All right, good morning everybody, thank you for coming in nice and early. So we'll get this started. This is hip arthroscopy from basic to advanced techniques. So we put this together because we wanted just a wide range for a wide range of surgeons from early career surgeons to middle and advanced surgeons just to give a broad range of ideas and topics and maybe some tips and tricks. So I'm Spencer Simon, assistant professor at NYU, and I will be, oh, I have no disclosures or I have, any disclosures I have are on the academy website. So I will be speaking about the basics of modern hip arthroscopy, then we'll be having Dr. Larson, of course, who needs a little introduction, he'll be speaking about complex can and pincer lesions, he's a prolific surgeon, he is a team physician for Minnesota Vikings. Dr. Robert Meisen will be doing tips and tricks for labor repair, he's a professor of orthopedic surgery at NYU, he's an extremely skilled orthopedic surgeon, one of the most skilled that I've seen. Dr. Young is in private practice, but he is also a clinical professor and a director of hip arthroscopy at NYU, and he'll be doing advanced techniques on abductor repair and rim fractures, and then we have Dr. Lomas, who's an associate professor of orthopedic surgery at NYU, he is the head orthopedic surgeon for the New Jersey Devils. He'll be speaking about some augmented techniques, including core decompression and hamstring repair. So hip arthroscopy and endoscopy can treat FAI syndrome as well as a wide range of extraticular pathologies. FAI syndrome, of course, is defined as early and abnormal contact between the femur and lats tabulum, usually due to abnormal bony morphology. This can lead to labral and chondrolabral injuries and appears to be associated with the development of osteoarthritis. As far as extraticular pathologies, some of which we'll touch on, these include greater trochanteric pain syndrome, which are things like abductor tears, there's also proximal hamstring repairs, internal snapping hip, AIS impingement, or sub-spine impingement, and sciatic nerve entrapment that can be treated with the scope. Just a graphic, an animation on CAM versus pincer lesions, so you can see CAM, of course, is abnormal bony outgrowth on the femoral side, which can cause injury to the chondrolabral junction, whereas pincer, of course, is more acetabular-based lesion, which creates more of a crush injury and a coup contrecoup injury. So an imaging protocol, I mean, my basic imaging protocol here is, and there's a couple different variations that I've seen throughout the conference, but there's AP pelvis standing, 45 and 90 degree bilateral DUN views for the alpha angle for the CAM lesions, the fault profile view for anterior acetabular coverage, or the anterior center edge angle, then we use 3D radio MRI imaging, which we've found to be very helpful, and we can get 3D reconstruction of that, which are somewhat helpful as well, and then if there's any suspicion out of normal femoral torsion or version, and dysplasia or borderline dysplasia even, a CT scan can be helpful. So the progression of arthroscopy around the hip has progressed nicely over the past 40 years. There's been a great evolution in our ability to treat pathologies about the hip, from starting with debridement to, of course, labor repair, and now more complex things like reconstruction, abductor repair, hamstring repair, and core decompression. Of course, hip arthroscopy is fast-growing, owing to improvements in the diagnosis techniques and outcomes of treating most of the CAM and pincer lesions, as well as labral tears, and while the number of hip arthroscopies is increasing, it remains a challenging case with a steep learning curve. This is due to multiple factors, including a tight joint, a thick capsule, the depth of the instruments from one's hands and the use of a 70-degree scope, and your typical intertraction time, which requires expeditious work. So with increasing cases, this stands to benefit more patients. It will help us create more advanced techniques and improve outcomes, but will there be an increase in complications? There's a large variability in the sports medicine fellowship experience, with just a large difference between the 10th and 9th percentiles, and at least as of 2012, there was a study reporting that most sports fellows were receiving less than 20 cases experience. So the bottom line here is it's important to start with the basics and then expand to advanced techniques in order to treat more patients more effectively and decrease complications. So I'll go on. I'll start with the basics of modern hip arthroscopy, which is setup, portal placement, and visualization. So for patient setup, this begins with a discussion with anesthesia. You want to consider relaxation and monitor the mean arterial pressures to control bleeding. Equipment includes pump, shaver, access instrumentation, RF device, and fluoroscopy. The pump pressure must be high enough to allow for visualization, but not so high enough to create extravasation, and consider using epinephrine and a 70-degree scope will be required. Positioning. Positioning is frequently done in the supine position, but can be done in the lateral position as well, so that's what that looks like. The OR table must be a traction table or a traction table attachment. It must allow for fluoroscopy, and you must be able to manipulate the extremity, which we'll speak about, for traction, flexion, and rotation of the hip joint. As far as post and postless, there's multiple pros and cons. Post can add lateral translation and may maintain traction better. For postless, that does decrease the risk for compression injury to the perineum. So there's this overall documented 7% complication rate in hip arthroscopy. 23% of all these complications have been related to injuries to the pudendal nerve, or the soft tissues in the groin. Distraction injuries account for 13%, and that includes sciatic and perineal nerve injury, as well as knee, ankle, and foot pain. Luckily, most do resolve by three months. So this is why postless traction was created. It was developed to prevent perineal injury. It requires this traction pad. So a tip on that is you want to remove all gowns under the patient, so the patient's skin is directly contacting the traction pad. And then I typically do still 10 degrees of Trendelenburg, although with the newer pads, it seems to be less, not as necessary to do Trendelenburg. The initial force with postless traction looks like it's higher than with a post, but it does level off over time, and it does appear to be safe and effective, with one study here by Omer Midan showing no traction-related complications in 1,000 patients. My technique for traction is place a well-padded boot on both sides. I use both sides. Bring the patient to the bottom part of the bed, place traction to the non-operative side. Then I have the operative side in abduction, a little bit of abduction. I apply traction, and then bring them into neutral rotation and internally rotate. That typically requires, sometimes you feel a pop, sometimes not, which I think it's debatable if you actually really want a pop, because some of us think that that could cause some actual damage. It requires usually 25 to 90 pounds of pressure, and you want to see about 1, 1.5 centimeters of joint space. Slight flexion and internal rotation of the femoral neck can be helpful. Flexion to relax the capsule, internal rotation to place the neck in neutral. But you don't want to over-flex to avoid injury or traction injury to the sciatic nerve. And an arthrogram is very useful. It can decrease the traction force required for distraction. So as far as access, the ideal portals allow for visualization, instrumentation, and are safe from neurovascular structures, and avoid convergence. We begin with marking the anterior lateral portal, just off the greater troch. It's just lateral and distal to the tip of the greater trochanter. Once the anterior lateral portal is created, I make a vertical line, and then a perpendicular line, like a plumb line coming down the ASIS to the center of the knee is made. And typically, the modified anterior portal is 2 centimeters distal and 2 centimeters lateral to the intersection of these lines. You can create a dollop portal, which is an equilateral triangle. And then the posterior lateral portal is in line with the anterior lateral portal, just posterior to the greater troch. The anterior lateral portal is shown to be the safest. So that's the first one that we make. And remember that the modified anterior portal is about 30 degrees superior and 30 degrees medial. So that can help. I use a percutaneous technique now to access the joint. I'm starting with a spinal needle. And the tip here is you want to feel the capsule and take that floor shot and really know that you're at the 12 o'clock position. So that will help avoid skiving anteriorly or posteriorly. And then once you push in, you place your 9mm wire. You want to see it at the cotyloid fossa. Again, if it's not in the cotyloid fossa, you're probably too anterior. When introducing the cannula, make sure not to break this wire. So just kind of pull back and be aware and just don't jam it in. It's kind of a feel that comes with some time. Once your anterior lateral portal is created, you want to see the triangle here of the femoral head and the anterior labrum. And so once you see that capsule, you'll access that capsule from the modified anterior portal. So you can see that here. So the outside-in technique. So this, I think, is an important technique to know in tighter joints with large pincers or even large cams. It's an alternative technique. You establish the portal and triangulate to the 12 o'clock position. And you begin arthroscopy by identifying the extra capsular space. And you can palpate, you can feel the acetabular rim as well as the labrum, and also use the reflected head of the rectus to make the capsulotomy. So the pros and pitfalls of access are feel the capsule before puncturing. Place the 9mm wire into the cotyloid fossa. Use the bevel of the needle, which I didn't speak about. So the needle, we use the bevel of the needle up and then down to avoid injuring the labrum and then the femoral head. Pitfalls would be entering the joint too far anteriorly or posteriorly, iatrogenic injury to the labrum, and iatrogenic injury to the femoral head. So I just want to touch on capsular management, because during access, of course, we need to address the capsule. The capsule is an important stabilizer of the hip joint. It's comprised of three ligaments. The iliofemoral looks like it is the most important. The zona obicularis are circumferential fibers that create a stability collar around the neck, and disruption can lead to significant edge loading and disruption in stability. So for the different types of capsule management, there's an interportal capsulotomy, a T-type, and a periportal. This is just making the interportal with a monoblock blade, which are safe. And then this is an example of how you can close them. The interportal capsulotomy, which is what I use, provides excellent access, I think. It allows for a relatively simple closure. I recommend keeping it small and keeping it lateral. That may help prevent feelings of instability. And try to keep it two millimeters from the labrum to help with repair. The periportal capsulotomy is obviously helpful, because you're not violating the capsule and risking injury to the capsule itself, but it looks like it's more difficult to access for a lot of it, for me at least. So your options with the capsule, and you want to think about what to do with the capsule as far as repair when you're making it. You can leave it open. You can partially repair it. You can completely repair it, and you can placate it. Luckily, rates of iatrogenic instability are quite low. As far as repair, I mean, I think this was somewhat, not controversial, but debatable. Outcomes were mixed for a while, with one large review showing all improved from baseline, and they could not endorse routine closure. Certainly, from what we're seeing, there's a trend towards closing it routinely, with Bendome having a 2021 paper showing improved outcomes in PROs. And just a couple tips on visualization. So for visualization of the labrum, traction sutures can be helpful. These are placed on the capsular side, and then they're snapped to the skin. I recommend taking a little bit extra time to debride and identify the chondrolabral junction. So that will help with passing sutures, and also with anchor placement, because you want to keep the anchors close to that side of the rib. So this is just preparing that. And then as far as the CAM goes, you can use traction sutures distally, use the shaver hood to retract the CAM, use different degrees of flexion, which we'll speak about. There's a couple different views that have been described as well, to assess the CAM. The upper deck view, and then the up-the-neck view. And it's basically, you want to look at this from a couple different angles, kind of like, say, if you look at a golf putt, you want to look at it from different angles. Fluoroscopy, of course, is helpful. Quick tips on fluoroscopy is you want to match your pre-op x-ray to the fluoroscopy, to fluoroscopy using the crossover sign of presence and the teardrop. Can also match the obturator foramina. Use it for access. You can use it for the pincer. Plan your rim resection pre-op so you have an idea of what you're doing. And then for fluoroscopy examination, Dr. Larson had this paper, which I definitely recommend everybody check out. There's multiple different flexion and rotation angles that can help you assess the CAM, kind of like, all around the world. So that is tricky, but we'll hear more about that shortly. So summary here is be comfortable with your equipment and setup. Be selective about the portal placement. Avoid labral chondral damage. Understand how to manage the capsule. Think about repair during capsulotomy. And use fluoroscopy to aid in access and treatment. All right. So next up, Dr. Larson, maybe? I'm up. Okay. Okay. Let me just bring this up. No matter how many times you've done this, no matter how old you get, I advise everybody to still put a timer up and make sure you're not taking too long when you give these talks, if you can, to be respectful of everybody. So I'll try to do that. Good morning. And I'm just going to be talking about some pearls for managing complex pincer and CAM type morphology here. These are my conflicts of interest disclosures that are in the program. So first we'll start talking about challenging pincer deformities. So this is a study that we did looking at 418 asymptomatic hips, CT scans. The normative data that we found looking at percent coverage of the femur around the rim. So anteriorly on average you have 38% coverage. Superiorly you have 67% coverage, and that actually correlates with a lateral center edge angle of 31 degrees. Then posteriorly we have 52% coverage. So how this can be helpful from this study is if we're looking at a radiograph and you're trying to figure out what's the potential rim resection that you might perform, I'll just in my head or actually measure out a lateral center edge angle of 30 degrees, mark the center of the femoral head, 35 to 40% anterior coverage. I'll draw the posterior wall just medial to the center of the femoral head here. And then I'll draw the anterior wall to the base of the teardrop around 35 to 40% coverage at the 3 o'clock position. So again, this just sort of helps to define the limits of your resection. By no means should you be resecting all of this every time, but it can give you kind of a guide. So for global, more profound overcoverage, I think there's unique challenges for labral management. So you can have this non-ossified rim and you can have the rim ossification. And the labrum's going to have different issues with each of these cases. So with the non-ossified rim, the challenge is that the labrum's usually normal, so you're having to resect the rim with the labrum potentially in your way. So it's just a little bit more challenging case, and you can see this is pretty extreme overcoverage in this case. One thing that can be helpful here, because you're doing a lot of rim resection, is I think it's helpful to do a takedown. I usually don't do this anymore, but do a takedown at least over the area of resection. You can see the articular cartilage that extends beyond the rim. And if you don't do this takedown to remove that cartilage, it's sometimes hard to advance the labrum back to the rim. So this is one scenario where I would consider actually doing a takedown, either focally or through that area. And then you can simply advance the labrum with whatever suture technique you want to use. So here you can see, obviously, significant overcoverage on this preoperative radiograph. And I really argue, always get your post-op radiographs. Get them at two weeks so you remember the case that you did, so you can really evaluate what you did. And you can do pretty much a global rim resection around the acetabulum arthroscopically. With the ossified rim, there's potential for an irreparable labrum. So that labrum or that rim ossifies, and there's just not much tissue left. So again, different issues. Usually, the labrum doesn't have to be repaired, so it's not in your way. But these can be very challenging cases. At the top left, you can see the lateral and posterior rim that's ossified. And then bottom left, we should be able to access all the way down the posterior rim. And you can really access that with extra traction and sometimes making a posterolateral portal. In the top right, you can see the anterior rim resection. And the bottom right, you can see we can get all the way down the anterior medial rim as well. The other thing that's helpful with these cases, you can sometimes get lost when you're in traction with how much resection you want to do. So intermittently release traction so you re-establish the relationship between the femoral head and the acetabulum so that you don't take too much. And then all of a sudden, you release traction, and you're like, wow, I took too much. Or you can realize that you need to take more. So that can be helpful. And as was mentioned just previously, sometimes you have the inability to access with traction. So you can see these fragments that are going to really probably negate the ability to get in. Sometimes you can still get in, and you have to make a further distal portal. If you go too proximal, you don't have the right angle. And then you can also, if you just barely get in, then you can make another portal that just finds your camera instead of having to see the anterior triangle. But in this case, and this will be the one that I'll give you some time to move forward back there. So in this case, you don't have to do it yet. In this case, just let it go for a second. So in this case, what I'm doing is I'm doing the capsuleotomy from outside in, a little bit of shave. And then you'll start to see the femoral head. I think it's important to use florals so you know where you are at the rim. You can see here, there's really not any labrum at the rim. So in this case, I'm just kind of working my way in. And I'm going to use a burr to start resecting this bone laterally and anteriorly first. And now you can move forward to 37. And then next, what I'm going to do is I'm going to make a capsulotomy switching my portal. So the camera is now in the mid-anterior portal. Now I'm going to extend that capsulotomy posterior. And once I've extended that posterior, you're now able to start accessing. Again, you can see there's not much labrum. You see that rim ossification. And now you're going to start resecting the lateral rim, going a little bit posterior. And now we can go to 116. And now what we're going to do is we're going to extend our capsulotomy anterior. So once we've extended anterior and we've resected some of the rim, you can see now we can actually get in safely. You don't want to try to force your way in. And it's always remarkable how with these cases, even though they might look degenerative, the articular cartilage can look very normal once you actually get into the central compartment. So now we're resecting a little bit of the bone fragments anteriorly. You can go to 311 now. And at this point, what we're going to do is the hardest part of the case is sometimes getting posterior. So what you want to do is you want to make another portal in some of these cases. So right here, I'm just extending my capsulotomy posteriorly. And then I'm going to introduce the burr, and I'm going to get the last portion of the posterior rim. And the one thing that you sometimes do is you actually have to resect that rim sort of under the labrum. So you can see the burr resecting under there. And you can see here on this floral image that we're getting all the way down that posterior rim. So now we've basically done a rim resection from anterior medially to posterior all the way inferiorly. But now, obviously, the challenge we have is we don't really have a labrum in this case. You can see the preoperative radiograph, which is pretty challenging. And I think if you're more comfortable doing a surgical dislocation for this case, by all means do that. And you can see the postoperative radiograph. So we can do a pretty good rim resection, but these are big cases and challenging and take a while. But what we're left with is labral deficiency. And I think this will be talked more about, obviously, later. But for me, I think a labral reconstruction is definitely a viable option in a revision setting. I think the role in a primary setting is a little bit debatable and not completely clear but in that case I wouldn't argue to do it but what I'm gonna you know if there's less than five millimeter width some people say a very hypertrophic labrum they consider doing a reconstruction I generally don't in that scenario but if we look at these images this is with the hip in extension after the labor repair in the top left and now I'm gently putting traction on and you can evaluate the seal and you see that fluid efflux so we know we've recreated the seal in the top left in the top right without a labrum you can see how it slides out and there's no seal there's no fluid efflux so you'll probably want to do a reconstruction in that case but the bottom right interestingly I've resected the labrum but this is a highly congruent hip and you can see there's still a seal even though there's not a labrum in that case so I would argue there's some cases primarily where you could consider not doing a labor reconstruction it is debatable excision of a labral fragments anteriorly so these are usually in the subspine location so most of these anteriorly you're gonna excise there you can see the fragment in the subspine location here you can see it on the video and what I would argue is don't try to tease this away with a knife or a thermal device what I would do is just use the burr and if you just start resecting this fragment it generally leaves more labrum and you can see I'm just resecting the fragment then what I'll do is switch portals and I'm just removing the last bit of bone on top of the labrum and you can do that with the burr without damaging the labrum and now in this case I've left enough labrum so I'm able to just put my anchors in repair the labrum and I would argue there's no reason to do a labor reconstruction in this case so if you're careful you should be able to tease these fragments away so also rim fractures which will be talked about later so I'm not going to go through video or anything but I think you just need to think about these sometimes they're large and you can remove the entire thing sometimes they're small as at the at the left and these are contributing to stability so you don't want to remove any of the fragment on the left images in this case you might want to leave it if it's stable after you do all your work or put some screws one or two cannulated screws in there to stabilize that fragment and again that'll be talked about later subspine impingement we've talked about this for a long time so here's obviously a case of an old apophyseal avulsion with a large AIS deformity you can see on the CT scan I do get CT scans on every single case anytime you're doing a scope if you see this ecchymosis you see this redness in the anterior capsule you want to think about subspine impingement for sure so go after it look for it here this is a technique we talked about the bottom images you can see there's the AIS the burrs right at that level and then I'm resecting it up to about the level of the sore seal but what we do is I like to make an anterior medial window and I think I preserve more capsule if I do this and if you do this you can see I can't reach it there but if I go through the window then I can easily go further up and you can go up a centimeter a centimeter and a half and for some of these big resections you have to use the arthroscopic knife and actually reposition yourself more proximally through that window to continue to go up if you use that technique you can see with these big deformities arthroscopically we can remove those arthroscopically and do a good job so again use a window might be helpful there what about challenging cam deformities I think you should understand that anteriorly this is predictable access posterolaterally and posterior medially we have challenging access and then posteriorly we have nearly impossible access if they have problems with a posterior cam lesion probably needs a surgical dislocation what you should be able to see so here we're looking at the left hip there's where we want to get medial proximally and medial distally all the way to the greater trochanter along the medial synovial fold and then you can see laterally and these are both with the hip inflection you want to go proximally along the lateral synovial fold and then work your way distally along the lateral synovial fold and you get all the way down to the greater trochanter and I never really make a T capsulotomy so this is with an interportal capsulotomy that I do this and then we go into extension with some traction and now what you can do is you can slide the burr underneath the capsule and around the vessels and this will allow you to go beyond the vessels and this is the way you're going to correct your AP x-ray this is the way you're going to correct the posterolateral deformity so you can see there you need to see a fluoro image on the back of the femur and if you have curved devices you can get even further around the posterior aspect of the femur so if we look at x-rays here this is our predictable correction obviously a big cam deformity I like to make a convexity into a concavity I'd like the x-ray to look like nobody's been there here's my pre-op x-ray on a tough one an AP x-ray that you can correct but again I'd argue get x-rays post-op to verify that you're seeing that so again we talked about these six specific views the AP three views the lateral three views that we get and again the CT study that we did that showed that these correlate to specific positions on the clock face and the two views the AP external rotation view and the flexion neutral view really depict the maximum alpha angle so this gives you kind of a 3d intraoperative evaluation I think on floral you want to guide that proximal resection initially in flexion then I go down towards extension now here I'm putting traction on you can see that posterolateral deformity going away as I go further posteriorly so I like to use floral to see that proximal resection dynamic assessment I think is critical as well extension abduction is one critical one for your AP deformities this will test the lateral femur against the lateral rim you want to look at flexion abduction about 40 degrees of flexion this is going to test the lateral femur against the posterolateral rim and I'm looking for an endpoint feel as well as improved range of motion these are the two most important for me and this is the one I think everybody does but I think it's the least important with flexion internal rotation because most of us can get anterior and do a good job with that resection so those are the three positions that I like to dynamically assess this is just an example here so I'm starting medially and I'm working my way laterally so this is a left hip I like to use floral again as I'm working my way up here I'll just stop get a floral image just to make sure I'm at the point I want to be to kind of correct that again starting by making more of a convex into a concavity then I'm going to go into extension here I'm putting some traction on and at this point I can now slip under the capsule and you can see here now go around the vessels and if you look to the right as I'm going through here you'll see that fat and see the vessels to the right and you can continue to go around that area and you'll see after the resection so again here's the initial one here's where I'm going posterior and then once you've completed this you go back into flexion here kind of complete up your recontouring getting distal getting medial do a dynamic assessment there you can see the lateral retinacular vessels you can see here where I've actually gone beyond the vessels further posterior I'm doing my dynamic assessment now I can see that now it's obvious I have improved range of motion I like to see the improved range of motion it has a more normal end feel medially you can see that I've resected all the way down towards the greater trochanter medially as well so what do we look at it as our pre and post op x-rays with this technique here you can see a poster lateral deformity a little pincer with an ass and the post operative x-ray that I'm happy with after the recontouring the rim or section in the osser section a little more challenging here where you've got this poster lateral and posterior medial deformity and again these can be corrected arthroscopically and then a little more complicated case where you have a large cam deformity with the with the rim fracture and this is a rim fracture where you can don't want to leave it but you don't want to take it all so I'm going to take part of that and then fix that with one or two cannulated screws so you can see here after the femoral resections and then also stabilizing that rim fragment in this case so I think in conclusion the entire acetabular rim can be accessed arthroscopically with appropriate technique that we've talked about management of your ass acetabuli and rim fractures are based on location and size and that'll be talked about again large subspine deformities I think are best addressed in my hands with a medial capsular window that we've published on labral deficiency can be addressed with a labral reconstruction but again I'd argue that the seal might be present in the absence of a labrum and some hips so think about that anterior cam deformities are predictably accessed with an arthroscopic approach inflection poster lateral deformities can be accessed with extension and sometimes traction and I think you should confirm your poster lateral cam resection with intra-op floral and also your post-op x-rays to really verify that you're making your intended corrections and accessing these more challenging regions thank you very much we'll just hold questions for the end if that's okay just to keep it moving and we have Rob Mosley who will be doing tips and tricks good morning thanks Spencer for inviting us all to this exciting morning at ICL I'm about 33 years out in practice I think my first hip arthroscopy was in 1995 and I was just excited to kind of get the scope in the central joint I think in a 60 or 65 year old gentleman I really want to pay homage though to to Tom Byrd and and Tom Sampson and also a former resident of mine Brian White been very instrumental in guiding me in terms of my progression in hip arthroscopy so we've already gone through a number of hip arthroscopy pro so I'll just kind of add some additional ones on so in terms of introduction we've already gone through some of the setup I'm going to go through some traction portals capsulotomy labrum FAI and capsule so in terms of the setup I've kind of progressed from the original perineal post to this pink pad that I've used over the past two or three years I had two cases of a pudendal nerve palsies and I have to tell you it wasn't much fun hearing about their ED in the office you know fortunately after four or five months it finally returned so when this was proposed as a possibility to do without the perineal post especially as I sort of got into doing more and more label reconstructions where they at least on the learning curve the perineal post can be can be an issue this pink pad has been pretty amazing I will say on a very thin patient it could be a little bit more challenging in terms of getting the traction to work I would tell you that even with these heavy boots that you put on the patient they will sometimes have ankle pain or foot pain that can take several weeks to kind of resolve just from the the traction force and like Spencer said you want to give a little bit of some Trendelenburg 10 degrees just to get that that force going up you kind of bring your ASIS down to the level of that outer pad for a combined procedure I'm not doing piriformis tendon releases arthroscopically I'm just a little bit too nervous about all the blood and blood vessels and the sciatic nerve so I'll sometimes do a hip arthroscopy first and then turn the patient over on a lateral side and then do a piriformis tendon release again you do get a chance to see some interesting tattoos at least in the New York City area if traction is not work working I've gone to this pearl of just kind of prepping out and just kind of venting out the joint so you can do all these little tricks of manipulating the hip but I'm always a little bit nervous trying to manipulate the hip while the hips on traction I don't want to obviously cause a niatrogenic fracture so just a simple simple case of just prepping it out take your spinal needle and vent the hip in terms of the portal placement I think I was originally taught to kind of go up the neck shaft angle but I've gone to a more perpendicularity as Spencer spoke somewhat I think Tom Bird mentioned something about if you have your spinal needle you do your air arthrogram and if the needle kind of flips up or doesn't flip up that may mean that you're going through the labrum I think about twenty percent of the time as you're doing your your interlateral portal you'll end up going through the labrum which isn't much fun but it can easily be corrected I use poster lateral for improved outflow you can just stick the needle in there as you as you go in I've been over the past couple years putting epi in the bags and it seems like that adds improvement to your visualization the pump pressure typically is 45 for the central compartment if you're doing peritrocheteric work or proximal hamstring work you have to realize it's kind of it's a very closed space so you don't really want to be doing it at 45 you're probably going to go down to 30 or 35 and the anterior portals typically about six centimeters anterior to the interlateral at the intersection of the SAS and the interlateral and the dala portal I use for reconstructions which is kind of that triangle that Spencer showed you so just a quick illustrative photo the one on the left shows the needle going through the labrum but even though you kind of commit to that portal on the skin you can redirect the needle to have it go above and above the labrum just redilate out using your cannulated trocars for the capsulotomy I use a typically use a banana blade but you can also use an RF and just be mindful if you can leaving a rim of capsule because I just got recertified I think for the third or fourth time and I did the WA and about five of the articles were dealing with capsulotomy and repair and T capsules straight capsules the bottom line is patients that have their capsule repairs do better than patients that don't have the capsule repair so you want to try to repair the capsule after you get done with your work I really almost never do a T capsulotomy I can't think of one time because I'm just a little bit nervous of how I'm gonna re-approximate and have enough tissue for that and typically if you play around with some of the tricks whether you want to pass a suture to kind of elevate up the capsule that can give you more space but I haven't seen the need to do a T capsulotomy so what about the labrum I think labral width is really important typically if it's less than 3.5 millimeters or so we did a an MRI study kind of looking at that I'm typically going to move on to a reconstruction because I find you just not getting enough of a suction seal with that 3.5 and oftentimes when you get in there you almost see this hypertrophic articular cartilage in part delaminated and what you think is labrum is cartilage and there's almost no labral tissue so I'd say from most of the time I'm consenting a patient to a possible label reconstruction with an allograft at the time of even a primary surgery assess the label thickness and depth look for pincer bone that's sometimes embedded in the labrum so really use your probe and correlate that with your imaging and x-rays preoperatively or CT scan look for the subspinous impingement but don't be overly aggressive with the resection for fear of HO I've had one case of erectus avulsion because I was over aggressive with these subspinous impingement resection and I think it's really important that you try to get as anterior as you can on your label repair I think some of the reasons why some patients have some residual pain is that you're not repairing that anterior labrum so make sure you get anterior enough on your labrum and then you can have a debate whether you want to use knotless or knotted anchors I typically like to tie down with knotted anchors but there's no harm at all with the knotless what about label reconstruction segmental versus circumferential I'm typically more from the circumferential camp and dr. white published this in the arthroscopy journal in the past four or five years and he found that label reconstruction led to a lower failure rate greater average improvement in the scores for patients 40 years and older so something to consider if you are doing hip work on older patients and this is typically his technique he takes a TFL and does a circumferential whip stitches to get about five and a half to six millimeters and it's a nice tight graft I was doing this for a while but I found that at least in my my hands and my help even though we're in a teaching institution the prep work for doing a TFL graph can take up to 2025 minutes so I've kind of either evolved or devolved to using either a peronealis longus or posterior tip tendon as the allograft choice and I guess we'll get into this in a little more time and so this is kind of the way it appears it's a nice tight graft and recreates the suction seal kind of running owns from four o'clock and a right hip all the way down to maybe 11 o'clock posteriorly Benjamin Dom's done a lot of work in terms of this pull-through technique that I've kind of migrated to using that post lateral portal as a means of pulling the graft all the way through so in this in this case you don't have to measure the length of your graft you can just whip stitch your proximal and back portions and pull it through and either use knotless or knotted anchors so there you see how he's pulling it through repairing it and at the very end you just kind of resect that posterior aspect of it one trick or pearl that I've gone to with passing the stitch so you can pull through is to use one of these curved suture shuttling devices so as you take it from your anterior portal to your poster lateral portal you can kind of grab it because with a 70 degree scope even though you're seeing a pretty broad view this kind of allows you to kind of get that initial passing suture to go through your post lateral portal. The pincer I think it's really critical that you use both the anterolateral and intermedial or anterior portals interchangeably and for CAM again you want to use both portals flex the hip up to about 50-55 degrees extend the hip and provide traction as we were just taught to reach that post lateral aspect of the CAM I avoid performing a T capsule for exposure so in terms of future pearls probably want to get a better understanding of how to deal with some of these articular cartilage lesions of the acetabulum and femur you know personally I'm also just trying to figure out where the ligamentum teres fits into this whole equation of taking care of the hip arthroscopically so those are two challenges that I've been thinking about want to thank you again for giving me your attention so we have Tom Young all right good morning everybody I'm going to be talking a bit about some advanced techniques and hip arthroscopy as we go through some of these we have labor reconstructions augmentations my my talk today will be on acetabular room fractures which Chris has already touched upon and some endoscopic luteus medius tendon repairs so I think it's important to recognize when you see what you think is a os acetabuli there's different varieties of these things right so you have to really understand preoperatively if there's a label calcification and os acetabuli or room fracture because when you get in for the surgery the the management is different from each one right and I don't really see radiologists whether it's an x-ray or MRI really distinguishing these three diagnoses so labrums associated with labral calcifications those can often times be repaired you can just remove the calcification repair to labrum an os acetabuli usually is associated with an attenuated labrum so sometimes the labral reconstruction may be required and a room fracture may require ORF right so you may need the cannulated screws to get that fixed so that's why pre-op identification is very important so this is a calcification you can see how you can tease that out continue with your pincer resection and do your labral repair this rounded structure here is more of a os acetabuli it's an accessory ossicle at the lateral margin of the acetabulum associated with pincer type FAI. This is Chris's article describing a large acetabular rim fracture and a cannulated screw to get that fixed because resection of that large rim fracture would lead to instability. So as far as terminology, you know, the os acetabuli and rim fracture oftentimes we overlap. Martinez differentiated this. He found that the os acetabuli is of cartilaginous origin, and it's oriented parallel to the joint surface. A rim fracture has a vertical separation line, and it's perpendicular to the joint surface. So what we need to know, resecting a large segment of acetabular rim can lead to instability or increased progression of osteoarthritis. And my feeling is an internal fixation of an os acetabuli rim fracture is indicated when the lateral center edge angle is less than 25 degrees on the AP image, or the anterior center edge angle is less than 20 degrees on the false profile view after removal of the osseous fragment. Epstein and Safran first described arthroscopic fixation of these rim fractures in 2009, and we feel about 3.5 to 7.7% of patients undergoing hip arthroscopy for FAI have these lesions. Typically males associated with cam morphology. So what's the pathogenesis of a rim fracture? It's a result of the aspheric portion of the femoral head, essentially a large cam lesion contacting the acetabular rim, and over time leading to a stress fracture, which typically oriented perpendicular to the hip joint. So this is a case presentation. This is a 24-year-old male with bilateral hip pain for three years. The right hip had greater pain than the left. He's a martial arts instructor, and he noted groin pain after participating in martial arts activities, tried conservative treatment, denies any previous hip problems or injury as a child. Essentially on his exam, positive impingement and favor signs and limitation in rotation. This is his preoperative x-rays. You see on the right side there's an acetabular rim fracture, which is the more symptomatic side. Left side does not have that rim fracture, large cam deformity. So some easy pre-op measurements on your AP pelvis. It's a lateral center edge angle of 36 degrees with the osseous fragment. Removing the osseous fragment would lead to a lateral center edge angle of 18 degrees, so it's essentially dysplasia. This is some CT scan views. You can see the large fragment, and I would suggest getting CT scans on anybody where you see an acetabular rim fracture on your pre-op x-rays. Some 3D reconstructions, sagittal view, you can see it's a relatively large piece. The MRIs of the patient, and this is a short clip segment of our arthroscopic procedure. So I had indicated the patient for acetabular rim ORIF. What I did here is I first went and fixed this acetabular rim fracture with a cannulated screw. I like using cannulated screws under direct visualization, just so that we don't lose a screw inside the joint. So I think one of the pearls here is to fix this first, and then do your pincer resection afterwards. Sometimes you do your pincer resection first, and then you don't have any strong bone support to actually fix if you do it in that order. Once I fixed this, resected the pincer resection, then I went ahead with my labor repair, obviously planning to put my labral anchors around the screw with enough space around it, and then completed with a chondroplasty. Once we fixed our acetabular rim fracture, we went ahead and did our camera section. Chris already has talked about some pearls for doing a good camera section. For my post-op management in these cases, I typically use a hip abduction brace to limit external rotation extension for all my FAI cases anyway. It's foot-flat weight-bearing with crutches for four weeks. Typically for repair or impingement resection, I do three weeks. So I add a week for this, aspirin, DVT prophylaxis, and Celebrex for HO prophylaxis. We have lots of good outcomes from the literature as far as acetabular rim fractures, and I already discussed some of these pearls. So moving on to greater trochanteric pain syndrome, it's a common clinical syndrome peaking between the fourth and sixth decades of life. Oftentimes you'll see a patient who's had intractable trochanteric bursitis, bursitis that's gone on for six months. By the time they come to your office, they've had multiple cortisone injections. It's a bit of the chicken and the egg, you know, is it the cortisone injections that are creating these tears, or are the tears first manifesting this way, and then the cortisone injections are used for symptomatic relief. We typically will want to find this in the middle-aged woman with lateral hip pain. Bird did a study of prospective MRI of 24 middle-aged women with greater trochanteric pain syndrome, and about 45% of them had gluteus medius tears. Another study looking at prospective ultrasounds of 75 patients with this syndrome found that 53 out of 75 had gluteus medius tendinopathy, and 23 out of 53 had full or partial gluteus medius tears. It tends to be more predominantly in females. So lateral hip pain located over the greater trochanter, right? So if you're feeling pain on palpation of the greater trochanter, you can oftentimes examine a patient and distinguish more muscular or tendinous discomfort versus intraarticular discomfort. Look for Trendelenburg-Gate. You know, I usually always have my patients walk down the hall so I can observe the gate, and it can affect both sedentary and active patients. Look for abductor weakness, and then confirm with an MRI. So understand on the MRI what your minimus looks like and your medius looks like. The medius is obviously more lateral. We'll get into the anatomy in a little bit, but this is an MRI showing a gluteus medius tear. You can see the gluteus medius tear on the AP view here. And I think if you're going to do these, you have to understand the anatomy. So when we look at the greater trochanter, understand there's four facets. You have a posterior facet, a lateral facet, a superior poster facet, and an anterior facet. And then the gluteus medius and the minimus are typically inserted on different facets. So first, the anterior facet, that's the attachment of the gluteus minimus. So if you have a pre-op MRI looking for a gluteus minimus tear, understand that your localization at the time of arthroscopy is going to be more anterior on the anterior facet. A lateral facet includes the insertion of the middle and anterior portions of the gluteus medius, and also continues anteriorly to cover the insertion of the minimus. That's where oftentimes these gluteus tendon tears will be both minimus and medius, because it's really at the confluence of the insertion at the lateral facet. The superior posterior facet is the main insertion point for the posterior portion of the gluteus medius. And the posterior facet, understand, even though that's oftentimes where the pain is, there's no insertion here. So you don't want to be inserting the tendon on the normal barrier of the greater trochanter. As far as surgical management, I consider there's a lot of correlation with the rotator cuff of the shoulder. Oftentimes the abductors of the hips are called the rotator cuffs of the hip. But you really want to get to this before it's too retracted. It makes surgical repair very difficult, or before there's fatty atrophy or significant muscle atrophy. In cases where there's a lot of retraction and atrophy, I go straight to an open repair. In minimally retracted cases, without atrophy, we can consider endoscopic repair. Understand the periatrochanteric space. It's a space between the greater trochanter and the IT band, analogous to the subacromial space of the shoulder. You can do a window when you do these repairs or longitudinal release. I've gone away from this because I feel like the IT band is accessory lateral support. So in case the gluteus medius does not heal, I think it's more catastrophic not to have a supporting IT band in that situation. These are my typical portals. I'll use a distal periatrochanteric portal and two proximal periatrochanteric portals. And then I like to vary between a 30 and 70 degree scope. Sometimes I'll start with a 30 degree scope first. I used to do an IT band split, and I found that just penetrating the IT band without doing a split is better. I use the distal periatrochanteric portal for viewing, and the proximal anterior and posterior periatrochanteric portals are usually for passage of sutures and anchor placement. I like a knotless configuration, especially on a surface where patients complain when they lie on their side that there's pain. I think having a knotless configuration is useful. And one thing to understand, it took me a while to understand, is if you just try to get a suture through the tendon, what you visualize as a tendon endoscopically, you're going to have very poor tissue. So when you're going outside in, so you're going lateral to medial, I think it's important to pass your sutures through the muscular portion of that gluteus medius or minimus, because on the undersurface of that gluteus medius or minimus is where a healthy portion of that tendon is going to be. So this is a video showing a knotless endoscopic gluteus medius repair. You can see a relatively small, minimally retracted tendon tear. I think that's a perfect situation to do it endoscopically. Keep in mind, when you have these potential spaces and it's not a joint, you don't have a significant amount of time to get this repair done. Just like the rotator cuff, the fluid is going to start insufflating the soft tissues. Your space is going to be less, so you really want to move quickly. At the time of this video, I used a shuttle suture to pass a nonabsorbable suture from medial to lateral through the tendon tear. And then I would pass this through a knotless device or knotless anchor, and then secure my fixation. A lot of these knotless anchors now have accessory sutures attached to the knotless anchor, so you can pass your strong tape as your initial fixation. And if there's any portions of the tendon that are still not completely stabilized, you can use the accessory sutures from these knotless anchors to get that fixed. It's a relatively simple technique. Once we get this pass with the suture lasso, you can use a bird beak. We secure it to the knotless anchor, and then create our pilot hole, and then insert that right in. All right, moving on. My post-op rehab for this, I let them do protected weight-bearing, 50% for four to six weeks. With two crutches or a walker, hip abduction brace for four weeks. It's really easy in the shoulder to immobilize the shoulder with a sling. It's much harder to have somebody non-weight-bearing. In fact, I think that if you have somebody lift their legs the whole time, that's probably more stress on the abductors than letting them do a little bit of partial weight-bearing, and I think that's more of a practical situation. Isometric strengthening and full weight-bearing by six weeks, 12 weeks to progress strength. I think this recovery is a bit longer than a typical FAI procedure. We expect our FAI patients to be running and doing sports at six months. I usually tell patients it's about 12 months for recovery for a gluteus repair. Surgical considerations, watch out for fat infiltration. They don't do well, just like in the rotator cuff. You can use the Goutalier classification for this, stage one to four, and I think that's it. I guess we missed some of the conclusion, but it's okay. All right, thanks so much. Guillaume, we'll do the last talk here on some augmented techniques. All right, thanks, Matt Sarin. Thanks to everybody for getting up so early, and thanks also to the other speakers for being here. We're going to do the last talk here on some augmented techniques. Thanks to everybody for getting up so early, and thanks also to the other speakers today. I've already learned more than I'm going to impart. So we're going to continue our foray into maybe less common applications of hip arthroscopy. We're going to talk about AVN and proximal hamstrings. So any time you're thinking of adding a scope to a perfectly good open procedure, you want to ask yourself why. So does it help us in prognosis, help improve visualization, does it help manage other injuries maybe that we find at the time, decrease pain, and is it more safe or potentially less safe than its open counterpart? So AVN, quick refresher, death of the femoral head due to vascular disruption. These patients often present with insidious onset. We classify these based on x-ray and MRI, the historic FICOD and RLA classification, and it basically goes from something not seen at all radiographically and then to full collapse and bipolar arthritis. I think the Kerboul angle is a good prognostic tool. And so for those of you who might not have heard about it, it's basically the subtended joint or the subtended angle that includes the AVN lesion, both on the mid-coronal and mid-sagittal MRI cuts with the largest femoral head diameter. You add those up, you get a number, and then you can grade it. And we'll talk about why that might be useful prognostically. So of course, in these cases, always consider medical treatment as an adjunct. Most importantly, eliminating risk factors, especially if they're on corticosteroids. But bisphosphonates and more recently, hyperbaric oxygen have shown promising results. But the mainstay of surgical treatment is core decompression. So historically, this was actually developed for Perthes disease. And interestingly, the concept was really discovered almost incidentally during samples for histologic analysis and then finding that there was some therapeutic benefit to it. But importantly, there is no consensus on indications. There is no CBT code, so you're going to be unlisted for this one. And multiple techniques abound. What we do know is that if there is subchondral collapse, so that infamous crescent sign, those patients will not do well with core decompression. But if it's at stage one and two, so no collapse, some studies have cited up to 60% to 80% survivorship at two to five years. More recently, we've added bone marrow aspirate. And I think the initial results were very bullish. More recently, some more detailed examinations have shown that maybe there is no difference. But I think the devil lies in the details. So this is where the Kerboul angle might play a role. So there's been a few studies looking at the size of lesion. And it turns out that if, again, you add the subtended angle at the mid-coronal and mid-sagittal cut, you're going to have, if that angle is less than 250 degrees, then BMAC might be actually more effective there. So technically, you've got your standard procedure with the large reamer, 9 to 12 millimeters. You can also do multiple drill holes, although that does incur the risk of a subtrochanteric fracture. And then more recently, we've been doing these expandable reamers, small cortical hole, and then you expand to try to maximize the amount of lesion that you can manage. But comparing all of them really has shown no difference. So let's talk about arthroscopically-assisted core decompression. So again, why are we doing this? Potentially, we can identify and treat concomitant labrum pathology. We can more precisely identify the area of avascular necrosis rather than relying on fluoroscopy alone. And then we can use this expandable reamer to decrease cortical disruption and maximize the area of lesion that we can manage. So results for this have been overall good, although we don't have any comparative results looking at corticompression without arthroscopy. Here's a case. So 50-year-old female. She had been on corticosteroids. Importantly, minimal response to an intraarticular injection. So we can assume by that that perhaps a lot of her hip pain is coming from the AVN. No obvious subchondral collapse, but you look on MRI, this is a fairly large lesion. The modified cubal angle just coming under the line at 230 degrees. So OK, this is indicated for a core decompression. So here's one set of instrumentation. This actually was designed by Tom. There's many out there. This includes a guide and an expandable reamer. And so you're going to access the joint just like you would normally. And then you can probe and actually see whether or not there's any subchondral collapse. So here's what it looks like inside. Labrum looks pretty good. Joint looks pretty good. As you're probing, you see there's a little area of softening there that I don't like. So there may be a small area of impending collapse there, but certainly fairly limited and probably worth still trying to do the core decompression. And so you basically pass your reamer over your guide wire, make sure it looks good both on the APN and lateral views. And then you backfill with bone marrow aspirate. And we usually soak it in these calcium phosphate sponges and then backfill with calcium phosphate cement. And that's what it looks like a few months later. So here's another case. This is a 27-year-old, also big lesion. In this case, there's also an associated labral tear. And so in her case, the joint looks pretty good and the bone looks pretty strong. So prognostically, I think we can tell this patient, you're going to do okay at least for the next five years or so. But you can see on that scope video, there's an anterior labral tear there. So we're going to do a little pincer resection and repair the labrum simultaneously, something that you might not be able to do or would not be able to do if you just did this radiographically. And then again, we pass our guide, pass our expandable reamer, and backfill. So interesting theory. This is out of China, so take it maybe with a grain of salt. But the thinking may be that if you do a concomitant arthroscopy or in some ways venting the joint, maybe this leads to lower intraarticular pressure and by default, atrocious pressure. It's just an interesting theory. I think maybe worth exploring. So to conclude with AVN, I do think that arthroscopic assistance does give this opportunity to fix concomitant lesions. Maybe it depressurizes the joint. But most importantly, it optimizes placement of your reamer. I think a very helpful prognostic tool and obviously more data to come. Switching over to proximal hamstring repair. So these are very common acceleration, deceleration type of injuries. And I think anytime you're going to do something, just sort of like Tom mentioned for the gluteus medius and minimus, anytime you're going to convert something arthroscopically, you want to understand the anatomy well. So here's a right hip, looking at it from behind. And you can see the conjoined tendon, combination of the long head of the biceps and semi T with some membranosis attached a little more laterally. And this is the typical approach that I'm going to do open. So if it's a non-retracted tear, I usually can just do it through a gluteal fold incision. You're going to mark out your ischial tuberosity, your sciatic nerve. And then you're going to find your crural fascia. So again, deep layer. So this, I think, makes the rationale for arthroscopy reasonable in that you're avoiding having to go through all these structures. But importantly, you're typically going to find when you do this open, and sometimes you don't find this, the posterior femoral cutaneous nerve. And the reason that that is important is that there's a fairly high incidence of iatrogenic injury of the posterior femoral cutaneous nerve when you do these open. So Aaron Critch looked at this. They found maybe it had to do with the incision. So if it's a gluteal crease incision, a much larger percentage of the patients with a nerve injury had that versus a longitudinal incision, so something to keep in mind if you're doing this open. What about the inferior gluteal nerve? So that's the nerve that innervates the gluteus maximus, and that lies about five centimeters from that inferior border of the gluteus maximus. Very important to identify that, or not necessarily identify the nerve, but identify that region so you avoid it. And then, most importantly, the sciatic nerve. So that's obviously the big gun in the back. And I think one thing that we sometimes don't think about, because we sort of think about identifying the nerve, isolating it, is that branches actually emerge very close to where the nerve passes the ischial tuberosity. So the motor branches to the biceps and semi-T only about four to seven centimeters from the ischial tuberosity. So very important to not skeletonize the nerve, whether it's open or arthroscopic. And then there's some other structures that you can identify open that can be helpful arthroscopically to navigate your way around here. So if you look at number one, that's the sacrotuberous ligament. That's important to identify the medial aspect of the ischial tuberosity. And then the quadratus femoris attaches on the lateral aspect. So those are both visualized arthroscopically, and I think helpful to identify the borders of your ischial tuberosity attachment. The reality is open repairs do quite well. So Tom and I have looked at this, and many other authors have, so really pretty high satisfaction. But we do have these issues with some neuropraxias and also morbidity related to open surgery. So I think it's definitely worth considering endoscopic management. As mentioned, sciatic nerve, posterior cutaneous nerve, inferior gluteal nerve, and then of course with open surgery, you can get this hematoma infection, et cetera. So positioning for endoscopic repair, really do it very similar to an open approach. I have fluoroscopy in the room. You're gonna need a radiolucent bed, pillow under the leg, and then I place that leg as far lateral to the edge of the bed as I can. Some people can put the foot on a Mayo stand and actually position themselves between the leg and the table. So there's a bunch of different approaches. Just kind of do what feels most comfortable. And then I identify all of my potential pitfalls. So my sciatic nerve, my inferior gluteal nerve, which is gonna be located pretty much right over that ischial tuberosity. Make sure I have a sense of where those hamstring branches, the motor branches emerging from the sciatic nerve are. And again, the posterior femoral cutaneous nerve, which will typically be a little superficial and sometimes medial to the sciatic nerve. Portals are gonna be on either side of the ischial tuberosity. To start, you may add some as needed, but about two centimeters to either side of the ischium along that gluteal crease. For fluoro, I airplane the table and then do an over-the-top view of the C-arm to try to get as on-fossil view as possible of that ischial tuberosity. So my needle's not straying too far lateral and potentially hitting the sciatic nerve. And then, sorry for the sound, but here we pass our needle. Once we get confirmation, we go there. And this is, I had a couple of chipmunks as my fellows. So, but we've got a fluoro here and we can go pretty far up. So up to the greater sciatic notch. And then for our anchor placement, we can manage it as well. So this is what it looks like inside. So here's a nice view of both the posterior femoral cutaneous nerve and the sciatic nerve. You can see they're very close to each other. This is a high-grade partial tear. I think that's a good indication for an endoscopic approach so you can incise longitudinally at the ischial tuberosity, then go deep. You can see the tendons completely, essentially evolved off of the ischial tuberosity, lightly decorticate with a burr and then pass your anchors and then tie them. I think a very important flag to point out for this is, this is not, and this is similar to the peritracheal anterior space, this is not a joint. So you don't have a capsule containing the fluid. Fluid will extravasate and you can develop compartment syndrome in the gluteal area. So very important to be extremely judicious about the pump pressure and time. So for pump pressure, no more than 25 millimeters of mercury. I do use epinephrine. I think that's helpful for hemostasis. Time limit, certainly 90 minutes. I try to come in under an hour and I'm always palpating the buttocks, making sure they're not getting overly infiltrated with fluid. Assistant always has a hand on foot anytime I'm near the sciatic nerve to make sure that there's no stimulation. These patients do not get paralysis. And for me, if it's greater than two centimeters retraction, I do those open. So there is this thought that, maybe in order to save some time, you can actually combine. So do some of the heavy lifting endoscopically, but then do a small incision to finish the repair. So here we've identified the sciatic nerve. This is, again, a high-grade partial tear. We're basically identifying the bone, that's the ischial tuberosity, then lightly decorticating, and then we're gonna pass our anchors. And then once your anchors are passed, you can actually convert and do a small incision. You know where your sutures are, so we're gonna go under the gluteal max, just as per normal technique, pass our sutures through the tendon, and then you don't have to worry. In fact, you've actually decompressed the gluteal space, so you don't have to worry about compartment syndrome. And again, where you're gonna do that is right at that inferior gluteal max border. So for post-op rehab, put these patients in a brace that limits hip flexion. I found that to be okay. I think you've gotta be reasonable. You know, you see these contraptions with patients, you know, with their knee flexed 90 degrees for four to six weeks. I mean, they're just not gonna be able to maintain that. I think this is enough, and then just repeat education, and I agree with partial weight-bearing, not non-weight-bearing. Of course, DVT prophylaxis, and then progressed weight-bearing, return to sport usually six to 10 months. Outcomes are good for this, really just as good as open, and in my experience, these patients feel much more comfortable, much sooner, less morbidity. And then you can have some other applications. So here's this deep gluteal pain syndrome, fibrovascular bands around the sciatic nerve. Again, you know, very low energy, cautery. In this case, this was hamstring tendonitis, so we treated it just like we might do open. And then calcific tendonitis is another permutation of this. Here's a patient with a lot of calcification, approximately in the tendon, and you can just debride the calcium like you would potentially in a shoulder. So to conclude, arthroscopy and endoscopy can decrease intra-op morbidity and augment visualization. I think importantly, aid in prognosis in these patients. Really have to understand the anatomy to avoid complications, and caution with that learning curve, just be ready to convert to open if needed. Thank you. All right, that was great. Well thanks to all the speakers, do we have any questions from the audience? Comment on our ticker cartilage delamination, when you incorporate in the repair or when you use curettage and microfracture, and then capsule reconstruction techniques and how you might do that, and then do you ever offer isolated bursectomy with no tear of the glutes? Chris, do you want to take cartilage or anybody? So I started doing peritracheal endoscopy and I actually got to a point where I stopped and I do everything open now in that space. Brian Kelly originally talked about it and then he found when he compared his endoscopic cases to his open surgeries, just like backroom talk with him, he's like, I just do them all open now. I think they're doing better for me. So I think I just tend to do that open, I do not do bursectomies, that's just not something that I've offered. What were the other questions again? Cartilage lesions. Yeah, so if you have a delamination of the cartilage, in my opinion, I don't resect that articular cartilage at all anymore. Generally what I'll do is I'll just get under it, curette it, microfracture under it, and for some reason it seems like the hip's the only place where that cartilage either just sits there and does fine or heals. So I don't remove cartilage ever. So if there's a defect, I do microfracture, but if it's a delamination, I'll leave that cartilage alone and microfracture under it and then I think it just stays there if you deal with the impingement well. So I have rarely done capsule reconstruction. Most of the time I've found that if somebody's having a problem with the capsule, they tend to be somewhat hypermobile, and if they are, the capsular repair wasn't done or it just wasn't done tight enough, and so I usually can lyse the adhesions and repair that almost every time. So I've had like one case where I did a reconstruction. Sometimes you can put anchors on the rim and if there's not enough proximal capsule next to the rim, you can actually pull the distal capsule up to the rim, so that's one trick you can use. And then I have used, you know, like Regenitin on a couple of cases, but that's a pretty rare procedure for me to do. How are you guys, how many stitches are you putting in the capsule at the end of these cases? Are you doing simples or mattress or? So I do simple stitches. I use non-absorbable stitches and I use four to six in every case and I've repaired every capsule for like 10 years. Just to add, for cartilage delamination, I think one of the big takeaways, if you've been doing this for a while, we used to take the labrum off the articular cartilage and separate it. Now that we don't do that anymore and you preserve the chondrolabral junction, when you fix the labrum, oftentimes that delamination gets tighter, right, meaning that it becomes less and I find that, you know, we did, we published a study on micro fractures just like in the knee. They don't do that great. I don't think it really, it's a plus type of scenario. But I think if you don't, if you preserve the chondrolabral junction, do your repair, the delamination turns out to be less than what it is. As far as peritrocanteric space, I used to do, for certain patients, both the labral repair and a trochanteric brisectomy at the same time. Over time, I realized the brisectomy was really not necessary. You know, you treat the intraarticular problem and the muscular stuff will go away over time. So I think it's very rare for us to do peritrocanteric work. And as far as a capsule reconstruction, I've had a slew of patients being referred recently for failed hip scopes and they're referred for a capsule reconstruction. So it's already in their head that they need a capsule reconstruction. And what I found is that the capsule, when I go into these patients, are fine. The labrum is typically deficient or they have some femoral rotational issue. So I think you will get referrals for capsular reconstruction just because patients have failed and surgeons don't necessarily know why they failed. But I think you look a little harder and there's probably another reason other than just the capsule. Yeah. Just to add one more thing about the peritrocanteric space, I would agree, you know, very rare, but like mom used to say, never say never, never say always. So isolated brisectomy, very uncommon. I've found, and the literature supports it too, PRP can be very helpful in these cases. And then anytime I see just isolated trochanteric pain, no tear, I'm thinking biomechanics. And so obviously this is not available everywhere, but having a patient sometimes do a gait analysis if that's available. Sometimes with physical therapy, it's just modalities and they're not really identifying the biomechanical issue. So that can be helpful in patients where it's, it's just isolated bursitis and there's no associated tear. Yeah, please. Just wanted to pull you guys as far as circumferential stitches or labral base, if you think there's a difference in when you utilize one versus the other. And then I've noticed in my capsular closures, as you get up towards 12 o'clock, that capsule really kind of peters out. So do we really need a watertight closure? Or is it really more of that sort of more medial limb of that iliofemoral ligament that we need to focus on? Yeah, so I agree with you in terms of circumferential, that's what I do. I'm just always concerned that I'm going to leave a little, almost like a stress riser where the tear might then propagate from suture to suture. So just for me, I just feel more comfortable doing circumferential and then the data seems to suggest that there's no difference. And as for the capsule, I agree with what you're saying. I do try to make it as watertight as I can. I probably don't put as many as Chris, maybe like four, three to four is typical for me for closure. So I think there's probably some debate about how separated they need to be. But yeah, I think you usually can get it. You know, you just sometimes need to expose a little bit more of the bursa, like overlying the capsule to identify the two leaflets. I always used the labral base stitches when I first started doing it and then I started doing circumferential stitches and I just didn't notice a difference. So now I pretty much always do a circumferential stitch because it's faster and easier. And for my capsule repair, I start laterally. So usually, I think wherever you start, it's where you end, where you start to peter out. So I start laterally. So I never generally have a problem laterally. And then as I come anterior, I don't switch my portals, I actually just switch my working portal and move it more anterior. So I'm kind of closing my way out of the joint. And then I'll always pass my last couple stitches. But I think you're shooting for 80 to 90% closure at least is kind of your goal. I would say anteriorly when you're putting stitches in, I'd just be a little careful that you don't capture the rectus if you can help it. I think that's what you have to be careful of. Yeah. Any tips and tricks on radial tears in labral repair, especially with the labral deficiency? And how do you deal with it? I don't see radial tears, you know, that often. But when I do have one, it really makes me push the envelope to do a labral reconstruction at that point just because I think there's going to be some underlying deficiency to the fibers. Because trying to do like a mattress side to side type tear, I don't think does as well just in terms of how the collagen fibers are spread out. And I think you're just going to be pulling more tension from one side to the other and it's probably not going to heal. What's the threshold there for a labral reconstruction in the labral region? Yeah, so I don't typically do segmental. I do circumferential. So I'll do the whole thing. But you certainly could argue for doing a segmental for that small segment. Yeah, I think that would actually be a good case for segmental augmentation, right? So instead of taking all that labrum down, just augment segmentally right around that area. And that should not take you that long, right, for segmental augmentation. I think radial tears in the labrum are super rare. And what I would tell you is that you may look back and find that some of them are actually iatrogenic. And so I think I used to think there were the buck and handle tears when I first started at the labrum. And I realized it was just because I put my cannula through the labrum. So they're probably more iatrogenic than they are because it doesn't make sense as much with the mechanics. But if you did see it, I mean, you could definitely go side to side. But I agree. You could probably do like a labral augmentation segmental reconstruction in that spot. You know, they used to always say that under resection of the CAM was a big problem. But recently I've had a couple of patients referred to me that had proximal over resection and loss of the suction seal and flexion instability. So I don't really know that we have a good answer for that. But since you guys do a lot more of these than I do, I just wanted to see how you guys deal with those when they get referred in and what your thoughts are on proximal over resection. Yeah, that's probably a big problem, yeah. I mean, it's obviously a problem. We've talked about it. I mean, I'm always looking. You know, I feel like that's a problem I can't fix. So what I'm doing is I'm looking for something else that I can fix. And if I see something else that I can do, then I think the key is try not to do anything proximal. Don't try to make it more round. You'll end up going further proximal. I think, like Martin Beck used to talk about trying to bone graft that area and doing that open. I think that's something you could consider. But I think once that happens, that is a very challenging problem to address. And I don't think you can really fix it. I mean, Mark Philippon tried to put a graft in there, like a soft tissue graft, like a remplissage, or something like that. And I just think they're challenging. And you look for other reasons to fix while you're in there and try not to do any more where they've already worked. I was just going to ask the panel if we could just, one thing that I think is interesting, just everybody say whether they do post-less or post, or if they do both, and what percentage. I think that's a good question. Yeah, I've also switched to post-less. For more fun, I'll go ahead. I do. I still use the post. I trialed the post-less for about a month. I didn't like the Trendelenburg. It just threw me off. You're used to almost automatically having your hands in the right position, and then the Trendelenburg threw me off. So I understand that you don't need Trendelenburg anymore with a lot of the post-less stuff, but my traction times are pretty short. And so I still use the post. I use post-less. Yeah, I'm post-less about 100%. I won't be long-winded. I wrote an editorial on arthroscopy about comparing the two. And I think the key is that both are fine. You just need to understand the pearls and pitfalls of each, and you just need to be good at managing either situation. I use a post almost every time, but I put them in Trendelenburg, and what I'll say is that a number of cases, even when I have traction on, I'll look, and they're not touching the post. So when you use a post, I think it's helpful to use Trendelenburg. I mean, I think I would say the same thing. My traction times are probably 20 to 35 minutes, generally. And I've had lots of complications in my career, and I'm not aware in probably 7,000 hip arthroscopies of ever having a pedendal nerve injury. So that's maybe the one thing I haven't had. I use a smaller post as well because I feel like I can dynamically assess them better with a little smaller post. So I think if your traction times are short and you put them in some Trendelenburg, it's totally fine. But I think postless is fine, too. Just know the thin, really stiff mail, you may need to be ready to back up with a post. That's the one case I'd be careful of. Do you find the post helpful for lateral translation, or is it just something you've done and you're just happy with it? Yeah, I think it's one of those things where somebody else would have to tell me how my post is helpful because it just seems like it works for me. But because I haven't gone to postless, I have a really hard time knowing what happens with that. But yeah, I can't answer that. Is that same for you, Tom? It's just you didn't like postless, and you're just good with the post and no issues? Yeah, it threw me off. If NYU basically said, we're getting rid of all the posts, I'd be fine. I'd get used to it. But when you do certain things, you feel like you're good at it a certain way. And it's like automatic, right? You pull one side, you pull the other. You go from lateral, lab, dot, post. And I would say sometimes the nice thing with the post when you're in extension, if you're trying to get a little bit further, or if the labrum's bigger and it's over an area of the femur that you're wanting to work on, instead of having to put traction on, you can just AD-duct against the post and it'll sort of laterally sublux a little bit, and you'll actually be able to work around that area a little easier. But you know, you have other ways you can do it postless, too. But just know these guys are doing traction time of like 20, 30 minutes, so, for the rest of us. Postless might be helpful. All right. Well, thanks, everybody. Thanks for the panelists, and thanks for the audience. Hope you have a great rest of your meeting. Yeah, for sure.

hip arthroscopy techniques

surgeons

portal placement

pincer resection

labral reconstructions

hip pathologies

labral calcifications

rim fractures

acetabular rim fractures

gluteus medius tendon repairs

greater trochanteric pain syndrome

AVN