So we're right on time, leading into the HIP session with Drs. Koiner and Laskowski. For the sake of time, we'll just go ahead and get started. First up is Karen Briggs, incorporating HIP outcomes into your practice from the Stedman-Philippon Research Institute. Thank you, everybody. Thank you for the panel for inviting me. I'm going to talk to you about our experience at the Stedman-Philippon Research Institute. It started 23 years ago, maybe. OK. Sorry, it started more than that. Dr. Stedman wanted to know how his patients were doing. And he said he had to collect patients from his data. And we had to document the physician's assessment. And all of this led to a great mechanism for research. Come on. So the next generation was Dr. Mark Philippon. He came in 2005. He said we had to prove that hip arthroscopy works. So we built a hip database. The question with the database is not only do you need what the doctors did, the surgical treatments, but we needed the patient's objective and their exam. And we added in MRI findings for some additional data. Now he tracks over 5,000 hip cases. And obviously there's a great benefit to this. The research benefit has led to him producing an enormous amount of hip research and being recognized for that hip research. So now comes database. Probably everybody wants one. I think everyone needs one, but you got to figure out what it takes. Staff, money, and what are the rules? There's some big decisions to make. You can be part of a group. There's lots of great groups you can join. They may even have software. Or you can use a commercial based software. There's lots of those out there. Where do you store the data? On-site? In the cloud? Who owns the data? The biggest question there is. And how will it be accessed? And what will you use it for? Just research? Quality control? What's going to be the real use of that data? Then you have to decide what you're going to collect. That's a big one. You have to write algorithms to validate your data. You don't want too many points or it's too big. You don't want too few points or you're going to miss that one crucial piece of evidence you're going to need down the road. We looked at the literature when we started ours and we just tried to decide what was important to patients. We did some patient questionnaires early and tried to figure out what they wanted to see improve. It has to be part of the culture of your clinic. Everybody has to believe in it. You have to educate your patients. It's their chance to participate. And then you have to educate the staff. Physicians, clinical staff, front desk, schedulers. Everybody has to know that their first thought should be, oh I wonder if they completed their forms. Whether it be on their portal or the doctor's surgical forms, it has to be part of your culture. But there's great opportunities. Patients are interested in giving feedback. Patients like when you ask how are they. They like it out, they like somewhere where they can give feedback. You can really manage their expectations. You can tell them, how did that other person do? And you can show them what the majority of patients did. But you need to stay in touch with your patients. Either return visits, referrals, all these things can improve your patients and ultimately improve their satisfaction. So it's a great opportunity to engage your patients. So the challenge is obviously the collection of the data. The patients don't want to fill out five pages. You got to get everybody on board and then there's a cost. But, and you can't ignore those lost patients. Once somebody quits talking to you, you just can't say, oh they're out. But again there's all benefits to the clinical side too. It can provide documentations for the clinical record. Many of the new commercial software can be linked to your clinical EMR. That builds relationships with the data. You get participants on their portal or however it's got to them, they feel that relationship that you actually care. And then you can use it for a tool as a for insurance companies or regulatory agencies or just for quality control within your own patient population. The patients feel an increased communication with their doctors. You can, like I said before, you can match the treatment with their expectations. If they say I want to be back to full activity in six months, you can show them a graph that says look you're not going to get to 100% until 13 months or whatever the situation is. You must keep the patients interested. You give them updates. You have to keep in contract yearly. If you lose them, you know it's hard to find them again. And then you have to master the art of the ask. Email, letter, or whatever it takes to get the patients back. Design everything with the patient in mind. So you can share research papers. Research isn't just for out for places like this. It's also for your paper for your patients. The patients use those to educate. Patients love to read them. They might not understand them, but guess what? They feel empowered when they read them. And don't forget those people who have suboptimal outcomes. Those people who didn't do very well or don't want to talk to you. They're still important to figure out why they did bad. If they don't want to talk to you, everybody has the right to refuse to participate. But don't forget those people who just have low scores. So you can do a single institution. Just you build your program. Takes costs and money. Money and time. I'm sorry. A key factor that I have heard over and over at this conference is you need somebody to take care of the data for QA and QC. Who does the queries? Who gets the data out? Who analyzes the data? Med students are wonderful for helping write the paper, but there's a great need for people who want to do clinical research as a career. So I suggest that you get with programs who have MPH programs or statistics programs and start building the next level of clinical research because they're hard to find and you really, really need them. So in conclusion, data is a valuable asset. Satisfied patients are the best to have, but you use one to get the other. Keep the patients engaged and support the culture that uses the data. Make sure your people believe in it. It is a good investment. You're a great surgeon and you can prove it. And finally, I'd like to thank these two wonderful men, Dr. Stedman and Dr. Philippon, for my career at Stedman-Philippon Institute. It was a long career and now we all go on to other things, but they're great mentors and they're the reason we have data. Thank you. she's going to teach us about FAI. Thank you to the program committee today for putting together such a wonderful program and I'm honored to be a part of it. So none of my disclosures are relevant to this talk today. In the next few minutes I'm going to go over CAMs, pincers, and subspines and discuss for each of these the preoperative diagnoses, interoperative correlation, treatment goals, outcomes, and then some pearls and pitfalls. So to make sure we're starting on the same page, as of 2016's Warwick agreement you may now hear more of what we call FAIS, femoral acetabular impingement syndrome. And FAIS is diagnosed when symptoms, clinical signs, and imaging findings are all present together. There are three main types of femoral acetabular impingement. The first is CAM type where excess bone is on the femoral head-neck junction and this is what causes impingement and labral damage as well as cartilage damage. The second is pincer type where excess bone is on the acetabular side and this is what causes impingement. And then the third is subspine where excess bone is at the AIIS and again the impingement causes labral and chondral damage. CAM, pincer, and subspine can all exist in isolation or you may find some combination of the three of those. So why do we want to treat FAIS? Well it was first in 2003, just 19 years ago, that Reinhold Ganz described FAIS as a cause for hip osteoarthritis. So in theory by treating FAI we remove the source of arthritis and therefore prevent arthritis from occurring in the hip. Brian Kelly described the layer concept which is an anatomical approach to hip pain. This includes layer one, the osteochondral layer, layer two, the capsuloligamentous layer, layer three, musculotendinous, and layer four, the neuromechanical layer. So for this talk I'm focusing on layer one but keep in mind these other layers as they're a complex contribution to the hip pain. Most patients with FAIS will present with an insidious onset of anterior hip or groin pain. It's aggravated by activity and sport, especially deep flexion and squats. They may describe mechanical symptoms such as catching or locking and they'll also describe pain with sitting. On exam you'll notice limited rotation, mostly an internal rotation, as well as positive impingement signs, mostly inflection, internal rotation, and adduction. On radiographs you can identify a cam on a 45 degree dung lateral x-ray. Measuring the alpha angle will tell you if the degrees are above 50 that the patient has a cam. Pincers can be identified on a standing AP pelvis and you may find signs such as a crossover sign. And subspines are best visualized on a false profile view as you can see here. My preference is to use a standing AP pelvis x-ray because as you can see in this patient the subspine or the supine x-rays will sometimes give you the misinformation that the patient has a pincer or retroversion of the acetabulum, which in fact goes away when you stand the patient up. The standard for diagnosing a labral tear is still an MRI. MRIs can also be helpful in identifying other factors like this impingement cyst seen in the setting of cam type impingement and alpha angles can also be identified on axial views. Additional advanced imaging can include 3D CT scans. I use a low radiation protocol and this gives you the nuances of the morphology of this cam impingement for example, this pincer impingement, or subspine impingement. If FAIS is diagnosed I always start with non-operative treatment first and this can include physical therapy, intra-articular injections, activity modification, or NSAIDs. However, if non-operative treatment fails then hip arthroscopy may be indicated. Once inside the joint the type of injury pattern will clue you into what kind of impingement is present. So on the left you see cam type impingement and on the right this is more typical of pincer or subspine impingement. Here's an example of the classic chondral labral delamination that's present with cam type impingement. And here is more evident with pincer and subspine. Would you mind clicking on the video please? Can you please click on the video here? So with pincer and subspine impingement there's an outside in impingement and the labrum will be erythematous. The goal in treatment here is to resect any excess rim bone in pincer type impingement and then in subspine you want to get the area beneath the AIS there. Subspine impingement may also exist above the level of the hip capsule and so careful dissection can allow you to access this area and remove excess bone. Once the central compartment component is complete, would you mind clicking on this video as well? Thank you. I'll then take the hip out of traction and move on to cam resection. So the cam resection is done with a shaver and a burr and once while doing this I will use fluoroscopy intraoperatively to assure that I have resected all cam bone. I'll also do a dynamic flexion of the hip under direct visualization with the arthroscope in order to determine whether there's any residual impingement. With all of these types of impingement, the treatment goal is really the same. We want to get rid of the excess bone. So this is an example of cam decompression, pincer decompression, and subspine decompression. Outcomes after hip arthroscopy have demonstrated a very high return to sport rate with low complication rate and in the literature reported low reoperation rate. Additionally your literature has supported that you'll see increased hip range of motion as well as improved hip kinematics after osteoplasty of that impinging bone. So pearls and pitfalls. With the cam resection, the number one cause for revision hip arthroscopy is residual cam impingement. So I will often utilize a t-capsulotomy in order to gain the visualization that you see on the right here so that I can completely resect the cam. It's also important to note that when when resecting the cam you're very close to the lateral retinacular vessels in the blood supply to the femoral head. So keeping this in mind is very important as you perform a cam resection. With the pincer it's incredibly important not to miss hip dysplasia and also not to create hip dysplasia by resecting too much bone. So having a very solid understanding of how to measure an appropriate lateral center edge angle is important. And then with subspine, burring the subspine bone puts you in the area of the proximal iliofemoral ligament or the capsule and then also the direct head of the rectus femoris. So care must be taken not to take too much bone or tendon in these areas. So in summary, femoroacetabular impingement can occur in cam, subspine, or pincer or any combination of these three. Appropriate preoperative diagnosis is key. And while I spent this entire talk talking about the bony morphology, it is incredibly important to respect the soft tissue as well. Thank you very much. Transitioning to tissue is the issue, labral reconstruction, Carlos Ganache. Thank you. Thanks for the opportunity. So I'm going to talk a little bit about layer two, I think. And I think that probably the biggest point to follow Andrea's talk is the fact that in most of these cases, these are revision situations, these reconstructions, and all of the stuff that she talked about is just incredibly important to look, make sure that you're not missing pincer, cam, subspine impingement, and that's the source of the failure. So in my opinion, the native labrum is always the best. So there really isn't, at least in my opinion, and I think the literature supports that, there's really no indication to sacrifice what is a normal functional labrum that can be repaired. Reconstruction should be used as a salvage operation. And most of the time, it's really not only is it more costly, but the complexity is significantly higher. Most of the people, unfortunately, do not have a lot of experience, and I think the chances of you doing a nice reconstruction on the first case that you do are difficult at best. The indications are really evolving. In my practice, what I typically do is very rarely will I do it as a primary. A lot of times, and I see a lot of stuff from the community and failed hip arthroscopies initially, most of the time it's really more about bony resection and CAM residual, as Dr. Spiker mentioned. But in many cases, it's really about figuring out exactly what the repair site needs to be done. If you have to do a reconstruction, a lot of times the best indication in my hands for a primary is somebody that has a lot of profunda that requires a large resection. And obviously, if they're young and healthy, then those are more likely to undergo a reconstruction. I love these videos. They make it look so easy. They make it look like you can really reattach a labrum very significantly and make it look perfect. I think the reality is, as a lot of the literature has indicated, that there really isn't, it's not a significant tissue that really works like the labrum exactly. So there are issues, and the chances that we're going to put that tissue on the perfect spot is really not very likely. One of the largest systematic reviews that's available is now a couple years old by IENI, and you can see that they looked at 265 hips on a variety of different studies. 76% of these patients had already undergone a prior procedure, and 86% were done arthroscopically. As you see, the THA conversion is still significantly high. Revision rate also almost 4%. So indications, and again these are what I stand by, are young active patients with really minimal tonus changes and either irreparable or ossified. And most people will look at less than two millimeters of tissue. This is what some of the revisions look like. A lot of patients that come in and have a huge area of a defect. Here, this is somebody that I already had had two reconstruction. I'll show you just a quick video, and you can see here she was a 30 year old retired ballet dancer. And as I started to do the procedure, you can see that there's a very large area of the superior labrum that was excised, but the nice thing about her case was that some of that chondrolabral junction was actually intact. And so in this case, I can do a little bit more of a limited reconstruction. We can incorporate the healthy native tissue. She's got a good chondrolabral junction to really use. And so in many cases, in my hands, what I end up doing is it's almost an augmentation of the remaining labrum. And so you can see I've repaired the residual more medial labrum, and now we get ready to measure and figure out what sort of size graft we need. The graft in this case is approximately a centimeter and a half. I typically pre-drill all of the holes or at least most of the holes for my anchors in anticipation of being able to pass the graft and just fish it through. So there's a lot of thought that has to go into the passing of the graft. That's the biggest problem. A lot of some of the videos and some of the lab stuff that we see, the graft starts spinning around. So you have to have control of the graft the entire time. And I use these, being at SCOE, we use these suture savers that actually work pretty nicely to really stabilize the graft so that you have good control and you know exactly what you're looking at. So with PEARLS, make sure to look for all of the other issues. A lot of these patients also have a significant capsular laxity that needs to be addressed. I also, one of the big summaries is you don't want to feel like the little doggy under the lady there when you're doing these. So really just be prepared. Educate yourself and do a lot of lab work. Thank you. I'll invite Joshua Harris up to teach us about hyperlaxity and dysplasia. Thanks Jovan. I want to thank Brian Waterman for the invitation to speak today and I appreciate everyone's attention for our six minute talk on hip instability. Here are my disclosures. They are also available on the AOS website and also via the QR code here on the screen. So the goals of this brief talk are to briefly go over the tips and pearls, my tips and pearls, on the clinical presentation and imaging of patients with hip instability to make a good diagnosis and to also discuss some surgical approaches to optimize your treatment. And so with any treatment, to have the best chance of success, it is an and statement. It is good decision making, it's great decision making, and also skillful execution of your surgical technique. And as we heard earlier, the Warwick Agreement really came up with the great idea of it's the triad of a patient's subjective symptoms, their objective physical examination, and their imaging. And we took that same idea and applied it to hip instability and came up with a hypermobile hip syndrome. And if you put all of that together and you look at the different terms and the variation in our literature for what hip instability really is, despite that variation, I think we can all agree that it's the combination and corroborating the patient's symptoms, their physical exam, and their imaging. So treating the patient, not just the x-ray. And so what patients will typically present with, their symptoms that they actually come in with, it's actually most of the time just pain. They won't come in and complain of a chief complaint of actual instability. They'll say their hip hurts, it's weak, it'll be loose. They'll also complain of snapping and popping frequently or giving out or giving way. And they'll typically participate in high flexibility types of activities like ballet, gymnastics, yoga. And despite the fact that Ehlers-Danlos is our prototype for soft tissue instability, there are many, many millions of individuals that'll come into our office, and I'm sure we've seen them all, of non-EDS patients that also have elevated Beaton scores, younger more than old, female more than male, that'll be at significant risk for hip instability. And so on your physical examination, measure the Beaton score in everyone. And when you're doing your physical examination, be very, very critical of your range of motion. Do it the same way every time for precision and for accuracy. As you can see in this patient right here, this is 150 degrees of abduction, and if you didn't actually measure the abduction, you wouldn't really be attuned to the fact that she may have significant instability going on. And when you're looking at the provocative instability maneuvers, you're stressing the capsule, you're stressing the labrum. And so you want to make sure that that's actually reproducing their chief complaint, why they're actually visiting you in the office that day. And when you look at their imaging, remember it's not just a lateral center edge angle. Lateral center edge angle is by far and away the most frequently used metric that we look at to look at structural instability, to look at dysplasia. But there are 37 other items that are out there that you can actually use on radiographs alone to actually measure that. And remember, radiographs are two-dimensional representations of three-dimensional processes. And so make sure you get multiple views when you're actually evaluating this. And specifically looking at the lateral center edge angle, remember it depends on where you're actually measuring the lateral edge. It's either the lateral edge of bone or the lateral edge of the sore seal. And the difference can actually be significant. It can be up to 10 degrees. When you look at the anterior center edge angle on your false profile, it can be up to 22 degrees. So these are big differences that can actually take someone from dysplasia actually even to a pincer. And so be very careful when you're actually measuring these numbers. And in the proverbial controversial borderline dysplastic group, it's not just the lateral center edge or anterior center edge. There are a number of other factors that you can look at that indicate real structural instability that would be at risk for failure with arthroscopy. That's a tonus angle greater than probably 7 to 10 degrees, unstable fear indices, high femoral version, valgus necks. And even in some patients with normal lateral and anterior center edge angles, they can have posterior superior undercoverage. And on your MRI, you can find a thin or a patchless capsule indicative of a high hip joint volume and also a big labrum. So at our group in Houston, we actually looked at a view called the splits view in which a patient actually gets in the lateral splits position in both internal and external rotation. And you can actually see objective femoral head translation. You can actually measure this actually in the office. And that view is actually predictive about 94% of the time of the presence of symptoms in professional ballet dancers. And so this view can help you in determining objective hip instability. Beyond that of plain radiographs, the CT is probably the best. It's the best that actually looks at the magnitude and the location of the dysplasia. But remember with CT, it does come with an inherent risk for ionizing radiation. And so you always have to keep that in the back of your mind when you're ordering these images. And so when you combine their clinical presentation plus the images, there are three different surgical pathways you can go down. For mild instability, for mild dysplasia, arthroscopy can work well. For more than mild instability, a periacetabular osteotomy, and for high version abnormalities, a derotational femoral osteotomy can work well. And so Dr. Byrd actually taught us best. Even the best operation will fail when performed for the wrong reason. And so trying to do a scope for structural instability is destined for failure. And Dr. Byrd learned from Dr. Andrews who said, it's probably best to actually know who not to operate on. And so for arthroscopy and structural instability, don't create dysplasia, don't operate on dysplasia, and don't use a capsule or placation to treat real structural instability. That's what a PAO is for. And if you do arthroscopy for mild instability, check the soft tissues. In arthroscopy, pay attention to what the hypermobile hip crevasse is actually telling you. This is actually the pathologic location where impingement is occurring and the subsequent levering-based instability is following. And so that's what you can see here on that arthroscopy view. And no matter if you're doing a labral debridement or repair or an augmentation or reconstruction, measure the actual strength of the seal. I think this is something that we dichotomize in our literature as an either yes, no, or thing. But it's a quantitative continuous data point that actually can be measured with some tables now. So that's an important one to measure. Same goes for our capsular management. And so every capsule, if you open it up, you should close it when you're all done. I close it with tape, usually five or six tapes. And you want to stress this hip just like you would do with impingement. We measure CAM corrections. We do a dynamic exam. You can do the same thing in significant extension and externalization to make sure that that capsule stays stable. Following surgery, communicate. This is one thing that's incredibly important for instability to make sure that your therapist or trainer, the entire patient care team is all on the same page to make sure that we optimize their post-op care. And so in conclusion, I think it's the decision making and the technique. And it might actually be decision making even more that's more important to make sure your patients have a good outcome in patients with hip instability. So thank you. Next up will be our debate on the hamstring injury. Chad Mather will be presenting the scope approach. All right. Well, thank you. Before I start here, I do want to make a note that this is the first time ever that the hip sessions have started in the AM, a specialty day in both ANA and the AOSSM. So when they tell the story of the hip someday, this 2022 specialty day will be on the map there. So thank you. And thanks again, Brian, for inviting me. It's always an honor to be here. So I'm bringing it up there. Yeah, I think so. I know I saw it. I saw it there, but not up there. But yeah, we can do that. Any audience questions at this point? Do you want to switch talks? Is there an issue? I saw it there, but then it was up for a second. By a show of hands, who in the audience has done an endoscopic hamstring repair? Good question. We're just going to wrestle for it. I don't like my chair. I'd just like to ask a question to Carlos and others, and Josh. Your role in your practice, the role of injections, and when do you use it? And as a negative injection result pre-op, and Dr. Spiker, portend a bad outcome? I use it. I don't 100% hang my hat on it. I think that if I've got a patient who... Some of these patients will, I think, have a fair amount of psoas pathology as well, and they'll kind of tell you, yeah, some of the front pain went away, but I still have a little bit of back pain. I think that is a very confusing conglomeration. So I kind of use that, especially in the younger women. They tend to have some of this low back stuff that I think confuses the issue. I would agree. I think the diagnostic utility of a good response to intra-articular injection is incredibly helpful when it's a very complex presentation of back, pelvic, hip. I otherwise use it pretty sparingly, but it is a good option for in-season athletes as well. If you know that they want to plan surgery after the season is over, it's a good way to get them through the next few months. I would agree that if patients have a positive response, I am more confident that they'll improve after hip arthroscopy. If they have a negative response, it doesn't necessarily mean they won't do well. Great. I think we're ready. Thank you. As soon as I walked over there, of course, it's going to come up, right? Yeah. All right. Very good. So I'm going to try to convince you that endoscopic hamstring repair is a necessary approach in your armamentarium. It's superior for over half of the injuries, and it's easier to perform than you might realize. So to start with, when we talk about hamstring injuries, you've got to consider the spectrum of injury. It's not just those water skiing, ecchymosis, fully retracted tears. This also spans through the minimally retracted tears, and then a lot of what we see is these chronic partial thickness tears and tendinopathies. But it's also important to note that there's concomitant pathology, that these chronic tears often occur with ischiofemoral impingement and forms of deep gluteal space syndrome. And so one of these interesting pathologies is sciatic nerve entrapment. This is a case of ischiofemoral impingement and a proximal hamstring tear. She had symptoms of both, and as you see there in the arthroscopic view, you can see that the nerve is trapped within that ischial tunnel between the two. And so I would argue that this is a proximal hamstring tear that is definitely best treated endoscopically. So it's necessary. This is my approach to it. So I use endoscopic repair for all the chronic partial thickness tears, basically anything where the tendon is up near the ischium and under the glute. And there certainly is a role for open repair, and then even more so for grafts. And if I'm doing something open, I'm probably using a graft more often than not. Factors for me that favor the endoscopic repair would be when that tendon's up under the gluteus maximus near the ischium, where the patient's larger, because it actually makes the endoscopic approach a bit easier. And when there's no history of acute injury, because there's less scar around the nerve to mobilize it. So here's our repair technique, and this technique was published a couple years ago on arthroscopy techniques, so it's available. Use a prone position. Use about four portals. The middle portals now shifted, I think, a little more distal. And the lateral portals are the most risky of the group. It's the one where the sciatic nerve is at most risk. So most of this procedure is really in the first few minutes, during the exposure. I like to start with the two middle portals and then work in line with the nerve, with the tendon, with blunt dissection until you're very comfortable where the nerve is. And it does vary in its location. And then I do like to note that it is functioning, it's working, it's inadvertently paralyzed the patient or something like that. And there's the posterior femoral cutaneous nerve there, too. So that's one of the advantages as well, that you can protect that, I think, more than you can an open procedure. You'll typically see these fibrous bands that sit around the semimembranosus, and it's important to mobilize nerve and remove those bands so that you can access the semimembranosus. I would say in my early cases, I probably wasn't getting all the way to the semimembranosus for the repair. I'll pass a suture across through the portals to help raise the roof, if you will, and retract the gluteus maximus. I take advantage of the normal anatomy and try to open these chronic partial thickness tears through the interval between the semimembranosus and the conjoint tendon. And that's what we're showing here. You go distal, just off the ischium, identify the fatty interval, and then you can track that up, maintaining the distinction between the two tendons that you can access. And I think this is the most anatomic way to access these types of tears. You can see as we pop through there that the undersurface is detached, and that's where most of these chronic partial thickness tears is. They're highly detached underneath and really, again, functioning more like a significant rotator cuff tear often that you would be repairing. So from there, it's mostly just the standard repair techniques. I've used different constructs over time, but I like this four-anchor, two in each of the footprints, a combination of mattress sutures that go both in the individual tendons as well as across the two to close the interval. And to me, this creates the most anatomic repair in the end. So we published in Arthroscopy last year our results, and this was a mixed cohort, some with acute partially thickness, acute minimally retracted tears, and mostly partial thickness tears. And we found there is improvements in our patient-reported outcomes that were clinically significant, return to prior activity baseline, prior activity level, and a reasonable re-rupture rate. And these findings have been reported by all the other authors as well. So in my experience, it has better access, you get a better repair, it's safer, lower risk of infection, lower risk of injury to the posterior femortaneous nerve, less muscle injury. And so I would say across this spectrum, it is superior for at least half of what we're seeing. And then finally, if you look back at these reasons why you do endoscopic repair, these are all the same reasons that we used to, the reason why we moved to an arthroscopic rotator cuff repair. So I would tell you, it's an extension of an existing procedure and a natural evolution of the treatment of these injuries, just like it was with the rotator cuff. We have lots of technique papers. I think there's nine or 10 techniques and videos available on arthroscopy techniques. And so I would tell you, it's easier to do than you might realize. And I think Josh and others will tell you that as well, that it's not as intimidating, it looks intimidating, but it's not as bad as you might think. So as I turn it over to Bamfy, I hope I've convinced you of these three objectives of my talk. Thanks. All right. Well, thank you for having me. I'm going to be arguing the counterpoint of doing an open repair and why we don't want to scope all of them. Just wait for my slides to come up here. Mike, while we're waiting, what percentage do you think you open for hamstrings? Well, that's actually going to be part of my disclosure here. How am I advancing? Here we go. All right. So all of my disclosures are on the website, but the actual disclosure for this talk is over the last year, I did 39 proximal hamstring repairs. 32 of those were endoscopic. So when I was asked to argue the open technique, I was a little challenged by that. Really, just seven of them were actually open. So I'm going into this having experience with both techniques, and I do think that there certainly is a role for the open procedure. They're not all the same. The acute retracted or the chronic full thickness tears that are scarred down to the nerve, in my hands at least, are not the ones I want to treat endoscopically. But the acute minimally retracted tears, partial thickness tears, as Chad just showed, are the ones that I think are fantastic endoscopically. The amount of energy that goes through the hamstring with these classic jackknife position water skiing injuries is certainly different than the insidious chronic use injuries you see with the long distance runners. And really, with this surgery, we're trying to recapitulate the normal anatomy, and you have to do that the best way you can with your hands. And so having that crescentic insertion of the semimembranosus deep to the conjoined tendon is very important to reproduce. And also staying away from the nerve. Mike Gerhart had a great study where he showed that nerve is a centimeter half away, and right above that is the PFC, and you need to stay away from that as well. And Chad's paper is awesome. It's the largest group of patients with two-year follow-up for endoscopic techniques, but most of these patients had a history of chronic symptoms, as he was just describing. So I can't think you can really relate these to all hamstring injuries. And we do have other outcome studies. This is from our group. We showed the endoscopic was equivalent to open. And also a multicenter study, which was done by Ben Dohm's group here, along with Aaron Critch in the Alabama group, showed that there also was no difference between endoscopic and open techniques. Twenty-five years ago, Bill Gerhart out of Duke described this surgery, doing an open repair on these water skier injuries, and the benefits of each technique can be elucidated. With regard to the open technique, I think that a Krakow whip stitch is going to be much stronger, going to have less risk of pull out of the tendon than doing the mattress-style fashion stitches that you'll see with the endoscopic technique. Also, it's easier to perform releases. Go distal. If you have a chronic one that's retracted distally, being able to utilize a graph, being able to utilize a nerve stimulator to figure out what's nerve and what's scar, those are all things you can only do open. And then with regard to cosmetic, I would argue that the incision, the glial crease, is probably more cosmetic than the multiple portals. You'll get dimples within the gluteus maximus as opposed to the standard incision they use for the Brazilian butt lift. So I do think that the cosmesis can play a role here, and endoscopic isn't always the most minimally invasive. Now, the benefits of endoscopic also can be listed out here. I think that having the transoxy equivalent type repair to compress the tendon is quite beneficial. I also agree that you can see the nerve quite better. You can protect the PFCN as well as the sciatic. It's easier to breed the footprint. But there can be some issues. We have these leashes of vessels that are in the area. This is one of Jovan's videos. And if you're inexperienced with the anatomy and you get into that bleeder, that's going to be an issue. And then to win the debate, I really just want to leave this video up right here. If you get into that sucker, that is not going to be a fun day in the OR. Now, what are the limitations of open? Well, it's a black hole. You're not really able to visualize the nerve that well. You can palpate it, but you never can really see it. It's difficult to really know exactly how perfect your anchors are. And then you need to have multiple systems to retract. The glute max can be a challenge to get out of the way. So what I actually do quite frequently is a scope open approach where this is actually an acute case, but he was around six centimeters retracted. And what I'm able to do is identify the nerve with the shaver. I'm able to really debride the footprint. And I can place in all of my anchors. And so I will use a little bit of a different setup than Chad did with regard to my portals. I have my 30 degree arthroscope right underneath the ischium. That's part of my open gluteal crease incision. And I use an accessory superior lateral portal with my instrumentation with regard to debriding the footprint, utilizing my bur there to prepare the footprint. And then an accessory stab incision to actually place my anchors in. But I can make sure in this situation that I have the anchors placed in perfectly. I'm able to recapitulate the insertions of the semimembranosus as well as the conjoint tendon. And then what I'm able to do is create a small open incision. This actually allows me to evacuate the seroma, which is nice. You can't really do that endoscopically in those acute settings quite well. I'm able to just grab my sutures, pass them down through the open incision, whip stitch the two large tendons, and then utilize a tension slide technique to bring them back down. So in summary, I think there's clearly a role for open endoscopic surgery. I think that the retracted scar tendons require an open approach. Once the learning curve is overcome, I think that the endoscopic approach sometimes is actually easier. I'm agreeing with Chad there. But there's always a role for that combination scope open technique. And I probably use that at least 90 percent of the time if I'm doing this open, unless it's really chronically retracted. But if you're uncomfortable, then you should just open. Thank you very much. We might have time for one question. If anybody has a question for us, come to the mic. Thank you, everybody. We appreciate it.

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