This afternoon's program is going to start with the last live surgery, where Shane Ngo from Rush Medical Center will be performing a labral repair and an ephemeroplasty. So I think we're ready to go live in there. Hey Shane, how's it going? This is Brian. Hey Brian. How are things going? Can you hear me? Yep. Great. Can you hear me? Yeah. I got a very good view of you here. Okay, alright. So thank you guys for hanging out with us this afternoon. So we'll just go through hip scope. You know, we've kind of gone through the liberty of going through the central compartment, so why don't we just kind of go to the arthroscopic view now. We can see that pretty clearly. Can you see the joint? Okay. So this is the inside of the joint. You know, we're looking posteriorly. There's the femoral head. She had a little bit of a pretty decent sized pincer, so we ended up doing a four-anchor labral repair. You can see the rim trimming that was performed. You know, and this is all the way to like probably our 3.30, 4 o'clock position, and then we extended it all the way to probably about 11. And so this is just a standard, you know, loop repair. We put in four anchors, one, two, three, four, with a pretty decent rim trim. So that's probably the extent of what we were planning to do in the joint. Is it possible, before you take her off traction, just to briefly show sort of the transition zone and how you think that may be being damaged by the cam? Yeah. You guys want to take the traction down? So yeah, here's the traction off. So we'll just go ahead and flex the hip up just a little bit, and you can see the, you know, the suction seal, you know, even which came together pretty nicely with a loop repair. And you can see that we've got nice labrum kind of laying over the head. I also kind of wanted to show the peripheral compartment. So here's the anterior capsule. You can see our interportal capsulotomy up here. You can see our iliocapsularis coming in over here. You can see the rectus, reflected head of the rectus coming over here. This is our anterior capsule, the iliofemoral ligament. Our gluteus minimus is over here. And so I like to do a pretty generous debridement. That way we can identify our structures pretty well in this peripheral compartment. And it'll also help us to designate where we're going to perform our T-cut. So I will do a T-capsulotomy. So we'll place our guide switching stick and then our cannula, and then we'll use this blade. We'll probably get to about the 50-yard line of where our previous interportal cut was. And then we'll just go ahead and extend that down the neck. And so are you doing a T-cut on every case now? Are you trying to preserve the capsule any differently? Or what's your approach to the capsule here? Yeah, so I would say I probably do it like 90% of the time in primary hip scopes. In revision, sometimes I'll just kind of go with whatever was done before. So if there was an interportal cut that was done, I'll also try to see what kind of elasticity is in the capsule itself. And so sometimes, even with a small interportal cut, if the capsule is fairly loose, then you'll get a pretty decent amount of visualization without actually extending the T. And so you kind of see once you're in there. But once you make your T-cut, you can see this nice visualization down the neck. And then I'll place these traction stitches. This is a capsular repair device that will then be used to pass these stitches. Hold the camera, please. And so we'll place... Just one second. I just want to make sure anybody who would like to, from the audience, has questions. I was told all of these microphones are live, so if you just come up, I'll sort of try to interrupt Shane. And if you guys have specific things you want to ask him, please feel free. Now we're in the lateral leaflet of the T-cut. Everybody see that? And so we're placing this traction stitch. And then if you watch what happens when we retract it, you can see you get nice visualization like that. And so are both of those traction stitches coming out of the same portals, or do you have them in different portals? Yeah. So maybe... Can you guys see the outside view? Yes. It's a little bit smaller, but we can see that. Yeah. So we got one through the dollop portal. That's bigger. And then we got one through the interlateral portal. And so here's our... This is our view. So... Hey, why is the table going up? Okay. So here, you can see the entire cam deformity. Here's the neck. This is the lateral extent. This is the medial extent. And so we'll now go ahead and start our osteoplasty. X-ray over here. Good. So we'll save that one. We'll put that on the opposite screen. And so I'll start my osteoplasty, the proximal extent. I'll start lateral first. And as you taught me, I kind of want to match the offset posteriorly. Essentially, I want to match the alpha angle to the beta angle. And so that's kind of my goal. So I usually try to start in halves. And so I'll go ahead and start laterally up here. And you can see, if you got this nice visualization, the osteoplasty usually can be done fairly efficiently. So I'm using a... I'm sorry, Brian? Is there any way that we can see the fluoro shot that you're using? It may not be possible based upon the setup there. I'm not sure. Yeah. Let's see the lateral. Lateral X-ray. Good. Do you want to put that up on the... So the audience can take a look? Okay. I know we can see that well. And so what are you doing with the C-arm to get that view? Because sometimes it's a struggle to get the perfect view that you want. Is there any specific way you look for it? Do you just tell the radiologist to get the view until you get it? No. Usually we try to see it back about 15 degrees, and then we try to cant it towards the foot about 15 degrees. And usually we try to replicate... I like to get that... Try to simulate that 90-degree done view, because that's the view I'll get in the office, and see if we can get that so we can reproduce that intraoperatively. Yeah. It's actually good to see the X-ray there. So this is not the most thrilling spectator sport, watching somebody do a femoroplasty. So is this a good time maybe you could talk about the history of the patient, what happened, and your diagnosis workup, and maybe if we get an opportunity to see some of the imaging that you have so we can correlate everything? Yeah. We'll put the X-rays up on the audience screen. It's up. It's up. Okay. So this is a 20-year... Hello? That sounded like there was a crash. Well I know a little bit about the history. So it was a 22-year-old collegiate soccer player who evidently was having some combination of hip and pubalgia discomfort. The pain was... And there was an extensive workup trying to determine... Are we back? Yes. Can you hear me? Okay. I filled in for a second. I gave him the first three sentences of the history. We lost you for a second. Okay. Yeah. So yeah. 22-year-old collegiate soccer player. She had mostly actually high adductor pain was sort of her presenting complaint, and so she was... We actually had the pleasure of having her trainer in the room with us, and she had worked her up and had been treating her conservatively probably for several months, and wasn't really getting better. Towards the end of the season, they got MRI imaging, and she had impingement, which was evident on the x-rays, but the MRI showed a subtle labral signal, but they also worked her up for pubalgia and core muscle injury and did not necessarily find anything impressive on that view. Okay. Can you show us the... Is there any other views you can show us? Otherwise, we can go back to watching you do the femoralplasty. Yeah. Do we have the... Do you have the next slide on the AP pelvis? So that's... You know, we took the liberty of kind of drawing out the lateral center edge angle and the tonus angle. I believe we had about 35 degrees. She did have a pretty prominent anterior rim, which is why we went ahead and resected that, and in addition to that, her tonus angle, I believe it was what, about five or six degrees, and so she didn't have any features of dysplasia that was concerning based on radiographic imaging. You guys want to show the next x-ray? And so this is our lateral view, and then you can show the next x-ray with the marks on it. And we had an alpha angle of about 55 degrees, and so, you know, I mean, not the largest cam deformity. You can see she's got combined type impingement. You know, imaging of the MRI showed a labral signal. We got the pelvic view, which did not show anything as far as rectus or adductor injury. And when she presented on a clinical exam, she actually had very high adductor pain, you know, with palpation, and I think for me, like, one of the hallmarks was that she just could not play. She couldn't kick at this point. She couldn't even run, and this was after several months of physical therapy. So I don't know, Brian, any thoughts about it? What's your, what are your thoughts on a diagnostic of therapeutic injections to complete your workup, and what's the role of a CT scan for you in the workup, particularly in somebody with kind of, on the more subtle pathology side? Yeah, so for me, the injection was pretty critical for her. You know, I think that, you know, with the high adductor pain, and she actually didn't have, you know, sort of classic, you know, impingement type symptoms, except that she couldn't kick or run. And so we did a diagnostic injection, and then we just asked her to basically try to simulate the activities that would normally cause her pain, and that included kicking and running and doing a little bit of soccer, and she basically, for the past few months, couldn't do any of it. Can you go into extension, guys? Into rotation. So after the injection, basically 100% of her pain went away, and she was able to kick and play soccer for the time in which the marking was effective. Now the, just back to the surgery, because you did do something that is probably critical in terms of bringing the leg out into extension and internal rotation. Are you doing that to try to get a little bit more on the superlateral posterior aspect of the head? Exactly. Right. So we're trying to get to that lateral cam. You know, here you can see our lateral synovial folds nicely, and I really tried to kind of cheat up to it. I don't want to go through it, but I do want to get up to it, and usually once I get behind it enough, I can usually get to that 11 o'clock position. And getting that leg in extension and internal rotation tends to help a lot. Great. And you didn't finish on the CT scan. Are you using CT scans for evaluation preoperatively, or are you not? So I do, if there's any sort of question as far as dysplasia or femoral torsional issues, if it's, you know, to me fairly straightforward, I won't necessarily get it as far as what the morphology looks like, but I like to do it more for those questionable cases or the borderline cases. I don't know, what's been your, are you getting it for everybody? I tend to do it on everybody. There's certainly some now that I feel like I don't need to, because I think the x-rays are pretty classic. I mean, it helps me intraoperatively to know what exactly the extent of the CAM is. My main concern is rotational abnormalities, and our MR is now, they're now trying to measure the version, so if there's an incongruence between the clinical exam and their morphology on the x-ray, they have sort of a spherical head but no rotation, and I'm concerned about a rotational phenomenon rather than a real intra-articular impingement, then I definitely think it's important to know that for prognosis. So what, do you have a certain threshold in which you would say, hey, look, this is, a standard scope is not going to cut it for you. We may consider like some sort of osteotomy. So I think it's a combination of the size of the alpha angle and the degree of retroversion. So if they have large alpha angles and they have retroversion, I actually think that can be achieved fairly reproducibly arthroscopically, because there's plenty of bone to take away. My bigger concern is with a normally spherical femoral head where you really can't take too much bone on the neck for fear of, you know, they've already got a spherical head, and there's really nothing to correct. I think the worst antiverted hip that I've operated on arthroscopically is minus 11, and I honestly can't tell you off the top of my head whether that person had any issues or not. I don't recall them that they did. Antiversion, on the other hand, if they're above 30 degrees, I start to get concerned about instability. Yeah, I agree. You guys want to talk about that a little bit? So anybody in the audience want to participate? Ah, too much. There's nothing worse than listening to two people talk. Too much. Huh? Four minutes for what? Okay, alright. So, you're doing pretty well on time. I think the, it says 1.16 and we're going to 1.30 unless there's some change in the program. I'm pretty sure that people are interested in capsular management. Yes. So, those are some of the bigger questions. Flex it up, guys. Even on the program, there's a lot of questions about it. So, interportal cut, you always do the interportal cut or do you sometimes do selective cuts to access the rim or is it always just connect the portals? For the most part, I'll connect the portals. Once in a while, I'll use an accessory cut if it's either far medial or far lateral, but I would say that that's pretty sparing as far as what my practice is. And that was your head, and it looks like you were heading medial there. Yes. Have you flexed the hip back up to try to get medial? Exactly. So now we're actually about 15, 20 degrees or so, but we'll go ahead and flex it up a little bit more, guys. Stop. Now, is there something different about your table, Shane, that allows you to do that? Because it's hard sometimes with the post to be able to move stuff around. So I always take the post out to do this, but even with the post out, you seem like you're manipulating the leg a little bit easier than I would expect. Yes. So we're using a couple different things here. We're using the Guardian table, which is that postless table. And so it does allow you a little bit more freedom of motion without dealing with the post. And so I didn't have to take anything out, but we're just kind of going through just gentle motion. I've got our fellow, Greg, is basically working the leg, and he's just doing some gentle flexion and rotation. Let's go flex it up a little bit more. Go ahead, guys. Good. And then, yeah, so it also gives you a nice dynamic assessment as, you know, once we finish the osteoplasty and we're going to evaluate sort of the motion of the hip, then we'll be able to see what it looks like at that point. So back to, so the capsule, I think it definitely helps you to move it around. Accessing, for me, medial, it's always flexion and external rotation allows you to get to the inferior medial aspect of it. If you have to go lateral, for me, it's exactly what you did, extension and internal rotation. Now, so you do do the T-cut now, and you said, what you said, about 90% of the time you'll do the T-cut? Correct, yeah. And I think, you know, if I have a ligamentously lax patient, I may not do it. But you know, for, I would say, the majority of patients, I will. You know, it gives you a nice view. You can see down to the neck. You can all the way get to the medial synovial folds. And I think it just gives you a better baseline as far as what your sort of surrounding anatomy looks like. And so you can see you got, you know, we're all the way here about, you know, 12 o'clock, and then we're going to work our way up the neck. And the neck also serves, I think, for me, as a nice template. And so it kind of gets me a sense as to how much, what the curvature is as I go proximal to it. And so I think just having that spatial relationship just kind of helps with a more efficient osteoplasty, at least in my hands. Now with regard to the sutures that you placed, the traction sutures, you just, are you just, they're just, what did you just, it looks like you just snapped them against the skin, so it's, they're self-retainers now, essentially, you're holding it. Right, so it's actually, there's nobody else retracting for me. You know, you get a nice kind of, you know, sort of opened up view of the entire joint. And again, you know, what I try to do is I try to just, you know, make that inner portal cut smaller. And I guess my thought is that if we can minimize the perpendicular fibers through the, you know, through the iliofemoral ligament and sort of use the native anatomic separation between the medial and lateral arms of the iliofemoral ligament, that I will have not necessarily caused any further harm, but I've kind of accessed the view much more expansively. So here's kind of what it looks like. That's good. It's a very good view. What about, so do you ever have problems with bleeding and visualization in the peripheral compartment? I mean, your view looks great. Is there anything special? Do you put Epi in your bag or anything, or is there? Yeah, I mean, I don't know if you guys have experienced this, but we've had an Epi shortage. And so it's kind of made life sometimes a little bit challenging. But our nurse, Faye Lara, was gracious enough to find some Epi for us. And so that certainly helps. And then also controlling the blood pressure as well helps quite a bit, flex it up a little bit, guys. All right, Shane, we've got another question from the audience. Ten minutes, he said. We'll wait for you until what? Okay. Hello? Oh, there it's on. Hey, Shane. It's Sherwin Ho from Chicago. Hey, Sherwin. How are you? Nice case. I appreciate you doing this. A couple of questions. I notice you're, as you're doing this, you're doing a lot of research. So I'm wondering if you could talk a little bit about what you're doing. I mean, you're doing a lot of research. going to decompression, how are you measuring how deep you are? Are you going by x-ray or just by feel and visualization? Like, do you have, uh, uh, something for the audience to tell them? Like, I'm going to go, I'm going to take four millimeters. Like I use the width of the ball of the bird as my guide, but, um, you're, you're just kind of going back and forth and a little deeper, a little deeper. And, um, and then are you like that? And are you 12 to three o'clock or are you, do you have a sense for, for us to give us your limits? I try to go from 12 to six if I can. Um, and, uh, that's kind of my, um, the extensiveness of it. As far as the depth is concerned. Yeah, I agree with you. Sure. When I, you know, I probably try to go about, you know, estimate based on the width of the burr. Um, but also using, um, our fluoroscopy as well, just to get a sense as to how much we've resected. And sometimes you can get a little bit sidetracked because you're just shaving away bone and then you don't realize how much you've taken down. But let's do a dynamic and just see where we're at over here. Um, yeah, we've all been there where she's like, Oh, let's see an x-ray over there. Great. Okay. So I don't know if you, can you guys show the x-ray? Go ahead and let's do the dynamic. We can see the x-ray over here. Good. So that's how much we've removed x-ray here. Sorry. X-ray over here. Good. So that's, uh, that's what it looks like now. X-ray. Good. And then, uh, why don't we flex it up a little bit more? And the nice thing about this table is that you can get pretty high x-ray in terms of flexion. Uh, x-ray again. Good. X-ray here. How flexed are you? X-ray. Can you guys do an outside view? Good. Say that. And then x-ray like that. Good. So, I mean, I think it's a pretty decent osteoplasty. Come on. We're about probably 80 degrees. You can see a nice, you know, dynamic assessment. We're underneath the labrum. You guys seeing the arthroscopic view now? Come down a little bit. We just flipped outside. Now we can see inside. That's good. Yeah, so you can see you've got nice movement under the labrum, impingement free, all the way posterior, all the way medial. And so that's kind of what I'm looking for here. Let's see one more x-ray up here. Good. So I like that. And I don't know, do you guys have any, any, this is 110. I think it looks great, Shane. Would you do any more, Brian, or am I missing anything? I wouldn't do any more. Yeah, I mean, do you ever get worried about like over a section? When I leave the room and a fellow's running the burr, yes. Okay. It's only happened once and it wasn't you, Shane. Ten years ago. Nobody you know. Let me get the shirt. No, I mean, of course, I think about over a section all the time. I think it's, you know, I think that one thing that I think is important, particularly when people are starting off, is that if you're not seeing a big change in your x-ray and you are using the fluoro throughout the case, make sure that the area of resection is being captured at the area where your fluoro is. So you may be resecting bone in the wrong spot. Okay. You have five minutes to close the capsule. Let's see if you can do it. So here's the capsule closure, you know, and with this, it's pretty nice because you can see everything real well. And again, this kind of goes back to, hold the camera, please, goes back to, you know, being able to see everything nicely. And you show us the outside view. Yeah. Okay. Thanks. And so we'll just kind of work our way up. And I like to tie and I'm sorry, pass and tie as we go. And so we're just kind of going up the neck over here. There's a lot of different, you know, kind of newer capsular devices that are out there. This one is called the Slingshot. It's kind of like a one-step spectrum. You know, the nice thing about this is that when you have those traction stitches there, it provides some tension. So you can see the traction stitch. I'll go ahead and pass my sutures. I think that I don't, I use the traction stitches when I don't do a T-cut, but I actually think what you're doing with the traction stitch there helps a lot, particularly medially. I find the lateral flaps very easy to retract with a switching stick, but the medial flap is sometimes it's kind of annoying to get under that. So I think the traction, so the lateral flap traction stitch is, that's going through the anterolateral portal and the medial one's going through the abdala. And you leave them in while you're passing the stitches, which also makes getting under the capsule easier because otherwise if you don't have those in, the capsule's lying right on the neck of the femur and you need a higher angle device. So what's the angle on that Slingshot thing there that you're using? And so you're cheating in a lot of ways, you're pulling the capsule up and using this. So that's why you make it look so easy. So I think what I also like about the traction stitches is that it gives you some tension to work against. And so rather than having it floppy up against the neck, if you have some of that tension, you're able to be a little bit more precise with your capsular stitches. So you're going up the T now, that's your, you're heading on your third stitch on the T. When do you take these traction stitches out? And how do you know what position you should put the hip in so that you don't over tighten the hip? And do you have any trouble with closing the interportal proximal to distal? Those are the three questions I think, at least those are the ones that I think are important. Are there other questions out there? I can't even remember the questions anymore, do you remember? What degree of flexion first with the hip, so that you're not over tightening this. And the interportal proximal to distal is sometimes a nuisance. If you have made the interportal cut too close to the labrum, you have to leave a little lip. Yes, yes. So I like to do my traction at about 20, 30 degrees, I'm sorry, my flexion about 20, 30 degrees. Sorry. Yeah, let me just loosen this one up. And I'll keep the... That's all right, this is actually a relief to see Shane, because this is the first time in the entire procedure we've seen you show any sign of humanity. So that was good that it took you actually an extra five seconds to grab that stitch. So I'll usually pass three of them, we'll have the hip in about 20, 20 to 30 degrees of flexion. We already took out one of the traction stitches, we'll go ahead and load up the injector next. I like to do that for my interportal cut. And then usually I'll pass two or three. Let's get a cutter, injector. So there's three in the T, and now you're using the injector to do the interportal. And are you going to change the position of the hip at all when you do the interportal for either passing or tying, or do you just close it out? I'll pass first and then tie. And so what I'll do is I'll go ahead and pass. So now we're in the lateral aspect. And then we'll load this one up and do our last stitch. Go ahead. So these are being passed again with the leg in the same position. And again, you can see it nicely over here. So now you're in the proximal limb using the injector. Let's see if we can show it. So there's a labrum. Did you have to switch portals to do that? So you put one limb through, and then you switched to the dala to put the second one through? Yeah, so this is through the dala. The first one was through the interlateral. Pull back on the canyon a little bit. And so you have each limb of the stitch coming out through the portal now? So here now I'm grasping the medial side. And then we'll go ahead and... So we have two stitches now. Sometimes I'll do three, but let's go ahead and tie it. Let's get the leg down. And so... So you're going to tie the interportal with a little less flexion than you would for the T-cuts? So here's... Because I started doing that as well, because I do think that there is the potential for you to over-tighten, particularly the interportal one. So I started tying these in about 10 degrees of flexion, almost full extension. And because I had a couple that I'd actually tested after I put them, and I put them into extensions, you actually saw them pop out. So I think this is something that may be important. Have you always been doing this, or you just recently started? I'd say probably in the past year or so, year or two maybe. Yeah, but I think it helps. Okay, thanks for calling me about it. I appreciate it. Yeah, I think it just... I figured it out the hard way. I had like two guys that had to go back to surgery. You're allowed... If you discover something new, you're allowed to call and say... I'll be sure to do that. But yeah, so yeah. So now we're just tying our last couple stitches. And so usually I'll do two or three, just depending on what it looks like. And we'll kind of reassess it and see to what extent it looks like it's closed. And my goal is to get like a watertight seal. And so I really want to get a complete seal. And I think what we found is that the rate of healing is actually very predictable. If you can lead the collagen fibers back to where it wants to go, then it usually will heal. And so I found this to be much more reproducible in terms of outcome. So we'll just take a look over here. So here's our one suture over here. That's our medial one. Here's our lateral. Got one, two, I think three down here somewhere. But, you know, so I think that's what we want to go for is we want it totally closed. You can see the rectus over here, the minimus up here, and then the anterior capsule right in front of us. Well, that's a great job. It's an amazing job. Everything looks great. Does anybody have any last questions before we stop? I think we stayed almost exactly on time. All right, I know that's hard to coordinate all this. We really appreciate that, Shane. An amazing job. Thanks, guys. Thanks very much. All right. All right, let's put one more in.

live surgery

labral repair

osteoplasty

hip scope

arthroscopic view

femoral head

capsule approach