Arthroscopic Technique for Treatment of Combined Pathology Associated With Femoroacetabular Impingement Syndrome Using Traction Sutures and a Minimal Capsulotomy Rishi Thakral, M.D., F.R.C.S.I., and Derek Ochiai, M.D.
Abstract: The use of hip arthroscopy is gaining popularity for diagnostic and therapeutic purposes. With our increasing understanding of hip biomechanics and pathophysiology, our techniques for treatment are evolving as well. The main aim is to preserve the joint and prolong the degenerative process associated with femoroacetabular impingement (FAI). In general, combined pathology is encountered when a diagnosis of FAI is established. In our experience, we have seen large number of patients with a combination of cam and pincer lesions with or without associated labral tears. It is optimal to address all symptomatic pathology with one surgical intervention. The described technique shows the feasibility of dealing with the hip FAI pathology by using traction sutures on the capsule through a 2-portal technique.
T
he concept of femoroacetabular impingement (FAI) has been established.1,2 It is known that FAI predisposes patients to osteoarthritis.3 Three broad categories of impingement have been described. Cam impingement is asphericity of the femoral head-neck junction or reduction of the femoral head-neck offset. Pincer-type impingement is defined by overcoverage by the acetabulum. The acetabulum may be excessively deep or retroverted or may have focal anterior overcoverage. A combination of cam and pincer impingement is the most common pathology seen.4 Over time, the preexisting morphology leads to damage to the labrum and articular cartilage damage.5 The symptoms are usually insidious but may occur acutely after an injury. The radiologic signs may be subtle. Anteroposterior pelvis, frog and cross-table lateral, and Dunn radiographic views of the hip joint are the first line of investigation and help to assess the neck offset. The presence of a labral tear and articular cartilage damage is best evaluated by using magnetic resonance imaging with an arthrogram. The first line of management is conservative with
From the Nirschl Orthopedic Center, Arlington, Virginia, U.S.A. The authors report the following potential conflict of interest or source of funding: D.O. receives support from Smith & Nephew and Arthrex. Received March 4, 2014; accepted June 4, 2014. Address correspondence to Derek Ochiai, M.A., Nirschl Orthopedic Center, 1715 George Mason Dr, Ste 504, Arlington, VA 22205, U.S.A. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 2212-6287/14182/$36.00 http://dx.doi.org/10.1016/j.eats.2014.06.010
anti-inflammatory medications (nonsteroidal anti-inflammatory drugs) and physical therapy. If the nonoperative measures fail, then surgery is contemplated. Surgical options are considered appropriate for patients with no significant radiologic signs of arthritis but with significant functional limitations and pain. Surgical options for treatment of FAI include an open Ganz surgical dislocation,3 mini-open FAI osteoplasty, and arthroscopic FAI osteoplasty. Mini-open and arthroscopic procedures have shown similar results at midterm follow-up.6-8 An arthroscopic technique to perform cam osteoplasty, pincer osteoplasty, labral repair, and capsular repair/plication is discussed (Table 1).
Surgical Technique Setup The patient is placed under general anesthesia on a hip positioning system with Active Heel Technology (Smith & Nephew, Andover, MA). One gram of cefazolin sodium is given at the time of induction; for patients weighing over 80 kg, we prefer to give 2 g. Both hips are examined for range of motion, especially looking for asymmetric motion when compared side to side. The body is secured on the table, and a wellpadded perineal post and shoes are applied. The operative limb is internally rotated, and axial traction is gently applied with the hip maintained in slight abduction. The opposite leg is abducted, and the fluoroscopy machine is brought in parallel to this leg. The target hip is sequentially adducted, brought in a midline position, and distracted for 8 to 12 mm, and images are
Arthroscopy Techniques, Vol 3, No 4 (August), 2014: pp e527-e532
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R. THAKRAL AND D. OCHIAI
Table 1. Indications, Contraindications, Operative Tips and Pearls, Pitfalls, Key Points, and Risks Associated With Hip FAI Surgery Indications Symptomatic cam lesion, symptomatic pincer lesion, symptomatic combined pathology, and synovial chondromatosis/PVNS (exposure technique) Contraindications Joint space 2 mm, articular kissing lesion/grade IV articular changes of acetabulum and femoral head, and dysplastic hip with CEA 45 may necessitate starting the procedure in the peripheral compartment first. Operative tips and pearls A well-padded perineal post should be used, and the heel should be padded adequately. The hip should be flexed to 40 to 45 before attempting placement of traction sutures to avoid cartilage damage. Frequently, the AL portal may be between the labrum and femoral head; to maximize access, it may be repositioned inferior to the femoral neck. The assistant should pull the traction suture in line with the capsule (lateral is pulled laterally and inferiorly whereas anterior is pulled anteriorly and posteriorly) for adequate exposure. The suture shuttle loop may wrap around the femoral neck: to avoid this problem, use a crab claw device to grab between the loop and then pull back on the free tails of suture, and visualize the crab claw holding the very end of the loop to make sure it is not wrapped around the neck. Cam osteoplasty extends close to the capsule insertion on the femoral neck; this ensures a smooth transition zone and adequate osteoplasty. For pincer osteoplasty, the camera may be positioned inside the superior capsule; this helps to retract the capsule and allows good access to the acetabular margin. When the surgeon is placing the suture anchors, he or she should angle the trocar of the drill superiorly close to the articular margin (and avoid penetrating the cartilage) to ensure an anatomic position of the labrum. The surgeon should make a marginal capsular incision at the beginning of the case with a shaver or knife; this allows easy re-entry into the joint if the instruments accidently slip outside the capsule, avoiding multiple blind entries into the hip joint, which increases the risk of iatrogenic cartilage/labral damage. The surgeon should cut the full width of the capsule to allow free mobility of the instruments as required. Pitfalls When the focus of the cam osteoplasty is in 1 quadrant, there is a risk of stress fracture occurring because of over-resection in 1 area and under-resection in another. This can be minimized by frequently switching the camera between the portals to visualize appropriately. High-quality preoperative radiographs should be obtained to evaluate for any underlying dysplasia (CEA
Abstract: The use of hip arthroscopy is gaining popularity for diagnostic and therapeutic purposes. With our increasing understanding of hip biomechanics and pathophysiology, our techniques for treatment are evolving as well. The main aim is to preserve the joint and prolong the degenerative process associated with femoroacetabular impingement (FAI). In general, combined pathology is encountered when a diagnosis of FAI is established. In our experience, we have seen large number of patients with a combination of cam and pincer lesions with or without associated labral tears. It is optimal to address all symptomatic pathology with one surgical intervention. The described technique shows the feasibility of dealing with the hip FAI pathology by using traction sutures on the capsule through a 2-portal technique.
T
he concept of femoroacetabular impingement (FAI) has been established.1,2 It is known that FAI predisposes patients to osteoarthritis.3 Three broad categories of impingement have been described. Cam impingement is asphericity of the femoral head-neck junction or reduction of the femoral head-neck offset. Pincer-type impingement is defined by overcoverage by the acetabulum. The acetabulum may be excessively deep or retroverted or may have focal anterior overcoverage. A combination of cam and pincer impingement is the most common pathology seen.4 Over time, the preexisting morphology leads to damage to the labrum and articular cartilage damage.5 The symptoms are usually insidious but may occur acutely after an injury. The radiologic signs may be subtle. Anteroposterior pelvis, frog and cross-table lateral, and Dunn radiographic views of the hip joint are the first line of investigation and help to assess the neck offset. The presence of a labral tear and articular cartilage damage is best evaluated by using magnetic resonance imaging with an arthrogram. The first line of management is conservative with
From the Nirschl Orthopedic Center, Arlington, Virginia, U.S.A. The authors report the following potential conflict of interest or source of funding: D.O. receives support from Smith & Nephew and Arthrex. Received March 4, 2014; accepted June 4, 2014. Address correspondence to Derek Ochiai, M.A., Nirschl Orthopedic Center, 1715 George Mason Dr, Ste 504, Arlington, VA 22205, U.S.A. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 2212-6287/14182/$36.00 http://dx.doi.org/10.1016/j.eats.2014.06.010
anti-inflammatory medications (nonsteroidal anti-inflammatory drugs) and physical therapy. If the nonoperative measures fail, then surgery is contemplated. Surgical options are considered appropriate for patients with no significant radiologic signs of arthritis but with significant functional limitations and pain. Surgical options for treatment of FAI include an open Ganz surgical dislocation,3 mini-open FAI osteoplasty, and arthroscopic FAI osteoplasty. Mini-open and arthroscopic procedures have shown similar results at midterm follow-up.6-8 An arthroscopic technique to perform cam osteoplasty, pincer osteoplasty, labral repair, and capsular repair/plication is discussed (Table 1).
Surgical Technique Setup The patient is placed under general anesthesia on a hip positioning system with Active Heel Technology (Smith & Nephew, Andover, MA). One gram of cefazolin sodium is given at the time of induction; for patients weighing over 80 kg, we prefer to give 2 g. Both hips are examined for range of motion, especially looking for asymmetric motion when compared side to side. The body is secured on the table, and a wellpadded perineal post and shoes are applied. The operative limb is internally rotated, and axial traction is gently applied with the hip maintained in slight abduction. The opposite leg is abducted, and the fluoroscopy machine is brought in parallel to this leg. The target hip is sequentially adducted, brought in a midline position, and distracted for 8 to 12 mm, and images are
Arthroscopy Techniques, Vol 3, No 4 (August), 2014: pp e527-e532
e527
e528
R. THAKRAL AND D. OCHIAI
Table 1. Indications, Contraindications, Operative Tips and Pearls, Pitfalls, Key Points, and Risks Associated With Hip FAI Surgery Indications Symptomatic cam lesion, symptomatic pincer lesion, symptomatic combined pathology, and synovial chondromatosis/PVNS (exposure technique) Contraindications Joint space 2 mm, articular kissing lesion/grade IV articular changes of acetabulum and femoral head, and dysplastic hip with CEA 45 may necessitate starting the procedure in the peripheral compartment first. Operative tips and pearls A well-padded perineal post should be used, and the heel should be padded adequately. The hip should be flexed to 40 to 45 before attempting placement of traction sutures to avoid cartilage damage. Frequently, the AL portal may be between the labrum and femoral head; to maximize access, it may be repositioned inferior to the femoral neck. The assistant should pull the traction suture in line with the capsule (lateral is pulled laterally and inferiorly whereas anterior is pulled anteriorly and posteriorly) for adequate exposure. The suture shuttle loop may wrap around the femoral neck: to avoid this problem, use a crab claw device to grab between the loop and then pull back on the free tails of suture, and visualize the crab claw holding the very end of the loop to make sure it is not wrapped around the neck. Cam osteoplasty extends close to the capsule insertion on the femoral neck; this ensures a smooth transition zone and adequate osteoplasty. For pincer osteoplasty, the camera may be positioned inside the superior capsule; this helps to retract the capsule and allows good access to the acetabular margin. When the surgeon is placing the suture anchors, he or she should angle the trocar of the drill superiorly close to the articular margin (and avoid penetrating the cartilage) to ensure an anatomic position of the labrum. The surgeon should make a marginal capsular incision at the beginning of the case with a shaver or knife; this allows easy re-entry into the joint if the instruments accidently slip outside the capsule, avoiding multiple blind entries into the hip joint, which increases the risk of iatrogenic cartilage/labral damage. The surgeon should cut the full width of the capsule to allow free mobility of the instruments as required. Pitfalls When the focus of the cam osteoplasty is in 1 quadrant, there is a risk of stress fracture occurring because of over-resection in 1 area and under-resection in another. This can be minimized by frequently switching the camera between the portals to visualize appropriately. High-quality preoperative radiographs should be obtained to evaluate for any underlying dysplasia (CEA
