Femoroacetabular Impingement (FAI) is caused by an overgrowth of bone on the acetabulum (pincer lesion) or an excess of bone arising from the femoral head/neck (cam lesion). FAI is often mixed pincer and cam pathology, causing impingement of the labrum between the acetabular rim and femoral neck during hip range of motion.

Procedure

Arthrex provides products for removing cam and pincer lesions, with the option to release and repair the acetabular labrum.

Asheesh Bedi, MD, (Ann Arbor, MI) describes a technique for retracting the capsule during arthroscopic cam resections using the new angled open half-pipe cannula.

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Capsular Management and Retraction for Cam Resection

So as you can see at this point in the case now, we've shifted our attention to the peripheral compartment just to orient you inside the joint. You can see I've switched the camera to the mid anterior portal. If you rotate your eyes there, you'll appreciate there's our prior labor repair sutures. We're in a cadaver so it doesn't maintain the perfect suction seal and doesn't. And the traction doesn't quite completely return to normal. But if you look now distally here, this is the orientation that you're looking at as you look laterally and posteriorly. Those are the inserting fibers of the gluteus minimus onto the capsule. As I rotate my eyes there anteriorly, you can see those are the inserting fibers of the capsule iris or branches of the iliopsoas muscle. And here you can see this nice intermuscular plane that I always look for, which is kind of the plane that's going to be covering our cam deformity. And if everything makes sense, you can see you can tip your hand up, you can see the labrum and your labor repair sutures there. That's going to be in the area of the greatest cam de-lamination. So it really helps to localize where we want to make our T capsulotomy, if at all, to visualize the Cam lesion. This is our single piece, as you can see CapsuleCut blade. You can bring this in. In my mind, this tends to come in best, as you can see here from your proximal anterolateral portal. And I can use it first to retract and see where is our cam delamination located, where is it beneath. And then once we've decided on the trajectory and the best angle to make our capsular flaps, we can commit right to that location and start to tee our capsule there, right in line with fiber. So as you can see there, we just lay it down. We cut right down along the head neck junction there like that. And I think as you're appreciating this makes two nice equal flaps there, one superior and one anterior flap there that's going to directly overlay our cam lesion. You can see we can start to spread those work a little bit inferiorly there along our capsule. You can also use the Dalla portal to make this cut as well. But it's been my preference to come from the proximal anterolateral portal as most of these Cam lesions, as you can see, tend to sit at this high anterolateral junction. Now do you appreciate there we have these nice flaps that we've preserved. We've cleaned. So these will be nicely there for later repair. And then as you appreciate we can retract this flap and drive up and see our perfusing retinacular vessels right here sitting at the head neck junction. Those are an area of of concern when you're burring and performing your surgery because we need to get up and high, but we also want to protect them. So there's a nice device here. This is a combination of a half pipe retractor I think as you can appreciate it, it's a slotted cannula that we can use to slide down. Can introduce our bur, but then leave it in place and it can actually function for us like a retractor of this capsule. So rather than having the capsule wrap up during our resection we can actually use it there. So here what we'll do is we'll slide it right along the handle of our beaver blade, which has now been lined up in line with our capsulotomy. So there you can see our half pipe cannula is in place. You can slide out the beaver blade. Perfect. So as you can see here, we now have our slotted cannula and retractor in place. There's our two capsular flaps. There's our anterior flap. Here's our supralateral flap. You can see how this nicely can tuck deep to the flap. And I can rotate around and even show you those superior retinacular vessels just peering around the corner there. This can now set here in this position and actually act as a retractor, not only to protect those vessels, but also to allow for introduction of your BR from that trajectory. And now we're in a position to go ahead and slide the BR. So you want to usually have a slightly increased angle. So the BR tip stays right up against. And if you notice that that brings in your your blade nicely and keeps the muscle out of the way. And I want you to see there I've actually taken the capsule retractor and tucked it deep to the flap. And I simply leave that in place. And now you can see that holds that lateral flap open. And I'm now in a good position to br making sure that I'm safe and protecting those retinacular vessels. Once we've introduced that with the half pipe in place, I can now retract the sheath of the BR back. And as you can see, this retractor, half pipe cannula and retractor is protecting me from those superior vessels. This now gives us a great trajectory to work and go ahead and start to perform our cam resection here, working from the anterolateral location. And as you can see here, nicely, proximally, right adjacent to our to our labrum, we can start to set the margin of our physeal scar here.

Bruce A. Levy, MD, (Rochester, MN) outlines a surgical technique for using the Arthrex® Flexible Arthroscopic Retractor to retract the distal leaflet of capsule after an interportal capsulotomy has been made during a hip arthroscopy procedure. In this cadaveric video, he outlines the retractor insertion steps and demonstrates the increased exposure and visualization of viewing down the distal femoral neck to perform an osteochondroplasty procedure for cam impingement.

Arthroscopic Retraction of Hip Capsule Featuring the Flexible Arthroscopic Retractor

So today we're going to show you how to use the flexible arthroscopy retractor as a capsular retractor for hip arthroscopy. And what we found is that when you have this in and around the capsule, it lifts it right up off the way, and you can look all the way down the femoral neck and get excellent exposure for cam resection. The use of the flexible arthroscopy retractor has essentially negated the need to do t capsulotomy, which has really helped speed up capsular closure. So the products that we utilize for this involve the capsule close Scorpion, the flexible arthroscopy retractor, a FiberSnare suture which is a number two, and the TRIM-IT hip cannula. Now we've already gone ahead and measured it and it's a seven. So we're going to go ahead and cut it. There's an inserter. And so we'll go ahead and lock that in. Now for the suture passage we'll take the take the flexible arthroscopy retractor out. We'll take the FiberSnare suture out. And then we're going to load it. So the way to load the capsule closed Scorpion is you take your FiberSnare and just make a little fold on it. You get your device in and then just pull. And it's now locked in place. Then what we're going to do is we're going to take the FiberSnare, and we're going to load it right in to the tip of the arrow, right in the center and fire. And then we'll take it off. And there we have it. Once we have it through, we'll just load it through the snare. And the retractor is ready to go. And you can pull on this pretty hard. You can see that it won't pull through for the other side of the retractor. We just take a number two FiberWire. We'll put it right down through the center and pass. And this is just going to be a passing suture. And we'll even those out. And now the retractor is all set. Okay. So here you can see we have both sides of the capsule exposed label side and distal side. Here's just a switching stick. So femoral head labrums here. One side of the capsule. Other side of the capsule. So over the switching stick we're going to drop in our TRIM-IT cannula. And then we're going to remove the inserter. And the cannula is in place. Now we're going to take a SutureLasso. We'll come through the cannula. We'll take a nice big deep bite of the capsule. And we'll try to get right up underneath it. And then we'll feed our wire in. Now we're going to retrieve our loop. Now we're going to load the FA through the loop. Okay. And then go ahead. Yep. Yep. That's it. I'll take the suture or the KingFisher now. And we're going to fold. Pull a little suture. Pull for me. Great. And then we're going to fold the flexible retractor. We'll grab it with the KingFisher. And then as you pull, I'm going to start to load. Go ahead. Great. Get that in position. And there you have it. You can see that we have outstanding retraction now of the entire femoral neck area. And we can look right down the neck. And we have outstanding exposure. You can see how the retractor literally just cups the entire capsular area. Here's an excellent demonstration of the flexible arthroscopy retractor in the hip. Lifting the hip capsule in one of my actual patients. Now I'm going to introduce the bur into the hip through the mid anterior portal scope in the anterolateral portal. And you can see that the far retractor moves as a unit with the bur. So there's not that much tension on the sutures holding the FA. And this allows it to freely move with the bur keeping the capsular tissue away from the bur at all times.

Imaging and Resection

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CoolCut™ Specialty Series: Hip-Length Shaver Blades and Burrs

BenjaminDomb, MD (Chicago, IL) describes his rationale and surgical techniques foraddressing bony pathology related to femoroacetabular impingement (FAI). Dr. Domb references his preoperative X-raysand multiple fluoroscopic images to demonstrate an arthroscopic surgicaltechnique used to treat the bony morphology associated with FAI.

Treating FAI Surgical Technique

We begin this process by evaluating the x rays critically. And it's very important to preoperatively plan any bony resections which may be performed. So we'll preoperatively template the acetabular rim resection and any femoral resection as well. We evaluate the coverage of the acetabulum as well as its version. And we can visualize the areas which require most resection by preoperatively planning the acetabular rim resection. We can ensure that we do not create iatrogenic dysplasia. Here we see the depth of the acetabulum and we can judge whether it is normal or coxa profunda or protrusio acetabuli. In this case, it's very slight coxa profunda, with the acetabular fossa crossing the line by a very small amount. We evaluate the lateral coverage here and the source social angle. We also evaluate the acetabular version looking for a crossover sign. So that's a crossover of the anterior rim crossing over the posterior rim. That crossover sign is a sign of acetabular retroversion, which in this case is very slight. It's important to know that a crossover sign is not an indication to perform an acetabular rim resection. In certain cases where there is anterolateral overcoverage, it may be accompanied by a crossover sign. But in other cases, a crossover sign may coexist with acetabular undercoverage. So the crossover sign must be evaluated in the context of the acetabular coverage. Here we can evaluate the offset and alpha angle on the done view, looking for cam type morphology, which can be addressed by a femoral plasty moving along to the arthroscopic portion of the procedure. We'll Will perform an exposure of the acetabular rim for a labral repair in this case. Taking care to preserve the capsule throughout the procedure. So this is an elevation of the capsule from the acetabular rim, not a resection or debridement of any of the capsule or substance. We're using an RF in this case to expose the acetabular rim. We'll want to perform a slight rim resection in this case and a preparation of a bony bed. This is the navex 360 degree flexible instrument with the radiofrequency wand attachment. The flexible instrument also comes with a variety of biters and graspers, all of which may be useful in navigating the sharp corners and curvilinear geography of the hip joint. In this case, we're using the anterolateral and anterior portals to begin the procedure. We use a bur to perform the acetabular rim resection. And this is done with the assistance of fluoroscopic guidance. It's important to note that the first fluoroscopic image one takes in the operating room is generally not a well aligned AP of the hip or pelvis due to the rotation or tilting of the pelvis on the distractor table. So the fluoroscopy machine needs to be adjusted in all cases to obtain an angle that reproduces the AP pelvis view, and that can be done beginning over the pubic symphysis to adjust the rotation of the fluoroscopy relative to the pelvis, and then moving ultimately over the acetabulum to adjust the inlet outlet view and make sure that we are reproducing the correct view on the fluoroscopy before using it as a guide. It's useful to bur from the bird's eye view, as you saw up to this point, but also using an upper deck view which is seen here. This is where the arthroscope is placed superior to the labrum. This allows us to visualize the acetabular bone all the way down to the subchondral bone, all the way down to the labrum or cartilage. As we resect more and we can judge the amount of bone resected relative to the bur size, this is a five millimeter bur. We've performed a labral repair. In this case the labral repair is demonstrated in other videos. So we'll move along to the peripheral compartment. Here we see the medial retinaculum and its overlying zona orbicularis. There this is the anteromedial neck the anterior neck. Whereas the focus of the cam lesion lies in this particular case the anterolateral neck extending all the way up to the lateral retinaculum. And it's important to visualize at least the entire anterior 180 degrees of The femoral neck in most cases of Cam type impingement. We can perform circumferential femoral it is. Here you see the lateral retinaculum. So we're getting up to posterosuperior femoral neck. You can see pulsations of the the vessels of the lateral retinaculum as well. So we can certainly address posterior cam impingement or posterior superior cam impingement as well. Capsular management becomes particularly important through this part of the procedure. Since we would like to perform a capsular closure at at a minimum after every case. And in some cases perform a capsular plication. It's very important to preserve the capsule throughout the procedure. This can be challenging as we are working through a small capsular window, trying to access all parts of the femoral neck. Here we use the wand, the RF wand, as a marker under fluoroscopy to define the most proximal extent of the femoral plasty. Essentially, under fluoroscopy, we can visualize where the femoral. Where the femoral head veers out of round. And that is the most proximal extent. We then perform the femoral plasty generally working from distal to proximal. And this is one fluoroscopic view that reproduces essentially a done view. And that gives us very good visualization of the epicenter of the Cam lesion. But we'll move the hip through a variety of positions and move the fluoro machine through a variety of positions, so that we reproduce a wide variety of fluoroscopic views of the femoral head and neck. It's important to remember that both the arthroscopic view and the fluoroscopic views are two dimensional views of a three dimensional object. It's very important that the femoral plasty produce a spherical contour. This should not be a concavity that's being dug into the femoral neck or head neck junction, but rather it should be a convexity. A sphere is a convex object, so the convexity of the spherical contour of the weight bearing portions of the cartilage should be extended into the femoral head neck junction. And we want to see that convexity under the fluoroscopic view until the point where the femoral plasty meets the femoral neck, at which point there's a sigmoidal concavity to allow the femoral plasty to meet the femoral neck. So in this portion where we're working here, this is femoral head neck junction. That portion should be spherical and therefore convex. And you can see that here on the Fluoroscopic view. Once again in a done view we can internally and externally rotate the hip using this done view to look more medially or more laterally at the portion that we're working on. So here we move to work more anteromedially we can work all the way down to the medial retinaculum and even beyond if desired. So we create a nice smooth, polished surface of this bone. This is cancellous bone. It does appear rough after concluding the femoral plasty. Even though we've smoothed it at a second look procedure. This will be coated with a smooth white substance, presumed to be fibrocartilage. So we'll buff that femoral head neck junction up to the point where the bony anatomy veered out of the spherical shape. And we've judged that both with the pre-operative planning as well as with the intraoperative fluoroscopy. Here we see the completed femoral plasty, and we can judge our spherical contour using the variety of fluoroscopic views. Once again, polishing some areas to make sure we have a very smooth femoral plasty. Completing our anterior inferior resections down here. And we're using the hood of the bur to protect the capsule throughout the femoral plasty procedure, so that we'll be able to perform a capsular closure or application at the conclusion of the procedure. And we have a nice smooth surface. By the time we've concluded now we bring the hip into extension. And we see an AP view of the hip. So we can visualize any superior lateral cam impingement with AP view. We'll remove a little bit of remaining soft tissue from the femoral neck that inferiorly and this superiorly now in the extended Position with the hip and the extended position, we can access the superior lateral femoral head, neck junction and any Cam morphology which extends superior laterally can be best addressed in this position of extension. We've brought the fluoro into an AP view, and again here mark the part where the femoral head veers out of round. So this correlation of multiple fluoroscopic views with multiple arthroscopic views is critical in the process of creating a spherical contour to the femoral head. Perform our bearing here with the assistance of fluoroscopic guidance. As always, and at the conclusion of the procedure, we can see our very smooth femoral head neck junction and if needed, perform a dynamic impingement test to ensure that there is no remaining impingement.

Travis Menge, MD (Grand Rapids, MI), demonstrates an arthroscopic cam resection using a curved hip burr, the ApolloRF® H50 probe, and DualWave™ outflow tubing.

Cam Resection Using a Curved Hip Burr, the ApolloRF® H50 Probe, and DualWave™ Outflow Tubing

My name is Doctor Travis Menge from Grand Rapids, Michigan, and today we're looking at a right hip for an arthroscopic camera section and femoral plasty. We're viewing through the mid anterior portal and we're working through our anterolateral portal. As you can see, we've got a large cam lesion looking from anterior to posterior. I typically start off using the H50 RF wand to help delineate where the extent of my cam is. Again, from a posterior to anterior direction, this wand allows me to retract the distal leaflet of the capsule and evaluate the extent of the Cam lesion without removing excessive tissue from the capsular tissue. To get the appropriate visualization, once I identify where the Cam lesion is, I typically will use the h50 RF to debride and remove some of the overlying cartilage or fibrous tissue that is often covering the Cam lesion. And again you can see this large Cam lesion. And this h50 RF wand does a great job in helping you outline the extent of the Cam deformity. Once we've identified and outlined our Cam lesion and the area of resection I'll use the curved shaver. The Torpedo to gently remove some of the edges of our capsule while maintaining the surrounding normal, healthy tissue for later capsular repair. What's great about this Torpedo is number one. The curved angle allows you to reach posteriorly as well, as it's a very precise and accurate resection. You can see we're cleaning up the edges of that capsule, but we're not removing or debriding an excessive amount of capsular tissue, which could compromise our capsular repair at the end of the case. Additionally, the tapered nose of this blade allows me to accurately resect the tissue that I would like to without causing excessive resection of the surrounding healthy tissue. We're now using a 5.0mm curved bur to address and resect this cam deformity. What's great about the curvature of this bur is that it really allows you to work posteriorly, and especially posterolateral, where sometimes it's difficult to access and you can create a nice resection. Again, working from a more posterior to anterior direction as you recreate the normal offset of the femoral head and neck junction. Another great tip with this bur is you is you can change how aggressive you'd like to resect by either using forward, which is more aggressive, or reverse on the foot pedal, which is going to be more of a polishing type resection. So to start off, I'll typically use a more aggressive resection with forward as we outline and resect this cam deformity. And the curved burr has a unique advantage of allowing you not only to access that posterior cam, but also the anterior cam much better than a straight burr. Another benefit with the curved burr is you spend less time switching portals as you're working on resecting a cam, especially large cam, where you often have to switch portals multiple times throughout the case. As you can see with the curved burr, as we're working on that margin to reshape that femoral head neck junction, you get excellent contouring with very precise removal of that cam deformity as we work more posterior and posterolateral. This burr allows you to access a lot of that cam that you'd have a hard time normally accessing with a straight burr. And often I'll switch between our h50 RF wand to work posteriorly and posterolateral as we debride the fibrous tissue covering the cam lesion, and as we continue to work more posteriorly, we want to internally rotate the foot and bring the leg into extension to help access that area. Now we're going to switch back to the curved bur. You can see how this curve allows you to work posteriorly and get the hard to reach areas of a large cam. Now the bone on this cadaver is very soft, but you can see the accessibility that you get with this curved bur compared to a straight bur. Additionally, the DualWave outflow is keeping our visualization clean throughout the resection and allowing an optimal resection with minimal debris blocking our view. As you can see, the curved bur is resecting the bone very nicely and allowing access as we move anterior in the hip. Here we are with completion of our camera section. Using the curved bur, you can see the access that the bur gave us to go all the way posterior as we work anteriorly as well. You can see that labrum is repaired very nicely, and we've got a great suction seal between the labrum and the femoral cartilage.

Femoral Neck Osteochondroplasty for Cam Impingement

Femoral neck osteochondral plasty for cam impingement. Hip joint access is initiated by inserting a spinal needle into the joint space, removing the inner stylet, and then inserting a nitinol wire. A metal cannula and obturator are then inserted over the top of the nitinol wire, and the obturator is removed, leaving the cannula in place. A scope and quick connect bridge are attached to the metal cannula for viewing inside the joint. Another spinal needle is used to create a mid anterior portal in the same manner with the insertion of another metal cannula. Insert the CapsuleCut blade through the metal cannula and perform an inter portal capsulotomy to connect the two portals. Next, insert a switching stick and then a clear detachable half pipe cannula to facilitate insertion of the Apollo bipolar wand. The Apollo wand is then used to cauterize the inter portal cut before the CapsuleCut blade is inserted again to create an optional T capsulotomy. Down the femoral neck. Traction is then reduced and the hip is flexed to relax the capsule and bring the cam deformity in view. The Apollo wand is then used to debride the periosteum away from the deformity, and mark the position of the cam resection. A curved, concave 5.0mm round burr is then inserted and used to decompress the femoral neck. The curved burr allows for easier access to the posterolateral area on the neck. The cam resection is complete once sphericity of the femoral head is achieved.

Osteoplasty

Burr, Round, HL, DiamondCut, 4.0 mm x 19 cm

Burr, Round, HL, DiamondCut, 5.0 mm x 19 cm

Child (D)

Product

Hip DiamondCut™ burrs feature a diamond-coated head that provides a controlled resection of pincer and cam deformities during arthroscopic hip procedures. These finishing burrs are engineered to minimize skipping and soft-tissue wrapping on the burr head while offering superior control.&nbsp;

Femoroacetabular Impingement

Osteoplasty

Hip DiamondCut™ Burr