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Hip Videos: Impingement
Proximal Anterolateral Accessory Portal Use Improves Peripheral Compartment Access and Capsular Management with T-Capsulotomy
One of the primary goals of hip arthroscopy for femoroacetabular impingement (FAI) syndrome is precise removal of pathologic FAI morphology while protecting and restoring the normal soft tissue anatomy. Adequate visualization is a key foundation of precise removal of FAI morphology and varying types of capsulotomies are frequently used to achieve necessary exposure. Anatomic and outcomes studies have influenced an increasing appreciation for repairing these capsulotomies. Thus one of the central technical challenges of hip arthroscopy is achieving both goals of capsule preservation and adequate visualization.Arthroscopic Capsular Suture-Lifting Technique for Treating Femoroacetabular Impingement Patients With a High Risk of Postoperative Anterior Instability
With the increasing popularity of hip arthroscopy, postoperative iatrogenic instability due to bony and soft-tissue issues has been noted by more orthopaedic surgeons. Although there is a low risk of serious complications in patients with normal hip joint development even without suturing of the joint capsule, for patients with a preoperative high risk of anterior instability—including those with excessive anteversion of the acetabulum or femur, borderline dysplasia of the hip, and hip arthroscopic revision surgery with an anterior defect of the joint capsule—capsulotomy without repair will result in postoperative anterior instability of the hip joint and related symptoms.Reverse Microfracture of the Hip Acetabulum: A Technique for the Wave Lesion
The long-term efficacy of the treatment of chondral lesions is very important to prevent hip osteoarthritis. Microfracture, autologous chondrocyte transplantation, and direct chondral repair, among others, are techniques that have shown good results in some cases. We propose a technique to treat wave lesions through reverse microfracture, with bubble decompression and adherence of the natural scar from the detached cartilage.Computer-Assisted Hip Arthroscopic Surgery for Femoroacetabular Impingement
Precise osteochondroplasty is key for success in hip arthroscopic surgery, especially for femoroacetabular impingement (FAI) caused by cam or pincer morphology. In this Technical Note, we present computer-assisted hip arthroscopic surgery for FAI, including preoperative planning by virtual osteochondroplasty and intraoperative computer navigation assistance. The important concept of this technique is that navigation assistance for osteochondroplasty is based on planning made by computer simulation analysis.Arthroscopic Identification and Management of Recurrent Iliopsoas Impingement After Total Hip Arthroplasty
Arthroscopic release of the iliopsoas tendon for iliopsoas impingement (IPI) after total hip arthroplasty (THA) at the lesser trochanter gives good results. However, where IPI then recurs, due to adhesions between the healing iliopsoas tendon and the surrounding soft tissue, and nonoperative measures have failed, a revision THA procedure is usually considered. We propose a technique of arthroscopic visualization of the recurrent IPI and a subsequent psoas tenotomy at the level of the hip joint using an outside-in capsulotomy approach.Endoscopic Lesser Trochanter Resection With Refixation of the Iliopsoas Tendon for Treatment of Ischiofemoral Impingement
Ischiofemoral impingement is a source of hip pain derived from impingement between the lesser trochanter and the ischium. Lesser trochanter excision has been recommended for recalcitrant ischiofemoral impingement through either an anterior or posterior approach. However, neither of these approaches involves refixation of the iliopsoas tendon. We describe an endoscopic procedure involving anterior trochanter-plasty, minimizing the risk of sciatic complications, with refixation of the partially detached iliopsoas tendinous insertion, potentially minimizing compromise to hip flexion strength and anterior hip stability.The “Bird's Eye” and “Upper Deck” Views in Hip Arthroscopy: Powerful Arthroscopic Perspectives for Acetabuloplasty
Arthroscopic acetabuloplasty involves trimming of bone from the acetabular rim. Although early techniques often involved detachment of the labrum prior to bone resection, recent studies have reported on acetabuloplasty without labral detachment. This method has the benefit of preserving the labro-osseous junction, but visualization of the acetabular rim may be more difficult. Compromised visualization can lead to incomplete resection and residual impingement. We describe an arthroscopic perspective called the “bird's eye” and “upper deck” views that facilitates optimal visualization of the acetabuloplasty without labral detachment.Puncture Capsulotomy During Hip Arthroscopy for Femoroacetabular Impingement: Preserving Anatomy and Biomechanics
We describe an arthroscopic technique for the treatment of labral pathology and femoroacetabular impingement that provides excellent access to the central and peripheral compartments while preserving the biomechanically crucial components of hip joint stability. The hip capsule and the ligaments within it have been shown to be integral to hip biomechanical stability. Other popular techniques such as interportal and T-capsulotomy inherently damage the capsuloligamentous complex of the hip and can be associated with postoperative gross instability, micro-instability, heterotopic ossification, and seroma.Arthroscopic Decompression of Greater Trochanteric Sciatic Nerve Impingement
Therapeutic extra-articular hip endoscopy is an effective treatment of greater trochanteric sciatic nerve impingement. We describe in detail technical pearls of the procedure including positioning, portal placement, and steps to obtaining adequate decompression while avoiding iatrogenic nerve injury.Arthroscopic Repair of Hip Labrum With Suture Anchors
The acetabular labrum and the transverse acetabular ligament form a continuous ring of tissue on the periphery of the acetabulum that provides a seal for the hip joint and increases the surface area to spread load distribution during weight-bearing. When a labral tear is suspected, the treatment algorithm always begins with conservative management, including physical therapy and nonsteroidal anti-inflammatory drugs. When conservative management fails, patients become candidates for arthroscopic labral repair.Modifications to the Hip Arthroscopy Technique When Performing Combined Hip Arthroscopy and Periacetabular Osteotomy
In the realm of hip preservation, hip arthroscopy is often used to address intra-articular impingement pathology, whereas periacetabular osteotomy (PAO) is used to address dysplasia and instability. Indications to combine these 2 procedures include hip dysplasia and symptomatic instability with a concomitant symptomatic labral tear or the other symptomatic intra-articular pathology (i.e., loose body, chondral flap). The arthroscopic portion of the procedure allows repair of the injured labrum and close inspection of the hip joint, and the PAO addresses undercoverage and/or inappropriate version of the acetabulum.Arthroscopic Focal Subspinal Decompression and Management of Pincer-Type Femoroacetabular Impingement
Femoroacetabular impingement syndrome is a common hip pathology significantly affecting not only the intra- and extra-articular structures but also the biomechanical function of the joint. Cam and pincer bony lesions have been extensively studied. However, during recent years, other types of extra-articular impingement between the pelvic and femoral bone have been investigated. When a prominent or morphologically abnormal anterior-inferior iliac spine (AIIS) impinges repetitively on the femoral side during motion, the subspinal acetabular region becomes prominent and extends toward the intra-articular part of the joint.Basic Hip Arthroscopy: Diagnostic Hip Arthroscopy
Hip arthroscopy is increasing in popularity for the diagnosis and management of hip preservation. The basics of hip arthroscopy positioning, fluoroscopic assessment, and portal establishment are reviewed in the first 2 parts of this series. This article is the third installment in which we describe a systematic approach to performing a diagnostic hip arthroscopy. A mastery of diagnostic arthroscopy is necessary for surgeons treating hip disorders.Circumferential Labral Reconstruction Using the Knotless Pull-Through Technique—Surgical Technique
Arthroscopic labral reconstruction is an alternative procedure for an irreparable hip labrum in the nonarthritic hip population. Although labral reconstruction is a relatively new procedure, data in the literature show favorable outcomes. Patients have shown beneficial outcomes from labral reconstructive surgery as well as when compared with labral repair and debridement patients. However, one of the challenges in performing labral reconstruction has been correctly measuring the graft to perfectly fit the area of labral deficiency.Screw Fixation of Os Acetabuli: An Arthroscopic Technique
An os acetabuli (OA) increases the contact area and surface area of the acetabulum and is important to maintain congruity of the hip joint. Thus preservation of this ossicle is important to prevent loss of contact area and ensure containment of the femoral head. We describe an all-arthroscopic approach to the fixation of OA with a compression screw. Initially, the fibrous tissue is debrided between the acetabular rim and the OA, a guidewire is placed through the OA up to the acetabular rim, and a screw is inserted over the wire.Arthroscopic Subcapital Realignment in Chronic and Stable Slipped Capital Femoral Epiphysis
Stable slipped capital femoral epiphysis (SCFE) is the most common disease in the adolescent hip, with an estimated frequency of 10.8 in every 100,000 individuals. Recent studies of the biomechanics of femoroacetabular impingement indicate that small anatomical deformities of the hip arising from SCFE can potentially cause permanent acetabular chondral damage. There is no consensus about the best treatment option, especially for cases of moderate or severe chronic slippage (Southwick classification).Posterolateral Acetabuloplasty and Distal Femoral Neckplasty, Labral Repair, and Capsular Plication for Hip Reverse Contre-Coupe Lesion
This article describes the arthroscopic approach and management of a “reverse contre-coup” injury to the hip labrum. The injury occurs in the setting of posterolateral acetabular rim over-coverage impinging on the distal femoral neck in extension causing the femoral head to lever out anteriorly against the labrum. Ligamentous laxity and associated loss of anterior capsular restraint allow increased femoral head translation, adding further insult to the anterior labrum. The arthroscopic approach entails not only a labral repair with correction of the osseous conflict but also restoration of soft-tissue stability to minimize anterior femoral translation.Measurement of Hip Contact Pressure During Arthroscopic Femoroacetabular Impingement Surgery
Cam impingement is caused by jamming of an abnormal femoral head with an increased radius into the acetabulum during motion. Therefore, the elevation of the contact pressure during the motion is suspected to be an essential pathology of femoroacetabular impingement. However, there is no method to quantify the hip contact pressure during motion. The purpose of this Technical Note is to introduce a technique to measure the hip contact pressure during arthroscopic surgery. The author believes that the current technique will be a useful tool for the detailed investigation of the pathophysiology femoroacetabular impingement and thorough evaluation of its therapeutic significance.Hip Arthroscopy Capsular Closure: The Figure of Eight Technique
Hip arthroscopy techniques have continued to evolve for femoroacetabular impingement and other intra-articular pathologies. However, there is still debate about the importance and technique of routine capsular closure. We present an efficient and reliable technique for creating a watertight capsular closure to prevent iatrogenic macro and microinstability. This Technical Note details our stepwise technique using figure of eight sutures to obtain a complete and secure capsular closure.Endoscopic Rectus Abdominis and Prepubic Aponeurosis Repairs for Treatment of Athletic Pubalgia
Review of the English orthopaedic literature reveals no prior report of endoscopic repair of rectus abdominis tears and/or prepubic aponeurosis detachment. This technical report describes endoscopic reattachment of an avulsed prepubic aponeurosis and endoscopic repair of a vertical rectus abdominis tear immediately after endoscopic pubic symphysectomy for coexistent recalcitrant osteitis pubis as a single-stage outpatient surgery. Endoscopic rectus abdominis repair and prepubic aponeurosis repair are feasible surgeries that complement endoscopic pubic symphysectomy for patients with concurrent osteitis pubis and expand the less invasive options for patients with athletic pubalgia.Compression and Flip Test for Diagnosis of Unstable Acetabular Labral Tears Using a Peripheral Compartment Approach
Assessment of integrity of the acetabular labrum is generally done via the central compartment under distraction of the femoral head from the acetabulum. With the technique of raising the extra-articular and peripheral compartment first, there is a need for testing the stability and function of the labrum from the peripheral side in a nondistracted position of the joint. The authors report on the compression and flip test (i.e., the flip test) for the detection of unstable, intrasubstance tears of the labrum or unstable chondrolabral separations.Arthroscopic Decompression of a Type III Subspine Impingement
Extra-articular hip impingement refers to a variety of hip disorders causing pain and limited function in young, non-arthritic patients. Recently, there has been an increased focus on analyzing the degree of anterior inferior iliac spine (AIIS) dysmorphism and its correlation with subspine impingement (SSI), defined as abutment between a prominent distal aspect of the AIIS and the anterior aspect of the femoral head-neck junction. Arthroscopic decompression of the AIIS is recognized as an effective treatment for SSI.Dynamic Hip Examination for Assessment of Impingement During Hip Arthroscopy
Arthroscopic procedures for treatment of hip pathology are growing exponentially as a result of continued improvements in the understanding of intra- and extra-articular hip anatomy and technological advancements in instrumentation. Nevertheless, it has been reported that the main cause of revision hip arthroscopy is related to a suboptimal intrasurgical management of the abnormal morphology in femoroacetabular impingement (FAI). Under-resection, over-resection, and in some cases combined under-resection and over-resection at different locations of the cam lesion at the femoral head-neck junction may lead to poor outcomes as a result of residual impingement or the iatrogenic creation of structural instability.Hip Arthroscopy for Removal of an Acetabular Rim–Based Osteoid Osteoma and Concomitant Femoroacetabular Impingement Correction
Minimally invasive percutaneous radiofrequency ablation (RFA) techniques are the standard of care for treating simple osteoid osteomas (OOs). Historically, OOs were treated with open en bloc resection or curettage of the nidus. RFA procedures have been linked to soft-tissue complications of varying severity. In addition, RFA may be a poor choice for periarticular OOs because of the potential for procedure-related articular cartilage damage. Hip arthroscopy is a widely accepted approach for the treatment of femoroacetabular impingement.Remplissage of the Femoral Head-Neck Junction in Revision Hip Arthroscopy: A Technique to Correct Excessive Cam Resection
Femoroacetabular impingement (FAI) is an increasingly recognized cause of hip pain. This pathology often involves abnormal femoral neck shape (cam-type FAI), acetabular over coverage (pincer-type FAI), or mixed pathology. Surgical treatment of this entity includes labral repair and femoral head-neck osteochondroplasty. A mindful arthroscopic technique is of paramount importance, because maintaining the integrity of the labrum and a corresponding neck volume has been reported to be vital in maintaining the hip suction seal.
