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Microinstability is an increasingly recognized diagnosis in young athletes presenting with hip pain. Causes of microinstability may include abnormality of the hip bony anatomy, acetabular labral tears, joint capsule laxity or injury, and muscle dysfunction. Borderline hip dysplasia is an increasingly recognized factor predisposing to microinstability. The capsuloligamentous structures of the hip, particularly the iliofemoral ligament, provide important restraints to femoral head motion, and iatrogenic defects can predispose patients to instability after surgery. Injury to the acetabular labrum may disrupt its important hip-stabilizing properties including the suction seal and improved acetabular depth. Hip muscle weakness or imbalance may result in increased femoral head motion within the acetabulum. The diagnosis of hip microinstability can be challenging, and the history is often nonspecific. Physical examination maneuvers include the anterior apprehension, prone instability, axial distraction, and abduction-hyperextension-external rotation tests. Radiographic features may include borderline hip dysplasia, femoral head-neck junction cliff sign, and an elevated femoralepiphyseal acetabular roof index. Magnetic resonance arthrography may demonstrate a capsular defect, capsular thinning, or labral pathology. Diagnostic intra-articular injection of anesthetic can confirm the intra-articular nature of the pathology. Management of hip microinstability focuses on strengthening the dynamic stabilizers of the hip through focused physical therapy. Surgery may be considered in recalcitrant cases where symptoms persist despite optimization of hip stabilizer strength. In such cases, addressing the primary source of instability through labral repair or reconstruction and capsular repair or plication can be considered. In highly selected cases, surgery can result in excellent outcomes.

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Background: Massive, irreparable rotator cuff tears (RCTs) remain a challenging clinical problem with numerous described treatment options. Bursal acromial reconstruction (BAR) represents a promising and evolving technique for a subset of patients with irreparable RCTs. Indications: BAR is indicated for patients with massive, irreparable RCTs with a primary complaint of pain, well-compensated shoulder function, and minimal radiographic degenerative changes of the glenohumeral joint as an alternative to reverse total shoulder arthroplasty or superior capsular reconstruction. Technique Description: Positioning per surgeon preference and diagnostic arthroscopy is performed. Subacromial decompression with a minimal and gentle acromioplasty is performed, followed by assessment of RCT repairability. If the tear is deemed irreparable, acromial measurements in the medial-lateral and anterior-posterior dimensions are obtained. Two pieces of acellular dermal allograft are cut to the acromial dimensions and affixed together using fibrin glue. The reactive side (facing the acromion), medial, and anterior sides of the graft are labeled. Two suture tapes are passed through the corners of the graft and self-locked and run diagonally in a cruciate configuration using an antegrade suture passer. Medial and lateral #2 fiberwire sutures are placed in a luggage-tag configuration. Neviaser (posterior), middle, and anterior acromioclavicular joint portals are created for medial sided suture passage. Medial graft sutures are shuttled through the respective medial portals and the graft is pulled into the subacromial space. The lateral sutures are then removed from percutaneous posterolateral, middle lateral, and anterolateral portals along the acromial edge. Medial sutures are retrieved using a suture grasper subcutaneously on top of the acromion through the percutaneous lateral portals. The sutures are tied through the lateral portals, starting with the medial-lateral sutures, and the knots are buried. Postoperatively, patients are progressed through passive, active-assisted, and active range of motion between weeks 2 and 6 and strengthening is progressed at 6 weeks. Results: Clinical results are lacking in the literature, but anecdotal results in our institution have demonstrated promising early outcomes. Discussion/Conclusion: BAR represents a promising alternative in the array of surgical options for treatment of irreparable RCTs.