These titles are the best. So my first slide, the middle, that's actually Lucha Libre. It's like a Mexican wrestling match. So I had to look that up as well. So anyway, I'm going to talk about arthroscopy and dysplasia. So look at the landmark PAO studies, Byrne and Boston experience. Ten-year survivorship, 82 to 96 percent, pretty good. Ten-year survivorship, 60 percent to 74 percent. That's long-term follow-up. But if we look at these studies, the degree of dysplasia is a lateral center edge angle of 0.6 degrees. The mean tonus angle is 25 degrees. This is moderate to severe dysplasia. These are not the patients we're debating and are clearly not in our arthroscopic-only ballpark. So the question is, what's in the arthroscopist's ballpark? Arthroscopy versus pelvic osteotomy, this is really what we're looking at is mild or borderline dysplasia, and really here lies the debate. So the controversial radiographic parameters when we're talking about an arthroscopy versus a PAO. So for lateral coverage, probably a lateral center edge angle of 18 to 25 degrees. Less well-known for decreased anterior coverage, maybe an anterior center edge angle of 15 to 20 degrees, but we really should probably talk about percent anterior coverage and anterior wall index. For decreased posterior coverage, again, we don't know. Global low-volume retroversion with a normal LCE falls under this category, and we ought to learn more about percent posterior coverage versus the posterior wall index. And then for increased S-tabular inclination or your tonus angle, this probably lies somewhere between 10 to 13 degrees when we're talking about controversy. I think clinical presentation is really key. Dysplasia is an imaging diagnosis, but what we're talking about is instability. Is it soft tissue or osseous instability? Do they have more severe disability, standing, straight-ahead walking pain like this gal? Or is it clinically impingement, where they have limited range of motion? They have dynamic twisting and pivoting pain and a large cam deformity. Or is it a combination of both? So how do I choose when I'm thinking about mild S-tabular dysplasia? Well I would consider sending for a PAO if they have excessive femoral neck anaversion and anterior undercoverage. Smaller femoral heads tend to be more unstable. Highly increased range of motion, combined soft tissue and osseous instability. They have more severe disability, and if you have global retroversion with a normal lateral coverage with really a minimal cam or a retroverted femur, probably better served with an anaverting PAO. I would consider an arthroscopy for the larger femoral head, the cam deformity, limited range of motion, pain with torsional activities, and global retroversion when they have normal lateral coverage with an anaverted femur and a large cam. So my arthroscopic approach. Avoid excessive traction. These hips are very sensitive to the amount of traction and time in traction. Preserve the labrum. They oftentimes tend to be hypertrophic, and I think they do impart a degree of stability for these particular hips. Dysplastic features with an irreparable labrum is one of my few indications to consider a labral reconstruction primarily, and avoid more than any rim decortication. I would also consider an AIS decompression if it's prominent. They tend to lever anteriorly. Consider a femoral resection if there's any levering intraoperatively, and they tend to lever more distally on the neck, and I always perform a capsule repair and oftentimes a plication in this situation, and do not cut the psoas tendon. So outcomes. We're probably comparing apples to oranges, and we're really only looking at the lateral center edge angle and inclination. We're ignoring the femur. We're ignoring anterior undercoverage and posterior undercoverage. So this is a lateral center edge angle similar to this one. These femurs are very different, and this would probably be in my PAO cohort, and this would be in my arthroscopy cohort. What about arthroscopy outcomes? If we just focus on labral preservation and capsular plication, this is what we want to know in a labral repair. So for arthroscopy, we have these two studies. Lateral center edge angle in the low 20s. Modified Harris hip score, improving up to the mid 80s. Another study here that Dr. Dohm did looking at the globally retroverted acetabulum, improving to the low 80s. So what about these two studies? So Brian Kelly and I both had a similar study looking at scope for dysplasia compared to a matched FAI cohort. They all had relatively mild dysplasia. Lateral center edge angle was in the low 20s, and mean tonus angle 11 and 6 degrees respectively. So if you look at those patients with labral repair and capsular plication, we both ended up in about the mid 80s. But if you look at the study, interestingly, Brian's study was between 2009 and 2012, and mine was between 2005 and 2013. So this is pretty early in the learning curve, and I should probably repeat this study. PAO and mild borderline dysplasia outcomes, very limited data. So two recent studies, lateral center edge angle 18 to 25, show an improvement to the mid 80s. And this study by Dr. Sierra looking at global retroversion with an antiverting PAO showed improvement into the low 90s. Klaus Siebenrock had this nice study looking at rim trim versus antiverting PAO and showing a better result with the antiverting PAO at 10-year follow-up. So when we look at surgery for mild dysplasia, arthroscopy up to the mid 80s, PAO up to the mid 80s. Global retroversion, low 80s, only one study for each, low 90s with an antiverting PAO. So I think there's no clear winner. Complication rates. This study right here looking at two studies, multi-center complications using the same grading scheme, arthroscopy of which Paul Boulay, who's going to talk next, was part of this study, overall complication rate 8.3%, major 0.5%, with a PAO of 30% and 5.9%. So my conclusions, caution and a thoughtful approach is required when approaching hips with instability and dysplastic features. Combined femoral and acetabular morphology needs to be considered, but we need to define the limits for anterior and posterior undercoverage. I think a predominance of impingement versus instability in clinical presentation may have greater surgical approach implications than your radiographic parameters. A well-done arthroscopic approach by high-volume experienced surgeon leads to equivalent outcomes with lower complication rates compared to a PAO, but the literature is sparse. We are likely comparing apples to oranges, and in my hands for many of these very mildly dysplastic hips, I choose a well-done arthroscopic approach. Thank you.

arthroscopy

pelvic osteotomy

dysplasia

hip

labrum preservation