All right, so, questions for the two of you. Oliver, do you feel like there's, you know, we were trying to decide whether to consider a PAO or an arthroscopy, and really we're trying to decide what's in their best interest, right? We're not trying to make a decision based on what we do or what you do. Do you feel like there's a gender issue that comes into play? Do you treat your young male with a large cam deformity different than your young female with a smaller femoral head if they have a very similar acetabular coverage? I completely agree. I mean, not only because of gender and this cam deformity or small femoral head, but also for the outcome results in the literature. I mean, there is not the same results related to gender. So we have to take into account that and personalize the treatment. I completely agree with that. And Al, what are some of the things that you will look at? Let's just start off with on history. Is there anything that the patient would present complaining of or by history that would tip you one direction or the other when you're trying to advise these patients on what to do? So I don't know if it's ever been proven, but typically if someone's complaining of more flexion-based pain, so if they're complaining with long car rides, sitting in class versus, say, weight-bearing pain and there's no substantial arthritis, I may lean more towards managing or recommending a PAO for that weight-bearing type of pain versus a sitting pain. But that's just kind of the gestalt of the history. Oliver, would you be more likely to recommend somebody who has a higher degree of disability prior to surgery versus a young athlete, let's say like a hockey goalie or somebody who's trying to get down into these high range of motion positions? Would that change your opinion about the approach, whether you start with an arthroscopy or whether you go straight to PAO? I completely agree, and I will tell you one case that I have seen last week in my clinic. I mean, this is a patient doing martial arts at this championship of European situation, and the patient comes to do a PAO, and you have to advise him that the range of motion will decrease a little bit if you do this surgery. So maybe you have to wait a little bit to do this surgery. This patient was 18, so maybe their career is two or three years more, so do your career and then come for the PAO, and maybe now you can do a hyparthroscopy. So you have to personalize, as I told you before, and depends on the sport that you practice and the expectations, you have to advise about the limitation of the range of motion after this PAO. So is it okay for us in those situations to consider the arthroscopy, but advising them that if they can still no longer do their sport or start having problems with living life away from that sport, that they'll then need to come back and consider the PAO? Is that an okay approach for some of these hips? Yeah, correct. Okay. I agree. Al, are there any things on your imaging studies that will help guide us with regards to whether an arthroscopy might be in that patient's best interest versus I think you might need to consider either seeing somebody who does periosteoabular osteotomies? So I still find plain foam x-ray to be very helpful. I love the CT imaging in this because it shows you the anterior wall deficiency. So there's basically two things that I look at. One is the sore seal, so the eyebrow, and if they've got a very short sore seal, meaning that you can almost sense that the amount of pressure going through that space is concentrated, and so the osteotomy may be a better option. And then number two, I'll look at axial cuts on an MRI for the volume of bone, either anterior or posterior, and get some sense as to how much a bony deficiency is across the anterior wall there. So those are the two things I'll look at. Vikas? Just a quick one, Al. Does femoral antiversion help you in your decision-making, the amount of femoral antiversion, whether an arthroscopy or a PAO? So when we have the ability, we will attain femoral torsion or antiversion in patients. And if somebody has high antiversion, so classically people say that's 40. I think it's probably closer to 30 degrees. Then I'll have them evaluated by one of my partners for either derotation and or acetabular correction. And I think on that same note, Oliver, would you say that somebody with a retroverted acetabulum, do you think having a greater degree of retroversion on the femur or more relative retroversion would be more likely to drive an antiverting PAO versus an arthroscopy? Absolutely. If you see the video that I put in the cadaver, you can correct everything. In this case, this is not a real retroversion, I think. This is prominent anterior inferior iliac spine and looks like a retroversion, but it's not the case because the three reconstructions. You have to be very careful when analyzing the position of the acetabulum because there is like one-third of the dysplasia that have a retroversion. So that's very important. And with the PAO, you can correct any deformity with this approach. All right. Thank you very much. And we'll move on to the next debate. Voting from the audience. The vote. Oh, that's right. Sorry. I thought it was obvious who won. So go ahead and do your votes. Let's see where we end up here. So how many people in the audience, we've got to see if there's a bias, how many people in the audience actually do PAOs? And how many do hip arthroscopy? So we'll have to take that into consideration, I think. I will say while the votes are coming, I wouldn't be up here without Tom Sampson. So he's from San Francisco. The first hip preservation course I came to was 20 years ago, outside of Union Square. So thank you, Dr. Sampson, for that. And Dr. Glick. And I think similar to one of the previous sessions that said if 80 percent of the world does hamstring grafts, then 80 percent of the people in the world are right. It doesn't necessarily mean arthroscopy is correct in this case.

periosteoabular osteotomy

arthroscopy

gender

anatomical considerations

individualized treatment plans