going to pause just for a second so we can close out the extra articular segment. And so if I can invite Drs. Burr, Dr. Noe, Dr. Mather and Dr. Busconi to turn on their webcams on. We have several audience questions. We're gonna go ahead and take care of that and then we'll go on to the debates. And so we'll spend five, 10 minutes here just to go ahead and make sure we answer all the questions that might be out there for gluteal tendon and for hamstring tendons. So let's see. First off, this is for the gluteal tendon. I'll start with you, Dr. Burr. One of the audience members asked about the iliotibial band. Do you split it? Do you go beneath it? And at the end, how do you handle it? I think from my perspective, I prefer an IT band sparing approach and that's why I'll enter the paratrocheteric space from anterior, develop the space, clear out any bursal tissue, then place my viewing portal through the IT band just posterior to the vastus ridge and working portal distally and place the anchors percutaneously. And again, I think if their abductors are in bad shape, they're probably using their TFL and their IT band to help compensate for that. So I prefer to preserve it. Now, some people think that they create a window to protect the repair site, but also if you use a technique where you just enter from lateral to the subcutaneous tissues, it obligates you to make a window in the IT band for exposure. But again, for me, I'd rather preserve it, but to be honest with you, there's absolutely no data that suggests that one method is superior to the other. Dr. Noe, can you open? I think you're muted, Shane. I agree with Dr. Burr. I also prefer to preserve the IT band at all costs. I think by placing cannulas and so forth, we're probably making some small rents in the IT band, but I don't consciously try to lengthen the IT band or create a window. Got it. Do you change your surgical technique based on the tendons that are torn, minimus versus medius? That was an audience question. Dr. Burr? No, I'd just like to sort of have an idea going in, kind of what I'm going to be faced with, whether it's medius or minimus or a combination of both. And on some of the more chronic lesions, they've sort of morphed together and I'm just sort of fixing them all together. That's where MRI helps you, but also this is a place that ultrasound helps. And interesting, ultrasound sometimes identifies the structural aspect of these tendon injuries better than MRI, because MRI just shows you the signal change. Got it. Yeah, I agree with Dr. Burr. I think getting a good understanding on your MRI before you actually begin the case will help you make a decision as far as whether to do it open and dyscopic, whether you're going to address the medius or minimus. As Dr. Burr had mentioned, in most cases, they're probably involving both of them, but there are some exceptions. And I think if you plan appropriately, I think you can avoid any pitfalls intraoperatively. So Shane, can you give us any pearls? You described that partial undersurface tear. Like, how do you find that? Can you give us any pearls to find that endoscopically or open? Yeah, so I think that the first thing is I want to look at my MRI before I start the case. I want to get a good sense as to, is this kind of a bias towards the medius or the minimus? And one of the things that I'll do is, I'll be pretty keen about doing a dynamic exam during the time of surgery. And so, usually when I enter the peritrochonderic space, I'll be abducted about 20, 30 degrees and I'll internally rotate the foot. And once I'm evaluating the gluteus medius and minimus, I'll ask my assistant to slowly bring the foot from internal rotation to neutral to external rotation. And oftentimes you will be able to see where the incompetence of the gluteus medius or minimus might be, just based on the way that the tendon is dissociated from the underlying bone as you start to rotate it. In some cases, I've also done like a bubble test where I've injected saline, where I suspect the deep tear is. And the last thing I would do is, I'll use either my probe or I'll use my shaver just to see where it feels like there's just a thin veil or a thin layer of tissue. And oftentimes using these different ways, you usually can isolate where the exact tear is located. Got it. Dr. Mather, I've heard you coined the phrase scoping when you talk about some of your protracted tears. Can you elaborate on what that would mean? Yeah, as I was saying in my talk, I like to use the technique that best fits the anatomic area that we're working. And when we're working up around the ischium, that's best done endoscopically and then we're working down in the leg, we do that open. So for a lot of chronic tears and even acute tears, I use that scoping approach where we'll spend the first 20 minutes burying the ischium, placing the anchors, then open it up and pull those out, pass it through the tendon and tie them up. Great. Is there, Brian, Dr. Visconi, how do you brace your repairs or do you brace them? Do you use a hip brace or a knee brace or does it change versus how big the tear is? Yeah, I don't really use the brace that much, Winston. You know, 30 degrees first two weeks, just a regular hinge knee brace and then extension and off you go. There are people who are doing these open hamstring repairs who are actually on their crutches for a very short period of time. So I've been actually weaning down my crutches. My gluteal medius and minimus repairs, I have on crutches for six to eight weeks, just like Tom does. My hamstring repairs, I'll have them on crutches for three to four weeks. Got it. Do you use a brace for your abductor repairs, like a hip brace? No, I don't use one. I find it really hard. A lot of the people in my area that I'm doing these on, you know, don't quite have the waist sizes and the thigh sizes that fit the braces that I would love to have them in. So it's fairly hard to do that. And I'd just like to make one point before we go. Remember, you can always do these repairs in a stepwise fashion, as Chad just indicated too. You know, go in, especially as fellows, go in, get into the sub, get under the iliotibial band, you know, and if you feel comfortable, continue on. If not, prepare to make a small open incision. It's okay. Just be prepared that you're set up to be able to make that open incision. I think that's how we all learn, Tom can talk too, as to how to get there. It's by doing these gradual approaches. Got it. And then one last question. Each of you have mentioned the use of biologic or PRP. How do you guys use that for glialtynopathy and for hamstrings anaphylae? Do you use it commonly for partial tears? Can you maybe just each of the panel kind of talk about how to use that? You know, I'll start on the furthest left there, but I think the FDA evidence from John O'Donnell and the study in Australia, that level one evidence showing that PRP does work for glialtynopathy has really changed my practice to tend to recommend that for most people with tendinopathy. I've increased the amount of time I put them on to protect the weight bearing over time, even asking them to use a cane until they get strong. And so it's a lot of recovery to go through. So I typically do try that for all of those patients. Shane? I will offer PRP in the office for both glial and hamstring partial thickness tears. I think that I find that my hamstring patients are more willing to try it. My glial patients, they tend to be a little bit older. I don't think that they usually are interested as much. Previously, we published a paper using PRFM, which is a membrane of PRP, essentially, that we would use to augment a repair, which showed that there seemed to be some improvement in some of the PROs compared to not using it. So I'm interested in it. I think sometimes I just have a hard time getting patients to agree to it. Dr. Burr? As I mentioned in my talk, the partial thickness abductor tears are a big problem. And it's not the surgery, it's the rehab that you're subjecting them to afterwards, which is four to six months of recovery. That's why anything we can come up with besides surgery, I think PRP, it's a big problem. PRP, if it works, great. The problem, as we all know, is that there's a cost associated with it. The insurance companies don't cover it. But also keeping in mind that often these are a little older population. And commonly, I'd certainly say at least a simple majority have associated intraarticular problems going on as well. And somebody doesn't seem to have any findings of an intraarticular problem, isolated partial thickness tear, I'm much more inclined to encourage them to consider the role of PRP. Perfect, anything to add, Dr. Busconi? No, not at all. I mean, my practice, other than my athletes, my practice is mostly traumatic large tears. So I don't get to see a lot of the subtle ones that the PRP can be helpful for. But I agree with Tom. The key here is the rehab because most of the people are coming in with very poor back, pelvic control, core control. And doing that without surgery usually is helpful. But if you can, if it's very large, then you fix it. Because I think the results speak for themselves. Perfect. All right, my friends, thank you very much. We'll close out the acurate particular panel. You guys are up for a period of time. Not you, Dr. Berg, you're coming back. You can turn your webcam off and we'll go. We're gonna move on to the debate session now, okay? So we're going to go back into the joint and we're gonna start a debate session. So everybody deals with mild osteoarthritis and we're gonna finally solve what we do with this twin-year population during our debate session. And so if you can pull up the debates, Alexandra. My charge in this debate is to support the role of arthroscopy in the management of mild osteoarthritis. The question that's usually asked is how much OA is too much for an arthroscopic approach. But as I'll highlight towards the end of this debate, that's not really the right question. My disclosures are available on the AOSSM website. Now for starters, don't confuse osteoarthritis with age. Age is not a contraindication to many of the things that we do arthroscopically around the hip, but OA is bad whether you're 73 or 23. As far as contraindications to hip arthroscopy, there are only a few objective contraindications. Advanced OA, such as tonus 3 changes, are less than 2 millimeters of joint space. Dysplasia is sufficient enough to warrant a PAO. There are a few objective parameters that are not contraindications. There are numerous studies that imply that tonus 2 changes are a contraindication, but there are really only three studies that look specifically at tonus 2 findings. One by Ben Dome demonstrated a 40 percent conversion rate to total hip in the presence of tonus 2 changes. But if you look closely, they actually had an 11 percent conversion of total hip among the tonus 0 and 1 changes. So there are other factors at work here. And I'm not throwing Ben Dome's work under the bus. As you'll see later on, this is a common theme. There are two studies that suggested favorable findings even in the presence of tonus 2, and both of those were reported by us. We found that those with tonus 2 changes didn't do quite as well as those with 0 and 1s, but they demonstrated both statistically and clinically significant improvement. A friend of mine warned me and said, Thomas, now people are going to think it's okay to scope everybody out there with tonus 2 changes, and that's not what we're saying at all. All I'm saying is that tonus 2 changes by themselves are not a contraindication to arthroscopy. Touching briefly on failed hip arthroscopy, the two most commonly cited reasons are capsulolabral adhesions and incomplete correction of impingement, but that's a discussion in itself. As far as failure due to advanced degenerative disease, I suspect that this is most often likely due to underappreciated disease prior to surgery rather than progression of disease after the surgery unless it's iatrogenically introduced. Remember that with FAI, the femoral head remains well-preserved until late in the disease process. So if you see any femoral-sided changes, that's a harbinger of a more advanced disease process. It's important to try to do the last operation first. Just a couple of x-rays illustrating rapid joint space loss reflecting that sometimes just repeating an x-ray can avoid an unsuccessful arthroscopic procedure. The deceptive appearance of joint space preservation can be exposed by a false profile view, here respectively showing anterior and posterior joint space narrowing. When you see studies that report appreciable rates of conversion of total hip replacement, I think that really calls into question their indications for the procedure. In one systematic review, they reported a 23 percent conversion rate to total hip among patients with arthritis. But in a puzzling fashion, they had an 8.3 percent conversion rate of those who didn't have arthritis. So why are patients with no arthritis getting converted to hip replacement? In our first two series of FAI patients, we reported a conversion rate between zero and 0.5 percent. Certainly that number is growing as we've expanded our indications, tackling more challenging problems. But in general, with careful patient selection, your rate of conversion to total hip should be particularly low. What about the presence of early osteoarthritis? Well, the question isn't how much arthritis is too much for arthroscopy. The question is, when does the pendulum swing from arthroscopy being a preventative procedure to becoming more of a palliative treatment strategy? Because as a palliative procedure, an arthroplasty establishes an exceptionally high bar as far as the success of the operation. We know that the success of arthroscopy is heavily influenced by the severity of the articular damage. I think it's wise to just assume that the imaging is going to underestimate the severity of the articular damage. And keep in mind that once any degenerative changes are noted on radiographs, the articular involvement is likely to be fairly advanced. Unreasonable expectations are another setup for failure, and that's true for both the patient and the surgeon. So in conclusion, advanced OA is an obvious contraindication for arthroscopy. In the presence of early radiographic features of OA, the treatment strategy starts to shift from that of a preventative procedure to more of a palliative operation. And in that setting, arthroplasty represents a high bar as a palliative procedure. Obviously, age is an influencing factor that you may be more likely to try at it with an arthroscopic approach in a young person. Subjective parameters, such as symptoms and expectations, are also likely to play a determining role. Greetings from Nashville, and everyone be safe. Everyone be safe. Thank you, Dr. Byrne. Dr. Dohm will be our next debater from the American Hip Institute. Thank you, Dr. Dohm. Hello, Benjamin Dohm here from the American Hip Institute in Chicago, taking the position that for mild osteoarthritis, total hip arthroplasty is the way to go. My disclosures are listed with the AOS. So it's simple. Scoping an arthritic hip is a bad idea. What can you fix arthroscopically? Many things. We can fix a labral tear. We can fix impingement with a very high degree of accuracy. We can even push the limits and do a reconstruction of the labrum or even a reconstruction of the ligamentum teres or reconstruction of the capsule. But what we cannot fix is osteoarthritis with a hip scope. Now, guess who said this great quote? The best surgery will fail when performed for the wrong reasons. None other than Dr. Thomas Burt. One of the great questions we have faced in the field of hip preservation is how much arthritis is too much? And the field of hip preservation deserves great credit for establishing a body of evidence justifying the existence of the field of hip preservation and of hip arthroscopy, which essentially conquered much of the early skepticism of hip arthroscopy and hip preservation. However, in investigating the question of how much arthritis is too much, we have recognized the limits. Patients with greater than tonus one or a joint space of less than two millimeters are less likely to benefit from hip arthroscopy, more likely to require a conversion to a hip replacement, and have lower PROs at follow-up compared with their non-arthritic counterparts. This same theme has been reflected in multiple publications. In the first one by Kemp et al., patients with hip OA had inferior results. In the next by Piuzzi, worse outcomes were seen as the severity of OA increased. And in the final study, OA was correlated with higher failure rates and increased conversion to total hip replacement by Lay et al. So if we're not recognizing the pattern in the literature here, then there seems to be no sign of intelligent life anywhere. There are several excuses that we make for ourselves. One excuse may be, well, we're not burning any bridge by doing a hip arthroscopy. We can always do a hip replacement later. That may not be true. One of our early studies looked at the results of hip arthroplasty after hip arthroscopy and found no difference in the patients who had had previous arthroscopy. In other words, it seemed that no bridge was burned. But when we looked subsequently at the minimum five-year follow-up of a similar cohort-controlled group, we found that the patients who had had previous arthroscopy had higher rates of complications and higher rates of revision surgery with their replacements. So in fact, it may be that we are burning a bridge by doing an arthroscopy if we know that an arthroplasty is going to be needed later. A second excuse we may make for ourselves, well, we'll save your own hip for a number of years. The question is, how successful will we be? Or will we be dooming the patient to several years of palliative care with injections or otherwise trying to keep their pain under control? Or worse yet, will we be adding coal to the fire and actually make the problem worse? Now, indications are clearly everything. And how we examine the hip is critical. If we don't examine it well, then we won't find subtle signs of arthritis. X-rays are very valuable. We've also found utility to degenerate MRI, which allows us to examine the quality of the cartilage numerically. And we found that a degenerate index of 323 or more was predictive of better outcomes with hip arthroscopy. It's also important to manage expectations. The expectations need to be matched between the surgeon and the patient. And we need to understand the limitations of hip arthroscopy and explain them very well to our patients. Now, guess who said this great quote? Son, you don't have to learn all the complications for yourself. You can read about a few of them. None other than Dr. Thomas Berg. In summary, the total hip replacement is the holy grail of orthopedics. It's been described in The Lancet as the operation of the century. At our center, we've developed a technique for robotic direct anterior outpatient total hip replacement. This takes human error out of the equation, allows us to perform it in an incredibly minimally invasive fashion, and with a recovery that is arguably faster than a hip arthroscopy. In summary, in osteoarthritis, there is only one greatest of all time, and that is the minimally invasive hip replacement. Thank you very much. Ben, you had me at the Tiger King slide, so it's going to be hard to beat that. Can I invite Dr. Dohm and Dr. Berg back? The Tiger King will always be the celebrity of the quarantine, I believe. I was instructed you're supposed to have fun with these debates. That was great. That was great. Dr. Berg, I've heard those quotes out of your own mouth, so I know that Dr. Dohm, that was authentic. I do appreciate that. So I've got a couple of questions. I was told you'd be the one to make the big speech. I will say, you know, just to start us off, Dr. Dohm, it is nice. I think I do envy you having the entire spectrum covered between being able to perform hip preservation and hip replacement. Some of us, those who are in the more preservation world, we have to find arthroplasty surgeons who will agree with us to replace some of these hips. And so when you actually have that tool in your tool bag, it really gives you a larger, a better algorithm, I believe. But Dr. Berg, you've always told me about the lifetime compensator, that 60-ish-year-old person with FAI who's been able to get along for their entire life, and you use that slide to basically say FAI can exist. What do you do in that 60-year-old who's got Model A, some FAI, and a labral tear, who's starting to get symptomatic? When you go in there arthroscopically, if you do, do you address the FAI at the same time, or is there a procedure in which you address the labral pathology? I think in today's world, if I'm going to go that route, the idea, well, let's keep it simple and just go clean it up a little bit, I'm not too keen on that approach. I sort of feel like that if we're going to bother to go through the process, I'll try to address it as completely as I can. I think the key thing you mentioned, radiographically, they've got some early signs of arthritis. To me, if you see any x-ray changes, the articular damage has to be pretty significant before you see any radiographic changes, especially in the subtlest amount of joint space. That's where, again, now you're not talking about a preventative procedure, you're talking about a palliative procedure, and compared to an arthroplasty, which is the most successful of all operations in orthopedics, you're swimming upstream with a palliative procedure with the arthroscopy. Got it. Ben, can you talk about, when you look at somebody who's got a little bit of FAI, a little bit of OA, how can you tell the difference as far as symptomatology? What leads you to believe the FAI is the problem versus what the OA is the problem? Winston, thanks. I'm not sure you can. We've certainly talked as a field about things like night pain and resting pain and a constant dull ache as opposed to a positional pain. I think those things may have some limited utility in identifying that the pain is more so arthritic than FAI. I do think when the pain is very specifically positional, that makes me think more FAI. And when the history of that positional pain corresponds with what I find on a physical exam reproducing those positions, then that sort of supports the mechanical thinking as far as the diagnosis. But to summarize, I'm still not sure you can totally predictably separate one from the other, and I think each can mimic the other to a degree. Got it. So, Dr. Dohm, my friend is 40, and he went out and got a hip resurfacing down in South Carolina. He's playing soccer again. Why not just do a resurfacing? I think a resurfacing is a great operation, and I do them. We've adapted them to be done through the anterior approach, which is an outpatient procedure. It's a quick recovery. And again, I think in my hands, a quicker recovery in a lot of ways than an arthroscopy. So resurfacing should be part of the conversation in my view, especially for the middle-aged male athlete. Now, having said that, anytime we have the opportunity, I'll argue for Dr. Bird a little bit here. Anytime we have the opportunity to avoid putting hardware in the body, I think we should. The younger the age, the harder we should try to avoid putting hardware in the body. We know that hardware doesn't last forever. We know that there are complications that exist with hardware that don't exist without it. So if we can preserve a joint, I think we all come from the standpoint of the field of hip preservation. And on some level, we consider arthroplasty a failure of hip preservation. Got it. So, Dr. Bird, it seems like everybody's talking about capsular closure these days. And these arthritic patients are in the tennis grade, too. What's your feeling about the capsule? Do you want to get that water tight? Or is a capsule at least part of the operation? I think oftentimes for these arthritic hips, a lot of times they tend to be guys mostly with very stiff hips. And sometimes that capsulotomy turns into more of a capsulectomy as part of the treatment. So I definitely don't get too aggressive about trying to restore the capsule in that population. And everything's kind of risk-reward. I think the risk of instability in that population is very low. And again, I have a sense that perhaps by excising some of that may give them a little better chance at some moderate pain relief if you're doing an arthroscopic palliative procedure. And I think getting back to Ben's point, you know, if somebody's got a painful arthritic hip, and yes, you're young for an arthroplasty, but are they supposed to sit around and twiddle their thumbs? And when they're in the prime of their life, they want to be active and they're looking for quality of life. I mean, if you got osteoarthritis that's bad, like say whether you're 23 or 73. Great. Ben, so I'm 50 years old and I really like to run. I got some arthritis in my hip. And Dr. Gwathmey says it's a little bit too advanced for arthroscopy. But I really want to run. So what am I going to do with me? Well, I think the first step is to counsel and educate the patient. And I tend to educate the patient that if there's hardware in the hip, impact activity is known to shorten the life expectancy of that hardware. So I've had patients with a hip resurfacing or a hip replacement who have run marathons, who have power lifted, who have fought in MMA fights. None of this necessarily with my recommendation, but it certainly can be done. Now, having said that, I tell every patient in this conversation, here's what I would do if it were my hip. If I had my hip resurfaced or I had a replacement, I wouldn't run, jump or do heavy lifting. That's me. Now, your hip is your hip. You get to decide what you want to do with your hip. If I replace it or resurface it or do an arthroscopy on it. Great. So, Dr. Byrd, for those tone of grade two athletes, is there a difference as far as return to play with time and what you tell us as far as expectations? Well, again, for especially for high level athletes, professional athletes and sometimes even collegiate athletes where their scholarship is their opportunity to get an education. Again, you know that the dyes cast on the future of their hip with tone is two changes. That's not going to this isn't going to be a lifelong solution. But oftentimes, especially in athletes, they've got a window of time that they get to generate some income that they'll never see again after their athletic career is over. And it's an economic decision. But the key is to make sure that the athlete or the patient understands this. So it's an informed decision that they're making. So from the audience, what about subchondroplasty? I have this this big cyst in my acetabulum or my thermal head. You can fill it up with cement or with some type of bone graft. What would you both of you what would you say about subchondroplasty? Go ahead, Thomas. Yeah, it's an area that we're exploring more and more. We've had some experience with it and that my volume of experience has not been enough to say that it's been a home run for a lot of these people. But if you've got a relatively young person with a significant subchondral cystic change in the acetabulum, it kind of makes sense to try to address it. The big thing is that if they've got a big defect in the acetabulum, then there's not much you're going to do to fill that subchondral cyst. But sometimes that subchondral cyst is associated with a little punctate articular lesion in the acetabulum. It's like a pinhole where they're getting a hose nozzle effect of the fluid pressure going through that small hole is what creates the hydrodynamics of creating the subchondral cyst. And I think those are the ones that, again, we've been working towards and it makes sense to address it. But I don't have enough data to tell you that the results are superior. And I've done those and with good effect, but I think there's a specific tidbit on patient selection I could offer there, which is that if the cyst formed in a certain spot, there was probably a mechanical reason why it formed in that specific spot. And if we can address the mechanical reason at the same time as doing the subchondroplasty for that cyst, then that has a good likelihood of success. So an example would be a CAM impinger who has a cyst because of the CAM impingement. We can fill the cyst and address the CAM impingement at the same time and change that mechanical load that caused it. A counterexample would be somebody with borderline dysplasia or micro instability who has a cyst. That for me is a no-go. That is almost a contraindication to a hip preserving surgery because we can't necessarily correct the mechanical force that caused it. Great. Thank you guys so much. I think we'll close this debate for now. I think that the audience would agree that I would thank both of you for what you've provided to the hip literature as far as the research you guys have done. So thank you very much, Dr. Byrd, Dr. Dohm. We got it all figured out. All right. Thanks, Thomas. Thanks, Quincy. I think we unanimously agreed. Yeah. This is an easy population to deal with. All right. So we're going to move on to our next debate. So you guys can, you're off the hook for the time being. So our next debate we're going to talk about mob dysplasia. So this is another one that we have to deal with these sort of tweener patients who are not quite, you know, it's hard to determine whether a hip arthrothia would be beneficial or osteotomy of some sort. So our first speaker on this debate is going to be Joshua Harris from Houston Methodist. So Joshua, take it away for arthroscopy or borderline dysplasia. The title of this presentation is borderline dysplasia, and I'm Joshua Harris. This is the first half of a debate with Dr. Andrea Spiker, and I'll be presenting the arthroscopic option. I want to thank AOSSM for the opportunity to present during the athlete's hip. Here are my disclosures. So borderline dysplasia is this nebulous concept with controversy primarily surrounding their terminology, and it falls along the stability spectrum. And I think it's best actually termed transitional acetabular coverage between normal coverage and dysplastic instability, structural instability. And so for purposes of this talk, we'll use the definitions that have been used in the literature, which have primarily revolved around a single lateral center edge angle between 20 and 25 degrees. However, it's also been reported as a tonus angle between 10 and 15, anterior center edge of 20 to 25, and within intact Shenton's line. And so I think one of the key take home points in evaluating this borderline dysplasia group is it's not just a lateral center edge angle, as you can see here. However, when you look at this lateral coverage, it's important to know what you're measuring. Are you measuring it to the lateral edge of the sore seal or to the lateral edge of the bone? We know if you look at the lateral edge of the sore seal, this is more of an anterolateral, an anterosuperior coverage. If you look at the lateral edge of the bone, it's more of a superolateral. However, remember, undercoverage can also be anterior. You can see this with a good false profile view, but the same concept applies. Are you measuring it to the anterior edge of your sore seal or the anterior edge of bone? This makes a big difference because it can be an up to a 10 degree difference, which makes a big difference for both diagnosis, but also for the treatment that you render. Posterior coverage can be the same. You can look at this on plain radiographs with a posterior wall sign or initial spine sign, which are more of signs of socket retroversion. The fear index is this new radiographic parameter that really does help define is the patient displaying signs more of instability or more of impingement. Depending on which study you read, it's between a 2 and 5 degree threshold. If it is above this value, this is something that leads more towards a diagnosis of instability. If it's less than this value, if it's less than 2 to 5 degrees, it's more signs of impingement. When patients present, they will frequently complain more of lateral pain or posterolateral pain. They'll display signs of snapping, both internal and external snapping, abductor fatigue, and even instability or apprehension. On imaging, signs of instability are going to be a hypertrophic labrum, iliocapsularis, even abductors. Looking at your capsule, it's going to be thin and patchless, an elevated fear index, and excessive femoral antiversion. Those are your signs of instability. The easiest way to dichotomize this, to simplify this, is if their clinical story, exam, and images are pointing towards instability, do a PAO. If their story, exam, and images are pointing to impingement, do a scope. If you look at Dr. Spiker's fellowship mentor, the key parts for a successful surgery, there are two parts. It's very simple. Appropriate patient selection and skillful execution of your surgery. Same thing goes for a bad outcome, bad indications or technical errors in surgery. This was what she learned in fellowship for a year. However, even in her recent YouTube video that was over one minute long, she actually says that hip arthroscopy is the better surgical technique. I'll be interested to hear her response to PAO versus scope. This is my reason why. It boils down mostly to the surgical indications, not necessarily the surgical technique. If you look here with multiple different studies, tonus angles that are increased greater than 10 to 15 degrees, huge increases in your reoperation rate. In the top study, it's 84% increase in reoperation. Tonus angles that are above 15, failure risk was significantly increased. In Dr. Larson's original study with a dysplastic cohort, there was a three times higher failure rate than an impingement cohort. These are patients with elevated tonus angles and low lateral center edge. If you look at neck shaft angle, valgus hip, neck shaft angle greater than 140, increased failures. Also patients that are overweight. And importantly, if you see a broken Shenton's line, don't do a scope. Ligamentum teres tear are secondary signs that instability has been going on. These are patients that are going to have worse patient reported outcomes. Also patients with femoral aversion that exceeds 25 to 30 degrees, they're going to do poorly with a scope. And that's where an open procedure is going to be your better option. However, in patients with good indications. And so if you pick the right patient, you can achieve patient reported outcomes and failure rates that are exactly the same as a normal coverage group. These are both very large cohorts, five year follow up, good follow up, greater than 80% show that you can achieve a nearly 90% minimal clinically important difference in patient acceptable symptom state. And no difference between your borderline and normal coverage groups. And this is with two separate institutions, very high volume, good surgeons picking the right patients. Don't forget soft tissue though. This is a very good study out of Denver that really looked at in patients that have an upsloping lateral sore seal. They also have high BITEN scores. These are patients that are going to be classified as soft tissue lax. And the more laxity you have with soft tissues, you may not be able to correct that with an arthroscopic procedure. And so a final reason why the scope is better. PAOs have a large number of complications. The major complication rate is over a third. Hardware removal rate is over a third. Grade three or four complications, which are very serious limb threatening or life threatening complications, were experienced in 6% of patients. And these are with the best of hands. These are experienced surgeons with on average nine years of PAO experience and on average over 200 PAO career cases. And these complications are not trivial, are not minor. These are nerve injuries, vascular injuries, amputations, high amounts of blood loss, long surgical times, transfusion rates, and ultimately still a real total hip conversion rate as well. And so when you speak to patients about this, also comparing incisions, although the ultimate outcome is the most important result that you need to discuss, it's not hard to decide between an incision that's less than a centimeter that you have to get a ruler out versus the larger open scar that you see here. And so in conclusion, borderline dysplasia is a controversial diagnosis, but it doesn't need to be. I think with clear definitions, you can really achieve excellent outcomes of that of a normal coverage group. And as I have shown here conclusively, arthroscopy is the superior surgical option as long as you have good surgical indications. However, in classical dysplasia with real structural instability, PAO is the right surgical technique. Thank you. Thank you, Josh. Our next speaker will be Dr. Andrea Spiker from the University of Wisconsin about PAO. Hello, this is Andrea Spiker at the University of Wisconsin. It's a pleasure to be here today. Borderline hip dysplasia is a challenging diagnosis. For the purposes of today's debate, I'll be arguing that borderline dysplasia should be treated with a periacetabular osteotomy. Here are my disclosures. The natural history of hip dysplasia is early hip arthritis, due to abnormal distribution of forces on the articular cartilage and elevated joint contact pressures. The goal of the PAO is to cut the acetabular fragment completely free from the rest of the pelvis, and then rotate that fragment to provide more coverage of the femoral head and improved load transfer across the hip joint. Outcomes after PAO are excellent. The 15-year survival rate has been reported as high as 92%, and the complication rate is very low. A majority of patients who get PAO will go on to return to preoperative or higher levels of activity. Even in minimal or mild dysplasia, the PAO has proven to have excellent outcomes. The PAO basically gives the dysplastic hip the same natural history as a normal hip, thereby reversing the natural history of dysplasia and preventing the development of arthritis. Some may argue that the PAO is an extra-articular procedure, but patients have intra-articular pathology on imaging. There's a very high prevalence of labral pathology, upwards of 90% in all borderline hips. However, this intra-articular pathology may actually be asymptomatic or inconsequential. Only a fraction of patients undergoing PAO alone ever need subsequent intra-articular work, so perhaps the reorientation of the acetabulum corrects the underlying pathomechanics, and that is what actually resolves the patient's symptoms. You can certainly always address both with a combined PAO and hip scope. Some surgeons may suggest that you should just try the hip scope first and see what happens. Well, there's a mounting body of evidence that by trying the hip scope first, we're not only setting patients up for failure, but we're subjecting them to worse outcomes when they eventually get their definitive procedure. Having a failed hip scope prior to PAO results in significantly lower patient-reported outcome scores after PAO, and while many studies show no impact of prior failed hip scope on total joint, there are a couple of studies that do indicate an increased risk of complications, so there's a potential that these failed hip scopes have consequences further down the line. And what if that hip scope is attempted first, but we never get a chance to do a second hip preservation surgery because of rapid catastrophic progression to end-stage ulcerative arthritis? This has been reported multiple times in the literature, and typically this happens within a year of the hip arthroscopy. The PAO has a reputation of being a much larger and harder to recover from surgery. While the PAO does involve osteotomizing the pelvis, the incision as seen here is relatively small, and with a muscle-sparing technique, pain is often very minimal. Currently, some surgeons are even performing PAOs with no post-operative narcotics. The main differences in post-op rehab between hip arthroscopy and PAO is the duration of weight-bearing restrictions, the use of DVT prophylaxis, and the fact that PAO patients go home early post-op day two instead of on the day of surgery. The argument for hip arthroscopy and borderline hip dysplasia assumes that all borderline hip dysplasia patients are the same. We know that there's disagreement as to what LCEA defines borderline dysplasia. It's reported between 18 and 25 degrees, or between 20 and 25 degrees. There can be significant variability in the measurement of lateral center edge angle. In this patient, for example, the actual sore seal is here, and the upturn of the sore seal is not providing thermal head coverage. The LCEA will be much lower if measured to this point compared to at this point. The other side of the hip is important to factor into the equation as well, and is often not discussed. Borderline dysplasia plus high femoral version, for example, has resulted in significantly inferior results after hip arthroscopy. Even if we do make the correct diagnosis of borderline dysplasia, the next challenge is to decide if borderline dysplastic hips are stable or unstable. How do we make the clinical diagnosis of hip instability? Well, there are a number of additional radiographic parameters which may help. Clinical exam findings such as the Batten score are useful, and there are several provocative maneuvers to test for hip instability, but all of these factors play a role and are often not considered. When hip arthroscopy is offered as an option, one key question is to ask what is actually going to take place at the time of hip arthroscopy. For example, there's a significant difference in outcomes depending on whether the labrum and capsule are repaired or not. When doing hip arthroscopy in the borderline dysplastic patient, there's a very long list of factors which are associated with poor outcomes after hip arthroscopy. Some of these are non-modifiable, and others are technique-based or modifiable, but there are a lot of reasons on this list that hip arthroscopy can fail to optimally treat the borderline dysplastic hip. So in summary, hip dysplasia should be treated with PAO because arthroscopy is not addressing the underlying problem in borderline dysplasia. Arthroscopy in the setting of borderline dysplasia is less predictable than in other types of hip pathologies such as FAI, and there can be a very high failure rate due in part to significant variability in what happens at the time of hip arthroscopy. Hip arthroscopy can worsen symptoms, accelerate arthritis, and result in poor outcomes after subsequent definitive PAO or total hip replacement. On the opposite end of the spectrum, the PAO is a surgery that not only offers pain relief and long-term excellent outcomes for patients, but also addresses the underlying pathomechanics and reverses the natural history of dysplasia. Thank you very much. Thank you. Thank you, Andrea. That was excellent, both of you. If I can invite both Dr. Harris and Dr. Spiker back up to the panel, we can solve this once and for all. So Josh, you actually, before we even get started, where did you get that video of that girl bending her leg over the back of her shoulder? Is that a personal video or did you find that somewhere? That's incredible. That's on the Google. Well, maybe that's when you're post-op patients. I was pretty impressed. So Josh, you talked about soft tissue. How do you change your soft tissue management? I know you're a T-cut enthusiast. Do you still do T-cuts on those folks or do you change your approach to soft tissue? So I still do a T-cut capsulotomy for a few reasons. Number one, a lot of the smaller CAM morphology patients that have excessive hip flexion, they will hit distal and anterior on the femoral neck. And I think the best way to truly get distal and evaluate that is to really make the T. The one catch with my T-capsulotomy that's evolved over the last few years is that I'll make sure that my T does not extend distally into the zona orbicularis because I think even with a good repair of that T-capsulotomy, I'm typically putting three or four non-absorbable sutures in the T-limb alone, I still don't think you restore truly the biomechanics of the zona. So I'll always keep it proximal to the zona when I do that. And so I think T really provides the best visualization to actually treat the reason the patient's in the OR. For the proximal side, I'll always close the inner portal, usually with a minimum of two or three stitches on a small inner portal cut, usually one and a half to two centimeters in length, with as much of an inferior capsular shift as I can do with that small of a cut. What do you mean by inferior capsular shift? You bring it back up superior laterally or what do you mean by that? Yes, so the distal limb will typically come from inframedial to more superior lateral with successive stitches. And so I'll usually put two on the medial side of my T and then one on the lateral side and they will go superior laterally in direction. So Andrea, if you have somebody with a large cam deformity and a shallow osteotabulum, do you handle that simultaneously or do you leave the cam alone or how would you address that? In most of my PAOs, I am doing a simultaneous hip arthroscopy. And as I've done more and more of these, I tend to address more arthroscopically. So I'll complete any inter-articular work, so labral repair, sub-spine decompression, cam decompression arthroscopically. And then the nice thing about being both an arthroscopic and open surgeon, as I'm doing the arthroscopy portion, I'm actually teeing myself up for the dissection that I'm going to need for the PAO. So then I will, over the capsule, start to elevate the iliocapsularis out toward the psoas tendon, which is typically what I had done previously all open. But yes, I take care of the cam as well and there's a high incidence of dysplastic patients having impingement morphology. So the scope PAO is a great way to just take care of everything all at the same time. So what do you do with capsule? Are you like Josh, you do a T-cut or you try to do a capsule application at the same time? Yeah, so a lot of the, and I have to say also, and Josh, you can talk to this as well, but in dysplastic patients, especially frankly, dysplastic patients, those scopes are actually more challenging than a typical FAI scope. You've got often a hypertrophic labrum, abnormal anatomy, the acetabular rim is upsloping. And so there are all these factors that make it a lot more challenging. So the one benefit is that a lot of these patients are hyperlaxed. And so sometimes I'll be able to use some suspension sutures in the distal flap of the capsule to retract enough to address the cam. But if I need the visualization, I will also do a T-capsulotomy and get the appropriate visualization that I need. And then what I have started doing is repairing that arthroscopically, T-cut arthroscopically, and then I'll repair the interportal open at the end of the periosteidular osteotomy. Okay. Josh, would you like to respond to that? Yeah. So I think the size of the labrum is a very critical point in this transitional acetabular coverage group, this borderline group. I've started to look at that a lot more closely in my preoperative discussions with patients. I think those that actually have the true radiographic presentation of this borderline group, if they have a small labrum, I think they are at a higher likelihood of failing. I think if they have a larger labrum, it's been able to compensate for a long time. And so I think that's one of the deciding points. I think their physical exam and their subjective story are also incredibly important. I think those that have real instability will frequently snap. They will say it's the audible snap that you can hear that's frequently going to be their iliopsoas. And the visible snap that you can see is typically going to be periturcantaric from the IT band, and Dr. Bird taught us that. And I use that a lot in my office every day. And so I think those are some valuable radiographic and then subjective measures that you can use in your patients in the office. Andrea, knowing you're going to rotate the acetabulum during your FAI work inside the hip, how can you plan for your new impingement lesion going to be? Because if you think about how you might rotate it, do you worry that maybe you're going to create a pincer or create some type of new impingement by rotating the acetabulum? Yeah, that's an excellent point. And I think that's one of the complications that we see in less experienced PAO surgeons. You can very easily create anterior impingement. And so one of the things that we actually do here is we 3D print the patient's pelvises and get a really good understanding of the patient's anatomy prior to derotating or rotating that acetabulum. And then I think there's a very, very important focus on anteverting while creating lateralization so that you don't over cover the anterior hip and cause impingement. A lot of these patients, if you look at the dysplastic population, have a higher anteversion on the femoral side than the general population. And so that tends to be less of a problem because their femur is also anteverted. In the borderline dysplastic patients, I think, as I mentioned, looking at that femoral version is really important to factor in, you know, what treatment out there that you're going to use and then how ultimately you're going to treat that patient. So, Andrea, can you comment on reverse PAOs? Basically, the over-covered anteriorly of the hypoplastic or the deficient posterior wall. What do you use for a cutoff deciding to do a hip scope for that patient versus do a anteverting PAO? So, the retroverting PAOs, I definitely do less frequently than the classic PAO to provide lateral coverage. I think, again, I really factor in the femoral-sided anatomy. So, getting a 3D CT scan to evaluate femoral and acetabular version beforehand is really important. And, you know, I have to say, as an arthroscopic surgeon as well, I'm hesitant to do a PAO on somebody who has adequate coverage. And so I think there is a lot we can do to the scope. And if that center edge angle is greater than 25, then I think, you know, looking for ways to address it with an arthroscopy is probably my first approach. But if a PAO is warranted, the results of a retroverting PAO have been shown to be very good as well. One of the audience members wants to know what your upper age limit is for PAO, or what do you use to determine who's not appropriate? Is it cartilage? Is it age? So, if you look in the literature, there are some people who use age 40 as a cutoff. Other people use age 50 as a cutoff. I really don't have a cutoff, per se. I really look carefully at the articular quality. We don't frequently use Degenerac and other studies like that. But I think, you know, evidence of edema or cystic changes really turns me away from doing any type of hip preservation PAO procedure. But if an older individual with pristine cartilage appears to be a good candidate for PAO, I won't use age as a cutoff. Josh, do you scope to patients who've had PAOs prior? And what perils do you have for approaching that patient who has impingement after PAO? Yeah, so that's a pretty challenging case to do. The ones that I've done, which aren't many, they've typically had a lot of scar tissue and just joint access can be a little bit of a challenge. Capsular labral scar, just like in any revision surgery, you always want to evaluate. Frequently, because of that acetabular fragment that you're anteriorly rotating forward, I think I really critique the subspine area and distally on the anterior femoral neck. I look for sclerosis. I get CTs and everyone pre-op in these situations to evaluate for sclerosis at both locations. All of the collision detection software that we've used before with three-dimensional modeling will show that that's where it hits. And I think in your post-PAO patient, if you're going to perform an arthroscopy, you really, really want to look at those areas. Make sure that you don't make the same mistake twice though. I think if the patient has already had a previous PAO, their coverage is good. If they don't have any femoral-sided deformity and their articular surface is poor, I think probably an arthroplasty would be a better option, especially if they're a little bit older. The audience would like to know if you could describe or elaborate upon how you use your LCEA and anterior CEA as far as you use a source seal. That's a question from the audience. What imaging views do you use? I like to use a standing AP pelvis. I think that it gives you a much better idea of the functional position of the patient's hip. Standing AP pelvis, I will get a false profile view, but I think the problem with the false profile is that there's a lot of variability depending on the obliquity that the radiology tech is putting the patient at when they take that shot. I think the false profile is a great view to look at sub-spine morphology, but maybe less reliable when they're looking at the anterior center edge angle. I really pay attention to the tornus angle, the acetabular inclination. I think that keys you in to sometimes people will have a normal lateral center edge angle, but up to 30 or 40 percent of them will have an abnormal tornus angle, so that's something to pay attention to. Then these new indices like the fear index, I think is a helpful addition. I think you really just have to take everything in together. I do the same. I do a standing AP weight-bearing pelvis x-ray, and I think the tornus angle is incredibly important. I think it's probably, if I had to pick a value that was more important, I'd say the tornus maybe actually be more important than your lateral center edge, but for the lateral center edge, I will frequently use both. I'll use the lateral edge of the sore seal and the lateral edge of the bone, and they do correspond three-dimensionally to different areas on your rim. I use both of them, and the same concept applies to my anterior center edge on a false profile. In addition to everything that Dr. Spiker said, you also have to remember that it's a higher dose of radiation as well to perform the false profile, and especially if the radiology tech has to repeat the image two or three times, that amount of radiation increases. So, last question for this panel. So, Andrea, what do you tell your patients when they might need a future total hip replacement after a PAO? Is it going to be more challenging, or what do you, how do you counsel that patient? So, I think, you know, in talking with my arthroplasty colleagues as well, the PAO does not seem to adversely affect their ability to perform a total hip arthroplasty, with the exception of the placement of the screws that we use. So, as long as those screw tips, as you saw coming down from the iliac crest toward the backside of the socket, are more than five millimeters away from the acetabular socket, they typically don't come into play when the arthroplasty surgeon is reaming the socket from the acetabular cup. So, other than that, you know, the portion of the hip that is approached for an arthroplasty is really relatively untouched. We use a rectus sparing, muscle sparing approach, and so there's really not too much scar tissue in the area. So, I don't think it really adversely affects their total hip arthroplasty down the line. Great. Dr. Harris, Dr. Spiker, thank you. That was outstanding. And so, that pretty much concludes the dysplasia debate. I'd like to invite some of the other panelists back. In fact, Dr. Dohm, if you're still out there, if you can come back, and if somebody kind of has all these different types of surgeries. Ben, are you still out there? Still here. What would you say as far as PAO and total hip replacement, and how would you counsel that patient who might need a total hip replacement later? Your question is the same one as for Andrea, as to whether it would affect the outcome of their total hip later? Somebody who does total hip replacements, do you change your algorithm at someone who's had a previous PAO or previous scope? No, I've certainly done replacements after a PAO, and I've done replacements after scope, and ours was, I think I mentioned in the earlier debate, that when we initially looked at the results of replacement after scope at a two-year follow-up, we weren't able to show a difference. And then we looked at the same cohort out to five years and did show a difference, a negative difference. In other words, a previous operation, I think, does to a degree, compromise the results of a subsequent replacement and potentially increase the complication rate. And that's sort of intuitive. The more that soft tissue has been messed with, the more possible reasons there are for continued soft tissue pain afterward. And of course, scarring plays a role too. So I counsel patients as to all of the above. Perfect. Well, with that, I think we've pretty much summed up and got everything solved this evening. So Dr. Harris, Dr. Spiker, Dr. Dohm, thank you. Dr. Byrd, Dr. Mather, Dr. Busconi, Dr. Noe, thank you, everybody, for being here. So if I can invite Dr. Noe and Dr. Busconi back up to the panel, we can try to close this thing out. Thanks, guys. You guys are awesome. It's an honor to be here. Thank you. That was awesome. Great work by all. So Dr. Busconi, Dr. Noe, Dr. Spiker, Dr. Harris, I just want to say thank you for letting me be a part of this. I don't have any further questions from the audience, unless you guys have any other questions you want to ask these fine surgeons. Brian, Shane, do you have anything else to ask these two? No. Great job. And I think that Tom Byrd and I share the same sentiments that it's time for us older guys to pass on to the younger group on this screen to move on to our next directions. We never recognized all of these things 15 years ago, and now we're at a point in time where you guys can truly affect young patients' hip pathology. So continue on, you know, continue doing your research, continue doing your great work. And I think the bottom line is you will bring us to the next level. You will elevate the bar to the next level in terms of taking care of patients' hip problems. So I can't thank you enough for your comments today about instability of the hip. I just want to say thank you, everybody, for attending as well as thank you, Brian and Winston, for co-chairing this course. You know, it's really remarkable how far this field has come along, and it's exciting to see all the progress that we're making. Unfortunately, we weren't able to do this live, but we're hopefully going to be asked to do so next year if we're back online. And obviously, I want to thank Julie and Alexandra for all their work behind the scenes. Great. So thanks, Andrea. Thanks, Josh. Thank you, guys. And remember all the attendees that are still on, you know, this is a CME course. So if you did sign up for CMEs, make sure that you do the necessary work to get that. Both Julie and Alexandra will get information out to everybody about how to complete your CME activities. Remember, courses are only successful if, indeed, you provide comments back to us. So it's very important for the virtual meetings going forward that we hear from everybody in terms of how we can make these courses better and better interactive. You know, I know for a fact that I am now going to hire all of Shane's audio PowerPoint people to do my talks, since by far he gets the award of the best talks out of everybody here. And, you know, again, I can't thank Winston and Shane. You guys are elevating the bar to the next level of stuff. And it's just been a pleasure working with the both of you. Julie and Alexandra and Greg Dummer and all the AOSSM leadership, this was a great, you know, first venture into the CME activities in a virtual meeting. I'm very proud of what everybody's done. Yeah, let me speak just for a second. I just want to say I was really looking forward to being in Chicago with everybody. And obviously, circumstances are not ideal. We had to kind of pivot pretty quickly. And I want to thank Dr. Bruce Culling and Dr. Nove for helping us make this look pretty easy. But, again, you know, a lot about hypertherapy is getting together and sharing ideas and going into the lab and sharing techniques. And so I want to thank Dr. Burr for showing me everything that I know and Dr. Bruce Culling and Dr. Nove for teaching me so much. And so thank you to AOSSM for letting us put this on. And I really, really hope we can do this in Chicago soon. All right, Alexandra, thank you very much. Why don't you conclude it for us? On behalf of AOSSM and ISSACAS, thank you to our course chairs, speakers, and to all of you for joining us this evening. This is the final webinar of the Athletes HIP 4-part series. We encourage you to visit education.sportsmed.org to view other online learning opportunities as well as to complete this educational activity and access your CME. For more information about AOSSM, please visit sportsmed.org. And, again, on behalf of AOSSM and ISSACAS, thank you again for joining us and have a good night.

video

debate

Dr. Joshua Harris

Dr. Andrea Spiker

borderline hip dysplasia

arthroscopy

periacetabular osteotomy

PAO

evidence

surgical techniques

patient selection criteria

complications

arthritis

individualized treatment