So I'm going to give the next talk, talking about bone resections and how to have an accurate bone resection. And for me, I think especially in particular for the athletes, this has been an important topic and I think it's been more important to be accurate in that patient population. So I'm a consultant for Smith & Nephew. So how do we accurately get from here, where we have this large cam deformity, some acetabular overcoverage, to here, where we have a nice resection in my opinion on both your AP radiograph and your lateral radiograph. We've already heard that preoperative three-dimensional imaging can be very helpful to get an accurate imaging diagnosis. So for pincer type FAI, I like to template these. Dean Matsuda has talked about this as well. I like to mark lateral center edge angle of 30 degrees, center of the femoral head, and mark 35 to 40% anterior coverage. I draw my posterior wall just medial to the center of the femoral head and I draw my anterior wall through the anterior mark to the base of the teardrop. And this is really my limit for resection, not an indication for resection. You've heard this as well. You want to reproduce a well-aligned preoperative AP pelvis radiograph with your intraoperative fluoroscopy with regards to the relationship between the anterior and posterior walls, as well as the relationship between the ileoescheal line and teardrop so that you know what you're doing to your fluoro image intraoperatively is what's going to happen to your postoperative radiograph. For me, this all starts with an interportal capsulotomy. So I begin by making my anterior interportal cut and then I simply extend this to about the level of the posterolateral portal. I think making your capsular cut about a centimeter away from the rim is important to allow for a repair, but in addition to get distal resection on the femur without making a T-cut. You can use the burr to fluorolocalize where you're at on the rim. You don't want to get lost, so you can see where you're at on the anterior rim, see where you're at on the lateral rim, and see where you're at on the posterior rim. When you have a more deep acetabulum, such as a profunda hip, here on the top left you can see the posterior rim ossification, and on the bottom left you can see the posterior extent that we can reach on the posterior wall, whereas on the bottom right image you can see the inferior extent that you can reach on the anterior wall. So we can achieve a pretty good global rim resection, but it's more challenging. You want to use your intraoperative fluoro. Consider more traction in a posterolateral portal for your posterior rim resections, and release traction to confirm an accurate rim resection as you can get lost sometimes when you're in traction. So here you can see this intraoperative fluoro image, pretty extensive over coverage, a post intraoperative image just to verify that you've done an acceptable resection. So what about the AIS? Well I found it helpful to make a medial window in the capsule. So I use fluoro to localize the AIS, you can see it there is that dark crescent, I'm localizing it with the burr. In the video you can see I'm making a window through the medial capsule. If I don't make that window I have a hard time getting proximal on the AIS, but if I go through the window I'm able to get very proximal and resect the AIS up to the sore seal without having to shave too much capsule and still allow for a repair. So what about CAM type FAI? You really want to know where you're at with regards to the anterior femur, so here we're looking at the hip flex 30 to 40 degrees, and medially you can get proximal and distal along the medial synovial fold, and then laterally you can get proximal and distal along the lateral synovial fold, really down to the level of the greater trochanter. So when I'm performing the procedure you first want to define the proximal resection which is roughly perpendicular to the femoral neck. Make a convex to concave resection which will give you a more normal looking hip, a more spherical hip. Perform this in about 30 to 40 degrees flexion, again this is your anterior resection. Here you can see we're starting medially, moving to the direct anterior portion, and then more anterolaterally using fluoro to kind of identify and better evaluate that resection. When you want to go posterior laterally you need to put the hip in extension, and sometimes you need to put them into traction. This allows you to then pass the burr under the capsule, reach around the vessels, and now you can work around the posterior and the posterolateral femoral head neck junction. So here you can see I'm posterior on the femur, with curved instrumentation you can go even further posterior. So we want to use these floral views that Shane was talking about. So views in extension, views in flexion. So here's my pre and post internal rotation extension view, here's my external rotation extension view before and after the resection, then we flex the hip up with external rotation before and after the resection, and then our internal rotation flexion view before and after the resection. And then I feel pretty good about my resection. How do we confirm impingement free range of motion? It's not just with a fader test. So I like to test them in extension abduction. This is testing the lateral femur against the lateral rim. And then you want to test them in flexion abduction. This will test the lateral femur against the posterolateral rim. And then finally in a fader's position where you're testing the anterior femur against the anterior rim. You want global impingement free range of motion. So does this result in accurate osseous resection? So here you can see a large cam on our lateral view before and after the resection. I think these are appropriate. Here you can see the more challenging AP deformities before and after the resection, which again I think are appropriate. Or even more global overcoverage on the acetabular rim that with an interportal cut can still achieve an accurate resection arthroscopically even if challenging. Rim fractures can be managed, and the AIS can also be decompressed arthroscopically. So pearls for rim resection, 3D imaging allows for an accurate diagnosis. Align the intra-op floral image with a well-aligned preoperative radiograph. Intra-op floral can help localize your position on the rim or the AIS. With a posterior rim resection, you may need increased traction in a posterolateral portal. Release the traction to reestablish the relationship between the femoral head and acetabulum for larger global rim resections via floral. And for the femoral section, deformities on your AP radiographs are more demanding and probably more important for your cutting and pivoting athletes. Anterior and medial corrections performed in flexion. Posterolateral correction is performed in extension, sometimes traction. Take the capsulotomy about a centimeter distal to the rim so you can get distal on the femoral neck and verify with multiple intraoperative floral views in flexion and extension and dynamically assess them. Thank you very much.

accurate bone resection techniques

pincer type FAI

preoperative three-dimensional imaging

intraoperative guidance with fluoroscopy

acetabular rim resection