Dr. Chris Tucke...: Welcome to the Arthroscopy Journal podcast. I'm Dr. Chris Tucker from the Walter Reed National Military Medical Center and the podcast's founding editor. Today in the podcast, we are discussing hip surgery in the setting of borderline dysplasia. I'm excited to be joined for this discussion by a colleague of mine who's an active educator and a leader in the field of hip surgery, Dr. Benjamin Domb from the American Hip Institute in Chicago. Dr. Domb was the senior author on the article titled No Difference in Patient-Reported Outcomes for Periacetabular Osteotomy and Hip Arthroscopy with Capsular Plication in the Setting of Borderline Hip Dysplasia: A Propensity-Matched Multicenter Study With Minimum 5-Year Follow-up, which is currently in press for the Arthroscopy Journal. His co-authors include Octavian Andronic, Edwin Chaharbakhshi, Patrick Zingg, Christoph Germann, Stefan Rahm, and Ajay Lall. Ben, congrats on your work, and welcome to our podcast.
Dr. Benjamin Do...: Thanks very much, Dr. Tucker. It's great to be here, and I look forward to our discussion.
Dr. Chris Tucke...: We recognize that the performance of hip surgery for a number of pathologies, most notably femoral acetabular impingement, has grown significantly in recent history, and with it, so has our understanding of many of the nuances of both normal and pathologic hip mechanics, the evaluation of the patient with hip pain, and the multiple treatment options available, both surgical and non-surgical. However, with respect to the topic of our discussion today, borderline hip dysplasia, there's still significant controversy regarding hip preservation surgery, as there's a paucity of literature on this topic, and specifically, no known comparative studies of osteotomy versus hip arthroscopy.
I'd like to first discuss the relevant concepts and principles more broadly before we can then dive into the specifics of your paper and the important findings and your conclusions. So to start us off, could you define for us borderline hip dysplasia and review the pathomechanics of this condition and how it contributes to a different treatment approach than hip impingement without dysplasia? I wanted us all to better understand what unique characteristics we need to take into consideration when we're approaching the management of the hip with borderline dysplasia.
Dr. Benjamin Do...: Thanks, Chris. It's a great question, and I think it's very important to have our definitions straight when we're having this conversation. So first of all, the concept of acetabular dysplasia in the hip is that the acetabulum, or socket, is too shallow in one form or another. When the socket is too shallow, there's not enough load-bearing area and/or there's a propensity for instability of the hip. That instability has at times been termed microinstability, which is to say there's somewhat of a wobble of the ball within the socket and/or an overloading of the edges of the acetabular chondral surfaces.
So in terms of what constitutes dysplasia, I like to quote Reinhold Ganz, who once said, "I'm a friend of no angle." It is to say that there's probably not any one angle that clearly defines what is a socket that's too shallow, and there have been a lot of efforts to come up with one. So many different angles are used together in our practice and in our evaluation. Lateral center-edge angle, anterior center-edge angle, FEAR index, Tonnis angle or acetabular inclination, Sharp's angle, just to name a few. And even there, we're just scratching the surface. Some of the latest proprietary technologies based off of CT have also tried to quantify the surface area of the percentage of the severe hemisphere of the femoral head that has acetabular coverage in a three-dimensional manner, and there's certainly some promise there as well.
So having said all that, the original definitions of dysplasia were defined by the good Dr. Wiberg, who defined borderline dysplasia as a center-edge angle between 20 and 25 and a true dysplasia of less than 20. The Wiberg angle itself, or center-edge angle, has had some modifications too. The Ogata modification defined it as not the most lateral bone we can see, but rather the most lateral edge of the sourcil. And I think a lot of us use the Ogata modification in practice of the Wiberg angle or lateral center-edge angle. So most of what we're talking about here in terms of the definition used in this paper is based upon the Ogata modification of the lateral center-edge angle, which is to say it's based off of the most lateral point of the sourcil, not necessarily the most lateral bone visible on the acetabulum. So we're using the sourcil.
So now that we've defined what angle we're talking about, let's talk about how we define dysplasia and borderline dysplasia. The original definition of borderline dysplasia was 20 to 25. Some years ago we expanded that slightly to include 18 to 25 mostly because that is sort of the range in which we have found that there are some options other than PAO. And less than 18 at American Hip Institute, at least most of those patients are getting a PAO. In the 18 to 25 range there's a conversation to be had between the arthroscopic options and the POA options, and obviously that's the crux of of this paper here. So it was an excellent question, I think, to complete answering, basically the definition used here was center-edge angle of 18 to 25 using the Ogata modification and the reason that dysplasia affects the mechanics of the hip is due to the causing of edge loading or instability or microinstability.
Dr. Chris Tucke...: In principle, how are these two procedures that you investigated, the periacetabular osteotomy or the PAO and hip arthroscopy with capsular plication, how do they differ in how they address this pathology of borderline dysplasia?
Dr. Benjamin Do...: So the PAO is a very powerful procedure invented primarily by Reinhold Ganz in the late nineties. And the procedure is a bony correction to the problem of dysplasia where an osteotomy is made close to the acetabulum itself, which enables for powerful correction. And the correction is typically an abduction, an anteverting, and flexion of the fragment. And those three movements, abducting, internally rotating, and flexing the fragment, allow for more anterior and lateral coverage. And we're also bringing a little bit of the posterolateral rim into a more anterolateral position.
So the idea is to solve the root of the problem from a bony standpoint, which is the bony dysplasia. Arthroscopic solution is very different. It's a soft tissue solution which recognizes that the bony problem isn't the whole problem. Most patients who have acetabular dysplasia also have ligamentous laxity, generalized ligamentous laxity, and in a lot of cases they have compromise of the other soft tissue stabilizers including the labrum and the ligamentum teres. So the arthroscopic solution aims to solve the soft tissue problems contributing to the microinstability. And the advance here was really first recognizing that microinstability in the context of borderline dysplasia is not strictly a bony problem. It's partially a bony problem and it's partially a soft tissue problem. So the PAO corrects the bony problem, the arthroscopic solution aims to correct the soft tissue problem.
In terms of the corrections themselves in arthroscopic procedure, we aim to restore all the soft tissue stabilizers, the first being the labrum with a labral repair, or when there's an irreparable labrum, a labral reconstruction. Ligamentum teres is an evolving field, some ligamentums are debrided. We perform the procedure for ligamentum teres reconstruction in very select patients, but the crux of the advance in our arthroscopic treatment of borderline dysplasia was the utilization of the capsule and capsular plication with an inferior shift.
So we first described that procedure 2013, I believe, created the procedure around 2010, the procedure utilized the standard interportal capsulotomy and borrowed some principles from the shoulder where capsular plication with a shift was a procedure that had long been done both with open and arthroscopic techniques for instability in the shoulder. And we aim to both tighten the capsule and perform a shift where we're accentuating the native spiral of the capsule, which provides a screw home mechanism and that screw home mechanism tightens the hip joint and extension resisting external rotation and anterior translation.
A good way to think about the capsule and this spiral is that at some point in our evolution we used to walk on all fours, and when we did our capsule was probably straight and then we became homo erectus some two million years ago and we stood up and our hips extended and when they extended, the capsule took a spiral and that spiral is maintained to this day and the spiral tightens the zona orbicularis like a noose around the femoral neck and contains it within the acetabulum and especially resists anterior translation and external rotation in extension. So the capsular plication has given us a tool to tighten the capsule and provide a soft tissue solution to the soft tissue component of the problem in microinstability in the context of hip dysplasia.
Dr. Chris Tucke...: That was a wonderful description of what's involved in this. I was hoping briefly you could maybe just give us a few of your keys to success when you're doing these hip arthroscopy capsular plications in treating borderline dysplasia. Maybe a few pearls for the surgical technique itself?
Dr. Benjamin Do...: Sure. So we have to think of all of the contributors to instability, and when we get in the joint, the first thing we do is a diagnostic arthroscopy to evaluate those contributors. So is there compromise of the labrum, the ligamentum teres, the capsule? Can we see it? The first thing we see when we do hip arthroscopy is how easily the joint distracts. And a lot of these patients you'll find distract quite easily and that's already a supportive finding in terms of the understanding of microinstability being present in this joint.
Next we'll evaluate the labral tear with our diagnostic arthroscopy, and there are various patterns that are more suggestive of instability like the inside out labral tears rather than outside in and delamination of the peripheral cartilage. And then third, ligamentum teres tears. So whether or not we're talking about reconstructing, we have shown previously that the more severe grades of ligamentum teres tears are correlated with more severe microinstability. And the reason for that is probably because this ongoing wobble of the ball within the socket puts repetitive traction on the ligamentum teres and causes partial tears or in some cases full thickness tears. So we can look at the ligamentum teres and to a degree at least we can infer how bad the microinstability has been based on the amount of damage to the ligament teres.
Then we undertake our procedure. We want to do everything we can to restore soft tissue stabilizers, so that means want to leave the patient with a good labral seal. If we do a labral repair, we want it to be an anatomic labral repair that restores the seal of the ball within the socket. So when we take traction off after that repair, we want to see good contact between the labrum and the femoral head. We've described various techniques to achieve that goal. Early on we described the labral base refixation technique and more recently the controlled tension anatomic technique utilizing the controlled tension knotless anchor technology that's come about in the last few years. And the goals of those techniques, all of them were to restore that seal so that when we take traction off, we see the labrum sealing against the femoral head.
When doing a femoroplasty or addressing FAI, we want to aim for a spherical femoroplasty. If we over resect, we actually create instability in flexion because when the over resection enters the joint, it loses contact with the labrum, the labrum loses contact with the femoral neck. So we want to be very cognizant to avoid over resections. Similarly, on the acetabulum, any acetabuloplasty or acetabular rim preparation should be very, very sparing in these cases. The worst thing we can do is take a dysplastic acetabulum, make it even more dysplastic by doing a rim trimming. So avoid the trap of chasing a crossover, for example, crossover sign in the context of dysplasia. We do not want to do a rim trimming if the patient is already on recovery.
And then finally, the capsule itself. We can gauge our number of sutures, the size of the bites and the degree of obliquity of the sutures. Those are the things that will determine the degree of implication and the degree of the shift. So our bite size determines the implication and the degree of obliquity determines the extent of the shift. Our number of sutures goes with both. So typically in these cases, we're going to aim for a minimum of four sutures and often five or six sutures. Each simple sutures, we typically use absorbable sutures, but others have used permanent sutures and we'll place all of the sutures before we tie the knots. That's a very important piece of the capsular plication. Placing all those sutures and seeing all of their alignment and then subsequently tying the knots allows us to know exactly how we're placing all of them and to have space to place all of them before we start closing down the space with the knots.
Dr. Chris Tucke...: Thanks. Those are some wonderful tips for success with the specifics for these hip arthroscopy procedures. Okay. I'd like to dive into the specifics of this published paper. Your stated purpose was to compare the minimum five-year patient-reported outcome measures after hip arthroscopy and periacetabular osteotomy in borderline hip dysplasia. Can you describe for us your research methodology and how you went about designing and conducting this investigation?
Dr. Benjamin Do...: Yeah, absolutely. I always enjoy doing multicenter studies and I think it does lend some power to our research when we're able to explore combining the experiences of multiple surgeons because something I always worry about with our research or anyone's research is to what degree can we extrapolate the findings and apply them from one institution to another? So I think when we're able to combine the experiences of multiple institutions, it perhaps makes them a little bit more broadly applicable.
So this was a multicenter study. We included patients who had a center-edge angle of between 18 and 25. Again using the Ogata modification. We excluded patients who had Tonnis grade greater than one, prior surgical procedures, active inflammatory disease, workers' compensation, or concomitant other surgeries, and we propensity matched our groups based on age, sex, body mass, and Tonnis osteoarthritic grade. Worth saying a little bit about propensity matching, this was a technique that was first brought to me by one of our research analysts almost 10 years ago, and at the time I hadn't seen it anywhere in the literature, so it struck me as a very powerful way to control for confounding factors, possibly the closest we could get to a randomized controlled trial in a lot of our surgical studies, especially in a retrospective analysis fashion.
So we started using it almost religiously about 10 years ago, and I'm very proud of that particular research analyst for having brought it to us and hence brought it to the literature, and I think it has become a very useful tool for many institutions now in many journals to control for confounding factors. So the propensity matching was between patients who had a PAO or had a hip arthroscopy at these two institutions in this range of lateral center-edge angle 18 to 25. PROs that we used include the modified Harris hip score. We always use a non-arthritic hip score, hip outcome score, and the iHOT as well. But between the two institutions, the workhorse was the modified Harris hip score, and we also used several chronometric measures including MCID, PASS, and MOI. We looked at the rates of future surgery as well between them and looked at preoperative radiographic predictors including the FEAR index and ligamentum teres lesions.
Dr. Chris Tucke...: Can you summarize for us your key clinical findings?
Dr. Benjamin Do...: Yeah, absolutely. We found a total of 28 PAO patients and propensity matched them to 49 hip arthroscopy patients, and the two groups were similar in terms of age, sex, body mass index, and LCEA. The follow-up periods were about eight years and seven years, respectively, for the PAO and hip arthroscopy groups. The FEAR index was lower in the hip arthroscopy group, but otherwise the rest of the characteristics were essentially very similar.
The two groups showed similar and significant improvements in the mean modified Harris hip score from pre-op to latest follow-up. So essentially both groups did very well from a clinical standpoint and had excellent improvement in their outcomes. Relative risk of subsequent surgery was about 3.5 in the PAO group compared to the hip arthroscopy group, meaning they had three times the relative risk of having a subsequent surgery, but most of that was attributed to hardware removal. The rate of revision was about 3.6% in the PAO group and 8.2% in the arthroscopy group. In the PAO group, one patient had a revision for intraarticular adhesions and that was an arthroscopic procedure. In the arthroscopy group, three patients underwent subsequent PAO and one underwent a revision hip arthroscopy. One of them underwent a subsequent arthroplasty.
So I think an important point to call attention to there is 49 hip arthroscopy patients and in an average follow-up of seven plus years, there were three patients that basically crossed over, meaning the arthroscopy initially wasn't enough and they went on to have a PAO. So three out of 49 and survivorship here is basically 98%. One patient went on to have an arthroplasty.
So these are really important numbers because some of the early skepticism of arthroscopic treatment for borderline dysplasia, particularly from the open hip preservation community, was that it's not going to work. It's not going to last a long time, it's not going to be durable. They're all going to need PAOs or they're all going to develop arthritis and need hip replacements, and those things just haven't happened. The arthroscopic procedures, when done well, have been very durable. There've been very, very low rates of crossover into needing a PAO and even lower rates of development of arthritis and need for a hip replacement. So when we're looking at a 98% survivorship at seven years, I think we can start to conclude that this procedure is not only working, it's working for quite a long time.
Dr. Chris Tucke...: Right. I think that was my takeaway from your paper with your major finding being that basically both the hip scope and the PAO groups show that they can have this clinically meaningful improvement at pretty medium term follow-up. I did want to dig deeper into one aspect of your findings, and I know our listeners probably aren't looking at the paper, but on table three, which is a table showing a comparison of the modified Harris hip scores for the PAO cohort, both pre and last follow-up, and then the hip arthroscopy cohort pre and last follow-up, you listed the change in the score and the change for the PAO cohort was approximately 15 points, and the change for the hip arthroscopy cohort was larger at over 22 points.
Now the P value between that difference was 0.06, so basically a hundredth of a point away from statistical significance. I was wondering what you make of that finding. First, do you think with a larger sample size you might've shown that to be statistically significant? But secondly, and probably more importantly, do you think that that difference, even if it is shown to be real, would be clinically relevant?
Dr. Benjamin Do...: Right, so we are comparing two procedures that are very much apples and oranges. The recovery after an arthroscopic procedure is quite different than the recovery from a PAO. The PAO being a large open incision dissection and the cutting of the bones of the pelvis, placement of screws. An arthroscopic procedure being an outpatient procedure with keyhole incisions where the patient is on a stationary bike the next day. These are really two different procedures. So the appeal, treating a group with an arthroscopic procedure instead of a PAO is fairly obvious, a much less invasive procedure potentially with a much quicker recovery, less soft tissue damage, and hopefully a better long-term outcome too.
So your question is do our results imply that and would a bigger sample size prove it with statistical significance when we missed that significance by 0.01 on our P value and very possibly those things are true. It is my sense from the greater magnitude of improvement in the Harris hip score that from a clinical standpoint, the patients are winding up in a better place when they have successful surgeries with an arthroscopy than with a PAO. Having said that, the results of PAO are very good. They're very good in this study and they've been very good in a lot of other studies over the years as well.
So I think it's probably premature to say that one thing is better than the other thing. At this point I think what we can conclude from the present study is that there is going to be a future role for both PAO and arthroscopic surgeries in the treatment of patients with borderline dysplasia, and our work at this point is to continue to marry the two and to refine the indications for one versus the other, but also to be able to offer any given patient both options. Shared decision-making is something that we've espoused and taken very seriously at American Hip Institute. Being able to offer both options in this case to a patient with borderline dysplasia and allowing them to make an educated decision for themselves, I think is probably the best approach because we will never get to a sense, say in any given patient that one is better than the other or the other is better than the first, and therefore allowing the patient to have a role in that decision, I think is a very powerful tool.
Dr. Chris Tucke...: Yeah, I couldn't agree with you more, and your answer is a very natural segue into my next point I wanted to discuss, which was regarding that patient selection. And in the discussion of your paper, you brought up the interesting concept of the potential for overcorrection of the dysplastic hip when performing a PAO, which could then potentially result in iatrogenic secondary impingement. In your study, in fact, two of your patients who had very low postoperative modified Harris hip score outcomes or those scores were less than 50, they did have overcorrection with their ultimate lateral center-edge angle greater than 40, and their Tonnis angle was less than 10.
You then contrasted that with the potential for undercorrection of a cam impingement when doing a hip arthroscopy treatment and several of your patients had post-op alpha angles that still remained over 55. So both of those technical shortcomings or procedural errors, if you will, could contribute to lower patient-reported outcomes. I'd like to hear your thoughts on this concept of patient selection and basically how low the floor can be for somebody's outcome after each of these procedures and how that weighs into your decision-making when you're offering patients a procedure and how you're selecting which one to recommend.
Dr. Benjamin Do...: Sure, absolutely. So any surgery can be done well or badly, and any surgery is done by humans and has a risk that we don't do it perfectly 100% of the time. When doing a PAO, the extent of the correction is really the crux of it. Under correcting or overcorrecting can both happen. An interesting anecdote is the concept of femoral acetabular impingement was actually discovered because of overcorrected PAOs. That led to the discovery of impingement because those patients had limitation of flexion and/or internal rotation because they were abutting against the overcorrected tabular wall. We very clearly can overcorrect the PAO and create impingement. We could conceptually under correct the PAO and not solve the problem too. But I think in general, in the field, overcorrection is probably more common in PAOs than undercorrection is.
In the arthroscopic surgery, there has been much attention drawn to undercorrection of FAI as a cause for revision surgery, and indeed we did draw attention to the possibility of undercorrection here in this paper. I must add that we have a subsequent paper that's on its way out called The Pendulum has Shifted and you can tell by the name of the paper where this is going. Because so much had been written about the risk of undercorrection, I think the field as a whole has had a pendulum swing where there's probably more overcorrection of FAI going on today than undercorrection in a lot of centers. And overcorrection of FAI potentially produces a bigger problem than undercorrection, specifically on the femoral side.
If we take an apple bite out of the femoral neck, when that patient sits down or flexes their hip, the labrum loses contact with the apple bite. And so essentially we break the seal of the labrum and all the work that we've done to create an anatomic labral repair or labral reconstruction is for nothing because the labrum is now not touching the femur and the seal is broken and it can't have its effect. I think we do need to be very aware of both undercorrection and overcorrection in both PAOs and arthroscopic treatment is kind of the long answer to a short question.
In terms of lower patient-reported outcomes, I think we have proven in other studies that accuracy and correction of FAI with arthroscopic means is correlated to outcomes shown in athletes in another study that relative risk of an athlete having a poor outcome is six or seven times as high if the femoroplasty is not done optimally. So optimal resection is absolutely critical. In terms of how this all weighs on our decision-making, we need to assess all the options available to the patient from the field. We also need to be cognizant of our outcomes of our procedures at our own institutions, and this is where I come back to how easily can we extrapolate literature from certain institutions to other institutions. We may have different patient populations, we may have different equipment, we may have different facilities, and we may actually have different surgical techniques.
So there are lots and lots of reasons why it's imperfect to extrapolate outcomes from one institution and assume that they apply the same way at another institution and therefore really incumbent upon all of us to follow our own outcomes and figure out which procedures are working best in which patients at our own institutions.
Dr. Chris Tucke...: Sure. I think based on our discussion, the results in your paper, I think we've concluded that both the PAO and the arthroscopic capsular plication can work for these patients with borderline hip dysplasia, and as you've said, doing what's best in your own hands is usually the most reliable way to care for our patients. I was just wondering, in your opinion as an experienced hip preservation surgeon, when you're sitting across from a patient now, what are you seeing as the ideal candidate for each of these procedures? When you're deciding between what to recommend them, what are you looking for and how are you choosing your ideal candidate for one versus the other?
Dr. Benjamin Do...: Yeah. Well, Chris, you and I are not that old yet, and even in our duration of our careers, we've seen a shift from a more paternalistic style of medicine to shared decision-making. And I think most of us have embraced that shift. And part of the reason we've embraced it is because we have the humility to acknowledge that not everything is known and that we can't always be sure what is the right answer. So if we know for sure one thing is better than another thing in a given patient, then sure we'll tell them. A lot of the time we don't know that for sure. And the borderline dysplasia group is exactly that patient. These are by definition tweeners. People are somewhere in between treatment with an arthroscopy versus a bigger open procedure. And so especially in this group, it's incumbent upon us to employ shared decision-making.
So I personally have very much embraced that our institution, American Hip Institute has very much embraced the concept of shared decision-making, and we apply that by educating the patient on what is known about the various procedures, what are the various options, and ultimately helping them make a decision that they feel is going to be best for themselves. That does a few things. First of all, it gives the patient agency for themselves. Second, I think it does allow some buy-in of the patient themselves because they've had a role in choosing the procedure. So shared decision-making definitely wins the day.
In terms of the factors that we consider, things that push us more toward doing a PAO are greater degrees of dysplasia, less coverage measured not only by the center-edge angle, but also by the Tonnis angle, the FEAR index, that anterior center-edge angle. People who have greater degrees of femoral anteversion, higher degrees of ligamentous laxity, those are all factors that may push us more toward the direction of the PAO. Things that may push us more toward an arthroscopic procedure, athletes, especially those who require super physiologic range of motion of the hip, like gymnasts or ballerinas or a hockey goalie for that matter, a PAO may be a career ending procedure for those patients. So there's a major appeal doing an arthroscopic surgery in them. Normal femoral aversion, the presence of an intact ligamentum teres, those are all things that may make us lean a little bit more toward an arthroscopic solution. So again, I'll share all of these factors and all of these considerations with the patient and ultimately we'll land on the decision together.
Dr. Chris Tucke...: Yeah, very insightful thoughts there. I couldn't agree with you more on the concept of shared decision-making and patient education in particular and having them have that buy-in, which I think those of us who've done it for a few years at least, can attest to the outcomes of the patient tend to trend towards better when they do have that buy-in like you've explained so nicely. Ben, you've given us a really very nice comprehensive and insightful discussion of the treatment of borderline hip dysplasia in light of your published findings and also your personal experience, did you have any other closing remarks you wanted to share before we wrap up?
Dr. Benjamin Do...: The questions have been just great, Chris. I really appreciate it very much. I think just one last thought to conclude with, concept of comprehensive hip care. The field of hip surgery has been a little bit fragmented and divided between arthroscopic surgeons, open hip preservation surgeons, and arthroplasty surgeons, and really all three of those areas need to be part of the spectrum of care and the spectrum of options that are presented to patients if we're going to truly employ shared decision-making and truly choose the right option in any given patient.
So whether it is one surgeon being trained in all aspects of hip care, including arthroscopy and open preservation or an arthroplasty, it's a combination of surgeons at a given institution or even a different institution to work together to provide those options. It's very important to be able to provide all of the options to a patient at your institution or with other surgeons that you work closely with so that we can avoid having a bias toward one particular thing over another, and always choose the best thing and help the patient choose the best thing for themselves. So that's my short plug for comprehensive hip care as it were, but I really appreciate the questions and sure appreciate you having me on the podcast today.
Dr. Chris Tucke...: It was our pleasure, Ben. Thanks. I want to congratulate you and your co-authors again on your work and this particular publication and your body of work with hip arthroscopy and hip preservation surgery, and thanks again for sharing your time and your thoughts with us.
Dr. Benjamin Do...: Thanks very much, Chris.
Dr. Chris Tucke...: Dr. Domb's article titled No Difference in Patient-Reported Outcomes for Periacetabular Osteotomy and Hip Arthroscopy with Capsular Plication in the Setting of Borderline Hip Dysplasia: A Propensity Matched Multicenter study with Minimum Five-Year Follow-Up is currently in press for the Arthroscopy Journal, which is available online at www.arthroscopyjournal.org. This concludes this edition of the Arthroscopy Journal podcast. The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal. Thank you for listening. Please join us again next time.
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