Thank you for inviting me, Mark. So just curious, how many of you in the audience do more than 50 hip scopes a year? Okay. More than 25? Okay. All right. So let's see here. These are my disclosures. So great talk, by the way. It was really informative. So we're going to build on the hip capsule here. So the hip capsule we now know plays an important role in the health of the hip joint. And, you know, we start talking about the hip capsule, I want to say, around 2000, 22 years ago. And I remember the first time I started talking about that, I think Tom Sanson was there and other people. And we weren't sure, but we knew it was an important part of the health of the joint. And understanding the reinforcing ligament, that's the main issue. The iliofemoral is the most important one. It's the strongest ligament in the body. Pibofemoral and ischofemoral. So if you do your capsulotomy, one thing I've learned over the years is try to preserve the iliofemoral ligament. I think more surgeons are doing that now, and we have less issues with the problem with the iliofemoral ligament. Because our capsulotomy are more laterally based, or periportal. So this is how we perform our capsulotomy for us. It's about 12 hours of capsulotomy. We can approach pretty much all area of the joint easily. And to close that segment, we use 2-number 2-vicral suture. So this is a study that we look at capsular repair versus non-repair. And we look at 42 patients in non-repair cohort matched with 84 patients who had a repair. And if you look at the Modified Iris Hip Score and the HUS-ADL, this is just data that we published in arthroscopy a couple of years ago. We found that the non-repair group had a higher likelihood of progressing to total hips. Almost 7. You can have traumatic capsular tear. You can have hip dislocation, prior open hip surgery. And as you know, sometimes in the eyes. So some of us have done this. Sometimes we do a small capsulotomy. We don't close it. Capsulectomy can be a culprit. In rehab, the capsular repair can fail. And what I've seen more and more over the past few years is some of these two things can pull a labrum away from the rim, or it can actually cause another capsular tear. Talking about instability and micro-instability, we still have to truly define what is truly micro-instable. We spent a lot of time studying this in our lab. And if you have excessive translation between the head and the rim, we're talking about 2 millimeters or more, you can have what we call micro-instability. Now if you look at the video that was just playing there, the log rule test, you can see the spatial normal thermal torsion. On the left, there's an endpoint to exhalation. On the right, there's no endpoint. Okay, so how do we approach these issues with a capsule? Of course, it depends, as Dr. Safran mentioned earlier. If you have good tissue, you just can do a primary repair. And what we found for us in our practice, we use the ultrasound a lot in the clinic, and I always like to do an axial distraction test in the clinic, but also I like to do dynamic motion to see if we can, in extension and flexion, you can see if there's any protrusion of musculature to the capsular defect and we can reproduce the pain. So for us, when we see a capsular defect, we have a patient. So why would spend all that time reconstructing a capsule? And I remember one of the first patients I saw with these issues was a baseball pitcher, an MLB baseball pitcher. And he had a great surgery done prior by a very good surgeon, but he had a big defect in the front. Somehow he tore his capsule. And he kept telling me, Doc, when I stand on my back leg, I feel unstable. And the only thing I could find was the defect in his MRI on the capsule. So we went ahead and prepared for capsule recon, and it's one of the first patients we've done. And I remember showing that video at one of the other meetings, which has proved to be very helpful. So it can obviously give you some stability, restore the normal anatomy of the hip. But what I've learned is, and you can see that picture there, that psoas looks very angry, irritated. It's not only the psoas gets inflamed, but the muscle hurts. So I think plugging the hole has a lot of benefits. So this is looking at the effect that we have on hip destructibility with a capsule recon. We did a capsule study, and when we did the capsule recon, we found in vitro that it was not that significantly different from the intact state. So that was encouraging to see that in the lab. And again, when do we perform this? Well, when the psoas is, and it's a sonar declares being connected to the femoral neck. We see a lot of these adhesions in patients who've had physical therapy that was not necessarily aggressive enough. So this is our technique. We measure the defect first. And normally our reconstruction site, so this is how we prepare the graft. I like to use IT band allograft for this. Usually it's a fairly large size, and I like to fold it. Truly, you should spend a lot of time teaching them how to do this. It saves a lot of time because how many you have to address, subsequent impingement, preparing the labrum. So you can save a lot of time having your assistant train for this and actually. So we insert this graft usually to the lateral portal. The way I insert it, I place my anchor in the subspinal region at 20 degrees of fraction. Then at the end of the procedure, we cycle it to make sure we have good tension, and the graft is stable. And again, we do this with two portals. For us, I'm used to using these two portals, so we do most of our work through this. We use Grasper. We use a mini-pass type of instrumentation. So over the years, we've developed better instrumentation to make this very. Now we use an instrument that makes it much, much easier, but we used to use suture shuttle technique to pass a suture. But now we save a step. We just do everything through a lasso. Then we deliver the vial. I use number two vial suture for this. To get the suture, again, I use a flexible tool to deliver the suture to me. Again, this helps your life much, much easier. Those for us. So again, I like to use for me. I'm used to use the IT band So we use a allograft for this situation I fully graph three times Suture loop at the corner makes your suture management much easier inside the joint and the pitfalls When you place your graph In the joint You know, you just have to make sure that You don't get stuck in it. Sometimes these graphs are pretty large. You cannot put it through the cannula So I do it freely in the soft tissue. So again using lateral portal has been very helpful for us To deliver these graphs a very large graph. So this is our outcome We compare capsule recon versus with IT band versus dermal allograft the IT band allograft. So for the past last few hundred cases we've gone Results at midterm we had 39 patient and these patient were difficult for it if in the six of that group was converted to total hip at an average 22.3 and an average 4.3 year follow-up and They had significant improvement Hussie DL and Huss sport scale and with the mean survival of 5.7 So encouraging result again difficult group of patient If you look at the scores, I mean The good scores we have good improvement, but again This is a very difficult. Usually the aggressive intervention. I think it's worthwhile to Consider that option when he's on this difficult group of patient So again, we discussed as a capsule is now we know is important part of the joint integrated the capsule definitely Allows for stability But also allows for eliminate the pain generator that sometimes can come from muscular nation, especially the source mass of the minimus If you can do a primary repair, it's the best option But if you're not can it do it because too much tension the recount of the capsule has been dull and you want to reinforce It that's it also an option, but I don't have a lot of data on that yet so thank you very much and We'll pass it on

hip capsule

iliofemoral ligament

capsular repair

total hip replacement

capsule reconstruction