I know we're a little bit beyond time, but we have our experts, Dr. Philippon, Dr. Lahl, and actually Dr. Jeff Nepple has been kind enough to stay. I'm happy to take any questions that we might be able to answer. Hopefully, you found this useful. Dr. Fritz? Do you encounter patients who have their, you know, potentially have a genetic error of psoas tendinitis? Yeah. So, I mean, I think daily psoas is an important dynamic stabilizer of the common, and we see that wear pattern intraoperatively with that. But, I mean, I think that that's a difficult problem to treat. The ileo psoas, when you've had to release, generally it lengthens but isn't a component as best you can. And if there's a capsule defect, I think you need to repair the capsule. You know, you need to try to give the static stabilizer at least a chance, the reparation of the capsule slash iliofemoral ligament. So, I don't know, do you guys do that any different, Mark or AJ, Jeff? Yeah, I mean, the data, a lot of it came from, there's some data from Wisconsin and some from Utah. And again, it's about a third that have severe muscle atrophy. And interestingly, no difference if you're doing it down at the lesser trope, if you're doing it at the capsular rim or at the peripheral compartment. But I think that's a very difficult problem, I mean, just to retrieve, of having issues of weakness. But interestingly, just historically, back in 2011, I did one of the first cases, as far as I know, Tombert and I were doing the first cases of issue from impingement, and I attacked it from excising the lesser trope canner. And I told the patient she would be weak for the rest of her life, but she was having trouble walking across campus. And so we did do her release, and she actually ended up with kind of 5 minus 4 plus strength, surprisingly enough. And that's because, you know, we talk about, there's been studies that talk about that, depending on where you are at the intercapsular rim, that there's 60% muscle and 50 than 40. But Hal Martin just actually published a paper in the Arthroscopy Journal that shows it's actually probably more like 20% tendinous attachment at the lesser trope canner. There's a large muscular attachment that's not on the lesser trope canner. And so for the overall, you end up maintaining a lot of the attachment. And I always tell my patients that when I do my lengthening that, you know, it'll retract. When you cut the tendon, and I do it at the peripheral compartment, do a little capsulotomy, and it'll retract about a centimeter. And then I figure that that'll fill in with scar tissue if it will and reconnect. And I actually have done a couple of revision lengthenings, and, you know, it reconstitutes that there's some tendon there that reconstitutes. And so, but why some get the atrophy and some don't, it is beyond me, and it's always a concern. And I always bring it up to the patients that there may be some potential for permanent weakness. But, you know, the pretty much 98% of the iliopsoas lengthenings I do these days are for the total hip patients that have the pain from the iliopsoas over the total hips. I rarely do a primary lengthening, but I do worry, you know. I think a lot of times we think about the recalcitrant iliopsoas tendonitis and think, well, maybe I should just lengthen it, especially if they have snapping hip. And those patients are probably the ones that need the iliopsoas most. I think the reason they get the tendonitis is because they may have either instability or dysplasia or ligamentous laxity, and it's being overused trying to maintain the stability of the hip. And cutting it is going in the wrong direction. And so that, and that's a difficult problem. And so in that scenario, you know, I think doing a capsular placation to try to maybe take some of the load off, if you will, from the dynamic stabilizers is, I think, the best you have to do. But I don't know. That's my approach. What's the open approach there? Yeah. Anybody else do it open approach? Yeah, so I mean, I think, yeah, that's a tough problem. But I think, again, you don't tend not to lose the entire early psoas unless you get for whatever reason that atrophy. And I don't know, do you know why they get the atrophy mark? Oh, yeah. Yeah, in spite of it, you know, it depends what the demands are, but, you know, this girl specifically, I remember she said her goal in her life would be if she could run, you know, run three miles, you know, she'd be happy, and she literally called me like two and a half years after I did her surgery, and she was back to running three miles every other day, and she considered that a slam dunk, and I'm like, thank goodness. I had no idea what was going to happen with that, so.

psoas tendinitis

psoas release surgery

capsule repair

atrophy

stability issues