Okay, I think it's a just after 7 so we should get started well Thank you very much for coming on the last morning of Anna at 7 a.m We got a fantastic faculty here To talk about cutting-edge advances in hip arthroscopy 2025 Perspective so our objectives today is to understand Techniques in labor repair and reconstruction will master cutting-edge approaches to FBI treatment Will stay informed in future trends including advanced imaging and MR as well as developments and then we'll go through some case-based scenarios for practical application So I get the honor to introduce our faculty. We got dr. Ben dome He's gonna talk to us about labor reconstruction using knotless pull-through techniques. We've got dr. Andrew spiker here. We'll talk about capture management lots of periarticular treatments and Dr. Shane know and all the advancements in hip arthroscopy with computer augmentation So, thank you very much. We'll start off with dr. Dome Thanks Ivan good morning everybody Intimate room. So let's make it a dialogue any questions chime in so talk about labor Reconstruction the indications and the technique using the knotless pull-through technique will cover an algorithm for labor management indications today technique advances and how those have led to evolution of the indications themselves and the role of the labrum revisited so Not every algorithm has to be the same But I think it's helpful to have an algorithm and this is roughly our algorithm at American hip Institute for treatment of a labral tear basically, if it's if it's repairable we repair it if it's irreparable then we've got a couple options for a Segmental defect with a preserved chondrolabral junction. We may consider augmentation with a compromised chondrolabral junction We'll do a segmental reconstruction and if the entirety of the labrum is diseased then we'll do a circumferential reconstruction Now we've established through multiple Biomechanics and other studies that the labrum plays an important role in protecting the cartilage It does so through increasing hip stability Creating a sealing effect and preventing lateral displacement and distraction forces This is a video from David Maldonado from the lab and you can see the labral reconstruction here resists Distraction the late the native labrum is the best partial resection of the labrum decreases the seal by 71% Repair of the labrum improves resistance to distraction by 92% to reconstruction not quite as much but still a lot at 66% And that's a time zero. These are biomechanics studies so we can reasonably Believe that after healing occurs that these are going to be even better numbers Reinhold Gans one of the forefathers of our field said the labrum's sealing mechanisms are dependent on the fit of the labrum against the femoral head And this was one of the guiding principles that led to a number of iterations in In my journey and American Hip Institute's journey both for labral repair and for labral reconstruction So one of the first iterations of those was called labral base Refixation and the rationale was just that to create this seal and we noted that some of the early techniques for labral repairs Sometimes caused the labrum that was averted or bunched or not in contact with the femoral head so that led us to a couple iterations of techniques with the technology at the time that enabled us to preserve the triangular cross-sectional shape of the labrum and Restore the transitional zone restore the seal of the labrum and even to do so without labral detachment Which was how some of the early repairs were done The next thing we noted was that previous knots were sometimes a problem in the revision setting and were in fact a nidus For scar tissue you can see that in this video here where there's quite a lot of scar tissue around a previous knot So we removed the previous knots And in this case, this is leading to us to a reconstruction Knotless tensionable anchor technology has allowed us to avoid that and allowed us to do both repairs and reconstructions With selective tensioning achieving a consistent seal they can save a surgical time They can avoid risk of not loosening and avoid the nidus for scar tissue a word of caution though We can over tension we can ever the labrum with either a knotted or knotless Anchor so we have to be aware of our tension So this led us to the next iteration of repair, which was controlled tension anatomic labral repair using this knotless anchor technology Which allowed us to achieve consistent seal of the labrum against the femoral head and to do so with insert or out selective tensioning of the repair sutures so we can see that in video form here and The anchors can be placed either through our Candle as our portals or through percutaneous Techniques in this case, we're using a dala portal and a scorpion to pass the repair stitch and then shuttle that repair stitch through the anchor here you see it's looped over through the shuttle and shuttled through and Then the next anchor is placed through a percutaneous portal Which is a useful option to have depending on where you are on the rim So The knotless pull-through technique. I don't have many gifts in life but if I have one it's making complex things less complex and Labral reconstruction is a complex Procedure no matter how you cut it, but we've tried to make this simpler and hence make it more accessible and reproducible for more surgeons so that's the knotless pull-through technique one of the Things that had that made it simpler is avoiding the need for measurement and in earlier techniques that I used We had to measure The length of the defect. I even invented this measuring stick that you see here I get $18 in royalties every year for this measuring stick. I no longer use it because we have Been able to avoid the need for measuring and I'll show you how So We start with diagnostic arthroscopy, this is a revision case you can see previous sutures and the Labrum is quite calcified. So we're removing this calcified labrum a couple other examples on the left side One of a shredded labrum one of a calcified labrum. These are cases where We'll want to do a reconstruction and we bevel the rim This creates a neo vascularity from the bone and it also can create a biomechanical advantage if we create about a 60-degree bevel Then we place all the knotless anchors and we do this all the way around the horn if In whatever part we're reconstructing. This is a circumferential Reconstruction that you're seeing here. And when I say circumferential, I mean everything except the transverse Stabular ligament so all the way to the TAL anteriorly and posteriorly And the anchors are placed through at least three different portals Depending on where we are on the rim Next we thread the repair limb of the suture through the most anterior through through the anterior part of the graft behind a rib stop and then we'll pull the graft from the mid anterior portal to the posterolateral portal or An inversion of this technique has been to pass it through the DALA portal and pull it out the posterolateral portal So here you can see all the suture anchors are all clamped in order that's very important for our Suture management and we're going to pull the graft through the anterior portal and out the posterolateral portal Remembering that the suture has already been passed from the most anterior suture anchor through the graft so there it is pulled out the Posterolateral portal so very creative name for the technique the knotless pull through technique. Thanks to that pull through So here we have the graft in the joint and we are now Converting that first anchor and you see that docks the anterior end and then in the video on the right we pass and convert the suture anchor sequentially working from anterior to posterior and this becomes I'll say fairly easy as labral reconstructions go because you have a docked anterior end the posterior end is pulled out through the Posterolateral portal and you simply pass and Pass and shuttle and pass and shuttle the anchors as you work your way along the horn now when we do a reconstruction with 10 to 12 anchors And a graft if we've got 12 anchors and each of them has three sutures attached to them That's 36 sutures and a graft all in a fairly tight joint all at the same time So naturally suture management is important Clamping the sutures from the anchors in in order and then releasing them in order is very helpful for that Here's an example of those clamps to help keep it organized And then finally when we've converted all the anchors We simply amputate the excess graft and remove it and that's why we didn't have to measure because we actually Completed the reconstruction before we size the graft there the Excess graft comes out the end and the grafts will be 25 to 30 centimeters long. They're much longer than you'll need For the reconstruction so we have graft to spare Finally we'll evaluate the reconstruction. We'll work our way around the horn here from anterior to posterior and we want to see that we have good approximation to the cartilage And there's a good junction and also that there's overlap between the graft and the native tissue both anteriorly and posteriorly At the ends of the graft take traction off and we want to see a seal of the graft against the femoral head Which we see there So what about indications? Now reconstructions may actually be stronger than native tissue So, you know one might ask why not repair the labrum and some authors have indeed advocated for reconstructing all Laboral tears we haven't gone that far and I don't think any of the other panelists have us have either but nonetheless there has been an evolution of the technique and the evolution of the technique has caused evolution of the indications because When something becomes more reproducible and easier and faster we can apply it in in more cases so we've clearly had an evolution of Technique from debridement to repair to augmentation to reconstruction over the last couple decades and we have applied labral reconstruction when the native labral tissue has compromised viability now, that's a little subjective and Different people see viability differently But something I've learned in researching this is that basically all the labral tears that we see have a diseased labrum Scanning electron microscopy shows prevalence of cartilage and calcification in the labrum is a hundred percent so they're all diseased to some degree and we have to make a Decision whether they're diseased enough that they're better off replacing it with a graft So for for us currently when to take the leap the indications in the primary setting are insufficient labral tissue segmental loss a calcified labrum or severe and labral intrasubstance damage And in the revision setting most failed previous debridements or repairs are an indication for reconstruction What the data shows a high rate of return to sport These are a number of publications. I'll fly through from our institution, but high rate of return to sport Circumferential reconstruction outcomes are comparable with a benchmark control group that had repairable labra This is an important thing to talk about how we benchmark So we're not comparing labral reconstruction to labral repair because these are applicable for two different kinds of patients We're comparing two different kinds of patients the patient who has a repairable labrum to the patient who has an irreparable labrum and our goal is to take that patient who has an irreparable labrum and get an outcome that is as good as The patient who has a repairable labrum and we've shown in these comparisons that we've been able to do that Labral repair still is the plan a for the repairable labrum repairs even have slightly higher patient satisfaction than for the irreparable Labra, but labral reconstruction gives us a very durable option for the irreparable labrum with an 87% Survivorship at five-year follow-up and comparable survivorship to the repairable group our tenure outcomes are impressed and labral reconstruction continues to be a durable option a Question that I had in my mind early on was what is the body's capacity to actually incorporate a graft? this is not living tissue and Fortunately, we haven't had many opportunities for second looks but we have had a few and I must say I've been quite impressed with the body's ability to Incorporate the graft and make it its own and we see that here with fully incorporated chondral labral transition And you can see that the anterior and posterior anastomosis between the graft and the native tissue are actually hard to see because it's so well incorporated between the graft and the native tissue So returning to our algorithm, we have a lot of options for a repairable labrum. We repair it for an irreparable one we can do labral augmentation segmental reconstruction or circumferential reconstruction and Atlas said to Zeus I asked not for lighter burdens, but for broader shoulders these variety of techniques Although complex techniques have given us broader shoulders with which we can tackle more different problems So know what's in your quiver all of these different techniques choose your cases wisely and always consider additional training Thanks very much I Took out the entire labrum in one of those cases took it down to bone before you did your reconstruction At any point in your career. Did you leave? The native labrum as bad as it looks and then just put a graft on top. Yeah, so that's what we call an augmentation and Depending on the tissue we have done Augmentations particularly for the diminutive labrum you've seen the labrum that's two millimeters wide and it's not big enough to Create a good seal in the native state nor nor in a repaired state But if we add graft to it, then perhaps it is now the question then is does it add anything to preserve that two? Millimeters of labrum and if it adds anything, it's the preservation of the hoop, right? There's some Circumferential hoop around the labrum. So maybe we're preserving those longitudinal fibers on we haven't seen a difference in our data with augmentation versus Reconstruction, so I'm not sure it makes a difference to preserve that tissue clinically, but conceptually that was appealing Yes but by the time we've prepared the Rim, we have basically denervated the entirety of the labrum So I'm more concerned about what happens to that tissue afterward I think that it doesn't have nerve supply at that point But is it going to be viable tissue that's going to be populated by the cells and you'll grow into something Reasonable or is it going to continue to be a floppy flappy thing? That's going to cause mechanical problems Yeah There are certainly cases where I've got a pretty good idea But I'm going to every case prepared for either so we always have grafts on hand and that's a luxury I understand isn't possible at every institution, but in an institution where we do a high volume of These procedures and some of them are going to be reconstructions. We can have a graft or many grafts always on hand So that's helpful and also consent every patient for it All right, well, thank you everybody for being here this morning, I'm Andrea Spiker from the University of Wisconsin I'll be discussing capsular management this morning. Here are my disclosures. None of which are related to this talk Except for this one So my major disclosure is that I am coming at this from a standpoint that I always close the capsule My capsule management typically involves either an interportal with suspension sutures distally or a limited T capsulotomy if needed So this morning we're going to talk through tips first to minimize capsule disruption and that will be talking about not cutting it in the first place leaving as much tissue if If you do end up cutting it and then some techniques that we can utilize to avoid cutting it further than we already have I'll also touch on strategies to repair the capsulotomy capsule augmentation and then capsular reconstruction briefly as well So as we've heard the trends in hip arthroscopy are pretty impressive There's been about a 5 to 18 fold increase in the number of surgeons performing hip arthroscopy between the late 90s and early 2000s and this does appear to continue to grow and So as such we are also going to see an increase in the number of revision hip arthroscopies each year and we've heard data that says the most common reason for a revision hip arthroscopy is residual cam and perhaps that's true, but I think capsular defects are probably more of an issue than we realize and Unfortunately, unlike a residual cam which is relatively straightforward to address in a revision of arthroscopy Capsular defects are much more difficult to take care of in a revision setting So here it's important to understand the anatomy of the hip capsule and as we know the iliofemoral Ligament or Y ligament of Bigelow is the strongest ligament It's the primary inhibition to anterior femoral head movement the labrum being the secondary inhibitor of movement It's also really important to understand the capsular milieu So Baton scores are important to look for hypermobility and about 33% of our hip preservation Population does have generalized ligamentous laxity as defined by the Baton score So one strategy certainly is that you could avoid cutting the capsule in the first place So this would be the impetus behind some of our colleagues using a periportal capsulotomy This is nice because you have small Entry portals into the capsule. You're not disrupting that iliofemoral ligament completely. However, the problem is that visualization is restricted when you're not able to move freely with your scope and instruments. So if you do cut the capsule, you can leave a large cuff proximally as seen here. And if you add a suspension suture to this area, you can elevate the labrum off of the rim, allowing for better, or I'm sorry, elevate the capsule off the rim, allowing for better visualization of the labrum. I also try not to debride any capsular tissue. So I use a sharp beaver blade to make this capsular cut in the interportal region, and then do not shave any of that proximal or distal capsule. And when we make that interportal capsulotomy, this has been shown to be the capsulotomy that actually disrupts the iliofemoral ligament. And we've seen this depiction of the capsulotomies, this being the T-capsulotomy here. And I would argue based on my exposure of the capsule during the PAO, that my T-capsulotomy is not where this dashed line is, but it's actually more lateral. So it's adjacent to not through the iliofemoral ligament. And so actually not as disruptive as some people are concerned it might be. Here's an anatomic depiction of an interportal capsulotomy. And you can see how that interportal is disrupting the iliofemoral ligament. But your T-capsulotomy, again, would be superior and lateral to that adjacent to the iliofemoral ligament. And in this study here, it was demonstrated that about 50% of the width of the iliofemoral ligament was damaged in all specimens that underwent an interportal capsulotomy. So in my mind, this is the one that we actually need to be a little bit more cautious with. So this shows visualization of an interportal capsulotomy. And I would say this is a rather large interportal capsulotomy. But you can see there's a nice proximal cuff to the capsule looking distally down toward the greater trochanter. You can see that capsule is all intact. And then proximally you have the indirect head of the rectus as an anatomic landmark as well. But here's a small interportal capsulotomy. So you can do an entire central compartment labral repair with a capsulotomy this size. And if you visualize it, you can see now that we're in the peripheral compartment, you can still actually get into the central portion of the joint quite easily in order to do a repair with a very small interportal capsulotomy. Now, another technique is to use retraction devices. So once you've created the capsulotomy using switching sticks, suspension sutures, so that you can pull on that capsulotomy, you don't have to cut it any further. And then one technique that I use is I actually clean the pericapsular fat quite extensively when moving into the peripheral compartment. And this allows for visualization of the capsulotomy you've made and then helps significantly in capsular repair. So here's the visualization you can get with suspension sutures in the distal limb of the capsule. You can see you can get quite far down on the femoral neck in many cases to perform a femoroplasty. Here's anatomic studies looking at the T-capsulotomy, and it has been shown to provide the increased joint visualization that you want when you're doing, say, a large CAM decompression. So it is a useful tool. And if I'm doing a T-capsulotomy, I typically use a radiofrequency ablation device. I think this helps when you're doing a capsular imbrication at the end of the case. I try to make it as small as possible and leave the zona obicularis untouched. So really start with a small T-capsulotomy. And you might also consider an L-capsulotomy. So if you look here, you can see the interportal, and then this is where I've made the L portion, and I don't extend the interportal medially toward the rectus at all. So it's quite lateral. And then once it's repaired, you can see we're left with that very small interportal portion of the capsulotomy, which is also repaired. So Brian Kelly taught me how to use a switching stick for visualization in the setting of a T-capsulotomy as shown here. I added a second one and coined it the chop sticks technique. So I often use two switching sticks. You can splay open the medial and lateral limbs, which gives you this great visualization of your CAM lesion when you are about to do your femoral plasteine. And another important concept is to move the hip when you have made a capsulotomy so that you can avoid cutting it more. So here we're extending the hip to get to that superior lateral portion of the CAM. And this really allows you to access areas that you might not be able to see with the capsulotomy that you've made if you don't move the hip around. Now, Dr. Dohm has described a capsular shift, which is a great way if you have a larger intraportal and you want to close down the capsule at the end of the case. So placing sutures at an oblique angle and then tightening these down will help. You can also put an anchor in the proximal rim if you find that you don't have enough of that proximal capsular cuff, and then place these anchors through the distal capsular portion to close down the capsule. There've been descriptions of capsular augmentation using bioinductive collagen implants. And you can see a number of publications and a number of technical notes describing how to do this. It's very similar to what is done in the shoulder. You can do a capsular reconstruction with dermal allograft, where you anchor the graft with those anchors in the proximal rim, and then lay it down on the distal capsule. There's also been descriptions of using the indirect head of the rectus as an overlay. So if you have lacking tissue in that area, you can cut the indirect and lay it down in the proximal aspect of the capsule. Now, if you're going to do a bigger capsular reconstruction, you can use tensor fasciolata autograft. This is a case I did many, many years ago, and I don't do autograft harvesting anymore. We're doing another procedure and we're in this area anyway. But this is a big dissection. Instead, you can use an allograft, where the graft comes from this area here. And while we've seen a lot of descriptions of, and arthroscopically assisted reconstruction, I've also used my PAO approach to do an open capsular reconstruction. So here's the PAO incision seen here. And if you look in the image in the right, this is the area where I would typically do a pubic osteotomy. And instead, I can put anchors in that under direct visualization, lay down a tensor fascia allograft, and then stitch it to the distal capsule in the case of a large capsular defect. And these reconstructions do biomechanically appear to restore the hip to its native capsular state in the cadaveric model. And then we've now seen some patient-reported outcome studies demonstrating that patients do well after capsular reconstructions if they have large capsular defects. So in summary, know your anatomy, your anatomic variations, know where the iliofemoral ligament is, and try to avoid it with your capsulotomy. If you're going to do a capsulotomy, keep the inner portal as small and as lateral as possible. Consider using a limited T-capsulotomy in line with the iliofemoral ligament or an L-capsulotomy. Help yourself with suspension sutures and retraction devices. And if you're me, close the capsule 100% of the time. If needed, often in a revision setting with large capsular defects, you can use acetabular rim anchors, capsular augmentation, or a capsular reconstruction. Thank you. That's great. Any questions? Well, Shane gets his talk set up. So if you keep all your portal, or your capsulotomy lateral, how do you get to sort of medial aspects if you need to do a reconstruction sort of all the way down to TAL? So I typically have my scope in the modified mid-edgier portal, and then I'm working from the anterior lateral portal. So my instruments are coming across the joint toward the medial aspect. So I think I can get more medial than if you have your scope and your instruments coming down or the capsules in the way. So I can kind of slide under the medial capsule. You can also use percutaneous approaches to the medial aspect of the rim if you don't want to cut open that intraportal capsulotomy more medial. Yeah, if you're doing that proximal suspension suture in the capsule there, are you pulling that through your mid-anterior portal or do you make an accessory further proximal portal to really pull it out of the way? Yeah, I typically just pull it straight through the modified mid-anterior. And again, my scope is going through that same portal. So I'll snap it very close to the skin and you can still sneak your scope in adjacent to that. Whereas with those distal suspension sutures, I don't know how you all like to do it, but I have one through the dollop portal, one through the interlateral portal. And then I have my assistant, I call them a marionette master. They're basically pulling as I go more medial or distal or lateral on that cam, whereas the proximal one is snapped to the skin. So one question for Andre. Pretty much same sentiment about always repairing the capsule except I'd say it's probably 99% for me. Maybe the 1% is adhesive capsulitis type of things, especially in a revision circumstance. Have you ever seen that? Yeah, I saw this last week. So the frozen hip was kind of interesting. It doesn't really show up well on imaging. So you're not really expecting it when you get in there, but you've got this massively thickened capsule. It's really stiff where you wouldn't expect it to be. I still closed it in that case, but what I did was a partial thickness closure. So instead of grabbing the entire thickness of the capsule, which is four times as thick as it normally is, I just put the top together to hold it in place and then was hoping for a little bit more mobility in that. Thank you guys for coming this morning. Thank you, Ivan, for organizing this ICL. So I'll be talking about software and the need for three-dimensional imaging. My name is Shane. I'm at Rush in Chicago. These are my disclosures. I think that this is probably something that we all see in the office. We're dealing with two-dimensional X-rays. We're kind of measuring these things kind of real time. And I would say that X-rays obviously are static. They're somewhat variable in terms of rotation. Exposure can be challenging. And quite frankly, two-dimensional imaging probably doesn't do a complex structure like the hip joint justice. So I do think that we have to move towards more three-dimensional imaging. So I'll kind of separate this out by how I approach the S-tabulum in terms of three-dimensional imaging and as well as the femur next. But this is a study that we published just kind of looking at the variation in terms of the global percent of volume. And you can see that there's quite a wide variety. Like on the far end, all these patients underwent hip arthroscopy early in my practice, but you had 46% volume versus 71%. And generally speaking, I'd say that there's a reasonable kind of histogram showing a bell curve in terms of what the normal coverage looks like. But needless to say, there's a large variety in terms of what we're seeing in terms of acetabular coverage. This is an example of all these patients have the same amount of percent of volume, but you can see that their lateral center edge angle varies quite a bit from 27 degrees to 34 degrees. And the quadrants of their coverage is different. So there is a lot of changes that are going on in terms of the morphology that I just feel like with two-dimensional imaging, we just don't appreciate that as well as we do with three-dimensional imaging. That's not to say that two-dimensional imaging is useless. Obviously using our measurements as we're accustomed to doing, lateral center edge angle, tonus angles, anterior wall angle, I'm sorry, anterior wall indices are all very important. And I think this study shows that actually the lateral center edge angle does have a strong correlation with the anterolateral and global coverage. So it is probably our best way to kind of understand what the morphology looks like with the limits of two-dimensional imaging. This is an interesting study that we did looking at three-dimensional models for dysplasia. And on the left, you can see a normal hip socket, borderline, moderate and severe dysplasia. And obviously it's intuitive, but you can see that the increasing degrees of dysplasia. So there's a significant change in terms of the coverage in the anterolateral, antermedial and posterolateral quadrants. But when you see kind of how it looks three-dimensionally, I mean, it's pretty eye-opening in terms of like how much there's a difference in discrepancy when you get to a more dysplastic situation. Three-dimensional imaging is also helpful when you're trying to understand like some complex orientation issues such as retroversion. This is a study that compared and correlated our 2D imaging to 3D imaging. And I think the one take-home point that I've taken from this study is that the posterior wall sign does have a pretty significant correlation with retroversion and probably better than ischial spine sign and crossover sign and so forth. So posterior wall sign, if you do see it on x-ray, probably does indicate that there's some degree of posterior undercoverage. We've also developed these loosened three-dimensional models I think is really helpful. I think one of the things I struggle with is just understanding the orientation of the walls, looking at crossover sign, posterior wall, ischial spine sign, anterior walls. I think all of these things are very difficult to see on two-dimensional imaging. And sometimes the exposure is not great. So it's really a struggle to see, but developing these loosened models really kind of helps to highlight these anterior-posterior wall relationships I think much more cleanly. One of the things that you have to do when you're using these models that you have to correct for pelvic tilt. And I think in these studies, we found that using these loosened models really helps to allow us to have more specificity when we're looking at crossover signs and retroversion and the wall indices. One of the interesting things that I think is kind of cool is that you can also simulate like weight bearing. So for example, like this is a standing AP pelvis and using the SYSP distance, you can see what the orientation of the pelvis is or how much pelvic tilt there is. And I think one of the things that some of the open hip surgeons might struggle with is just understanding anatomy when they're going from supine, doing their PAOs to standing, because obviously you can't simulate that in the OR. But when using these models, you can simulate with a three-dimensional model, you can go from a neutral position to a supine position to a standing position just by understanding their SYSP distance. And so you can rotate the pelvis so you can go from a simulated weight bearing situation. So here you can see the standing AP pelvis and the simulated weight bearing model on the right. And you can see that they kind of correlate with each other and it helps us to understand the orientation of the walls as well as the degree of dysplasia. So I think models like this are really helpful when you're doing some of these corrective osteotomies so that obviously you can't have the patient stand up during surgery, but you can simulate their models just by understanding what the relationship is. Let's talk about the febrile side. We've done a lot of studies looking at sort of the three-dimensional anatomy of the femur. This is one of the early studies that we did characterizing the CAM in terms of height and volume and comparing males versus female. And it's intuitive again, just to understand, but obviously the males have larger CAM deformities, larger volume, larger width, height, and so forth compared to females. We've definitely tried to transition from a CT-based model to an MRI-based model. And I think these MRI models are gonna become more common. I think something that I think would be a huge benefit to our patients and to ourselves. But obviously one of the struggles we've had is just trying to make it as good as a CT scan. CTs are cheap, easy, they're fast. MRIs are just more time consuming. But this is a study that we compared MR to CT to laser scan and have shown that they're essentially equivalent in terms of the surface topography. This is a similar study that we've done, again, comparing CT versus MRI in the cadaveric model, both pre and post osteoplasty. And again, showing that they're equivalent. And this is some of the more interesting things that we're doing in terms of doing statistical shape modeling with our MRI models and just trying to understand using point clouds on the left and then doing pre and post resections on the right and just showing like what the resections look like and where the areas of most prominent deformities live. So these are some of the more interesting things just to understand some of the, I guess what I would describe like modes or the types, subtypes of like cam deformities that exist. So you may see like a far lateral or a far interior and hopefully we'll have a large enough collection that we'll be able to identify like the different types that exist. You know, if you don't have some of these software in your own institution, you can basically get CT scans and send it to some companies and they can help process these images so you can have the information kind of right at hand. I think this is one provided by Stryker that's really helpful. It can show us the three-dimensional anatomy really nicely. It can show you your femoral indices, your acetabular indices. It gives you models that you can manipulate so you can understand what the orientation looks like kind of real time. And you can manipulate these so you can really get a good sense in terms of what the anatomy really looks like. So, and I think one of the things I think is beneficial is that if you're in solo practice, you've got no other partners, nobody else that does hip preservation, like in your area, you can just send these out and it really gives you confirmation in terms of like, you know, am I really seeing the proper acetabular orientation? Is this dysplastic? Is it not dysplastic? Is it borderline? Do I need to refer this out? Can I keep it in house? And they can turn around like fairly efficiently. So it kind of gives you a check to make sure that what you're measuring and what you're seeing is actually, you know, what they're processing on the backend. So how do we apply this in our own practice? So this is one of the computer vision tablets that's provided that you can use in your OR today. There's no preoperative imaging required. There's no planning required. There's nothing that's really required. You just have to plug this tablet into your fluoroscopy in the OR and it kind of sits pretty nondescriptly. This is a study that we did on a cadaveric model comparing computer vision interface versus fluoroscopy alone by two different surgeon, an experienced surgeon and a novice surgeon, seven fluoro, seven computer vision interface, and showing that with the experienced surgeon, there was similar accuracy when using computer vision interface compared to fluoro. But with a novice surgeon, you can see that there was a pretty significant discrepancy in terms of what the alpha angle looked like when using fluoro compared to computer vision interface. And this is just like a depiction of the yellow is fluoro, the blue is a computer vision interface. And you can see that there was a significant difference, especially at that 1145 to 1230 position where I think some of the novice surgeons may struggle a little bit with using fluoro alone. I think the computer vision interface does help to decrease that learning curve. And again, it's easy to use, easy to implement. It doesn't disrupt your workflow. I would say that it takes a couple of minutes to set up both pre and post-op. Here's just an example of just how we use it in the OR. You get these six different views from like 1145 to 245. And again, orange and yellow represents a large cam deformity. You'll go ahead and do your typical osteoplasty using fluoroscopy, you can establish like where your resection will begin. And then you'll, I typically like to go after the most prominent area first and try to recess that. And I think one of the nice things about using this software is that you can really try to recreate the sphericity of the femoral head. And I think it's transitioned us from going from more of that sharp kind of osteoplasty to more of that spherical or light bulb appearance that people are describing. So you'll do your distal neck contour. I think one of the things that helped me appreciate when doing my osteoplasty is that, focusing more distally actually than proximally. And I think that really allows you to create that nice spherical shape. And then this is what the proximal contour looks like. And you can do your dynamic exam, fluoro, hip check and just kind of get all that feedback that you can just to make sure that you leave the OR pretty satisfied with the resection that you do. And then this is your final post-recession check. Same thing, you just have to push on the femoral head and neck and it'll calculate it sort of real time using computer vision interface. And again, green means that you've completed your task. You can see from 1145 to 230, everything is green. And this is just an example at 1145, that 70 degree alpha angle to 46 degrees. And you can see that you've created that sphericity that changed the offset. So I think in the future, eventually, I think with these software packages that we'd be able to just see the patient with one imaging study. For example, like an MRI, you can process all the information you need, 3D, 2D models, you can move them dynamically, quantify everything that you need to do. And I think that going forward, that I think would save us time, resources, save the patient radiation. And I think that would sort of be sort of the ideal model. So the use of 2D x-rays has proven to be limited. Unfortunately, I think that's kind of the current state of the art. We got to move to three-dimensional models just for better understanding in terms of the three-dimensional morphology of the S-tabulum and femur. The models are dynamic, you can change the lucency, you can change the orientation, and they would have a significant clinical impact. The models can describe the deformity of the CAM by height, volume, and location. These can be used for preoperative planning and postoperative evaluation. Many challenges remain in the more widespread use of three-dimensional models in the field of hip preservation. However, their implementation would undoubtedly have significant impact in our practices. Thank you very much. Questions? I do, I really like the idea of 3D models, so we'll talk about that more when I go here too. But how do you get it so you can get a good 3D model with an MRI? Because I'll tell you, our site is having huge problems trying to be able to recreate that. Yeah, so you can't do it with your regular clinical sequences. We use what's called like a flash Dixon sequence. And so there are a little bit more cuts that need to be obtained. And then once you do that, then you have to process, you gotta segment them. And it's very manually intensive right now, but hopefully some of the software packages that are coming would be able to help auto-segment that makes, because I think the part that takes the most time is the segmenting. So I have my researchers do it. They say it takes them like three hours to be able to segment like one MRI model. So it's like kind of not really feasible to do that in your clinical practice today, but I think the software is probably coming very soon. Shane, this is interesting because there have been a few publications recently talking about how the MRI isn't necessary when we're diagnosing hip pathology. So this would potentially change that movement to get rid of the MRI if we're using these, which is great. So actually out of curiosity, does everyone do an MRI for their hip arthroscopy? Yeah. Does everyone do a CT scan for hip arthroscopy? Okay. Does anyone not do a CT scan for hip arthroscopy? I do it for select cases. CT only for select? For only select cases. Is that because you have a 3D model from your MRI? Yes. And then, yeah, I mean, I would say for revision cases, I'll get a CT scan. For cases that I'm not sure about, I'll get a CT scan. If it's a clear, you know, normal coverage, you know, I typically won't get a CT scan. Okay. I'm curious too. I mean, one of the big parts of approval for surgery is that the MRI has to show a labral tear for us. So I mean, is anybody getting hip arthroscopy approved without an MRI in the United States? And then what is it like in Canada? Well, I'll tell you in Canada, there's no approval process for surgery or anything at all. You just have to go through the waiting period. So if you wait long enough, everyone has a labral tear. The flip side though is, again, I think the studies for MRI, at least in Canada, is it makes no sense because people wait to get the MRI because there's a wait to get the MRI. By the time they get the MRI, then they have to send it to us. They may not have even done a single other imaging source or finding any other pathology. So that's the impetus of, in Canada, we don't care if you have an MRI before you send it to us. We want to be able to find a problem long before that. My family's all in Ivan's province, and I can say that by the time you get diagnosed and treated for a labral tear, you're probably dead. Yes. Labral tear may not be relevant. That's the sad part. So many questions. Best talk of the day so far. Thanks, Ashin. One was, you mentioned correcting for the standing position. So then, and I think you mentioned on one of your slides, basically a false crossover side on a supine view. So you can get a standing x-ray, obviously, and if we think that that's the right thing to assess them on, do you assess them on the standing view, and that's where you look at crossover, or is the carrying angle of the pelvis relevant? Some people may not carry it exactly in the coronal plane where the ASIS and pubic symphysis line up in the coronal plane. What's your thought? No, yeah, so I like to use standing AP pelvises. I think that doing that simulated weight bearing, I think, is really helpful for the open surgeons. I mean, Andrea, maybe Ben, has some comments on that, but I think one of the things that, my partner that does open surgeons always talk about is when they're doing their acetabular corrections, the patients are supine, and so they don't really know what it is gonna look like when they're standing. And so I think this then allows them, I think instead of having, because when you're getting a CT scan, the patients are supine as well, and so it only gives you that supine view, but you really wanna understand what it looks like when they're standing, and so that gives you a better idea as far as the orientation, is there a retroversion or not? How does the displacement change when they're supine versus standing? So I think that was kind of the impetus for that. That's great. Okay, so we'll go on to our last talk, and then we'll go through a case or two, depending on our time going through. I'll talk about 3D modeling and ultrasound-guided hyperthrosphy. I've had different troubles in, or different needs in Canada, as you can hear here. So by the end of this session, you'll be more familiar with use of 3D modeling in hyperthrosphy. We saw it in the computer software-generated thing. We use more of a analog version, and then we use ultrasound-guided hyperthroscopy. So use of 3D models in hyperthroscopy. We just saw that x-rays, you really get a 2D view. I think it's a fantastic mode because we can't do CT scans on all these people afterwards to keep following them up, but it gives you a nice snapshot and something to compare to afterwards. MRI, we also mentioned, it helps with that inter-articular process, but for myself, it takes too long to get down that path. I really like this guide of where to do these views, essentially trying to reproduce them, because the trouble is every time they send them to us or from different sites, we get very different frogleg laterals. We have very different done views. Every technology does it differently. So it's not very consistent that way. When we look at this in terms of treatment, why are we caring on how this cam goes away? I really do think that trying to be able to improve it maximally will give you that long-term benefit. I think Ben's shown this, and I think that's critical because we have a chance to change natural history of how people do. Now, to do this, seeing where the cam is, I think is essential, because every time you draw it, you see it from an AP pelvis point of view, and it's really tough to see where that lateral aspect of the cam is. So with a 3D model, if you look at it directly from above where you really can't see with an x-ray, you can see the extent of that cam. It's a posterolateral aspect. And again, spending time from the shoulder aspect, if you look from the top down, you can see it much more efficiently to be able to get rid of it. And I think I try to show this. So this is that top-down view, and the cam actually extends very posterolaterally. So if I rotate that back to a normal AP view, that's the only time you can see to connect that. To make that AP look perfectly curved, you have to go very posteriorly, more posteriorly than you think you do. So again, this three-dimensional view was really helpful for me to understand every nuance, and it's not that way all the time. Every one is unique. So a 3D printed model tends to help improve seeing cam deformities. We tried to use this to do a study design for this, looking at this, and we've been able to see that when we do have a 3D model out there, we're much better to improve the resection just because we know where to anticipate where to get this velocity that way to get that apple angle, especially in that AP view. Funny thing is that while it improves that, it also seems to improve the DUN and the frog leg lateral as well, because we're looking for things we may not normally be looking for. So every time we go through, we were able to see that with the cam, even though we have fluoro in there, even though we know what we're trying to do, the post-op x-rays seem to be more consistent that way. In fact, we just finished going through our, or finished recruiting for our randomized trial, just trying to see if prospectively we're actually seeing this, or it's just a retrospective education-based thing. And it's only our single site to be able to do this using three-dimensional models that we print versus our conventional imaging. And we're actually finding a significant improvement that we can be much more consistent in the resection on all the three views when we look at x-rays afterwards. And we do have an e-poster here to be able to show that. Our IHOT measurements, as we go through following these up, again, we don't have the full two-year outcomes on everyone yet, but we have a majority of them coming back through, it does look like a trend. So we do get, if we get 3D prints with better resection, better alpha angles afterwards, we are getting better outcomes, kind of following what Ben had shown in his paper beforehand. So why is cam resection better in a 3D model? Well, you know, we do everything with 2D, we have fluoro in there already. I think it's really the perception. So in a 2D, even when you have a computer-based model where you can spin it around, I find in surgery, I don't look at all the nuances of this. Whereas during surgery, sometimes I can see these little nooks, crannies, corners, shapes, different things like that. So I can take the model and be able to visualize exactly that part, get reoriented and be able to take that cam down to the right spot. So hopefully you can see all these, every cam seems to have a different angle variation. I can see that type of a curvature here and I can match it to what I see during surgery. So something like this, this one's a more of a posterior cam. You can see, I can see it on that Apple pencil there, I'm just trying to draw. And as surgery, I'm trying to see that aspect going posteriorly. So an area that I'm not used to seeing, following all the way down, right adjacent to the acetabular rim there, and you can see it and try to remove it right to the point that you want. Because under fluoroscopy, it's a very different angle that you have to put this on. This makes it easier to see while the hips and socket, and then when you can't see it because it's deep inside the socket, you can actually add a little traction to be able to get it to the right spot. In Canada, we also have other problems that go on is access to rooms to be able to get all the hip arthroscopy done so the wait list doesn't happen long enough that they die before we can fix their labrum. So to do this, usually we need lots of x-rays and stuff. And to be able to have the 3D models actually really helped us do the resection. We realized that in our surgery center over here, we don't have leaded walls, we don't have the ability to bring x-ray and we don't have the funds to do that. So we need to explore something else. So very often we haven't had to use much of fluoro to be able to assess that camera section, realize that we can do a lot of hip diagnostic injections to make things better. And so since we can get inside the joint with ultrasound, with the guided needle, we figured that we can actually do the same in terms of x-ray where we can get our lateral portal, be able to get in here, figure out where the location is, we can pop through the joint, we can be able to access the mid anterior portal this way. So with x-ray, we can find these things. But we're using a two-dimensional image to be able to see where we are in the joint to be able to confirm that we're in the right spot. Well, using ultrasound, the nice part is it's a dynamic exam. We can actually move the ultrasound while observing in that very same plane where we're going. And in this place, this is sped up by two times just so you can see where it is, but we can actually see it go through the exact right spot between the acetabulum and femur. We can identify the mid anterior portal that way and use a confirmatory test to make sure our angle is within a millimeter of the tip of the capsule. And because we can get that three-dimensional view in a two-dimensional line where you're controlling it, it makes it easier to be able to get that positioning. And we'll be able to show that we can get in with less heterogenic injury to be able to get to the right spot and then use our three-dimensional models to be able to help us guide. So hopefully you've seen that, using more analog methods of three-dimensional reconstruction we can help improve the camera section to improve hopefully long-term patient outcome. And now that we can use ultrasound to get access into the joint, augmenting with our 3D models to be able to make sure we do a better job. Thanks. Thank you. Can we put up cases and then any questions? Yeah. For the 3D model, I had recently attended one of my patients and I twisted the two bones separately because I thought that was gonna help me like be able to get a mimicry experiment in it, but I didn't get the orientation that it was giving me naturally. Did you like experiment with both? Yeah, this is great. So when you first go through this model, I brought this one because I just tried to take pictures of it and I try to show why it's a little bit different. When I first tried doing this, again, I tried to print them separately thinking that I could do exactly the same thing. I could move around just like Shane does in all his graphic images and become very good at figuring out what to do. I quickly realized that I cannot do that. I want them attached exactly how they are. This helps me because I can personally visualize where it goes. And in this case, if it will pass around, you can see this is like a double cam. There's so many variations of cam, it makes it tough because sometimes I don't perceive this on the X-ray or even miss it on the CT just because the lighting changes all the time too. And so if I print them separately, I get very confused. If I print them together, that's where it reiterates how the computer model identifies all those perfect lines where the 12 o'clock is, where the one o'clock is, where the two o'clock is. And then where the relationship between the acetabulum and femur are. So I like them together. Number one, it takes less work to do. This doesn't take three hours. This actually takes about 30 minutes to be able to process and then hit print and then 3D model prints overnight to be able to get you for the surgery the next day. But then it allows you to be able to see the interaction of those two to be able to find your resection. It just essentially it's like a roadmap. I get lost very often going through because x-rays look like I'm doing the resection. I'm like, something's still not quite right in here. I don't see everything I wanna see. I can go back here and look at all the ridges to be able to find out exactly where I am. And then all of a sudden, I can get the resection to exactly the plan that I want to do. Evan, the ultrasound guided portal placement is awesome. We tried it in the lab and I found it to be very challenging. I was wondering if you change the position of your patient when you're using fluoroscopy versus ultrasound in the operating room. Yeah, so this is great. I changed a lot of stuff. Again, I learned how to do hip arthroscopy supine from Carlos Guanche and Scoey. The trouble with that is, if you do ultrasound, ultrasound is, if anyone does a ultrasound guided injections, ultrasound does get heavy after a while, especially if you have to do a bunch of different stabs if you're learning where to do. So it's easiest if you hold it in gravity and it coming straight down. So I changed my way I do hip arthroscopy, which is instead of a supine position, I do it all in a lateral position. Nice part about lateral position is you just hold the ultrasound to be able to see right down. You can actually see this exact 12 o'clock position quite perfectly. So I do all my x-ray or fluoroscopy the same way. It's just A to P beam is kind of crossways. So it actually doesn't change any positioning. In one of our centers, we actually have both x-ray and ultrasound that helps our fellows train to get back and forth. And when you first start, if you want to do a transition that way, it's actually really nice. You have fluoroscopy to go and try your portals. But just before you do that to confirm yourself if you ever get lost, use ultrasound first to get started. And you can actually hold the ultrasound probe there. Take philosophy like, oh, now I know why I can't see what I'm doing. I'm just not in the right spot. And you get orientated. Once you get oriented and you can see the acetabulum. And the nice part of the acetabulum, I didn't print the whole thing to save time, is the acetabulum in this part up here is completely flat. So if you have the ultrasound, you try and make a very flat plane to see the acetabulum. You can see the ridge and almost all the time you can see the cam. The most problem that people get, or I get when I first started, was I have the ultrasound beam on the GT, thinking that that's the femoral head. And that's where I get all confused. If you go just slightly anteriorly, because GT is usually slightly posterior, slightly anterior, that's where you get 12 o'clock. You see the acetabular rim. And then it's usually very simple. Well, sorry, very simple. That's the easier way to get in. What about trying to use any ultrasound to assess the cam? How accurate is that? So this is the next part. And I think I really enjoyed actually reading your papers afterwards, after we had chat about ultrasounds. It's a great way to discuss. And at first, again, I'm not an ultrasonographer. I just use this because we didn't have access to x-ray to get inside the joint. But as we're doing this, what I found was, I went back to do injections afterwards in people with pain. And to assess the cam, it's actually fantastic. Because if they're lying down and you put an ultrasound on this and you can pan across, and I know this is too far away to see right now, but you can see medial cam super simply. And things that my x-ray, my post-op x-ray follow-up said the cam was removed medially. It wasn't removed. Because then those patients who did have pain afterwards with excessive rotation, we do a CT scan to follow up and we can see that cam. We do revisions for those things. But I do find you can get a good measurement of the cam. You don't have the same way to, it's a very different way to measure though, because you don't have the whole head to measure. You only have surface anatomy because the acetabulum takes away that point. With your own modeling in there, I'm sure you can actually put that into your algorithm to be able to get, if that predicts what you want to do. But ultrasound can measure surface anatomy of anything you can see quite easily. Any other questions? We have cases. Do you want to put up a case? I think we only have time probably for one. Do you want to do yours, Shane? Sure. Yeah, we can skip through. Oh, can you just skip over to... Go again. For the dysplastic femoral head, so if someone you're doing PAO on, they have a femoral head that is also dysplastic, so it is aspherical, and you have more of that straight line going down. What do you guys recommend for femoroplasty? Because you can't make it spherical. I do a little shaving, distally, but I'm trying to imagine where the PAO corrections get the. I still am not super satisfied with how it looks on the next right after this, so I just wanted to see your, take your guys' thoughts on that. I do the same. I think I try to, because I'm doing the hypertheroscopy before the PAO, I try to extrapolate where the acetabular rim will be after the PAO, and create space on the femoral neck, even though it doesn't always look spherical, but you're creating a concavity in that area. Okay, let's get through this one case. This is a 20-year-old male hockey player, no past medical history, complaining of left groin pain, two years of hip pain, gradually insidious over time, pain 6 out of 10, there's some stiffness, worse with sitting, sleeping, staying the same, only temporary relief with activity modification, anti-inflammatories, and therapy, physical exam, flexion 100 degrees, extortation to 20 degrees, introtation to minus 5 degrees, pain with impingement testing and favor testing. So here are the x-rays. So this is, you know, a patient that you might see. I guess, what kind of concerns, Ivan, are you thinking about with this particular x-ray here? Well, there's obvious CAM, that looks like a prog-like lateral AP, can't tell if it's white herring or not. So the CAM looks like it extends quite medially, because that's quite a lateral x-ray, that's like it extends quite posteriorly from the AP view. The ascabular side is concerning, the AP has that big chunk of either off or fracture or calcified labrum or something like that. And that's prog-like lateral, there's some changes, it's not nice solid bone, so quite worried whether it's, you know, refractured, ossifying now, something's not happy. The only good news is I don't see any ascabular cysts, you know, in a 20-year-old, I'm quite concerned about the cartilage. So Ben and Andrea, what are you guys thinking in terms of what this fragment, oss, or rib fracture, what... Yeah, so I'd like to probably zoom out a little bit to have a better perspective on what the coverage would look like without that fragment, and CT scan would be helpful for me as well. But my question mark here is, can I remove the entirety of the fragment, or do I need to preserve part of it? Certainly need to remove at least part of it, because it's over-covered as is. And in a lot of these cases, if I can remove the whole fragment and not leave them dysplastic, then great, I'll do that. If I can't, then I'll basically treat it as if it's not there, do a rim trimming the same way I would if it were not a separate fragment, make multiple K-wire passes across the fibrous union between the fragment and the ileum, and then anchor it with my label repair, much like a bony Bankart. You can use screws also. I've used screws at times. I do the same, and I would also agree that the CT scan in these cases, it was really helpful to understand where on the rim that is. Yeah, and I think obviously the size and location is important, but yeah, I think this is one of those cases where two-dimensional imaging probably just doesn't do it justice. Here's just the MRI, just so you get a good look at that. So pretty decent size OSS, obviously large cam deformity. This is the MRI, doesn't really add much, but here's one that we use like a three-dimensional model from MRI. So one of my researchers made this last week, but pretty decent size OSS. What were you guys thinking? Keeping it, taking it out? So can you go back? Is that more posterior, like where it's 12 o'clock when you rotate it? Yeah, so it is definitely more posterior. So I think taking into consideration the femoral version is important too, because you're thinking about dynamically where the hip is moving and where there might be pressure. If it's very retroverted or antiverted, then it's pushing on different areas of the rim. Sometimes on the X-ray, in the standing EP pelvis X-ray, I actually put in my note the lateral center of jangle medial to the OSS and then also lateral to the OSS to understand, to Ben's point, if it comes out, are you going to make this patient dysplastic? Another note on the MRI, I don't know if you've encountered this as well, as we were talking about insurance approval hinging on the presence of a labral tear. Sometimes they'll report no labral tear present, because the labrum is actually very nicely fixed to the OSS. And then the problem is that it's unstable at that fibrous union point. So I don't know if you guys have run into that too, but I've had denials because they say there's no labral tear present. So yeah, I think with this particular case, I think the question is, what do you do about this OSS? Do you fix it? Do you not fix it? Do you do, as Ben talked about, bony vein cart-type repair? Or do you not do anything? I think there are some speakers that have shown that once they remove the cam deformity, then they've gotten follow-up X-rays and they seem to heal. So I think everything's kind of on the table. In this particular case, we did elect to put a screw in it as well as anchors to help reinforce the labor repair. But I don't know if you guys have some experience with this, but it is pretty challenging just kind of given the instrumentation that we have putting screws in. And I find that to be not a very pleasant scenario just because our instrumentation is not very good for it. I have to say, I've had a screw break, and it was in a dysplastic patient that she had a very large OSS and did a PAO in the same setting. So fixed it with a screw and then did a PAO. And I don't think I rotated her enough. So she was still edge-loading a little bit on that fragment and broke the screw. And since that- Like intraoperative? No. Oh, post-op. Like a year post-op. So then I had to do a revision to get the screw. So it fractured at the Fribestrand Union and had to go back in to pull just the head out. So I've become a little bit gun-shy with fixing these since then. I agree. I mean, I think the reason she failed was because there was still a stress point there. I hadn't rotated her enough with the PAO. So if you're removing the cam, potentially there's no more stress at that area. It should be fine. But I have, since that time, not fixed as many. So this is really, again, this is really well done. It's super hard to do something like this. There is no guide for this. I know that in the shoulder world, we were trying to do bone-rest percutaneously. But this actually kind of shows similar things. It's very difficult to get in, especially with the cantilever screws. It's tough to do with non-cantilever screws in a reverse philosophy setting. But you can see some bending of the screw too. Yeah. Right? So because we don't have systems and guides to get that drill across and then to get compression through there, and this compression is through tensile bone, it's really, again, to get that bite, I can do all that to make sure that it holds what you want to hold. Yeah. So have you guys been able to work around that with the shoulder? Still in the process? No. So with the shoulder, we've actually changed. They've been very good to get us the fracture screws. Because this is not quite as big a bite, I don't think. I'm just trying to look in there. But the OEO type of screws, they've been able to cancel us. So the very large thread, 4.5 screws, and that's been able to get excellent fixation. At least bi-corporate fixation on the glenoid. So you go all the way across. All the way across. And the pelvis is quite a bit further and a little more scary. Yeah. So that was that case. How mobile was that fragment, Shane, when you were intra-op? I find that they're not that mobile, but they are somewhat. I mean, it definitely moves, I think, compared to a non, no fragment. But yeah, I think that's the question. Do you have to fix it or not? Or do you have to put a screw or not? And I agree with you. I think that they're not easy to do. And I don't know if you have to fix them. I think repairing it and just keeping it in sight to removing the deformity might be enough. When you have a CAM like that and you're doing a good femoroplasty like you do, you're really taking a lot of load off of that fragment. I mean, it's a very different load environment post-operatively. So to your point, that may be enough. Whether or not it heals. We have seen with the multiple K wire drilling across it and then fixing it like a bony bank guard, have seen bony unions with those in the majority of cases. So I've personally leaned toward using screws less often because of having seen that. I won't say never. Never is always wrong. Out of curiosity, when you're planning that osteoplasty on the CAM side for something like this, something really large and very posterior, do you try to take a more posterior lateral arm a little bit deeper so you don't have any loading on that thing? Kind of like an offloading osteotomy? Yeah. I mean, I think that's where you probably have to pay more attention to the CAM if you feel like your acetabular side is just not going to be as precise as you want it to or you just can't manipulate that side as well. Is this a case that you would bring all the... Do you have the 3D modeling in every case that you have? Do you have to choose when you use it or not? I have to pick and choose it. So is this the one that you bring it in for? Yeah, yeah, for sure. Any other questions? I think we only have two minutes left. We probably don't have time for the whole one. I'd like to thank everyone for coming. Thank you for our great speakers. Thank you.

hip arthroscopy

labral reconstruction

capsular management

computer augmentation

imaging technology

knotless pull-through technique

3D imaging

capsular augmentation

3D printed models

ultrasound-guided arthroscopy

surgical planning