Thank you, Andrea. Great talk. Next up, Josh Harris. Dr. Josh Harris, Methodist, Houston. Thanks, Sam. Go. I think this talk will segue nicely from Dr. Spiker's preceding talk. So greetings from Houston, Texas. We'll be talking about hip instability. And it's nice that we drew a pretty stark dichotomy between the radiographic diagnosis of dysplasia and the clinical presentation of instability. And that's what we're going to talk about, hyperlaxity, hypermobility, instability. Here are my disclosures, none of which are relevant to the talk. So just as we did with the Warwick Agreement years ago, diagnosing hip instability should really be a triad. It's the patient's subjective symptoms, their objective clinical physical exam, and then their objective imaging. And when you put all that together, I think this really sums up nicely with a hypermobile hip syndrome. But if you look in our literature, our literature is replete with different words to describe this concept. And so instability, laxity, micro instability, hyperflexibility, but I think the take-home point is it's their story, their exam, and the imaging put together to come up with a diagnosis of hip instability. And when these patients come in, oftentimes they'll give you this diagnosis just by what they're telling you. And so when you look at this, most frequently they'll tell you it's pain, but they won't say my hip feels unstable. They'll use words like giving out, giving way, buckling, shifting, snapping, popping. They'll describe this story to you. They'll describe it's dislocating, as you can see here. They'll participate in flexibility types of sports, ballet, yoga, gymnastics, et cetera. And not everyone will tell you that they have Ehlers-Danlos. Actually, that's a pretty rare thing that you'll actually see in the office. But when we looked at our Houston Ballet, there were a minimum of 60 different genes that may predispose individuals to either bony or soft tissue causes of hip instability. You can see those listed here. But oftentimes you can get a crude measure of their instability just by getting a Baten score. They'll typically be young more than old, female more than male. When you take their story to your physical exam, by definition, hypermobility means more range of motion. And so you'll look at their range of motion, supine, lateral, and prone. But the instability tests that you want to look for are the tests that we just went over with Dr. Spiker's talk. And you're really trying to see if their physical exam maneuver reproduces their chief complaint of pain. Is that why they're there in the office? And that's what you want to do with every physical exam maneuver that you do with these individuals. And as you will find, there is oftentimes a lot of overlap. And this is a clinical presentation of an impinger or someone who's unstable or instability. Oftentimes the very highly sensitive but poorly specific impingement test will be positive in pretty much everyone if you just push hard enough. And so, but instability patients are gonna more frequently complain of lateral more than interior pain. They'll obviously have greater range of motion. They'll exhibit both internal and external snapping, and they're much more likely to have apprehension. As we just heard, this is not just a lateral center edge angle. There are a number of different things that you can look at on both sides of the joint. For plain radiographs, in addition to lateral and anterior center edge angles, I look for elevated tonus angles, the upsloping lateral sore seal, unstable fear indices, anterior and posterior wall indices as well. If you get a CT scan, I think a CT scan, a 3D representation, you can really get a lot of bony information for structural causes of instability. You're gonna be looking for higher ephemeral version. You're gonna look at combined version and simply put just the 3D coverage of the socket on the ball. For MRI, some of your measures of instability will be how thin or patchless your capsule is, and you'll be looking for that globular hypertrophic labrum. You can also do this thing that we came up with this idea years ago. It was called the splits view. I actually had a patient that came to the office and just said, it only hurts when I do the splits. And so we looked at that with x-ray and what you'll see on that bottom right photo that if you zoom in, they'll exhibit a vacuum sign, and that is essentially real femoral head translation happening. You break the suction seal, the capsule is lax, and their hip will actually grossly be unstable, and you can represent it with a plain radiograph as you can see here. On your preoperative imaging, I'm frequently not an arthrogram MRI guy, but you can actually see inside this MRI right here, it'll represent what you're going to find in arthroscopy, usually pretty highly correlating. So this is a globular hypertrophic big labrum that's much more likely associated with instability. That can also happen with this everted hypertrophic labrum that's stuck up on that upsloping lateral source seal that you can see right here. If you do obtain an arthrogram, you can see the capsule or thickness, you can see whether it's torn or not. But I think one of the things that you'll frequently see is even if you put five, 10 milliliters of fluid in there, you can actually break the seal. If you see that broken seal, that's obviously a measure of instability. This is one thing that you can represent on all different imaging modalities. This can be on plain radiographs, CT and on MRI. This is illustrating where the impingement is occurring and then the femoral head is translating. It is levering out. And this is the hypermobile hip crevasse that Dr. Philippon originally described and we've actually looked at as well. In those individuals where their clinical presentation is for instability, if they fail non-surgical measures, treat the structural causes with structural surgeries. Don't try to use an arthroscopy to fix either acetabular dysplasia or excessive femoral anteversion or retroversion. And those that actually do make it to arthroscopy before you even make your first skin incision, I think you can actually get a lot of information by performing an air arthrogram, how much air is actually reaching the joint. That's 35 milliliters of air in an Ehlers-Danlos patient. You can see the zona identifying your peripheral compartment of both above and below it. This is a video from Dr. Westerman. After you actually make your arthrogram, you can actually see how much femoral head translation is going on. This is a combination of both bony and soft tissue reasons. Don't use arthroscopy. Don't use capsular placations to treat those structural causes. Use structural surgeries for those. Don't over-resect the rim. Don't create dysplasia. If they're unstable, don't cut the psoas. Always repair the capsule. Don't debris the ligament and teres in these settings. And as Karen's talk earlier was nice in that the labral suction seal, it serves a biomechanical function. But how do we know what that function is? We don't quantify this. We just talk about a seal, yes or no. It's probably a lot more complicated than that. So I think we have to measure it. Somehow, I think as a community, we need to do a better job at measuring the strength of the seal. Newer technologies, I think, will hopefully be able to identify that. And we talk about the dynamic exam, the arthroscopic exam, for the measurements and evaluation of impingement. I think we should be doing this with instability as well, and especially for a capsular placation. Every single capsular closure that I do, I will extend the hip as far as I possibly can and externally rotate it as far as I possibly can and really try to see, is the capsule opening back up? Because I know that when they leave the operating room, they're going to do a lot more on their hip than I can right there. And the one thing you want to avoid is this is an inner portal that's popping open from about 30 degrees of external rotation. And so communicate this with your patient, number one, but also their care team that's going to be helping take care of them following surgery. And so I think if you put that clinical presentation together, the H&P and the imaging, making a good decision is as important, if not more important, than the actual surgical technique itself. And use arthroscopy to placate your capsule as needed and restore the seal in these unstable patients. Thank you. All right. Thank you, Josh. That was great.

hip instability

symptoms

clinical exam

imaging

arthroscopy