All right, so this is our last section here. We'll just do a couple cases. We'll try to get through it pretty quickly so we can get going here. First case, 37-year-old female, status post-hip arthroscopy a few years ago, complaining of ongoing pain for the last several months. She describes the pain as pretty sharp and stabbing, worse with ADLs. She's tried conservative treatment, therapy medications. She had an injection as well. On examination, she's got limited range of motion. She's kind of painful with provocative testing. Here are her x-rays. You can see the joint space looks fairly well-preserved. Anything about this x-ray that's concerning at all? So we've identified, it's not published, I'll just give you a little tip. We've identified a subset of these patients that have what I call a chevron sore seal. That's what she has there, which is like this. And for some reason, I don't think these patients do as well. I can't tell you why, but that's the first thing I see in her sore seal line over there. What about the femoral side, Ben? You wanna, any comments on that? Yeah, it looks like she still has a residual camp. So, you know, still some evidence of impingement. So in a patient like this, I probably would get a CT scan. 3D femoral anatomy. Steve, you wanna just kind of go through the MRI here? Yeah, so residual cam. She's got a little bit of fluid extravasation up front, but it looks minimal. She's got some changes over her greater troch, as well with some changes on her tendon. Some of the cartilage, maybe, on some of those cuts didn't look completely healthy. Okay, so I guess, Al, as you're considering this patient for surgery, what are the things that you're thinking about in terms of what you might be planning for her? This is a good example of, I think doing a diagnostic injection sometimes is very helpful, because the question is, was the original surgery the right surgery? Was the correct diagnosis made? And sometimes doing selective injections, whether it's to the bursa, to interarticular, and trying to stage things out as to what you think you may find. Mike, how about yourself? Anything on imaging that would lead you one way or the other? Yeah, I mean, I think she has a pretty well-covered hip. I think this is one you think you can help, because she's got fairly significant residual CAM deformity. So I think even just getting rid of that is gonna make her a lot better, and then getting prepared to do whatever you need to do for labrum and capsule. So you tell her it's a possibility, you may need to re-repair or reconstruct the labrum as necessary. Obviously, my mantra is do less, so trying to do as little as you can. But so if the labrum looks good, fix it, and if not, then either augment it, like Dr. Philippon said, or reconstruct it as necessary, and then take a close look at her capsule. I kind of want to take a poll from the panel here. What do you guys think of this labrum? You guys just want to go down the line as far as what you're thinking, what you plan to do? I think the labrum is, seems to me it's healthy, it's got good tissue. What concerns me a little bit is the, I was seeing some areas where the capsule looked thin to me, and you had some adhesion. Like this labrum here looks like it's been pulled a little bit, but I think you can re-fix it if it's a little unstable, if you probe it. But the tissue looks good to me as far as, from what I see there, it looks like we have good, I would have to probe it, but it looks like it's good tissue, and the labral height is more than six millimeter. Mike, you want to, what are your thoughts on the labrum? I think it looks unstable. I think a lot of times when they get significant adhesions post-operatively, it almost like the capsule will tug on the labrum, and that'll make it unstable and make them feel similar. So release the adhesions and see what you're left with. And then if you've got something that you think is gonna provide a good seal, then re-repair it, and if not, then augment it. Al, what are you doing with this labrum? You gonna debride, you gonna repair, you gonna augment, reconstruct? So what I'm trying to figure out is why is she coming back a few years later? And the classic stories are you've got either residual impingement or residual chondrolabral instability. These are intersubstance. It looks like an intersubstance repair, I think, and I'm not, I will very easily pull a trigger and do loop sutures around this just to cinch it down, because a lot of times that micro-motion, I think, is what's the pain generator. How about you, Ben? What are your thoughts on this labrum? Yeah, this is one that I would repair. I think the tissue, after you remove the adhesions, you know, as Mike mentioned, I think that that's a potential cause of instability. You know, sort of dovetailing from my talk, this is one that I probably would go for a biologic augmentation and inject BMAC. Steve? This looks like enough tissue for me. I would repair, if any, and she looks like she distracts quite a bit when, with her space that you've got, so I would be worried a little bit about this hip being a little on the unstable side. Yeah, so I think kind of all the things we touched on, she did have some residual impingement that was resected. We also mentioned that her capsule looked a little bit insufficient. I think in this particular case, I thought it was interesting that I thought the labral tissue looked pretty good, and so for me, it was just a debridement, less of adhesion, and just kind of let it be. I feel like, in some cases, sometimes when you repair it, sometimes you might avert the labrum, and the tissue quality itself kind of looked reasonable enough that I just thought that, you know, there are other reasons why I think the patient was still having pain, and I think the capsule was a significant contributor as well, as we looked at the MRI, and it looked like there was a pretty significant capsular defect. Any comments from the panel on other ways of managing it, or things that you may have done differently? Yeah, the capsule, I agree with you. I think there was a defect, and I think you're able to close it there. If not, I would augment the capsule, but it looks like you're able to get a good closure. And the capsular tissue here looks pretty healthy, so when you go and you develop the edges of that capsule, for an interportal capsulotomy, when it fails, it'll flip over on itself, so you gotta be careful that you're not taking and repairing what looks like capsule on the edge. You have to look for that capsule over the top, and free it up, and bring it back over, and then you can get your length. Okay, next case, 24-year-old female who complains of two years of hip pain. She had a left hip arthroscopy that was done a couple years ago. She said that she had initial improvement, but approximately six months later, she began to develop pain again. At this point, she's not able to be physically active, can't participate in sports. Her exam shows that she has reasonable range of motion. She has pain with provocative testing. Here are her X-rays. Ben, any thoughts on the X-rays? Yeah, she looks like a relatively well-covered hip, would still wanna get a CT just to look at the version. The previous slide said that her alpha angle was 54, but it looks like she has some femoral head and neck, loss of femoral head and neck offset as well. MRI, Al, do you wanna walk us through this? So it looks, can't tell if it's a fat-suppressed T1, maybe it is. Typically on a potential revision case, what I'm looking for is anything that's out of the ordinary, right? So you look for stress fractures, AVN tumors, you can check that box, I don't see any of that, right? So then the next thing is, is there subchondral edema, tendinopathy, can you see anything that's residual? MRI all in all looks, the cartilage, sort of the stippling in the cartilage makes me feel like there's some chondromalacia, but there's nothing on the MRI that jumps out as concerning in my opinion. Mike, what do you think of the history of her initially doing well for six months and her pain kind of started to recur? Yeah, I think when you have, there's two things you worry about, certainly what Dr. Philippon has taught us about capsule labral adhesions, it does look like she's probably socked in there on her MR. There's just a complete obliteration of the, if you go back to that MRI scan, you can see that there's not really much between the labrum and the capsule. And so that's one of the things you worry about is kind of that delayed failure, they do well and then they don't, because they may be a scar former. This is probably someone that if you're gonna revise them, you think about using Losartan. And then like I said, sometimes if you clean it out there, then the question is, what are you left with? And if you don't have much tissue, then you may need to augment that labrum. Yeah. Dr. Philippon, what was your thoughts on this? Yeah, I was looking at your labrum there. This one might need an augment after you remove the adhesions. Yeah, this is pretty classic, a lot of adhesions there. And her story makes sense. She was well for a while and she formed the adhesion. And this tissue is not super, I would have a hard time not augmenting that. So I would release the adhesion like you said and then augment it if necessary. And if it's less than six and then address the capsule, I didn't really see well in the MRI, but the capsule might need something also. And just go down the panel guys, I wanna hear from everybody what you would do with that labrum. We heard Dr. Philippon's thoughts. This is probably an augment for me. Same. Yeah, augment for me. Yeah, I like this case because I think it's a pretty common scenario that you might see and the clinical history kind of matched up with her findings as Dr. Philippon had mentioned. She was doing well initially and she just seemed to be like this adhesion former. So for her, she did undergo a labral augmentation. After the breeding or releasing that chondrolabral adhesions, it just seemed like the labral tissue itself was fairly diminutive. Any pearls guys in terms of augmenting the labrum? What kind of height do you guys like to see? Like what graft do you like to use? Any other tips or tricks? No, it looks good. I like to use autograft personally, but this looks great. And I start, again for me, I like to start medial from the side. One trick I've learned is I like to deliver my graft from my lateral portal. So less of tissue to go through. And I do it without, I just place my anchor. I'll just use, I know there's different technique out there, but now with the new instrumentation, it's relatively easy. Slide it down, fix it medially and fix laterally and fill the gap. But this technique is really great also. I think a couple of things. One is in the initial part of these revisions, I tend to use a lot more radiofrequency than I do the shaver, because I think you can almost get a natural augment sometimes with some of the capsular tissue or some of that adhesive tissue. So sometimes that avoids the need to have to do a reconstruction or augment. But in this setting where you don't have much tissue remaining, I tend to use a slightly smaller graft when I'm augmenting maybe five to six millimeters. Maybe a seven millimeter graft if you're gonna do a full reconstruction. Because a lot of times if you're using IT band, which it looks like this, I don't know what that is, Shane. Is that IT band? Tibant. Tibant, but if you use IT band, you can kind of shrink it down with the RF if you think it's a little bit oversized. But you certainly don't want to stuff them, because then they'll feel like something's stuck in there. All right, let's just quickly go through this last case. 36 year old woman, prior hip arthroscopy about five months ago. She said that she was trying to get out of the bathtub and felt a pop. Unable to weight bear, brought to the ED. Ben, what are your thoughts on this history here? Yeah, so felt a pop would have me concerned for capsule dehiscence, delayed, maybe the capsule never healed. Would certainly want to get an MRI once she is discharged from the ED. Steve, have you seen any of these before? Wow. I have two in my practice from early, which is what makes me scared of the capsule. So this is anterior dislocation after a hip scope with instability going through the front. And this is someone who, if they came in like this, I'd be going in pretty quickly to go in, address potential loose bodies and I would repair their capsule. Yeah. MRI, Al, you want to make a couple of comments on that? So this is an MRI arthrogram. I always have to ask the patient because sometimes it's an effusion, right? Certainly, at least on this, the anterior capsule or the femoral ligament stripe looks missing and you can see that psoas, a lot of times the psoas will be herniating through there. But it does look like this is post-reduction would be my guess. And the question is, timing-wise, when do you pull the trigger? Because you can get a lot of extravasation if you try to scope these early. Mike, when are you taking this patient back to the OR? You know, it's funny, because I think early on in your practice, if someone has an issue, you're less aggressive. And then as your outcomes get better, if they have an issue early on, you're more aggressive. So probably I would take her back pretty quick for this and try and fix the capsule if you can. You worry about that MRI, it looked like there was some deficiency there, though, Shane, so that may be one you need to reconstruct. Dr. Philippon, any thoughts on that? No, I think I would do this, go back in right away and close that capsule. And yeah, if you have too much tension, you can always recalm. It looks like you have some laxity distally there, so you'd be able to bring it together. Yeah, so I agree with the panel. I mean, I think this is one of the ones where, I mean, she clearly wasn't undercover, no dysplasia. She obviously dislocated her hip, she's unstable. This is one that needs to be stabilized, I believe with soft tissue. Any concerns about doing it arthroscopically? Would anyone send this and have it done open? No, you can do it through the scope. I trust you. Yeah. But yeah, I think it's also usually the proximal capsular tissue is insufficient. So I think putting in proximal anchors are really helpful. So I like to use double loaded suture anchors with tape. I think one of the pearls for me is I usually use one set of stitches and I use it through the proximal side and the second set of stitches through the distal side. So in this particular case, the white is through the distal and the purple is through the proximal. And oftentimes, you know, obviously we can't really mobilize the capsular tissue very well. So I mean, basically you'll bring the white stitches up as much as you can to see if you can kind of close that defect as much as possible and then overlay a capsular graft over top of it. I prefer to use acellular dermal graft. You know, Dr. Philippon likes to use IT band. Allograft, do you guys have any other pearls about capsular grafts, capsular reconstruction? Yeah, I mean, I think one of the things you have to be careful about is using those sutures from those anchors. Sometimes they're like excessively tight underneath the capsule and they can almost act like an abrasion, it can lead to significant abrasions. And some of them that we've gone back on from outside institutions that have had where they just use like a simple suture, like one limb through the top and then brought it all the way underneath it. There's too much tension on the capsule, the capsule will look like it's okay, but underneath that stitch is really, really taut. And then that can either break and lead to kind of almost like a retained loose body in the joint or lead to recurrent effusions that can be problematic. And so sometimes using it more like a mattress suture as opposed to using it as a simple loop can try and avoid that. And then I tend to use IT band allograft as well. I think it's just a little more pliable and kind of more consistent with the native kind of thickness of the capsule that I kind of fold it over once or twice. So, and then kind of sew a little patch. Steve, you've had experience with xenografts. You want to talk about that a little bit? Yeah. So, I mean, I guess I've always used the dermal allografts. Okay. So I've never used xenograft. I like the strength in the different planes, but I guess I'd maybe defer to Dr. Philippon because he's got the study that shows that it's maybe not as good as IT band and I'd be willing to switch if someone could make me believe. Yeah. Yeah, the dermal allograft actually has good results also. It's just, we had a subset of patient, small series where they had a little bit of a reaction. So that's all I can say to that. We went back in and unfortunately it was a reaction to the graft. All right. Well, Dr. Philippon gets the final word. I think that'll close the HIP session. We'll have Dr. O'Brien come up and just give us some closing remarks for this Anna Biologic Association's specialty day.

hip pain

hip arthroscopy

chevron sore seal

labral repair

capsular graft