So we're going to ask the panel to come on up, and we'll follow up that wonderful talk by Mike, just kind of talking about a couple of cases on borderline hip dysplasia. I'll speak through these first slides. That was a great introduction to our topic. I want to thank our panel for being here, Dr. Stephanie Bouza, Dr. Michael Salata, Dr. Jeff Kneppel, and Al Stubbs here, as well as Dr. Ngo. So I'll skip over this. We'll head right into our case. This is a case presented and given to me by Dr. Andrew Spiker. It's a 39-year-old female, had some spinal surgery, so that may scare some people off already. Bilateral hip pain always hurts. Acute worsening over the last year, right greater than left. Some physical exam findings here that might be important that you'd want to know. Range of motion was pretty good, so 0 to 120, again, positive fader or impingement signs as well. So you might not see that in some of the dysplasia patients, but in this case, we did. A Baten score of 5 over 9. So I'd like to ask the panel, maybe starting with Stephanie, to look at these x-rays and tell me what you think about the right hip. Yeah, so it looks to me like the right hip is dysplastic. She has an up-going sore seal, hard to see the anterior wall, and I also am concerned about that spinal fusion with regards to the anterior wall coverage. She does have some decreased femoral head-neck offset, but as I was saying in the last presentation, with more of a flattening. So to me, it looks like dysplasia. Anyone else? Sharon, I'm stepping in for BK. Yeah, to me, it's the up-sloping sore seal that's the most concerning here, and then she probably measures pretty shallow. So this is one that I'd be concerned about trying to make better with just a scope. Yeah, I think there's a bunch of factors at play for her. One is her previous spinal fusion, which is going to alter her spine mechanics. And then the other thing is that she's 39, which is problematic for both a scope and a PAO, right? We know that over the age of 30, the outcomes in survivorship of PAO are not as good, and so that's definitely something that you've got to kind of take into consideration for her as well. And what do you think about tonus angle in her case? Yeah, it's high. You know, I think she's probably going to be in the mid-to-high teens, probably, for her. Yeah. And the impingement or the alpha angle as well? Yeah, that'll be increased. And then the other thing that you can look at is the widening. So she's got a lateralized joint center, right? There's like widening between her ilioceal line and her femoral head. And so this, you get concerned about that. Her fear index is probably going to be elevated as well. So based on all the current available data that we have, this is a hip that's at risk of failing an isolated arthroscopy, but at 39, it's a tough one. Yeah, I think I'd agree. And then the other thing, pointing towards instability, IRF 40 degrees doesn't make me think that CAM deformity is impinging, and the inclination probably the most impressive of all those. No, I'd agree with that, too. And here are the measurements. Any additional comments on any of the measurements that we see here? I do think, you know, the acetabular index is really important here at 17.3, so may lead you down the pathway in your decision making. Do we have the femoral inversion, Sharon? I don't have that, but certainly, I believe that that was fairly normal. Yeah. So MRI, she obtains an MRI, and I want to know from the panel, maybe, Shane, you can start out with, do you do an MR, or do you do an MR arthrogram in these patients? Yeah, usually for patients, you know, 39 years old, I usually start with a plain MRI. I'll reserve MR arthrograms, you know, typically for younger patients. Agreed. I would start with a plain MRI. Mainly, I'm concerned about the cartilage here. She does have some clear labral pathology, as well. Does anybody use the crescent sign to evaluate patients? That's an MR arthrogram sign for instability. No, but some of the things that we look at, if you look at, she's got a ton of edema around her abductors, as well, so she's probably got some component of lateral overload, secondary to her instability. And then if you look at her, the view that's showing the labral tear anteriorly, kind of posteriorly, there's some thinning of the cartilage, kind of more posterior and inferior, which is where you'll often see it in these patients. And what about labral size? Are you looking at labral size to evaluate, you know, whether you're going to consider a PAO versus arthroscopy, or both? Yeah, I think it's one of the variables. Sometimes it doesn't go along with the picture, though, so here it looks a little large. The other thing that's important to me here is the rim looks pretty good. Sometimes you'll see the same patient with major cystic change in the anterior rim that is heading towards arthritis. And how about additional imaging? Who would get additional imaging routinely? I always get a 3D CT scan. So she got a 3D CT scan here. Again, we'll give you more information. Confirms a lot of the information from your x-rays, alpha angle, again, maybe your center edge angle a little bit smaller, so now we're looking maybe less borderline, but still in that range. I think an important thing is also the acetabular aniversion, so her combined version was pretty high. So not just the lateral center edge, but really taking into consideration the version. All right, so now you have your decision-making process. The issue is, are you going to do arthroscopy alone, PAO alone, or PAO plus hip arthroscopy? What's the panel's thoughts on that? There's like an old saying, just because someone wants to eat poison, you don't have to give it to them, right? So if they say they really don't want a PAO, but it might be the right answer, I mean, sometimes if you talk to them about the reason that that would make sense, they start to get on board with it. But I think an arthroscopy alone is likely, I mean, probably this one, because it's being shown did great, but I think it's at risk of failing. I think with the labral tear, I mean, I know that's under study right now, but based on that, the data that we just presented of a 27% increased risk of reoperation after a PAO alone, probably some kind of combined surgery if you're going to do something. Yeah, I think in this age group, sometimes arthroscopy can be a nice staging tool, too, that you don't get in there and see a lot more cartilage damage than you thought was happening that might preclude your PAO. But if the joint's otherwise healthy, I think it's best served with a PAO. I think this would be a nice discussion with the patient beforehand, that they may have an additional surgery if you go with arthroscopy alone. So she did undergo arthroscopy. And so we talked a lot about the radiologic signs of, you know, how we determine what to do. Does anyone on the panel use any arthroscopic signs once they get into the hip to indicate that they may need to do something further later on? I start getting really worried when you start getting that central head wear, that paraphobial breakdown that kind of tells you that the hip is not very healthy and it's a sick hip. And that's one that I'm not so happy to see when I get in there, although while some people still get better, they're also the ones that I'm not surprised if they aren't. And I think the labral hypertrophy that you see, and then also what's called like an inside-out cartilage lesion where you see the break of the cartilage farther down the face of the acetabulum as opposed to being right at the labrum, that's consistent with kind of a sheer injury and an instability pattern. Yeah. I think those are important points that when you're in there, you know, do you make that, you know, you make that decision whether, okay, this patient may need something more if this doesn't go well. And those two issues are really important to look at. So that concludes a view of the, this one's a video. Again, any more thoughts about this? The labrum was fixed in a mattress-type fashion and no rim section because of the borderline dysplasia. Any other thoughts about the cartilage wear, consistence with instability or not? I mean, I think the biggest concern for her from a cartilage side is probably the stuff on the head. Like her acetabular stuff, as we know from even the FAI data, is pretty well-tolerated. But the femoral head side stuff is the stuff that's probably most concerning. I agree. Again, just some additional views on this. Her CAM was resected. Do you find that's unusual in dysplasia like this to have a large CAM lesion or is this something that you see pretty often? I mean, definitely. Yeah, I think you can definitely still see combined impingement and instability morphology. So I don't think it's totally surprising that she had a CAM lesion. This is what I call the double whammy, like the old game show with Wink Martindale, if you remember that. But you don't want any whammies and this is a double whammy, right? You've got an impingement morphology with a low-volume acetabulum, right? And you were saying staging. I like to look at that anterior wall volume with the scope and also with the axial cuts of the MRI. Great. And then, again, the question that was mentioned earlier, really about the capsule, what you do with a capsule in these patients. And the capsule is imbricated. And I wonder how everybody would handle the capsule in this case. This is a difficult hip. And they'll probably have, this is a challenging one because if you have failure of your capsule, you are going to go in the wrong direction very quickly. And so you've got to do what you can to make sure you maintain that capsular tissue throughout the case and that you're not getting into it with your burr. And you do an adequate closure and how to really protect them afterwards to keep them from stretching out their repair. So I would, I mean, I personally would do a periportal and do as much of a minimal disruption of the capsule as I could. And I think that's a good point because some of the ones that fail not only fail, but they're worse off than they were before the scope. And I think that sometimes some of these things we're doing are destabilizing the joint even more. And I think just one word of caution for if you're going to treat these borderlines, because the femoral head morphology is different than a standard CAM, I think the risk that you run is going too high with your proximal resection. So if you start where you might normally start, you end up getting kind of a big kind of drop off and an over resection of the proximal CAM, which can then lead to kind of like mid flexion instability because they'll lose the conformity of the head. So just understanding that there's that proximal flattening above the physis, that's not where you want to start your resection. I think that's an important lesson for folks that are delving into these things. Yeah, I think that's a great point. So she did well for a while, but then didn't. And so next steps for you on this patient. Would you image again, re-image? I would probably re-image again and look at her cartilage, because like we were saying, the hip can start to fail pretty quickly, especially if there's already some evidence of cartilage wear at the time of scope. So MR arthrogram this time was done. Shows the cartilage wear, cyst formation, and a new labral tear. Revision hip arthroscopy done with additional repair. And the decision to do the PAO was made to improve the hip. So this is still early on case, but shows the decision making process for the PAO. Would anyone consider not doing the PAO at this point on her, given her age, and allowing her to do any injections, or wait for a total joint replacement at some point? I bet you if she showed up in my partner's clinics, she would have gotten a total hip from the beginning. Go ahead. Yeah, I think here at least it's only been six months of this. It goes on two years later. Sometimes the opportunity to save the joint is gone, and it progresses pretty rapidly. But I think a PAO here makes sense. And I think this is probably an example of like the arthroscopy worsening, the instability leading to progression of her disease. So that's also something to consider. It's not a benign intervention. There's some data that suggests that arthroplasty after a scope may have a higher complication rate. And so I think it's definitely somebody that's not just a throwaway. Just do it. And if they fail, you'll do a total hip, because sometimes they do worse. So really having hard conversations sometimes with patients is the best thing to do. We have only just a few minutes left, and I wanted to get to this case quickly. Again, the difference between patients who have borderline dysplasia and have an LCEA of 18 may be much different than those who have one of 25 or 24. So this is a 17-year-old, much younger patient, bilateral hip pain. Pain is in the groin, failed conservative management seen previously and sent to a physician who does PAOs, or two of them at least, and both said that she didn't need a PAO. This is what her x-rays look like. Does she have borderline dysplasia? Can you tell from your plain x-rays? Would you be considering this at this time? Do we have any measurements? Sorry. I mean, I'm not so concerned about the dysplasia in her, because the tonus angle is a little bit better on her. Yes. And I at least like to see that it's neutral. So I'm not as concerned. And when a patient is borderline like this, how do you, with additional measurements, determine whether it's unstable or not? Michael? I mean, I think you can look at the fear index for her. That's certainly one of the measurements you can make. That's probably, obviously, the tonus, and then the fear has been the one that seems to be most helpful. I mean, there are some subtle signs of kind of some widening of that clear space, not as severe as the last patient we saw, but I think this is probably your classic tweener that you're thinking about. I mean, we've gotten pretty aggressive with doing PAO at our institution, because we feel like they do better and longer. So sometimes these patients are one that will do well for like 18 months to two years, and then they'll come back, and then there'll be some question about, you know, is it their labral issue? Is there a capsular issue? And so, you know, I think if this patient were to fail, then probably her borderline dysplasia would need to be more significantly considered. And I think low-dose CT here is a really nice tool, that planar radiographs are good, but not always perfect. We haven't found fear to be as useful, that if you're fear positive, you're definitely unstable. But if you're fear negative, you can still be unstable as well. So I think you just have to take everything with a grain of salt. Yeah. An additional thing that we've started doing more recently is dynamic ultrasound can be helpful too, to try and find some subtle instability. This is a great example of that anterior wall low volume on an axial cut. You can see it. Right. It's pretty dramatic. Right. So these kids are tough, because the parents want a quick fix, and this is a long-term commitment. Right. I think the PAO discussion is critical, but it's a tough sell, and I think, especially based on their activity status, right, you're asking for a 12-month commitment, and you got to get these early to get the best results, I think. And just to quickly go through, she did have low-dose CT scan again, and underwent arthroscopic surgery. And the question, and you have already answered that, is if this fails, is she a candidate for a PAO? And she's actually asking for one. So she's coming back asking for one if this fails. So I think that's a really important point, Dan. I think we're out of our time for this panel, so I'd like to thank the panel for their contributions, and we'll move on. Now to what to inject in the hip, biologic augmentation steroid, or HA, by Dr. Ben Wachukwa.

borderline hip dysplasia

panel discussion

treatment options

arthroscopy

PAO