So we'll just continue along. We'll have Al Stubbs talk to us on hip soft tissues, repair the labrum, and the capsule. Thank you for this opportunity, all of them. I will say the disclosures are announced, but I would encourage all of you, if you're not a member of ANA, please join. And also for our hip preservation group, Ishelle, I'll throw a note out for that this year. So strategically, we like to make sure we're protecting tissue, preserving, and repairing, and understanding that what we see in the hip is really a kinetic chain of all these tissues. And the enemy of a good outcome, we've talked about this, is really arthritis and dysplasia. What we see in a lot of these patients really is a mixed bag of problems. And this instability states is something that's only just recently getting understood, and I think ultrasound is helping us with that. We have noticed that in our patient population, we actually tested these patients that had labral tears, at least confirmed postoperatively. But preoperatively, they noticed that their proprioception actually decreased. And what we've also found is these angles are not very helpful. The research suggests that the surface area and volume really only correlates with that tonus angle. Everything else is highly variable and not very reproducible, so just understand that. What we're talking about today is really looking at the labral and articular cartilage in the capsule ligament as complex. The literature really supports labral repairs, especially in these early arthritic patients. Most of the work we do is through two portals, but we will use additional portals to help us. These labral tears come in a lot of different flavors, but the bottom line is you want to try to preserve this tissue. Because when you resect it, especially in these dysplastic patients, generally you're not going to have as good an outcome. When you start scoping, you're going to have a learning curve. And generally, you're going to do a lot more capsular exposure. And I would encourage you to make sure that you've got the devices you need to close the capsule if you're doing a lot of capsular opening. This is just an example of what we used to do, but basically you can use an RF. My preference is to use a beaver blade. But the idea is staying parallel to that cartilage and minimizing the amount of resection just enough to be able to get around. Hip instability comes from a variety of factors. And what our concern primarily, and I think the panel emphasized this, is this iatrogenic component and affecting things through more of a capsular exposure. The small dysplasia, we talked about that. And really, there's a lot of factors that go into making this decision. When you're doing these capsulotomies, it's really a matter of changing the fulcrum. And I usually recommend not connecting the dots if you can, because usually that makes instrumentation a lot more difficult. And you start having a lot more compromise to the capsule. There's a variety of problems with sutures. I usually recommend using Vicryl. I know a lot of people use permanent suture, but we've seen a lot of issues with that. There's a variety of special equipment that has changed a lot of what we do. In our practice, we've actually gone to just dilating portals using a 4-5 cannula. And just with good fluid management, that's made a huge difference. This year, we actually started doing this sort of needle arthroscopy, which has a much smaller footprint, really about the size of a 14-gauge needle, which is great when you're trying to avoid capsular problems. So again, sparing the capsule. Mike Salata showed a nice little video of this. But there's a variety of injectors and things that you can use. My preference is to use a 70-degree angle. And this is a way to use a lasso to pass suture. But there's a variety of devices out there that make this more predictable. The big question is, if you're closing the capsule, it's really a volume-preserving problem. If you're actually shifting that capsule, you're trying to reduce the volume. And generally, we try not to over-tighten patients. So generally, if we see, we try to avoid really manipulating the capsule a lot if there's any kind of arthritis, if the bony congruency is good, and we've had a good chondrolabral preservation. The times to shift the capsule or really try to do that volume reduction is when you've got symptomatic collagen laxity or where you feel like your back's against the wall, you're scoping somebody that has some dysplasia and soft tissue compromise. So the pearl is really to minimize your capsular exposure whenever possible. Acknowledge that there are three soft tissue rings. We didn't talk about the zona orbicularis very much, but preserving chondrolabral junction, trying to preserve that zona orbicularis in the capsule ligaments complex, avoiding unnecessary rim trimming. Seen a lot of problems with that in the literature. And avoiding debridement when repair is possible. So in summary, really advocating preserving the labrum with strategic portal placement, respecting these hip stabilizers, and strategic capsulotomy and other visualization techniques to reduce at-risk instability patients. Thank you so much. Thank you.

hip soft tissues

labrum

capsule

ligaments

ultrasound