All right. Good afternoon. We're going to go ahead and get started. This is ICL 101, Borderline Hip Dysplasia, Hip Arthroscopy versus Periosteolar Osteotomy. My name is Matthew Kraler from Texas Tech University. I'll go ahead and introduce our other faculty, and then each of us will get started with about 10-minute presentations, and then we should have plenty of time for questions at the end. So I'll get us started by answering the question, how do you define borderline dysplasia? Next, Dr. Ochiai from nearby Arlington, Virginia, will discuss physical examination findings in the borderline dysplastic. Shane Ngo wasn't able to make it today, so Dr. Ochiai will continue by arguing why he would always do hip arthroscopy for borderline dysplasia. Next, Ernie Sink from HSS will make his argument as to why all borderline dysplasia patients need a pelvic osteotomy, and then I'll wrap things up by discussing why I favor a combined approach. So how do you define borderline hip dysplasia? These are my disclosures, neither of which are directly relevant to today's talk. So the first thing to recognize here is that hip dysplasia is not necessarily the same thing as hip instability. Several studies on this topic define borderline dysplasia based on a lateral center edge angle, most of which reporting it based on a center edge angle between 20 and 25 degrees, with some studies defining borderline dysplasia based on a center edge angle between 18 and 25 degrees. But I think we can all agree there's a big difference between a 17-year-old female with a center edge angle of 21 and a Baden score of 9 versus a 34-year-old male with a center edge angle of 24 and a Baden score of 0. So we really need to take other parameters into account when we're deciding on an appropriate treatment for these patients. So rather than asking the question, how do you define hip dysplasia, or how do you define borderline dysplasia, we really should be asking the question, how do you assess for hip instability? And so we'll go over each of these four bullet points, which are all factors that I take into account every day when I'm seeing these patients with borderline dysplasia and trying to come up with the best treatment approach for each one. So in terms of demographics and clinical exam, these are the risk factors that I think about when assessing for hip instability. Certainly females more than males. Hypermobility. Any Baden score of 4 or more puts me on high alert. A Baden score of 7 or more, and at that point I'm sort of thinking, is there a reason why I should not be doing a PAO in this borderline dysplastic patient? Increased hip range of motion, specifically internal rotation. And then level of activity. You know, the patients who want to get back to running marathons or participating in triathlons or skiing Black Diamonds, these patients are really putting their hip to the test. And so if there's a patient who I'm sort of on the border of whether or not they need a PAO, but they're a very high-level athlete, I'm more apt to recommend a PAO because they're really testing out their hip and whether or not it's stable. One thing that's not relevant, but that I was taught during my training may be relevant, is sitting versus standing pain. So the theory here was that patients with a primary diagnosis of impingement would be more likely to have sitting pain as they're sitting with their hip flexed and putting their hip into that impingement position, whereas patients with a primary diagnosis of instability would be more likely to have standing pain as they're standing and that sheer stress between the femoral head and the ostabulum causes pain. So we actually prospectively did this study last year, and we found there's no difference. Regardless of a primary diagnosis of impingement or instability, patients are more likely to have sitting pain rather than standing pain. So this is no longer something that I ask patients about. In terms of plane radiographic parameters, all of these parameters listed here have been shown to correlate with either hip dysplasia or instability. Now which are most important? Well, we just recently published this study, a systematic review of risk factors for failure of a hip arthroscopy-only approach in patients with borderline dysplasia. And the radiographic parameters that were most important were a tonus angle of at least 15 degrees and an anterior wall index less than 35%. So these are what I consider most important in addition to the center edge angle itself. In terms of advanced radiographic parameters, multiple studies have shown that patients with hip dysplasia or instability have labral hypertrophy. And so if you have a borderline dysplastic patient and their labrum looks large on MRI or under direct arthroscopic visualization, that would make me more concerned for instability. Femoral ostabular cartilage hypertrophy is another thing, and you can see this on MRI. You can also see it on your plane radiographs in terms of the joint space width. So normal joint space width is probably somewhere in the range of four to four and a half millimeters. But if you have a patient with borderline dysplasia and their joint space width is six and a half millimeters, I'd be more concerned about instability in that patient. Femoral torsion is a good one, and I get a CT scan in every patient who I'm considering hip preservation surgery on. And if I have a borderline dysplastic patient and say their femoral torsion is 30 degrees, well, that's not enough for me to do a femoral osteotomy on, but it does make me more concerned that this patient is more unstable because their femoral head is pointing more anteriorly. And so I'd be more likely to do a PAO on that patient, even though their femoral torsion is not enough to consider a femoral osteotomy. And then last thing, an upsloping lateral source seal. We've published on this before. You can see this on CT scan. You can also see it on plane radiographs. And then lastly, intraoperative parameters, meaning things that you can see during hip arthroscopy in a patient who maybe you weren't already considering a PAO, but maybe you want to consider a PAO after seeing some of these things. So again, labral hypertrophy. The next thing is an inside-out acetabular chondroflap. So back in 2019, we published on the two major types of acetabular chondroflaps. And by far, the most common type of flap is an outside-in flap, which is associated with CAM type FAI. But if you see a flap that looks like the one in the upper right, where it begins towards the center of the joint and heads out towards the labrum, that is called an inside-out acetabular chondroflap. And that's due to shear stress between the femoral head and the acetabulum. As that femoral head frequently has these very mild subluxation events, it creates shear stress. And at some point, perhaps, it creates a flap that, again, begins towards the center of the joint and heads out towards the periphery. And the last thing is a windshield wiper sign. So we just published on this. And this is a rare finding. But when you see it, it's a sign of severe hip instability. And the theory here is that in patients with severe instability, that femoral head is always in a position of subluxation. And when it's subluxated, it creates tension against the joint capsule. And as the patient internally and externally rotates their hip, that joint capsule rubs against the supralateral femoral head and creates initially a chondral defect, and in some cases, eventually creates an osteochondral defect. And so these arthroscopic images in the upper right, this is a patient who had no prior hip surgery. But this sort of looks like a femoroplasty, right? But this is all related to the windshield wiper sign. And you can see the 3DCT in figure A there with the femoral head subluxated and that osteochondral defect in the supralateral femoral head. These patients absolutely need a PAO if you see this, or at least a femoral osteotomy depending on what the femoral torsion is. So in summary, borderline hip dysplasia is often defined based on the lateral center edge angle alone. But we really need to take other factors into account when we're deciding on an appropriate treatment course for these patients, meaning soft tissue only versus bony stabilization. And there are multiple clinical, radiographic, and intraoperative factors which can be used to assess for hip instability. Thank you. Hi, I'm Derek Ochiai. Welcome to DC. Hope you're enjoying it. So my charge is going to be talking about physical exam findings and borderline dysplasia. Here are my disclosures. None of it's relevant. So patients may present with groin pain with sitting. They may present with posterolateral gluteal overload pain. It's both. So you can't really say, OK, this is lateral hip pain, so it has to be like bursitis. But they can present either way. Females, obviously, more commonly present with instability. But males can also have borderline dysplasia. And they can also have instability. So I don't rule that out just because of their gender. The physical exam findings for borderline dysplasia overlap with micro-instability. All of these tests are mainly used to see how unstable the hip is, like how much can you get it to translate. The more positive tests, the more diagnostic reliability. Just like a slap tear, if you have a biceps tension test and anterior tenderness, it's better than if you only had one. So the range of motion may be increased. We talked about hypermobility and Baten's sign. And then there's the anterior apprehension test, the prone instability test, the abduction, hyperextension, external rotation test, and axial distraction test. So the Baten's signs is this fifth digit, hyperextension, thumb touching the forearm, elbow hyperextension, knee hyperextension, and palms to floor with the knees locked. There's also weird ones. So if you've had EDS patients, they'll show you different things that they can do. Like this person can twist the leg around the posterior, and they don't have any increased version. That's just them. All right. So this is the anterior apprehension test. It's hip extension, external rotation, and then I just bring it up to you. So make it sort of like a Jobe relocation test and an anterior apprehension test for a shoulder instability. The axial distraction testing, definitely test both sides with this. And put the hip in about 30 degrees of abduction, and then you're trying to feel for instability or shock. Prone external rotation test, you put an anterior directed force on the greater trochanter as their inflection and external rotation prone. And the abduction, extension, external rotation test, which is done laterally, and again with an anterior directed force on the greater trochanter. Don't forget labral tear tests. That's an Arlington test, Faber test, twist tests, because there's overlap again, and you do them all. So no physical exam finding in isolation is perfect for borderline hip dysplasia or micro instability or a combination of both of those. Just like with other joints, multiple positive physical exam findings can increase the diagnostic sensitivity for instability. And the reason that I am sweaty right now is I just got off the golf course where my daughter just won the DC State Golf Championships. So I'm going to be talking about Shane Ngo's talk. So if you put Shane's talk up, please. So Shane is unable to be here right now. He has plane problems in Chicago. So his charge was to say that hip arthroscopy for borderline hip dysplasia is enough. And that's the handsome fellow right there. I'm sure none of his disclosures are relevant. Let's kind of go here. So there's borderline dysplasia that is 18 to 25. And as Dr. Karate talked about before, there's a difference between there's borderline and borderline. It's not the same. An 18-year-old dancer and a 20-year-old goalie are totally different. And you really have to tailor your approach based on the pathology and also based on what the patient's expectations and goals are for sport. So one on the left is a hip arthroscopy. The other is periacetabular osteotomy. How do you choose? Is it more impingement or is it more instability? And I think this is where physical exam findings and history, like actually talking to a patient, is really important in trying to figure this out. Do they feel like their hip gives out when they step off of a curve? OK, that's more instability. Do they feel just like a pinching when they're cutting playing soccer? That's probably more impingement or labral tear pathology. I'm not advancing this. Is somebody else doing that? Or is this going on its own? OK, it's not my talk. So there's all of these factors, Bain's activity, age, lateral center of jangle. And you're trying to figure out what is the right thing to do for this patient. Again, he showed these three different ones. This one has a lateral center of jangle of 18 and a tonus of 12. Dr. Crowder was saying that 15 or greater, you'd be really thinking about doing a PAO in conjunction with a hip arthroscopy. At least that's what I would do. The alpha angle is 56, OK, a little high, not crazy. He was talking about the two-year outcomes for borderline hip dysplasia after hip arthroscopy. And the numbers are pretty good. We have come a long way in hip arthroscopy since when I was first starting out. And I thought the capsule was just something that got in my way to get to the labrum. And we're certainly more in tune with capsule stability. That advanced on its own. Let's see if this will go. OK, I think it will. So this one is showing a labral tear. I just saw that on that slide. Is it going to just go on its own? I don't know. There it is again. There it isn't. Cartilage looks great. There's no acetabulus of chondral cysts. Why is this going again? I think we just, oh no, this is a different one. Is this different? OK, lateral center, sorry. 23 and tonus angle of 12, again, less than 15. Lateral center angle of 23. OK, are you really sure that that's 23? Maybe it's 24. Maybe it's 22. It's not 18. It's not 16. Alpha angle of 60. You really have to measure these out. You can't eyeball that and say that that's 60 degrees. Because I could say that that's 55. We're going to go through this MRI. Do I click this to have it go through? No. OK. Or do I tap it? So this one has a large acetabulus subchondral cyst along with the labral tear. And maybe if I tap, no, that doesn't work. And this is the coronal oblique views. Big labral tear, subchondral acetabulus cyst, and then a large subchondral labral cyst and a large acetabulus cyst in this patient. Honestly, this is one that I would do a combined PAO and a hip arthroscopy on. Because that acetabulus subchondral cyst is a bad prognostic sign in somebody that young. And I would be throwing the kitchen sink at this and doing a PAO at the same time. So the version was 22, kind of more on the instability from a tonus angle standpoint. And their acetabular coverage, they were undercovered. Again, I would do a PAO. But this is Shane's talk, so he did a hip arthroscopy on this patient, I'm presuming. And so I think we're talking about the third one now. OK, so the third one, tonus 12, lateral center angle of 22, obvious CAM impingement on both sides. So he did a hip arthroscopy on that patient as well. So the evidence for treatment for borderline hip dysplasia, hip arthroscopy has systematic reviews. Hip arthroscopy and PAOs have case series and systematic reviews. Midterm results with patients age 40 years or older with borderline dysplasia, very good five-year outcomes with either below 40 or over 40. So it's the health of the articular cartilage. It's not necessarily the age of the patient. Conversion to total hip replacement over 40, 14.5. That's kind of what you'd expect, because this patient has had instability damage to the articular cartilage more than somebody who is 18 years old, where a hip arthroscopy with capsule replication and labral refixation or reconstruction can be curative. Looking at the fear index, not that much different with a fear index of greater than 2 or less than 2 for a minimally important difference with the sport-specific hip outcome scores. So looking at radiographic factors, there's the anterior center edge angle, like best seen either on CT or false profile, your fear index and your anterior wall index. And I'm not sure why I had that there. OK, looking at hip arthroscopy with capsule replication and labral preservation, 10-year outcomes, both groups, I mean, the difference is not really, they're good. The minimally clinically important difference is 70%, survivorship 82%. I would take that for this type of population. Here's another talking about a matched study with minimum 10-year follow-up with the borderlines had 63% MCID control, 69% not that much different. Borderline hip had a pass score of 46 and the control had 85. So yes, it's better not to have borderline dysplasia. But that doesn't mean you should do a PAO. The failure rates, almost the same. I mean, the success, not failure. 86%, 82% with a 10.7% revision rate versus a 3.6% conversion rate, not bad. So independent predictors for failure treatment, again, tonus angle of greater than 15, age greater than 40, female sex, having any arthritis, and having a labral debridement as part of your treatment, which hopefully nobody in this room would do. So that's the same slide again. Can we just do that one? All right, oh, so let me see if I can, can you go back? I think I, can we go back? All right, so this is looking at a stage hip arthroscopy and then followed by a PAO. The two-year outcomes were 68% MCID, PAS was 64%, and survivorship was 100%. That's two-year outcomes. And this was a MAT study that's under review, so I guess this isn't actually published yet. The PAO and scope was 77%. The scope was 81%, no difference in MCID. The PAS was 54% with the PAO and scope, and with the scope alone, it was 69%. The survivorship is very similar, and everybody who had a scope, they were, you know, the 2.5% of them were later converted to a PAO. There's multiple other studies that I won't. So PAO plus scope showed better or equal patient-reported outcomes compared to isolated PAO across 20 studies in this systematic review. I would, if I have a patient, I'm going to do a combined, has borderline hip dysplasia, I'm going to do both. I'll do the hip arthroscopy, and one of my colleagues will do the PAO, either staged or combined. So in summary, for borderline hip dysplasia, you know, contemporary techniques are not what, this is not your grandfather's hip arthroscopy. You know, label refixation, capsule management is very important. If there's CAM impingement, certainly address CAM impingement when there's no instability. And there's a low failure rate with great outcomes with hip arthroscopy alone. I think they can be even better if we choose some that we actually do a PAO on along with the hip arthroscopy. So that's Dr. No's talk that I tried my best with. Thank you. That was a great pinch hitting, let's see if, all right, well it's a pleasure to be here. It's my first HANA conference and I appreciate being asked to be part of this. I don't have any disclosures except one, I love hip arthroscopy and love sending patients to my five or six arthroscopic colleagues. And two, I am skewed because I see about 20 to 25% of my PAOs had a prior hip arthroscopy and about half of those more than one. So those are very challenging patients. So I'm coming at it from kind of a neutral perspective. These were my charges, that PAO is the gold standard for treatment of hip dysplasia, it treats the primary pathology which is lack of bony coverage and patients do not need a labor repair if they have a PAO. So the most important thing is what's the pathology? We should ask what the pathomechanics of each hip are. There's labral, cartilage and rim damage and pain from both impingement and dysplasia. Their symptoms are remarkably similar, sitting pain is very common in patients with dysplasia due to the overload of the psoas and they sit and it hurts. So the diagnosis and decision should be made on patient history and exam, three-dimensional properties of the acetabulum femur and what is best to treat the anatomic variation. This is a great article on osteoarthritis and cartilage which is a very high impact in orthopedics and they found for acetabular dysplasia each degree reduction in LCE below 28 degrees was associated risk of 13% for OA and 18% for total hip replacement. So we do know the natural history of hip dysplasia. If you look at the radiographic acetabular dysplasia natural history, so these are other sided hips or longitudinal long-term studies, what they found and this is a couple studies showing the same thing, LCE less than 25, tonus greater than 8, femur head coverage greater than 80% have a risk of osteoarthritis. So borderline dysplasia may result in long-term osteoarthritis, therefore consideration should be given to a PAO to address the mechanics, not just pain. So here's a 39-year-old female, I did a PAO on one side, she was asymptomatic on the left side with a mild dysplasia but went on to wear and tear over six years. What is borderline dysplasia? It's like there are certain things in orthopedics that we don't know where they come from. So is it greater than 16 because the original natural history study shows if the LCE is less than 16, that hip is going to have some arthritis or is it 18 or 20 to 25? Who decided this? Like what did we use to decide it? And how does it differ from mild dysplasia? So borderline is really nonspecific and based only on one radiographic finding and excludes the patient's three-dimensional anatomy. As John said, coverage may be deficient in more regions than just the classic anterior or lateral. So looking at more than LCE alone may result in some arthroscopic failure. A lot of the hip arthroscopy failures I see is when I get a 3DCT and the whole femoral head is showing in the front but the lateral side is normal. So the anterior wall index would be short, so three-dimensional imaging is necessary. Now this is a paper that I don't think gets enough play right here. This is from Ottawa and they found recent advances in the dysplastic hip using three-dimensional imaging, found multiple patterns of instability. So we actually call it, Ottawa A is when there's acetabular anteversion, which is another word for saying when you compare it to the posterior wall, there's just not enough anterior wall coverage. Rarely is the lateral, posterior lateral acetabulum over-covered and the anterior under-covered. It's usually just a deficient anterior wall. Acetabular retroversion, and these are normal LCE patients, may result in posterior lateral under-coverage. You can have occult or mild dysplasia or iatrogenic instability with alteration of the rim complex. So here's a classical anterior Ottawa classification A where the anterior wall, let me go back, where the anterior wall doesn't cover much of the femoral head and you see the same thing on CT scan, or the posterior where the posterior wall is very horizontal and there's posterior lateral insufficiency, or the classic lateral. Now hip arthroscopy is more commonly performed for all hip pathology and there is success in cases and here's many articles. There is, many are single center series cohorts with very diverse inclusion criteria. The one done at our, at HSS, that's a 10-year follow-up now, they're not the same patients that I'm doing PAOs on with labor repair and capsular plication. This was a current comparison, just talked about 14 studies, only one comparing PAO and arthroscopy. The complication rates were similar. The conversion to total hip was similar. The primary findings is significant improvement for borderline dysplasia treated patients with PAO arthroscopy. Yes, of course, you're helping pain, taking care of the soft tissue, you're helping pain by moving the PAO. With low complication rates, low rates of PAO conversion following arthroscopy and low TA, total hip arthroplasty conversion rates. However, the reported conversion rates to PAO were anywhere between 0 and 16%. Now it's more frequently, it's more frequent for many of us to evaluate patients with previous hip arthroscopy at tertiary referral centers. And they are women with borderline dysplasia, occasionally males. I can count on one hand over 15 years that I've done it in a male, the head's bigger, it's less common. And like I said, about 20 to 25% of my patients are female that have PAOs. And it's usually due to unrecognized subtle dysplasia, secondary to deficient exam, imaging, and education, excessive rim resection, or the hip arthroscopy may be chosen since dysplasia is only mild. I hear that a lot from patients. If you look at the anchor group, we found the failures of PAOs after hip arthroscopy, they're the more subtle ones, LCEs higher, female, lower BMI patients. If you do PAOs in that group, again, many of them are the mild ones that are harder to diagnose and a higher tonus angle. So surgeons should rely on more than the lateral center edge angle to determine if the patient should be treated with arthroscopy alone. We're repeating this study, but our two-year studies show if you have a PAO after hip arthroscopy, the patients do improve, but they don't do as well. Now that was narrowing it two years because maybe it's just rehabilitation, but a trial scope just because the dysplasia is mild may compromise outcomes. But in some patients, as long as they're educated and that's what they want to do, maybe some dancers, hockey players, some other things, they see both of us and if they have one, if they don't do well, then they come back and see me. But the PAO is a multi-planar deformity. It addresses multi-planar acetabular deformity associated with borderline dysplasia. It can effectively treat the dysplasia with acetabular reorientation and it is the only surgical treatment that changes the natural history. If you do soft tissue work, they may feel better, but it doesn't change the problem that might lead to OA in the long run. It's a balancing of the maloriented horseshoe-shaped acetabular cartilage over the femoral head. So if the hip pains from instability, the PAO increases the bony stability and may have the largest effect of changing the mechanics and changing the natural history, as I mentioned, which soft tissue may or may not do. It's been around for 35 years. Techniques of bony cuts is consistent, but there's been a lot of approach and perioperative modifications. In 2025, again, the bony cuts are very consistent, smaller incisions, more efficient surgery with less soft tissue dissection and blood loss, shorter hospital stays, there's even outpatient PAOs being done now, reliable outcomes with a very low revision rate, minimal complications and centers that do a lot, and the indications has expanded. The benefits, fragment mobility, that piece, if you do it right, you can move it with just two fingers and put it wherever you want. You can do correction of subtle abnormalities. You can change your version just subtly, your anterior and posterior wall index. You can move your LCE. If you don't like 30, you can go to 33. It remains extra articular, and I do find that avoiding the joint, if possible, is a good thing to do because I think once you enter the joint, you get scar fibrosis, and the joint never looks quite the same, and it maintains the abductors. We have increased precision now with correction. I used to just put it up there and go, that looks good, but now we use things like, I use Radlink that measures pelvic tilt, so you want to get your pelvic tilt interop, the same pelvic tilt as your standing x-ray. The most important thing I look at is anterior and posterior wall balance, and then LCE, and you can dial in your LCE to whatever you want it to do, so you can get more in the target range. Chris Peters has his version that he's used and had some improvements in PROMS. The indications for me are symptomatic patients that failed conservative treatment, so especially if they're teenagers, at least six months of conservative treatment, much of it is going to be glute weakness, especially if they have an aversion, and they have all different sorts of deficiency. Again, we look at more than just LCE angles. Now what are the outcomes of PAO with mild dysplasia? These are two Boston studies showed successful in this borderline group. These are spherical hips that are concentric when you're done, so that makes a big difference versus the more moderate and severe dysplasia. It's a diverse cohort, so maybe it's mild on one view, but not mild on another. The anchor group found similar improvement between lesser and greater deformities, although the lesser ones tended to have lower WHO scores, and that's an interesting find because some of these patients seem to be rather debilitated for the level of dysplasia they have. When we looked at our mild dysplasia group, certainly nothing's 100%, so I'm sure it'll change with longer-term follow-up, but they did a little better than severe dysplasia. Again, I think these are concentric joints, and you can make them look pretty normal when you're done. When we look at the adolescent group, again, they did very well with high MCID values. Now it's not all anterior-lateral coverage. Every PAO has different coverage. I used to just antivert every one, and I'm sure those don't do as well. I find myself either not changing the version or slightly retroverting more than I do antiversion. So the study out of Byrne found that PAO is better at 10-year follow-up than rim trimming for those with true acetabular retroversion, and we now do retroversion with our osteotomy, so these are normal LCEs with anterior undercoverage or antiverted fragment. We did 21 hips, these Ottawa A, and they were comparable to the regular PAOs. Most PAO patients can return to sport. So the return to play was reported at 80%, but again, for those high level, it's a little lower. So I think that's probably very similar to hip arthroscopy, 65% returned to dance at one year. The dancers, we slightly undercorrect, but I don't hold them back from dancing. Complications, in centers that do a lot, they are there, but they're rare, decreased neuropraxias, implant-related issues, you take them out, delayed union or stress fractures, especially in the older patients, hip flexor tendonitis that we see in both arthroscopy and PAOs, the majority of these are treatable. Now this is a paper that Daniel Nawabi did, and I'm on this paper at our institution, and then the other paper to the right is done by Andrea Spiker when she was a fellow with us, and the borderline dysplasia group treated with scopes versus the PAOs, they're different cohorts if you look at their CTs. In the borderline group, their acetabular version is 3, 10, and 15, and we found about the same in our control group of FAI patients compared to PAO patients, which was 1, 10, and 16, so this is 1, 2, and 3 o'clock, basically how much anterior coverage there is. And if you look at the PAO group, it was 8, 15, and 21 with a higher femoral version, and a lower alpha angle. So they're different groups of patients that are treated, at least our institution, with PAOs versus the borderline with the mild dysplasia treated with a scope. Now what about the added value of hip arthroscopy and labor repair? We do about 33% to 40% scope PAOs, and they're going down a little bit. Arthroscopy PAO can be performed with good outcomes. We do it on the same day at our institution. PAO alone can be performed with good outcomes. So we want to know what literature supports the added cost and value of concomitant hip arthroscopy. This is a North American thing. It's a lot less common in Europe, and it's a lot less common in Canada now. And are scope PAO outcomes better than PAO alone? Well, there's a couple studies now we just recently published in American Journal of Sports Medicine, 53 patients had a scope PAO with labor repair versus just scope and look and not do anything. In 170 PAO alone, PROMs were collected at one, two, and the longest at six years with an average of 4.2-year follow-up mean. What we found is the same group MCID and no difference in improvement between groups. Patients that had a true labral tear with a separation that did not have a hip scope did just as well as those that did. So there are patients for scheduling reasons that just decided not to have the scope PAO since we do them on the same day, and there was no difference in that group either. And now we have an anchor randomized controlled trial group where there is nearly 100 patients in each group. Now we're entering four- and five-year follow-up, and we showed no difference in that cohort as well. So in conclusion, there's really no significant benefit measured by PROMs for hip arthroscopy in the setting of a PAO, and at least the concept of doing it makes sense. But when you look sometimes and see the little stitch and then you're moving the whole piece, you're like, does this really matter in the long run? And maybe it does in some patients, but who are they? So now we do it in those that had a prior arthroscopy that we don't know what's on the inside just to make sure, or if they have a little too much arthritis. Sometimes the really big patchless labrums we want to fix, actually Hollis Potter at our center says leave them alone. Those are the ones I don't want you to put a suture around, but she's a radiologist. Or if the patients really want it, which seems to be more than 50% of the driver because they ask about their labral tears. And then sometimes it's a subjective decision. You do one anchor, two anchors, you're in a hurry for a meeting, you don't think it needs an anchor. So it is still subjective, but there are definitely times you're happy you're there. So in summary, I think it's a very safe and predictable procedure for borderline dysplasia and instability. The PAOs we're doing now are different than 10, 15 years ago. Improved recognition of instability is what's critical and important. Patients do achieve high levels of function. There's a very lower vision rate, and it avoids some of the catastrophic outcomes that are observed in young female borderline groups that we see after hip arthroscopy. Thank you. All right, why I favor a combined approach. Before we get started with this talk, I need to clarify, I am not advocating for combined hip arthroscopy and a PAO in every portal anasplastic patient. But when I do see a portal anasplastic patient who I feel needs a PAO, based on everything I discussed in my first talk, then I am also recommending hip arthroscopy beforehand, and I'll explain why. So when we talk about the principles of hip joint preservation, there's really three key factors that we need to be aware of. And those include FAI, hip dysplasia, and femoral torsion abnormalities. Each of these three pathologies is treated with three different surgical procedures. And so when we see a patient with two or three of these pathologies, we really need to consider treating those patients with two or three different surgical procedures. And we know about how common it is for patients to have concomitant CAM type FAI and hip dysplasia. But why not just do a PAO and then do an open femoroplasty at the end of the case in these patients? Well, based on this recent systematic review and meta-analysis, arthroscopic osteoplasty results in a significantly lower rate of revision compared to open osteoplasty, nearly three and a half times lower rate. Now this study that Dr. Sink just mentioned, why not just do an isolated PAO? This is a multicenter randomized control trial published last year that won the Otto Frank Award of 97 patients who underwent isolated PAO with or without open femoroplasty versus 91 patients who underwent hip arthroscopy plus a PAO. And at 12-month follow-up, there were no differences in any of these patient-reported outcome scores, but only 12-month follow-up. And I'm not sure that's long enough to really discern differences between these two groups. Now Dr. Sink did just mention that there's still no differences a few years later, so we'll see when those new results are published. And then this systematic review and meta-analysis published in the Yellow Journal last year of 20 studies. Of those 20 studies, six studies directly compared isolated PAO versus hip arthroscopy plus PAO. Of those six studies, three of them found significantly greater improvement in patient-reported outcome scores in the combined hip arthroscopy and PAO group. And there were no studies which found significantly greater improvement in any patient-reported outcome scores in the isolated PAO group. Now when we talk about combined hip arthroscopy and PAO, this can be done either in a staged or simultaneous fashion. Now the benefits of staged procedures are logistically this is easier. I think most surgeons doing both of these procedures do them on different tables with different patient positioning and, at least in my case, at different hospitals. I'm doing hip arthroscopy at our outpatient hospital with a postless hip arthroscopy table and then PAOs at our big university medical center with a lot more inpatient support if necessary. You can avoid arthroscopy fluid from entering the surgical field during your PAO and making the PAO even more difficult than it already is. This third bullet point is currently unproven, but theoretically you can reduce the rate of capsule labral adhesions by allowing your patient to get on a stationary bike between procedures immediately following their hip arthroscopy. And then lastly, this is a rare scenario, but you can potentially discuss opting out of a PAO if you encounter substantial articular cartilage damage during your hip arthroscopy and you think it might not be worthwhile putting this patient through a maxillinvasive surgery with a prolonged rehab duration when most likely they'll need a total hip replacement within the next few years. To my knowledge, there's only one study that has directly compared staged versus simultaneous procedures. This study published out of the University of Rochester two years ago, a retrospective comparison of 39 combined versus 23 staged procedures. In the staged group, there was an average of 37 days between procedures. And again, at one-year follow-up, no significant differences between groups in terms of any of these patient-reported outcome scores, but again, only one-year follow-up. And by two years, no conversions to total hip arthroplasty, but short-term follow-up. We need a longer follow-up to really discern differences between these groups. So in summary, for borderline dysplastic patients who I feel need a PAO, I recommend combined hip arthroscopy and a PAO in a staged fashion. I like to stage these only about one or two weeks apart. And the reason why I don't like to space them out longer, say a month, is because really these patients are even less stable after their hip scope than they were before surgery because their hip capsule hasn't healed yet. And so I don't want these patients to be in a prolonged instability state. And so I only like to space it out a week or two, get them on a stationary bike in between. And that's the last point. Get them on a stationary bike beginning the night following their hip arthroscopy, and every day thereafter up until the day of their PAO to theoretically reduce the rate of capsule labral adhesions. Thank you. Thank you. Okay. So Dr. Sink and Dr. Ochiai, I want to join me up here. We have plenty of time for questions, so ask away. Hi, guys. Great talks. I like that. But this is a PAO question for the borderline groups. Are your goals of correction different between the borderline and the more severe dysplasia? I don't have a ton of these under my belt yet, but I was trained as more of a slight under-corrector that I think I'm switching now because I've done a couple of these borderlines where I'm like, how much, if I'm not correcting it that much, how much am I actually doing? So I've sort of switched where I think maybe the borderlines might need more of a correction. And then when you look at the magnitude of change compared to the more moderate to severe dysplastics. But please let me know what you all think. Yeah. That's a good question. I'm an admitted over-corrector, slightly. And it remains, where we're seeing arthritis when they get older, it's the medial joint first, and maybe they're, and that's where the joint reactions are. So part of me is backed off a little bit and having the RadLink software or the Ortholink software. I mean, I can dial it in to, like yesterday I was happy, wasn't happy when I was at 29 or 30, but I was able to change it to 33.5 and I was happy with that. So regardless of the type, I like to get the lateral center jangle personally, 30 to at the most case 38. But if they've had prior surgery, if they have EDS, if we look in there and the labrum is just this ball of things that we release, I will sometimes over-correct and oftentimes it's not uncommon to have a tonus angle just slightly negative. Now I don't know if that's just sort of my thing. It might be other people are happier with lower LCE angles. But in the mild group, it's basic version is as important to me as anything. So I hope that answers the question and I tend to get around 33. My goals don't change whether it's borderline or frank dysplasia. And I'm not actually measuring a center jangle after a PAO. I'm really just looking at the shape of the socket and the anterior and posterior balance. So I want a concentric roof over the femoral head. And if it's a short socket, I might have to go with a slightly negative tonus angle to get that full roof. But basically I want a roof and then I want good anterior and posterior balance. I'll check internal rotation during the case before I put my screws in. And I want anywhere between 5 and 15 degrees of IR. And if all those things match up, then I'm happy with that. Yeah. That being said, you look at the fovea of the femur with a leg in neutral position. You know, that's non-articular surface. So you want to start, I like to start my medial part of my sore seal right there and then go over. So the first thing I do is how does it look? And then I actually think the thing is keeping me from having it at 40. To me, that's because I have some ones before I started using the software, now I kind of back off a little bit more or so the extremes, but yes, you try to get the best fit. And sometimes the small roofs and a high fovea, you can do something the femur, but they don't like it. If you change the femur in a scaly mature person. So we get a negative roof angle to maximize the surface area. And that being said, we're going to be using finite element analysis. They're doing that in Iowa and there's some technology out there where we're going to try to find the horseshoe shape. What's the best position for the horseshoe and multiple planes, because everybody's got a different articular surface in the acetabulum and perhaps where one, one size treats all is probably not the right thing to do. So we'll probably do a prescripted correction based eventually, hopefully on what their, what their horseshoe looks like. And one other thing is takes more time, but I get a flat plate X-ray in the operating room and I have a perfect AP pelvis X-ray from the clinic where the coccyx is lined up right with the pubic symphysis. And I get that same exact view with the same pelvic tilt in the operating room. So whatever coccyx body or whatever is at the pubic symphysis or the same distance above the pubic symphysis, I get the same exact view and rather than just a CRM image, because it's better if you get a perfect AP pelvis X-ray, you can really more accurately assess what your PAO looks like. How would you use a thermal side in determining what to do or what not to do? Yeah, I will, I ask, what is the Astaver version and what's the femoral version? Those are the two things I want to know. So if they have a retroverted femur, I'm going to add a little bit more anterversion because I figure they're putting more force posterior laterally. And if they have more commonly an anterverted femur, I'll make sure that I bring the piece forward more and make sure I don't antervert the fragment. So but I still want the posterior wall at the center of the femoral head in every case. And it just depends what the socket will give me. But sometimes I'll bring it forward more in those cases. So yeah, I want to know exactly what it is. And the range of motion is less dictated by the CAM lesion and more dictated by what the femoral version is. So you know, changing it with just a camera section is kind of a rare thing. I think femoral version plays more with and with extra articular impingement. So in cases now, more of us will stay out of the joint and we'll resect the AIS and subspine area to improve range of motion. For me, I'm taking everything into account and it's not a simple black or white thing. So if I have a patient with frank hip dysplasia and a femoral torsion of 45 degrees, I'm doing a DFO and a PAO. But let's say I have a patient with frank dysplasia, but they only have five degrees of internal rotation on exam. Then I'm going to do an anti-torsion femoral osteotomy and a PAO. Because if I just do a PAO, they're going to have a negative internal rotation after surgery. And then depending on what activities they do, they might not be happy with that. So I'm sort of taking everything into account and putting it together. I'd like to just... So we do a lot of scope PAOs. We do them at the same center. I do think once we move to everybody's being at an outpatient, I wonder what forces that will create on do we... But the cost is remarkably different to have your scope at an outpatient surgery center and then you come two weeks later to a major hospital and get a PAO within patient fees. So I do think the cost is not an insignificant difference because of the non-surgeon fees that build up in these patients. Obviously insurance companies may place a role on us. Like I know one insurance company has even said if they have EDS in their chart, no hip scope. I think that's Cigna, right? And EDS is another... We can go into that diagnosis for a while because I think everybody could have it that has a PAO. So we still do scope PAOs and I have no problems with it. But it does lead... We can do one of those a day and then follow up with a PAO because we use a different table. So I just tell the... If you want it, then you have to wait a little longer because those slots fill up and I get an extra cup of coffee. I can squeeze in a Peloton ride even before the PAO. So I don't have a personal problem with it. I just don't think it's necessary. I think four of the last five scope PAO patients, nothing was done. And it was done just because it was sort of almost demanded that the patient want it that way and I'm going to allow them to do it. So again, I think we have to figure out who is best for this. And there are some patients that will benefit and I don't think we know yet. So I'm not against it. It's just, I don't know how necessary it is on everyone. Yeah, I would concur with that, but also there is a table where you can do a hip arthroscopy and PAO without changing tables. So myself and my PAO colleague, we've done about 15 on that table and it's great. It saves you like an hour. Yeah, I know the table in the taller patients, it's a little harder. And then the problem I have with the imaging, so what we do is the RadLink takes three or four pictures and stitches an AP pelvis. And when you have those bars, it affects the software, so you can't do it. So that's the only thing that I had, the problem with the table. But otherwise, I think it's a great idea to do both. And I know like Andrea, other people have figured it out. So a lot of it is just your comfort. I just had a question about RadLink. I'm not familiar with that. Yeah, I just say it I mean it's it's so right now there's two companies that do it ortho grid Which was just purchased in rad link The only difference between the two is the ortho grid doesn't measure the PSSI index, which is your pelvic tilt so you have to make an assessment by look what we used to do looking at what the operator size is and where the you know where the Where the sacrum is But they both measure it in the operating room off the rad link has a separate tower that I show with our Some CRM say you don't have to and then the person we call in to LA and they do the measurements and I'm standing there And I'm like, yeah, that's good. So you compare it to the pre-op So, yes, it's commercially available it's the company They also use it our institution edsu uses it for anterior hips And the deformity people use it a lot for deformity corrections, so they don't they're gone with the old Bovey cord is no longer in existence because it measures their angles very well for it. So it's a smaller company I think it's harder to get into hospitals and it used to be for a bunch of purposes But it's really been beneficial. You can still do it without it I'm just saying it's it's now one of those things that we didn't have for 10 or 15 years and now it's like oh, I really Need it, but if the system goes down we just proceed I still think the question is I still think you could you're moving the socket So whether you have it or not, you still have a huge benefit and I don't know if it changes the outcomes But there's two companies that do it and hopefully there'll be others that can allow you to measure it But you probably get your AP pelvis and you do your measurements before you put the screws in right where you just well Like I said, I don't actually measure but you probably could if you have the packs you could do it Yeah Yeah, and Gon said he always just brings, you know, bringing it forward is the majority of things. And there are studies now that show a false profile when you're done. So I just like to, I like to say that the sore seal's grabbing the femoral head. That's the way I look at it. So again, there's a whole field that we're, we're going to probably in the next decade it'll be different. All right. Well, if that's it, thank you all for coming. Thank you.

borderline hip dysplasia

hip arthroscopy

periacetabular osteotomy

lateral center edge angle

hip instability

hypermobility

patient treatment

femoral version

RadLink technology

joint preservation