Global Pincer Impingement: Scope All the Way: Go Big or Go Home! Brian D. Busconi, MD Chief of Sports Medicine & Arthroscopy UMass Memorial Medical Center Brian.Busconi@umassmemorial.org
Disclosure • Consultant – Arthrex – Mitek
Focal Pincer Impingement • Crossover sign • Upper region of acetabulum • Ischial spine sign • Posterior wall sign • Commonly treated arthrscopically with good results
Global Pincer Impingement • More severe • Deep socket with generalized overcoverage • Acetabular protrusio • Coxa profunda • CEA of >40 degrees • Traditionally treated with open hip dislocation
Pincer FAI FOCAL GLOBAL CEA >40 CEA 25-39 Medial Acetabular Floor Crossover sign
Challenges to Treatment of Global Lesions • Hip distraction • Larger force needed • Central compartment access • Difficult access from anterolateral portal • Posterior rim access
Arthroscopic Technique • Lateral position • 10 degrees flexion, 20 degrees abd, internal rotation • Serves to compensate for hip anteversion and improves access to central compartment • Typically requires increased traction force compared to focal lesions • Establishment of modified mid-anterior portal
Arthroscopic Technique • Perform capsulotomy first • Inside-out or outside-in technique • Access to acetabular rim • Percutaneous piercing of capsule and passing of capsular sutures • Prior to acetabuloplasty • Allows for greater retraction of the capsule away from pincer lesion • More space to work and visualize
Arthroscopic Technique • Approach lesion from superiorly and work down towards labrum • May approach in a specific sequence to help set the level of resection throughout the rim –Superolateral>anterior>posterior (Matsude, et al.)
Arthroscopic Pincer Resection
Labrum Considerations • Be prepared to deal with labrum • Pre-existing tears • Iatrogenic detachment • Knotless labral repair
Radiographic Endpoints • CEA < 35 degrees • Anterior margin ratio (Gross, et al Arthroscopy 2012) = 5 • Neutral posterior wall sign
Outcomes • Safran and Epstein, Arthroscopy 2013 • 3 patients, 4 hips with protrusio acetabuli treated arthroscopically • Reduced symptoms, improved function at 2.5 yrs • Botser, et al. Arthroscopy 2011 • Systematic review of 26 articles, open vs. arthroscopic • Mean Harris hip score improved 26.4 for arthroscopy and 20.5 for open • Overall return to sports higher for arthroscopy group • 1.7% complication rate for arthroscopy vs. 9.2% open • Arthroscopic: lowest complications, lower revision rate, fastest rehabilitation rate
Outcomes • Matsuda et al, Journal Hip Preservation Surgery 2015 • Prospective, multicenter study (3 surgeons) • 18 hips with global pincer, 127 focal • 24 months follow-up • Post-operative non-arthritic hip score improved significantly in both groups with final scores be similar • No difference in patient satisfaction at all time points • No difference in THA conversion • Overall outcomes for arthroscopic treatment of global pincer FAI are comparable to those for treatment of focal lesions
Conclusions • Significant challenges to arthroscopy in treatment of global pincer impingement • Outcomes comparable for both global and focal pincer lesions • Arthroscopy advantages: • Less Invasive • Lower complication rate • Faster rehabilitation • High patient satisfaction
Thank You
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