All right. So, 5 o'clock. Thank you, guys, for coming to our ICL. This is ICL 224. We're going to be talking about when and when not to use grafts, really during hip arthroscopy and what our clinical indications are, because we certainly have seen a pendulum with regard to how many reconstructions we're doing and whatnot. All of our disclosures are on the Academy website, and this is our faculty, myself, Mike Banfield. I'm out of Cedars-Sinai, Kerland-Jobe in Los Angeles. Liz Scott is down at Duke University. Tom Wirtz is here at the New England Baptist, and then Jovan Leskowski is at the – in Akron, Ohio, at the Crystal Clinic, correct? Yep. And, really, there's going to be no regional bias, because of the fact that I'm representing the West Coast. Jovan has the Midwest, Tom has the Northeast, and then Liz has the Southeast. So we'll have all of our different perspectives on how we're approaching these things. With regard to how we're going to do this, I'm giving the introduction right now, then we'll have about a half-hour discussion on the labrum, repair, augmentation, as well as reconstruction. I'll come back up, and we'll talk about the capsule and, you know, when I like to augment the capsule, and then Jovan will finish us off with the extra-articular, not just gluteus medius and minimus, but also hamstring, and augmenting those and adding grafts. And if we have any time, we have a small enough group here, you know, we'll do some Q&A. But let's get started, and I'll hand it over to Dr. Scott, or Dr. Wirtz. Okay, hi, for showing up at this time. See some familiar face from this morning at 7 o'clock, the ICL, so perfect, hardcore. Thanks for coming. And also seeing Steven, right, my PA in the back, it's awesome, because he does all the grafts, so maybe get some input there. But yeah, basically, I'm going to talk about labor repair, augment, reconstruction. I'm going to do the first part of the talk, and then Liz is going to take over her part. So let's just get going. So disclosures, nothing really close with regards to this talk, some website. Yeah, diagnostic workup in general, I mean, this is just general background stuff for any kind of patient we see. I think I want to highlight, again, injections, like we talked about pretty much in every talk today, how important they are, ultrasound guided. With regards to the labrum itself, if there's a tear or not, nice paper from Chad and Shane saying, well, actually, and Josh Harris, actually, the MRI itself really is not that helpful primarily to look at labral tears or full labral tears, but maybe more important to look at other bad stuff that might be going on the hip. But I think the value for me in MRI in this setting, when we're thinking about labor repair, reconstruction would be, hey, what's the size of the labrum? Is there a tear? Yes, no, but for all purposes, also, what's the size? Because one of the things we'll be facing is if we're in there and there's a small labrum, it might not be big enough for a repair, then we're thinking about reconstruction. So look at the MRI, seeing the size, not only cartilage lamination and a tear, but maybe also looking at if there's any signs of labral eversion. So it's not a sign of hip instability, something we want to address. So obviously, AVAN, all the other stuff as well, we want to see in the MRI. So labral principles, why are we so concerned about the labrum itself? It's a stabilizer with a suction seal as well. I want to be able to restore that. So do we have enough tissue to restore labral suction seal? And then the other biomechanical function of it as part of the stability, proprioception as well, I want to see if the native labrum has that. Reconstruct the labrum? Probably not, obviously. So again, ultimately, it's about stability. So what are the options? What can we do with the labrum? I could debride it. It's very rare, I would say, these days that we do that, maybe partial debridement in some cases, repair, reconstruction, or actually an augmentation. And with regards to reconstruction, it could be segmental or circumferential. Now, when I say circumferential, it's not going to be 360, obviously, 270 degrees. But around the globe, basically, that's the extent we could do. Well, is it repairable? That's the algorithm, basically, we're looking at. Look at the labrum, probe it, and see what's going on with the size of it, the quality of the tissue. If it's repairable, well, guess what? That's what we're going to do. Reparable tears, debridement, again, rather rare. And then reconstruction. So general OR setup, switch to a postless five, six years ago, I guess. And that's important, I think, overall, having a system where you can get the traction on and off easily. It doesn't necessarily have to be postless. For me, I thought, in the way I use the system nowadays, being postless is easier, worry less about the traction time. But for me, it's also easier in a reconstruction setting to let on and off the traction. So if I want to evaluate the labrum, I repaired it, and I'm not sure is it good enough in the end, I can let off the traction, do a dynamic exam, look at the label suction seal, and then easily put on the traction again. That's one of the other benefits of a system like that I didn't appreciate right at the beginning when I started. Portals, typically, I use three with a dollar. In a reconstruction setting, I might use a fourth portal as well. Post-reliable portal depends of what technique I would be using. For a shuttle technique, probably post-reliable. So again, labor repair or refixation, the goal is to have an acetabular rim with a nice labrum next to it that provides a label suction seal. The idea is to preserve biology ideally, proprioception, counter-label integrity, and again, that's label suction seal. I think you mentioned briefly the pendulum, right? So I feel personally the pendulum has swung a few years ago very much to, hey, let's do a reconstruction primary, you know, more and more. And I think that pendulum is swinging back. At least that's my personal experience and personal communication with my colleagues we see on these conferences. I think people are a little bit more cautious now of doing primary constructions or in a revision setting even also trying to see, hey, is there any tissue we could just try to repair? And you have good outcomes with a good repair as well, even in a revision setting. So yeah, again, you want to have that label suction seal. Something happened to the picture on the right. There was a nice label suction seal. But anyhow, so the idea is here to think about in the repair setting as well and later in reconstruction, the repair or reconstruction starts with portal placement. You want to have the portal in place so you can get to the areas of the rim you need to get to, capture management, traction stitches to get the capsule out of the way so you can perform a nice repair reconstruction, seeing the drill holes, having good visualization, facilitating the repair or the reconstruction. Suture passage then as well, depending what kind of grafts, what kind of anchors you use, knotless or not. And then also when the graft, when the graft, for example, is in, how do you manipulate and use the sutures to get around? So, okay, reconstruction is better as debridement, over-debridement, I would say, based on the literature we've developed over the last few years. So if you look at this labrum on the left, good luck trying to repair that. That's probably not going to happen. So if you debride that, then there's nothing left really. So the option here would be reconstruction. So now, can we back this up with some studies? We have, there's tons of outcome studies as well, but biomechanic initially, that was the studies that helped us say, hey, well, if you have a suction seal reestablished with even a segmental graft, there is more stability. So, okay, so what are the indications for reconstruction? Depends a little bit on who you ask. There is, I feel, a little geographic variation there for sure. So if you're living in the Denver area, it's probably a little bit more likely that you're going to get a graft. But, I mean, look at this top picture or the video. That's a revision. Obviously, you see those knot stacks, see the labral tissue, whatever's left of it. Yeah, that's not going to fly probably for repair. But if you go in there, and often if you're partially ossified a labrum, working on the rim, freeing up whatever you have, and then looking, sometimes you get surprised. Actually, this past week, Tom Byrd, Dr. Byrd, was in town with Traveling Fellows, and we had a case where there was a partially ossified labrum, and I got in there, I said, great. So he's in the back watching me, and now I have to do a recon, perfect. And I said, hey, so what would you do in this setting? He's like, yeah, you know, good question, let's see. Well, we'll start a little bit with a rim trim and see what happens. It did, and it had nice labral tissue. So just don't be ready for it, but you may not, even a partially ossified labrum, need to do a reconstruction in the end. Labral hyperplasia, so too small of a labrum, less than five millimeters. I think that's certainly something where we would think about a labral reconstruction. Everted labrum, so if it doesn't perform its function, because there is no suction seal, suction seal, then you probably would typically do a labral advancement, and if there is too much labral advancement, it's redundant, meaning you have to take too much acetalbarin to get a seal. Hey, Tom, can I interrupt you for one second? For that case that you had last week, on your consent form, were you consented already for a labral reconstruction? I consent every patient to a labral repair and reconstruction. That's the same thing I do as well. Yeah, and we always have the conversation, listen, most likely, very likely, it's going to be a repair. Now, if it's a revision, and say, well, most likely, it's still going to be a repair, but the likelihood of a reconstruction is a little higher. But everybody is consented for that. I would, I mean, probably you guys, Sam, or? Yeah, the majority of time I'll have to do that, unless it looks like it's something that's very easily repairable. Yeah, yeah. The same for me, unless some of my under 18s, or it's just a very clear, not macerated labrum, I don't necessarily put on the consent form, but I always talk to them about it in pre-op. Got it, okay. Yeah, we always have labral, like, grafts available. So yeah, ready for it if needed. So yeah, and then in a revision setting, I mean, the first one I talked about was primary, right? But revision setting, certainly, the risk or the need for a reconstruction is certainly higher overall. But again, I would give it a try, see what it looks like. Once you free up adhesions, maybe take out some loose suture anchors, or sutures from prior repair, and see what the labrum looks like. Probe it, prepare the rim as well. You know, often you're surprised you can still get something. So, hypoplastic labrum, less than five millimeter, calcified, ossified labrum, and then a status post debridement, so whatever's left is not good enough. Then I think, yeah, let's do a reconstruction. Augmentation, I think that's fairly rare for me. I've done a few, but overall, when it gets to that, typically it's more of a reconstruction, at least in my hands when I see it. You want to make sure, like in everything we do, that there's no other ideologies of their pain or discomfort. So, make sure you do a good workup. And obviously, a revision setting, make sure you're not just focused on the labrum. Make sure that everything else is perfect once you're done. You know, revision, residual cam, all that stuff you want to be addressing. Doesn't make sense to fix the labrum, but not the other problems that might still be lurking there. So, advantage to labrum reconstruction, it restores the labrum suction seal and improves, therefore, stability, removes pain generators. So, some of the ideas was, if you have a painful labrum in a revision setting, you just leave it in there, it's probably still going to be painful. So, the postulate was that if you take it out, that would be better overall. The flip side of that would be maybe taking out also proprioceptive fibers. So, recon versus augmentation. So, if there's no labral tissue remaining, then obviously that's a recon. Augmentation, I'm a little bit hesitant. I've seen some revisions now of people who did augmentations and there's a ton of tissue in there and there's basically a lot of adhesions. And I feel like if it comes to that, I'd probably rather do a reconstruction of the augmentation because I'm worried too much tissue in there. And let's see, moving on, there you go. So, here video of a reconstruction going around and then here this re-establishing that suction seal. Probably not well appreciated here, but the force required on the right then when we take it out and also do a dynamic exam was higher than without the torn labrum before. Okay, so I'm glad I changed the picture of Dr. Dohm here than is here. I had another picture, but this one is nicer somehow. You aged well over the last few years. Mike Almond is not here, I believe, so can't make fun of him, perfect. And Andy Wolfe. So, here I put those pictures up because basically these were the, and apart from Dr. Philpon as well and Dr. Wyatt, these were the main players to, like for me in the end, to pick the technique I'm using. So, I started with a kite and I went to the pull-through technique from Ben and Ligma from Andy Wolfe tried that as well. But in the end, I kind of had a little bit of a going back to the roots with the kite technique from Almond and Sanjeev. So, basically just different ways of doing it, passing the, shuttling the graft in and the kite technique. Basically, you use two anchors to kind of, as a shuttling device, pull through beautiful in a sense of, you know, you had a long graft in there and you can size it perfectly to what you find in there. So, you don't have to worry about sizing perfectly with measuring in the joint. So, that's another benefit here. So, why is it harder than a repair? Well, it's, you know, good luck. It's a little small tube and you have to- Are you changing your technique based upon size of the defect? So, if I have a larger defect, I would probably do that pull-through, exactly. Yeah. And then also use different anchors to different parts of the rim. But yeah, you have to get a thick graft through a small tube. There's a lot that can go wrong there, right? I'm sure all of us been somewhere in that position. So, and some of those grafts are stronger than others. So, I think, you know, in terms of graft choice, debent, posterior tape, fascia lata, pre-sutured grafts might be coming out now as well. But for me, in our setting, I'd like to use a fascia lata because I also have the luxury of having an awesome PA to be able to do and make a wonderful graft. Why fascia lata? Once you roll this thing up and put all the sutures in, it's a very sturdy graft. Posterior tape, swelling, a little bit softer oval, I think, you know, it might look nice when you put it in. But I also feel like when I probe, I want something solid in there. It shouldn't just look good, but should also feel good. And that's for me personally in my hands, that's the fascia lata works best. So, shuttling techniques, things can flip, the graft can flip, makes it nice and fun, right? For a good day. So, make sure you have good techniques going step by step without causing any problems there. And then once you have the graft in there, it can obstruct the view. So, the way I do it, I also pre-drilled my holes already. So, once everything is in there, I just have to pass the sutures and kind of refixate the graft in between my shuttling anchors. So, the more steps you have in any procedure, the more it can go wrong. So obviously there's more complexity here. And perfect sizing, this is if you do a segmental, for example, you don't do the pull through, you make sure you measure adequately. And there's different techniques to measure. And typically whenever I measure, so anchor to anchor for segmental, I would add five to six millimeters for what we do. But you know, if you do the pull through, you don't have to worry that much about it because you can size it in the jar. What density of anchors you'd like to use for these? Like your spacing, your spacing of the anchors? So I mean, I would say, you know, one o'clock at like each an hour, basically long clock phase, pretty much similar to what I would do in a repair. So again, complex techniques, you wanna make sure you avoid any other issues that might trip you up. So capsule management, traction sutures, sizing is important. Solid graft preparation. Again, have a good team to work with. If you, by yourself, you have to do the S-tubber and trim, debridement, then turn around, do the graft. This case takes forever. Ideally, you wanna have a setup where you go in, you realize, okay, needs a reconstruction. Say, let's go get the graft in, graft master, everything going. You keep going. You debride, you place the anchors, drill the holes. Then if the graft isn't ready, you let traction down, you work in the peripheral compartment, take any residual cam, get everything done. You need to get done, then get back, put traction back up, throw that thing in, fixate it, and then you close the capsule and go. So it's a team effort, and then more so in a labor repair, I would say. And then you wanna make sure you place those anchors, like in a repair, very close to the rim. Now, in a reconstruction, you can probably go a little bit closer to the rim and want to. You can use a curve drill guy there as well to make sure that you don't evert the graft too much. So again, technically demanding, needs experience, high skill level. If you're not comfortable with it, send it to somebody who does this on a regular basis. That's better than going in there and causing more trouble. An indication's obviously a key, and I think there, for me, it's like, what do you see inside? Do you really have to pull the trigger on during a reconstruction, or do you wanna try a good repair, being meticulous, freeing up the soft tissues and see what you can get? And sometimes that's a decision based on, hey, try a repair, and if I have this setting where I'm in between, I'm not quite sure, and I'll do a repair. I place the anchors in a way that I could, in between, place other anchors if I need to, let traction down, look at it, test the suction seal. If I'm happy, I'll leave it. If not, traction back up and do a recon. So. All right, the torch has passed. All right, so Tom did a great job going over indications, some of his tips, general tips for labor reconstruction. I'll take you through some of the more specifics on technique, and then hopefully we still have time for a case. There are my disclosures. So labor reconstruction, if you do a lot of them, maybe not so bad. Some of you might look at that picture and say, eek, how do I avoid this? As Tom said, what makes labor reconstruction hard for many of us, we may not do it very frequently, and any time you're doing a case you just don't do often, increases the blood pressure. Depending on your technique, you can start to feel like you have lack of control over graft. Like the picture on the right, it's in your face, you can't see anything, you put it in there, now what? You can have difficulty measuring the graft, have some mismatch, particularly once the graft is in and it starts to swell, of course suture management, and then difficulty accessing all the way around the joint if you need to do a circumferential labor reconstruction. So hopefully I can go through the steps here and give you some tips or make you feel a little bit better about how to do this. Yes, these are some of Jovan's pictures that I've borrowed. So I like doing a modified pull-through technique via posterior portals. This is originally Ben Dome's technique. It's actually not how I started, or how I learned labor reconstruction fellowship, but I learned that once you're on your own and you don't have a PA, like Steven in the back to make your graft for you, I realized I really liked this technique. The fellow or the resident or the medical student could keep a hold of the graft during the case, keep good control over it, and I no longer had to worry about measuring the graft. So I like it because it keeps the graft out of the way on tension, shuttle it in, again, no measuring required. No matter what size of defect you have, it works every time. And as I'll show, you can actually use knotted or knotless anchors in the middle. So whatever is your way that you, or whatever type of anchor you like to use, you can still use with this technique. So you just kind of choose your own level of complexity as far as suture management. So this is a four portal technique like what Tom showed. So you do end up making a posterior lateral portal through which you'll put the graft. I'm also, again, an iliotibial graft fan. It's uniform. You can, typically I use the whole thing, but if you want to, you can slice part of it off and reduce the thickness if you have a very small patient. I think you get less swelling of the graft compared to other choices. And particularly if, again, if you haven't done many of these, and this is going to be a long case, that can really play into your favor. And the entire graft in general is usable. So this is just my little cartoon there of how to prep the graft. So you're going to circumferentially prep it. You want to leave a long tag on your distal end. And typically, it generally ends up being about seven millimeters in diameter once it's done. But again, you can always take off some if you have a small patient. Acetabular preparation, you want to take your, uh-oh, it's supposed to play here. It's thinking. Very good. You want to take your time, really prep completely so you have enough space for that graft to sit, obviously while preserving your capsule. You can leave just a little sort of rim behind of the prior graft. It doesn't have to be completely bare. It's whatever is your kind of comfort level. Oh, now it plays, of course. Anchors, so again, you sort of have two options. You can do on the left, if you're a knotless person, you can go ahead and place your holes for your anchors and have them spaced out, know how many you need. Or you can do like the video on the right. So go ahead and placing all of your anchors and just managing them out of your four portals. So again, it's sort of choose whichever option makes you more comfortable. Graft insertion, this is my favorite part. So you're gonna take your far medial anchor. One limb goes out the mid-anterior portal. Other limb goes out the posterolateral portal. Thread and tie your graft on. And then in you shuttle it. And there it goes. Then it's really just a matter of sequential fixation. So again, if you are a knotted person, then it's just simply passing each anchor and tying down. Most critically, your assistant is pulling on that graft the entire time lightly so that it stays on tension, so that it stays out of the way of your camera. And for me, that was a really helpful thing when I switched this technique, is I just felt like I had a lot more space to be able to see inside the joint. Oh yeah, and then of course, final point is your last anchor needs to be passed through the graft, not just around it all. So that it is firmly fixed. So an ideal completed reconstruction should look something like this. Again, it doesn't have to be circumferential every time. This is just an example that it is. And then of course, test your suction seal. So make sure you don't have a labral mustache instead of a labrum with a good seal. And then again, why I've decided I like this technique is I think it's very teachable, reproducible, modifiable. And thank you, Jovan, for teaching me how to do this in lab. I think this picture's now from like four or five years ago. That was him and me at a Anna lab. And also Tony Ondraad, who I visited last year, who also helped me with this technique. I think we have time for a quiz. Yes, good. Okay, so of course I could have picked a case that is a totally macerated labrum or a completely ossified labrum, but then we would all say, well, yes, we should reconstruct it. So that's boring. So instead, I'll give you a more controversial case. So this is a 34-year-old peloton, pelotoner teacher. She's got a fairly normal lateral center edge angle, normal version, small, nothing exciting to write home about. There's her 3Ds and MR. Maybe she's a little anterior undercovered, despite having a lateral center edge of 36, like she doesn't just look like it on the 3Ds. And then small labral tear that you may not be able to see well. So I got in there, okay, a little cartilage damage, not so bad. But then when you look on top, you can see that there's a little bit of cartilage damage that's not so bad. But then when you look on top at that labrum, and once I put on top of it, I realized, wow, this is a really thin, small labrum, really, really thin all the way, there we go, all the way around, which I've now nicknamed the, you know, itsy bitsy teeny weeny yellow polka dot bikini sign. So what do you do when it's this small? Can you repair it? Or do you just say, nope, not doable? I think it kind of depends upon what Tom was saying. You know, once you start doing some of your rim trim, you know, you clearly want to be careful anteriorly there where she already is deficient though. And you see what you get. You know, I think that we did a study looking at the size of the graft that you need in there for stability. And you want to have at least six millimeters. And so to me, it looks like that's pretty small. This would be one that I probably would augment. I think that otherwise it looks healthier. Cartilage looks great. So I just put a smaller graft in there. And then with regard to passage, it's so easy to get that smaller graft in there and then incorporate the whole thing together. Dovan? Yeah, I'd be with Mike on this one. This is why MRI is critical, although it does not affect whether or not the labrum is torn or not, apparently. But again, you can assess how hypoplastic that labrum is. Rim trim, you got to be very careful on this one because she's anteriorly undercovered. But I would agree that augment would probably be the pathway here. And again, a segmental in this area, as long as you need it, would probably be wise. Because if you try to suture that thing together, if you tie a sliding knot on that, it's going to rip in half. And so your fixation is going to be tenuous. And are you going to be able to restore a suction seal in that particular situation? Yeah, I would agree as well. I mean, after rim trim, there's probably nothing that's going to look better at this point. So I would do probably an augmentation for this. Yeah, so that's what I wanted to do. In pre-op, I discussed potential augmentation with the patient. As it turns out, she really did not want a graft, partially for kind of belligious regions. So I did a repair. And to try to help myself, I put the anchors kind of on the face of the acetabulum, so sort of in the cartilage. And then was very, very careful and managed to get it repaired. And was very lucky that when I let suction seal down, I had a seal. But that was definitely a nervous moment. And then for contrast, and I'll show you a patient I had about three weeks later, Borderline. We actually indicated her for a hip scope and a PAO. She was hypermobile. She was seen by my open hip partner. And we decided we would do a combined case. And then she similarly got in there. And again, very small, hypermobile labrum. And I repaired it. And then I let down suction and really no seal. So again, augment, reconstruct, leave it. She's getting a PAO. She's gonna have more stability. You want a mic? I think I would still augment, personally. I'd probably leave it because of the PAO. It looks like capsular management was good there, but I'd be very meticulous about the capsule in this particular situation. I'd leave it. I liked it. Did she have like, didn't look at the acetabulum before, but was there a clear sign of, yeah, I see that secondary rim there. And that probably, if you look at the MRI in certain sequences, you'll see the labral aversion. Yeah. So you could advance that. But if you're doing a PAO anyhow, I think you're probably gonna end up. It's rare for me to do a primary augmentation or reconstruction, but on the ones that I do, typically it's somebody that has EDS or some collagen disorder. And I think that adding new collagen there is helpful, even with the PAO. Yeah, agreed. So yes, there's always the question, with a hypoplastic labrum, what is a good enough seal? I don't know if, you know, everyone's threshold in this room is probably different. We know what a great seal looks like, and we know what no seal looks like, but those ones in between are a little bit of a challenge. All right, that's all we got. Moving on. All right. All right. All right, great job, guys. So we're gonna transition over now to the capsule and encapsular augmentation. My disclosures are on the website. We know that capsular closure is critical. You know, the capsule's important. We used to neglect it. We used to think it was pathological and just leave it open. But many studies, both biomechanical as well as clinical, show that a good capsular closure's very critical. And Tom, when he was at Rush, looked at the size of the capsulotomy, and it's directly related to instability. But if you repair your capsulotomy, then that takes it back to baseline. The interportal capsulotomy, at least in my hands, is really the workhorse. I think that it really helps with regard to your visualization of the compartments. If you are trying to do something complicated, such as a labor reconstruction, I think that it's fairly critical to have. You are cutting through the iliofemoral ligament, however, though, and that can lead to some iatrogenic instability. I think the addition of a T is fine. It's not something that I regularly do, but if I have a very large can, then I'll potentially do that as well. And I think that the T actually is probably a little safer than the interportal. So you do wanna minimize that interportal as much as you can. In that regard, there are several surgeons that try to utilize a periportal capsulotomy technique. Alan Zhang, one of them, Mark Safran, Scott Martin here in Boston is a proponent of it. I personally find it to be quite difficult to do some of the more complex procedures with that, as opposed to interportal, probably just the way that I've been trained. But also Christopher Eddy looked at the outcomes of periportal versus a well-closed interportal capsulotomy, and they virtually were identical. So I really don't see a downside of doing the interportal as long as you can properly repair it. There we go. So furthermore, Steve Aoki has done a lot of work to support closure. He had a group of patients that either were not closed at the primary surgery or had failed their closure and had significant pain. And he found that they had significant instability at the time of surgery. And by repairing that capsule, he was able to restore that stability and had significantly improved outcomes. So he looked at all of his patient report outcomes pre- and post-disrevision surgery and found significant improvement. I don't know why this isn't advancing. There we go. And then finally, with regard to the clinical outcomes, Shane Nose Group looked at complete closure versus partial closure at both two years and at five years. And they found significant improvement with the complete closure. So all in all, we know the capsule is important. We know we need to close it. We need to get it to heal. So why would you augment it? If you're able to close it and restore that stability, like Tom showed with his biomechanical studies, that should be good enough. Well, they don't always heal. They don't always. And sometimes you will have them pop open. So if we can decrease the risk of that, that would be ideal. You also have situations in the revision setting where you have an irreparable capsule. You have a big hole in the capsule. So you need to close that with a patch. And I think that in some of the cases with the EDS patients that have this global laxity, you may want to do a capsule replication, but then also try to add something to that construct to increase the stiffness. So I think that augmentation can be very useful for that. And so based upon what your goal is, I think that that's going to determine what type of graft that you would utilize. So when I am closing the capsule, I really like to try to restore normal anatomy. This is a pretty slam-dunk case. I like to make my interval between my reflected head at the rectus and my capsule and just close the capsule down, usually with simple stitches, sometimes figure of eights, but just have a nice anatomical closure. But sometimes you're in a situation like this where you have this ileo psoas staring at you. You really have no capsule. It appears to be closable. And so with regard to the first augment I want to talk about, it's actually the patient's own biological augment. I do think that the reflected head can be quite useful in a situation like this. So this is that case. This is after her T-capsulotomy has been closed. Now I'm proceeding up into the inner portal. So you can see that ileo psoas staring at you. If you don't close that down, you're going to get fluid tracking up there, and they're going to have intractable pain, and it's a nightmare when you're trying to see these for the next six months in your clinic. I'm creating that interval in between my reflected head and the capsule, and then I think that this sub-spine anchor is critical. This can really help you cinch down your capsule in front of that ileo psoas to close off that ileo psoas notch. So I pass those sutures down through there. That's going to bring my capsule down, but it's still not very good tissue. It's still pretty thin tissue, so this is where I think that utilizing the reflected head is quite nice. So I'm placing some stitches in here. I'm using a figure of eight, and I'll be able to close that down. But I do worry about leaving that reflected head intact. I think that there's going to be some pull in there, some pull in the capsule, and that can lead to some pain. So what I'll do after I've incorporated this is actually release this distally so that just the biological soft tissue of that reflected head is adding to our capsular strength there. And then after you've done that, you're able to close the remainder of the capsule. So I think that in the right circumstances, this is a 24-year-old girl. I was not thrilled about trying to put a graft in her in this setting. But it worked out quite well. Then in the cases that we have where they just have capsular instability, and this can be in a patient with a collagen disorder that you're getting from the clinical history. I also think that when you're pulling your traction in the OR, if you're able to, you know, just do 50 pounds or less and they open up a centimeter, to me that's clinical laxity as well. These are the ones that I'm going to be placating. This is, you know, a technique that Ben described, gosh, probably a decade ago at this point. But he's doing an inferior shift, really trying to accentuate the screw-home mechanism of the iliofemoral ligament. And I think this works quite nicely. Another thing that I like to do that I got from Mike Salata is more of a mattress-type stitch. So I've taken my stitch and put it in a horizontal mattress setting. And the nice thing with this is you really can dial in how much placation you want depending upon how much of a bite you get from your femoral limb of the capsule. And once you tighten this down, it'll really be a pants-over-vest sort of situation with those two limbs of the capsule. And it can make it, I think, another form of a placation. Mark Safran has also described doing more of a rotator interval type of a placation. And we looked at all these in the lab. And the surrogate that we're utilizing is external rotation to see how much stability you are, I guess, you are gaining from that. And they all actually have their own benefit with regard to all these different techniques. So really, whatever's best in your hands. But I do think that adding something as an augment to this as well is quite useful. And I think that the bioinductive implants can work quite well. You could consider utilizing a dermal graft here as well. But I think that with the techniques we have and the instrumentation, this makes it quite easy just utilizing these PLA staples to introduce this. The only thing that you got to remember when you're utilizing these is these are designed for the shoulders. So sometimes in our patients, the instrumentation or the cannulas are not long enough. So you do have to be creative with that. And I have some other videos to show that as well. But from a clinical outcomes perspective, this has actually worked out quite well. It's almost gotten to the point where I wonder, gosh, you know, if we can figure out the cost effectiveness, should I be throwing this on everybody, you know, if it's going to save me, you know, people that are not having their capsules reopen or something like that. Not saying that that occurs too often, but even the two that occur throughout the year is enough to make me want to add something to try to avoid it. And then with regard to capsule reconstructions, when these people have these multiple surgeries and they have these huge holes on your MRR program, I think you certainly need to be ready to put a graft in. I have been prepared to put a graft in much more than I have actually put the graft in because typically you can't get these closed. Liz may be able to speak to this because I think that she does quite a bit with she and Chad down at Duke. And this is actually one of Chad's videos here. This is, you know, you can see that large adhesion coming across from the labrum over the head of the femur. You can peekaboo your iliopsoas in the front there. So this clearly needs to be brought down. And obviously this is something that you're not going to be able to utilize the reflected head of the rectus to try to close down. So I think that this is the correct indication for doing a capsule reconstruction. He's doing this with a dermal graft, essentially like you would do a superior capsule reconstruction within the shoulder, where he's placed his anchors typically between the 12 and 3 o'clock position on the acetabulum and then shuttling these in. This is somewhat of an older video that I probably got from him maybe five years ago. You can see he may have changed his technique. I mean, when I've done this, I've done it this way. I've actually tried to use the device that one of the companies have that will actually put the patch in for you, not the bioinductive implant, but actually a dermal patch and secure it that way. But frequently that's far too short to be able to work within the hip. The issue with capsule reconstructions and the reason why I try to avoid them if I can is just because they're not great. I mean, it's still a very procedure to utilize in a salvage-type position in that if you look at the biomechanics, and this is from Philippon, if you compare the reconstructed capsule compared to not even closing your inner portal, you still are not getting the same stability. So I think that it's an improvement, but it's still not going to be the gold standard. So even much more so than doing a label reconstruction in our primary cases, you certainly don't want to do a capsule reconstruction on those. So you've got to have good capsule management to try to avoid that. And then Philippon did look at his outcomes. He compared IT band, which he folds over a few times to get around three millimeters of thickness, versus a dermal allograft. And he found that the IT band actually did much better, likely probably to its stiffness. And then he looked at his outcomes over three to five years, and he did have 10 failures during this time period. But of the remaining 29, they actually did quite well with regard to their hip outcome scores. So we — Mike, quick comment. Yep. For the dermal allograft, it was really interesting. I've done a handful of these, thankfully, and most were patients referred by other surgeons. But one of the things that I found that makes a significant difference if you're using a dermal allograft, the epidermal side should go on the side of the articular cartilage in labrum. Otherwise, it tends to be this big, scarred-up, giant mess, and they tend to lose a lot of external rotation with it. So I think that that matters, because we want it to heal to the S-tabulum and the inferior limb and the tissue around it, but not necessarily to the labrum repair or recon, if you have to do that. All right. So I have a case. This is a 44-year-old female, has a documented diagnosis of Ehlers-Danlos, so genetic testing. And she's had her right hip scoped about a year ago. It was a revision that I did on her and did well. Now she's coming to get her left side done. She's failed all conservative care, you know, and really wants surgery. So you guys can't say you're going to try to treat this nonoperatively. And this advances. This is her MRI, just some of the pictures, so you can see that really wispy capsule. So I know what I had to do on the other side. So with regard to this, what's your conversation with the patient? What's your surgical plan? Well, and this is a primary case, this isn't a revision, it's just a primary case. Oh, it's just a primary case. Um, I mean, so I think you have to, no matter what, you have to Yeah, I think maybe, but typically for me, it's always a repair for the capsule, unless you really, if it's super wispy and whatever, but I don't think I've ever done it. Mike, go back to the films. So, the second that I look at her plain films, everything to me screams danger, danger, danger. You've got a valgus, anti-vertebral neck, you've got a decrease in the femoral interval. The MRI further increases the danger because we've got a wispy capsule that does not look substantial. So, number one is your approach to this should be very, very, very cautious. I know we've indicated it for surgery, but your portal placement is critical. You have to be as low on the head as absolutely possible because if that capsule tissue is going to disappear, it will always be from the proximal leaflet. I will be locked and loaded with multiple suture tapes. I don't know if I would have had a pre-op talk with her about augmenting the capsule, but I would tell her that we may have to do more than not, and these folks post-op tend to stretch out everything that you do. So, be locked and loaded. Read Ben's paper on capsule placations. They still use this technique in these particular situations. So, that's my concern, that not only is it thin, but the quality of the tissue. Exactly. Because of EDS. So, for me, and I kind of gave this away when Liz was up there, I actually did a labral augmentation as well because I wanted to give her as much stability. I was able to pull her out with 25 pounds of traction. So, very unstable hip. But with regard to the capsule, just as you guys are saying, I like to do the placation. So, I did more of a mattress placation like I was describing before. And, you know, her capsule tissue was robust. I was able to get a nice repair. But, you know, in this particular type of patient, I think that this is, for me, the gold standard is the augmentation. So, utilizing one of these bio-inductive implants, this is a size large. And with regard to the length of the instrumentation, so you can see I'm not utilizing the standard cannulas they have. Utilizing a slotted cannula and then going down there, just so you're not constrained, but you're able to get a very, you know, nice circumferential placement of all these PLA staples. And, you know, she did well on the other side, so hopefully she'll do well on this side as well. Was that based on your paper in 2021, you get a bad duct tape? Maybe. Mike, the other comment that I'd have is suture tapes are your friends here for capsular closure and placation. Significant difference in the amount of capsular tears I had switching from number two fiber wire to a suture tape type device. They tend to grip that attenuated tissue better. They tend to hold it better. And if you want proof, just try to pull your patient off the table using your capsular sutures, number two versus tape. And you'll notice the tapes, you can actually shift the table around. How often are you guys assessing traction after you've closed the capsule? I know Josh Harris does that routinely. I never do it. It terrifies me. I don't either, Mike. Why put in all that hard work? Well, I'm gonna hand it off to you, Javon. We've got about a half hour left and let's do some extra articular stuff. Okay. Are you putting the staples in the capsule or in the cup? Into the capsule. Yeah, they're small little dissolvable PLA staples. Thanks, Mike. Well, yeah, now we get to move outside the hip joint into the extra articular space. And what you're really gonna hear here is a tale of two tendons. And what I mean by that is there could be not a better juxtaposition to the hip surgeon than the quality and attenuated nature of an abductor tendon tear versus the quality and thickness of a hamstring tear. My disclosure is available on the Academy website. So we'll start with kind of a brief overview. We'll talk about the different type of grafts that are available. We'll start with gluteus medius and minimus, and then we'll move on to hamstring tears. And really the take-home point for me, for all of you for this talk, is the true difference in the quality of the tissues that we're working with. As you guys know, the history of abductor tears has been very, very brief. Started in 1997, Ben contributed greatly to the field with his paper describing partial thickness tears. But really we were blind to this for a very long time. And I remember one of my trainee, or not trainees, but one of my mentors as a resident said, you know, Jovan, there's only two problems in the human hip, arthritis and bursitis, and they both go away eventually. And so he couldn't have been more wrong, and we've learned so much along the way. What I will tell you is the patient that comes to you that's referred with chronic greater trochanteric bursitis, there is no such thing as that. But the majority of these folks have tears. This is from the radiology literature, looking at both MRI and ultrasound. And really what I want you to understand is there is a multitude of people that suffer from this problem. It's a predominantly female problem. Nine tears for gals to one tear for guys. I helped Femi out with this paper. We talked about some of the findings that you'll see within the joint here when people have symptomatic GTPS and the implications upon outcomes for these folks. So why did I get into this space? Why did I start augmenting my repairs? Well, I went through a very similar journey that I think most of the people that treat these in the room are. If you look at the radiology literature, which is where most orthopedic failures hide, that failure rate's somewhere between 16 to 35%, perhaps even higher based on more current literature. And I got sick of seeing this. This was one of my X-ray texts that I put 10 million sutures into and ended up with a re-tear, essentially a biologic nonunion of her repair. And so this, really when I think about this for both my abductors and my hamstrings, what are my indications? When do I indicate somebody for augmentation? Number one, massive to large tear size. This has been well-bore out in the rotator cuff literature. But again, we know that large rotator cuff tears heal very, very poorly and have a very high re-tear rate. I believe this is the same for abductor tears, a little bit different in the hamstring world. Medical core morbidities. For nicotine users, they must quit. I'm proud to say I've gotten most of my patients to quit other than my own dad who smoked for like 50 years. Diabetics, I wanna make sure their hemoglobin A1C is under control. And then any real catabolic process, I look at my rheumatoids that are on the DMARDs, people that are fighting perhaps cancer or something along those lines. Those are all catabolic states. And those make me more keen to augment my primary repair than not. Re-tears, revisions. Mike and I were talking about this before this talk. Re-tears, revisions are almost always gonna be a go for me for an augment. You wanna be critical of how much atrophy you have in your muscle belly. And then again, tendon tissue quality. And I'll show you a couple of demonstrations of that here shortly. Sorry, the clicker's acting funny. So Jovan, do you have a abductor that you do not augment? So I've gotten so far overboard on this that I'm probably fixing 95% of my primary repairs with an allograft or with a synthetic graft. My journey on this, I started using what I was taught. I spent time with Brian Kelly after fellowship and Tom Bird wrote a wonderful paper on the technique here. What I was puzzled with was this was a really difficult operation. And I felt like it shouldn't be a difficult operation. So I took everything that I knew from the rotator cuff world and essentially tried to apply it to this. Is there a place I'm supposed to point? Here's it. Over here. Over there. Maybe there's a better clicker. Anyways, so I make these portals under direct fluoroscopy. And the reason I do this is I want you in your mind's eye to think you're approximately to your lateral portal is almost a 50-yard line view, an over-the-top view of the peritochonturic space. And then if you line up your dollop portal with the lateral facet, that'll make antegrade suture passing easy for you. It'll be easier to slide under that tendon. It'll make it more efficient. So what about the IT band? So Robbie Westerman and I wanted to understand, okay, what should we be doing with the IT band? Is this something that needs to be preserved? Does it need to be split? Is there a difference? And sure enough, an IT band split, although it causes a higher level of pain postoperatively early, the retear rate is lower. I was publicly shamed once when I gave a talk on glutes that I was opening up the IT band. So I went through a phase where I closed it after I opened it, and I caused about 20 cases of snapping IT band. So if you do open it, leave it open. And I'm not talking about a huge whack. This is from the vastest tubercle, just the tip of the greater trochanter that'll help offload that. If there's one thing that you need to understand, if there's one thing you remember from my ramblings, it's this paper, December 2019, JBJS. You look at the anatomy of the gluteus medius tendon and its insertion is the same for the minimus. That tissue can be less than a millimeter in some cases. And truly, right where the two tendons join is where that tissue is the thinnest. That's where most tears originate from. And that's where the idea of augmentation came from. So is this true in the real world? It is indeed true in the real world. There's a great example of a full thickness tear. We can see that in thesaphytic change, and you can see how unbelievably thin and attenuated that tendon is. As one of my mentors, as the resident said, like doing a Brostrom is like sewing snot to a moonbeam. I would argue that this tissue is the same. Highly attenuated, not great to be able to repair and grip with, and again, augmentation is critical. Now, augments don't matter if you can't do a good primary repair. Great example in your upper left, that was a full thickness tear of the medius and minimus who came to me from out of state. Four triple-loaded anchors, so I'm ensuring that my primary repair is going to be stable. Augmentation is not a panacea unless your primary repair is stable. You can do single or double. Understand that your footprint coverage is better with a double row, but that does not increase the strength. It is truly the amount of sutures through the torn tendon tissue that matters most. So open versus scope, I debated Brian Kelly on this. The irony of it is I flew out to New York City to learn how to do this for him, and now he's going open. His argument was time. It's so much easier to do it open, so much faster. I can tell you because of the new portals and being able to be fast out with this, you can do this as fast if not faster than an open repair. But the addition of lowering the complication rate, the addition of lowering the blood loss, these are patients that tend to be older. They may be a little bit more frail. This is a great way to save you from getting into complications overall in an open versus a scope. This I give my wife credit to, the simplified shuttle technique. She saw me in my office trying to figure out how to make augmentation easier. I had a shoebox with multiple canulas stuck in it and a bone block glued to it, and I had about 300 sutures going left, right, up, and down. She goes, what are you doing? I'm trying to figure out how to get this piece of tissue in the shoebox through this little canula. She goes, just make it simple, dummy. And that was my eureka moment. What this allows by using two sutures and two sutures only, you have the bull by the horns, and this allows for what we call in situ tensioning of the graft. I'm going to pull that graft until I have absolute perfect contour of that to my underlying abductor repair. I can place my anchor right where that ring suture retriever is, and for my resident, it leaves a bullseye in that dermal graft in order to pass that suture. Now, this is a spattering of a couple different grafts. You can see on the far right, this is a newer graft that is both structural and bioinductive. That's bovine type collagen on your far right with a PLLA mesh into it. The middle is a pure bovine type on collagen. There's no structure to this at all. It is purely bioinductive. My end of about 25, it simply could not withstand the forces placed on the abductors, and so we got away from that. And then my old kind of fallback, Acellular dermis, is on the far left. We've been adding a bioinductive pledget to these as what we call the sandwich technique, and again, because that is purely structure, pure biology, and a mix of both structure and biology. Do these heal? So this is a great example of a patient that I caused the iatrogenic snapping IT band on. Good for me. And so we went back in to do an IT band resection. You can actually see that these grafts do indeed heal. They do indeed bioincorporate, and you can see the epidermal layer never totally changes completely, but the deep layer to that on both MRI, and you can see it on ultrasound, bioincorporates into that tendon, and it makes for a really nice outcome for somebody who has a thin, attenuated tendon tissue. So failure rates. So there's not much in the literature about this, but you can look at this one-year outcome study, 96% satisfaction rate, 2.7% retear rate. You can look at the video on the right. That's one of my failures. I left the graft short of the anterior facet where the minimus inserts. It is indeed like a double-row repair. It's a stress riser in that area, and you can see a macerated, full-thickness tear of the minimus that we had to do an augmentation. Looking at seven to 10-year follow-ups, this is the large implant that we were talking about, and that showed 93% satisfaction rate with an 8.2% retear rate. So these do indeed work. Again, this is a powerful tool. I want you to really, really, the take-home point is this is a thin piece of tissue that we're repairing. The medius and minimus are thin. They're attenuated. Think augmentation more often than not. It'll make your life a lot better. We'll switch gears here and go to the hamstrings. Thomas? Great question. Just since we're on those grafts right now, structural versus bioinductive, for example, what's the, you've obviously done a ton of these now. I've had a couple revisions where somebody had put a structural graft in, and I went in there, and it was just like this floppy piece of tissue that was stuck on top of, like it was not integrated at all. Any pointers, anything that might have gone wrong, done wrong, or anything based on your experience? Or maybe also to the audience, I guess, or the panel. Yeah, anybody who wants to chime in, please chime in. So I would call that a biologic failure of integration of the graft, and I've had those before. Far more easily detectable on dynamic ultrasound than they are on MRI. And again, you can have your ultrasound technologist and your ultrasound radiologist- Just on top. Exactly, abduct them, and you can see the graft dance a little bit. You noticed that how tight my grafts were on that? I went to using suture anchors, very small 1.8 millimeter label repair anchors, in order to fixate that graft, because again, the tendon tissue is not reliable to hold that graft in place firm enough to allow it to heal. Michael? Yeah, I completely agree. I think that it has to do very similarly to the density of suture anchors for a labrum. I think that what I got from Javon several years ago is that these grafts are stretchy, and you can just stretch them out to put them exactly where you want, and then that will readily compress that area to give you that biological compression. And what I did in that revision setting then was also just to fixate them and then do a double row on top, like a suture bridge on top, so to get it down. But the other thing, bioinductive, I'm not gonna mention obviously any brand names, but I did that for a while, and I had two revisions I needed to do. And why? Because they had huge seromas. And one of them kept draining, and it was the only time I actually had to wash out something the whole time I practiced. So I stopped using that. Have you had, maybe also in the audience, anybody similar experience with like overwhelming kind of inflammatory response that seems to be going on basically? I don't know if it's the staples or what the thought is of you or the audience. I've certainly seen it. And initially, it made me stop using it as well. But I would say that it's actually really the minority. Maybe 5% of the time, people have like this weird reaction to it. So I've started using it more, but only for really good tissue. So really good tissue in a younger patient that has like calcific tendonitis or something like that, where I'm just trying to augment with a small little repair that I did. Yeah, I'll just add. I've also found, I agree with you, that ultrasound is very helpful post-operatively evaluating these. I've had a few that I've re-MRI'd, and even at an academic medical center, they just, they don't know what to do with the augment in there and the repair and muscle that may not look so good anymore. But when I've sent them to ultrasound colleagues, I've been able to get a much better read on exactly what was going on with the augment and the tendonitis. Yeah, and I would encourage to explain to your colleagues in the radiology world what we're doing with our augmentation graphs and what they're able to see. So we actually did a, like a dinner and learn, and we brought acellular dermal tissue and had them look at it on saw bones with ultrasound so they would understand what that looks like, both hypoechoic, hyperechoic, et cetera, et cetera. And the graph thickness does affect that. Ben, any comments? Tom? Our more experienced folks. Thanks for everything you do at Arthur Scott. Yeah, it's a remark. It'll it'll adhere to the underside of the IT band And it is sometimes I'll make accessory accessory portals to try and release all that But I learned how to do that from all these horrible retracted rotator cuffs that I ended up inheriting The deep side as well. I have an old video if you drive into a partial thickness tear on the deep side and look up at The scope it's remarkable. It's blown to hell and there's all these little adhesions left right up down everywhere else How much time we got 12 minutes. Okay. So a proximal hamstring tears I think of these in two different varieties the full thickness everybody in this room knows it's the big eggplant leg I'll show you an example that what I want you guys to start to think about is the partial tears I will tell you that that as much as I love how Martin I feel he's led us astray The majority of what I do in the push your hip has been partial thickness tears We've nicknamed them amongst our group of friends as the hidden hamstring lesion ones that do not show up on MRI that can be detectable either arthroscopically or by MSK ultrasound Again, I like to test these both seated and prone at 90 and 30 Housework shows that 30 degrees will isolate out. Send my member gnosis a little bit better again. You're not gonna miss this This is the old eggplant leg. Those are the full thickness tears I will tell you that you can have a full thickness tear without this giant eggplant leg like if the fascia of the Proximal hamstrings does not go they'll show up with just a scant amount of yellowish greenish drainage around their knees So don't think this is just path to mnemonic But in that case you can know that it's fully torn Every single time in terms of this that we published on this years ago with Carlos Guanche Thank you to Carlos for teaching me how to do this Came up with a new portal and a little bit different approach than how Carlos did it and we actually kind of changed together In the and as this is developed and I'm addressing now all tears including full thickness tears We published on the new inferior medial portal. This allowed it repair all acute hamstring tears. We published on this in December 2023 This is how these cases start the subglutal bursa We call this the positive Dixon sign after my nurse Megan Dixon If you get the scope underneath glute max cleanly and you're in the subglutal bursa, it always looks like this in a partial tear It's red. It's bloody you may get confused This is where fluoro comes into play and with fluoro It's like using GPS to make your way home If you've got bad traffic, it'll get you around it And then you simply start to clean that bursa off What Carlos liked as I started from an area of relative safety on the medial aspect and work my way lateral He did a little bit different, but I got him to change eventually this credit goes to howl and also my terrible lower back Understanding the issue for moral biomechanics is critical If we abduct the leg and move it away my shavers on the ischial tuberosity The sciatic nerve goes with the femur that abduction technique will move it further away This will give you more room to breathe as you're addressing these both open and endoscopically, but those are true It's great from my lower back because I could just stand in between the legs Rather than trying to operate like this for 45 minutes to an hour So partial thickness tears. This is the classic hidden hamstring lesion So we've cleaned off the bursa laterals to our left medials to our right Look at how unstable that is that was read as mild tendonitis tendinopathy on MRI And again, this is by an experienced board certified MS MSK radiologist I sent this case to my Ultrasound colleague who said yeah, maybe a 25% tear or so of that tendon This is what it looked like when you got into it So you can see the ischium huge and testific change there You can see all these collagen fibers that have failed over time And again, I think two things happen one is we like supine in the MRI So the hamstrings is crushed up against the ischium number two is just like I showed you that example of the large Echemosis of the thigh gravity will eventually drag that fluid out It's not like a cuff where it's entrapped by the deltoid itself. This will drain down the leg in a chronic situation I just scoped a patient, North Carolina last week five years of pain and his initial MRI showed a high-grade partial thickness tear His most recent was read as tendinopathy and I think that fluid drains because it has a place to go and gravities in the works To tendon tears. These are great to address through the scope. You can see our ischium. They're not much retraction We got lucky the most lateral aspect hung tight there And these are nice because you can find the stump readily And even if you want to convert this to open this gives you a great chance to be able to place your anchors Anatomically, I just did another one last week from Utah where the anchors were placed in the inferior pubic ramus It was an open case that was done rather than in the true ischium So even if you're not going to do these endoscopic from start to finish It's like the old days of shoulder arthroscopy You can put the scope in you can get your anchors in an accurate place and you can even tag that distal stump of the Hamstring three tendon tears. This is again a great indication to go scope first We can see inferior ramus on a right quadratus femoris at the bottom, right? And the ischium sitting there as bears the baby's butt essentially this will allow you to prep that area You can place your anchors And if you're brave enough, you can find that stump attendant The other advantage to doing this is the scope fluid will dissect out that exact pathway down to the stump of that tendon It'll make your open repair far easier. This is a great example what happens when you wait too long This is four and a half to five weeks 10 centimeter retracted tear There's the stump of the tendon to our left is the sciatic nerve and I looked at my scrub tech and said who crapped in My pants adductor magnus there. There's the proximal ischium. And again, how do we control that stump? How do we get a hold of that? How do we protect that nerve and and really the credit goes to my grandfather on this So this is the hamstring pulley technique. So my family's from a tiny country that used to be part of Yugoslavia He had a pulley in his barn that we would use to take bales of hay up top So I said, well, why can't we use this for a distally retracted hamstring tendon? So double-loaded all suture anchor at the very inferior aspect of the ischium. We find the stump We're using our inferior medial portal and you'll see as I activate that pulley What this will allow you to do is identify any areas of scar tissue around that stump You can see as we're delivering this up into the surgical space. We're gonna be able to better visualize this You can see what adhesions lie Distal to this and make sure that it's going to be mobile enough for you get this anatomically reduced back down You can see my attendance junction there and you can see 15 centimeters retracted We got another three three to four to go. But again, this is something that can be done Endoscopically for these high-grade partials retrograde suture passing is a very very nice technique I try to plan my medial portal based on their ischial angle So in the MRI the night before I'll measure an angle and I'll try to get this so it's in line and parallel Just like I showed on that glute and this will allow you to pass the sutures efficiently. We're going outside the box This is a labral repair device rather than you know Our traditional tendon repair devices But you can see we can get these sorted out and you can pass a tremendous amount of sutures in a very short amount Of time on the lateral leaflet. We're using that same medial portal You can see the sciatic nerve and push from case nerve is far to our right side of the screen there And you can use self retrievers or you can if you have a skilled assistant you can pass there And again, you can be expeditious with this These don't have to take a year in a day to do good fluid management good visualization techniques here And you can work back and forth and do these rather quickly This is a great example of another partial thickness tear three triple loaded anchors I've since switched to suture tapes like we discussed about in the capsule portion of it But you can see here three triple loaded anchors for a total of 18 sutures Nine on the medial limb nine on the lateral limb and these are in a horizontal mattress configuration You can even do these in a Mason Allen. I know some people have talked about using a double row for these comment Mike no, okay looks like it's I'm gonna say Full thickness I'll use a combination for these the most simple is an integrated suture pastor. So we've got control of the stump This is about six centimeters retracted and we're using a Mason Allen configuration Our black stitch is a horizontal mattress and we've got two verticals interspersed between it between those stripy blues and the solid blues Once we repair these down, this is that same tear I want to assess is this an anatomic repair? Is this keyed into the footprint of the ischium you can see right there? There's our first perforator from profound ephemeris underneath quadratus femoris There's the sciatic nerve there laterally and I do a little stress test of the aura I want to make sure these are solid repairs and these are ones that are gonna be able to stand the test of time So why augment these the whole point of everything I showed you these are thick durable tough strong tendons So the first augment I ever did was because of a crab very wealthy patient who had houses all over the country including a beach house in Rhode Island and a five-story ski chalet in Vermont walking along the beach three months post-op crab bit him on the toe and Ended up retearing so this was an earlier case not the same one that I'm going to show you here But you can do this with a dermal augment same technique. We're gonna shuttle this into position this I'm fine with you Using you know suture shuttle techniques grabbing the tendon itself because again, this is robust thick tissue It's the it's the contra distinction to the gluteus medius and minimus and you can see the completed augmentation there Again, this was that newer graft that's both synthetic and type 1 collagen. We've done a revision repair on this patient This was the crab one. You can see my resident struggling to tie knots there. That was pretty funny to me So I thought I'd show it to all of you But again, we're using that same kind of technique you can see suture lasso again grabbing that nice bite of tissue They're shuttling a PDS in place and then using that to shuttle a suture tape in place And you'll see once we shuttle this into position suture tape will slide through this is an oldie, but a goodie This is how people repaired rotator cuffs back in the 90s But again a great way to do that and then again, we're using that same in situ tensioning We want to make sure that this is going to be contoured to that underlying tissue This graft is different than dermis. It does not have compliance It will not stretch and give as much as a dermal graft So understand that when you do your inside to tensioning and then you can see this is the completed repair with augmentation But again, if you're rich rich people like to do rich things So what we ended up doing for them is adding a little bit of plate rich plasma to this So basically bathe the graft in it money wasn't an issue to them So we added a bunch of orthobiological that he'll thankfully patient did quite well So what about chronic one? So I was not as smart as Josh Harris Josh Harris did one of these and bailed I did three So for a chronic retracted tear you can do use Achilles to augment and bridge the gap My end of three showed a very very poor outcome. My friend John Christopher Eddie showed this This is a great example of adapt innovate overcome He did it open but he realized how far proximal the issue was so he put defogger on the lens of the 30-degree orthoscope and use that to Dock that graft into position on the true aspect of the true lateral aspect of the issue and then bridge that with a an Achilles This was Josh's end of one example a beautiful dissection of the sensory nerves there and you can see that bridging gap again They still in my hands at least perhaps Ben or Tom can chime in did not work very well for me So again a tale of two tendons. We've got one set of tendon tissue That's attenuated and terrible and difficult to sew and work with augment all the time the second is Robust thick tendon tissue that you can get great bites on and it'd be able to get an anatomic repair Understand that augmentation works understand what your indications are and again understand the differences biomechanically between these tendons Those are my kiddos best part of my life But my boy gets a special shout out because that was the second degree black belt test last Saturday and he broke two bricks with his bare hands. He's done. Thanks A great job Javon. So we just really have a minute left. Is there anything from the the audience any questions? So, so what percentage of capsule do you think you're closing now? And just to pull you guys, how many sutures are you typically putting in? Or not even sutures, how many passes across the capsule? So a figure of eight would count as two. Four. Two figure eights for the average microscope. Three to four. Three samples across the inner portal and one across my little mini-teeth. But suture tape. How about you, Ben? Four is average. Five or six if somebody is going out of state. About the same for me as well. Eitan, your paper was partial closure versus complete closure, and you just found a trend to be even better with the complete closure, correct? It brought to us what I think is our primary problem. I want to thank my faculty as well as the audience for participation. You guys have a great meeting.

hip arthroscopy procedures

grafts

labral repair

augmentation

reconstruction

biological augmentations

synthetic augmentations

modified pull-through method

irreparable tissue

abductor tendon tears

hamstring tears