I was going to say last Thursday when we had three hips that were nondistractable, but this is ‑‑ yeah, it was the worst day. Anyway, I'm going to kind of piggyback on something that Travis had talked about a little bit. It wasn't necessarily something that happened in the operating room other than kind of opening my eyes to probably a problem that we see more often than we want to give it credit for. This is a 16‑year‑old female gymnast. She's had two years of hip pain, rated as an 8 out of 10 under VAS, unable to compete in pain with ADLs. She's obviously failed everything else. You know, traditional measurements, center edge angle of 23.1, which would put her into a borderline characteristic, angle of 10.1 with a negative fear index. But she really has this short arc acetabulum and had some offset issues, and so we kind of worked her up. Just ‑‑ we talk a lot about these things, but just to kind of give you guys some parameters, center edge angle traditionally has been described as less than 20 for dysplasia. Between 20 and 25 for borderline and over 20 is considered normal. Astabular inclination or tonus angle, you should be using in your practice if you're not. It's kind of the inclination of the roof, which can lead to instability. Greater than 10 has been predicted to have instability with over 70% sensitivity. Less than 9 is considered normal in my practice. 9 to 12 is borderline and greater than 12 is considered dysplastic for sure. The extrusion index on an AP pelvis is the percentage of the uncovered femoral head in comparison to the total horizontal diameter. And about 27% or greater on coverage is considered with posterior on coverage. The fear index as described by Martin Beck is an angle between the acetabular roof and the femoral growth plate. And a fear index less than 5 degrees had an indication of being 79% chance of having a stable hip. So in these borderline hips that you're trying to determine, are they stable? Are they unstable? Should you scope? Should you do a PAO? Some of these things in combination can be very helpful to help you make those determinations. The fear is basically the angle measured between the central part of the fiseal scar and the femoral head growth plate and the acetabular inclination angle. And that kind of tells you that the forces that were put on the joint while they were developing were pushing the ball in as opposed to pushing the ball out. So this has been something in my practice that we've used as one of the things to help us differentiate between do they need a PAO or can you get away with a scope. These are just other kind of definitions of dysplasia. So her advanced imaging showed a lateral tear anteriorly. On her examination, she had flexion of 105 degrees into rotation limited at 15 and a high Baton score as Travis has talked about. The Baton score you should be doing in your practice. If you're not, it's a measure of hypermobility. If they're hypermobile, there's about 6.5 times greater to be likely in dysplastic hips. And a Baton score in dysplasia was about 4 or higher. So this is something to think about. So the questions for me really at the end of the day is can you scope it? Can you do a PAO? Do you do it combined? Do you stagger it? Do you do it in a single stage? Does your thinking change if this is a male patient? If they're playing a different sport like if they're a butterfly hockey goalie or a football player as opposed to a gymnast, what do you do with the capsule? Do you close it? Do you leave it open? Do you placate it? So we treated her. We did an osteoplasty. Here you can see her labral repair. You can see some impression there at the head neck junction where she was impinging. We did what I thought was a reasonable osteoplasty. We repaired her capsule. You can see a figure of eight stitch there secondary to her borderline nature. So we did placate her a bit. She did well for about two years which is what you're going to see with these patients. Went back to ADLs with limited to minimal symptoms. She went back to swimming and soccer but was unable to return to gymnastics. She comes back two years later presenting with increased symptoms. This is just kind of telling you that hip dysplasia and FAI can exist in the same hip. And so in this situation this was one of the first patients that we converted to a PAO in my practice. And after her PAO she was pain free, zero out of ten pain. She was back to all activities including gymnastics with a Harris hip score of 100. And so one of the things that I wanted to kind of bring up with this is that I think the question for us always is what is good enough, right? So what is enough? Is it that they get increased function and decreased pain and for how long is that appropriate to say that you're successful? Is it that we're trying to prevent arthritis which I don't know that we're really doing that at this point but that's obviously the holy grail of arthroscopic hip surgery and hip preservation surgery. And so can these patients be doing better? And this for me was one of those things that really changed my practice in that she had done reasonably well for a couple years returning to sport. Not all of her sports but a lot of them. She had decreased pain and improved function. And even when she came back in two years she was still doing relatively well. But then when we converted her because of ongoing symptoms that just never really kind of turned the corner, she has a hip now and it's been six or seven years since we did it. And she has essentially zero pain in her hip and has a totally normal function. So that for me was the practice changer was trying to recognize some of these things that I think I don't know that one size fits all with this. So I think everyone's always like well when do you scope a hip that's borderline, when do you not? I think you have to start trying to determine information about which hips can do well and which can't. So we know that a lot of hips that go on to have PAOs are getting arthroscopy. There's a 192% increase in that in the anchor group studies of a dysplastic hip having a previous scope. We know that in several studies when you ask the patients how they do, so their PROs may go up, but when you actually ask them are they satisfied with their operation, almost 40% say despite improvements in their PROs they indicate the procedure was unsatisfactory. So even though their numbers may go up, they don't like how their hip feels. And so what about if you just do a plication and Ben showed that patients over the age of 35 had worse outcomes and were 2.25 times more likely to fail. So this is that group that traditionally if you're over 35 you don't consider a PAO, but these are the groups that are most likely to get converted to total hip. And what about doing a PAO if they fail the scope? Well the anchor group has shown that it's not as good. So if you do a PAO as a primary index operation with or without an arthroscopy for these borderline hips, sometimes they do better when you do the PAO as a first line. So it's just something to think about. I'm not advocating for that always, but it is something to start thinking about in your practice. So what's most important, this is the other thing that you'll see sometimes when you go to do your dynamic examination, you flex them up and they sublux. It's going to make you kind of sick to your stomach and if you're not doing a PAO in this patient maybe you should be. You can usually eliminate this at the time of surgery by closing their capsule and you'll see in this video that we were able to do that. But then you worry about in the postoperative setting how much pressure is being put on that anterior capsule to maintain stability of the joint. And I think a lot of the patients that have capsular ruptures in the postoperative setting are these patients that you're asking their capsule to be the primary stabilizer of their joint when it really shouldn't be. So here you can see with the capsular closure, when you go to do that same position the hip will not come out. But then the question is in the late postoperative setting, this may be one of those, Shane has done some really nice papers on early progressors, late regressors, and these are probably some of those patients that are in that late regressor category where you didn't correct their bony morphology on the socket side and then they end up having a late failure. So in my practice what's most important, young female patients, bilateral pain that is the same, severe impairment, more pain with weight bearing than with static positions, significant posterior or lateral pain components, so if they have a lot of buttock pain or lateral sided discomfort in addition to the traditional anterior pain, you need to think about this hip as potentially being unstable. They have a high degree of ligamentous instability on examination. They may have snapping and they may get a pop when the hip is hyperflexed. So when you go to do your fader and you bring that hip into that internal rotation position and flexion and they get this almost clunk, that's probably the hip kind of subluxing. And when you're doing it in the clinic that's a little scary because you're like, oh sorry about that. Sorry mom, sorry mom, didn't want to make her do that. But it is one of the things that I've seen in these patients. Imaging and elevated inclination, that's one of the most important things in my practice that has changed is looking at the inclination angle. Looking for that caudal or posterior on coverage. Looking for the fear index. Center edge angle is the least important measurement in my evaluation of these patients when you're thinking about borderline. And looking for this kind of flattened dysplastic pseudocam morphology. So they almost get, because the head is not loaded at the chondroepiphysis, it flattens first and then you lose offset. So there's the traditional cam that Travis showed in that one patient that he's like, this guy probably doesn't need his capsule closed. And then you're going to get these kind of done laterals. They don't really look like a cam. They're not spherical, but they don't look like a cam. And that's probably secondary to instability of the hip joint. And then in the operating room, if they're easily distractible, if they have an inside out cartilage lesion, which means the cartilage breaks from the socket side and not the labral side, those are all indications that those patients may have a component of instability. And then posterior subluxation and a dynamic examination. You're still going to probably treat that patient arthroscopically when you're in there. But if they do fail in the postoperative setting, having a high threshold for trying to understand how dysplasia may be a part of that picture. Avoid over resection on the rim. If they're uncovered posteriorly and you take bone away from the rim and it's too much, you'll make them globally unstable. I think instability episodes. I mean, Travis talked about one today. I think it's many people that do a lot of this. And I'm sure maybe in your practices as well, patients have instability episodes after surgery. And so don't take too much bone away from the front for every degree, for every millimeter of bone you take from the front of the hip in the traditional area of where you're going to do your labor repair. It'll change your anterior center edge angle by two degrees. So you may make them functionally dysplastic. And then Shane has done some nice follow-up studies after we did this study, looking at concentration of the forces on the remaining articular cartilage. So instead of preserving a joint, you actually may be making them worse and driving them towards a higher risk of arthritis. So it's just something to think about. So thank you. And if there's any questions or if there's other things we can talk about. Did you end up re-scoping that hip before the PAO? We did. And her labrum was healed and her capsule was healed. She had a couple of adhesions that we took out, but the actual inside part of her joint looked pretty good, which is crazy. So just diagnostic, debridement, get out. Diagnostic, debridement, get out. I always do a lysis above the capsule too when we're in there too. So I'll kind of peel everything off between the muscular layer and the capsule. And then she had her PAO and she's been really happy with it. And like I said, I think this is a bit of shifting sands as Shane kind of talked about when we first started doing this and I learned from him. So we did every single hip that we operated on, we lengthened the psoas. It was like the biceps of the hip, right? It was the package deal. And we've learned a lot since then. And I think this is continuing to evolve. I think things like femoral retrotorsion, femoral antitorsion, and then acetabular morphology is really going to start to creep into your practices, whether you like it or not. And that was the thing for me. It's like taking the red pill. Once you see it, you can't not see it. You know what I mean? My quick question, when you entered the hip and you scope before the PAO, did you just pop in and look around or did you do a partial inner portal capsule? So I just, I usually do, I don't, I do like a Perry portal for those. So I don't do, I don't open the capsule in the, in the postoperative setting. I just look around and if there's something that I need to treat, we can open it up again. But most of the time we just do enough to be able to look around and put a probe in. Do you think it's even necessary? I don't, I don't know the answer to that. I mean, I think most of the time when you get an MRI, as you guys know, and from getting a postoperative MRI, depending on the radiologist that reads it, they're going to say postoperative change versus possible or you will retear. So I think you're obligated to take a look. But in the ones that we've gone back on, I, the labrum is almost never retorn, you know, and, and that, I don't know, I'm kind of a heretic, but I think the labrum is like the less, the least important part. You know, I'm moderating a session later today on like, what do you do with the labrum? Do you reconstruct it? Do you augment it? I think if you get the bony work, right, the labrum becomes secondary in terms of the importance in the operation. One thing I just want your thoughts on, you mentioned this, the paper on the PAO outcomes were worse at post-hip scope. There's a huge selection bias in that paper, obviously, because those are by definition revision patients in a similar fashion. Scopes after PAOs are also worse than scopes alone. So I wonder if it's, and I'm interested in your thoughts, I wonder if it's the revision population that don't do very well, or is it really the scope that's causing the poor outcome? Yeah, I mean, I think the other thing is the variability of the quality of the arthroscopy that was done as the index operation, right? So, I mean, I'm sure everyone in this room has seen some disasters and we probably have all had disasters. This is a whole talk about our own disasters. And there's a steep learning curve with this operation. And I think, you know, sometimes if the quality arthroscopy is not very good, then obviously the outcome's not going to be as good, right? If they have a big capsular defect or they have deficient labrum and you have to start doing crazy stuff, like putting minotaurs in there like Chad does, you know, or the double-double, you know, that obviously is not going to do as well as a primary arthroscopy. So I do think there is some selection bias with that, Travis. But the biggest question for me always is like, how can we make these people better? Like how can we improve the outcomes and what are we missing in the ones that fail? And I think one of the things that we're probably starting to talk more about is instability. I remember when I was really young and Shane and I were out at Vail and someone was talking about hip instability at the Vail Hip Symposium. We were looking at each other like, these guys are idiots. And now I'm literally giving a talk on hip instability. So how the tides have turned. Any questions about any of these talks that we can answer?

surgeon

hip pain

hip dysplasia

ligamentous instability

periacetabular osteotomy