Hip Arthroscopy Peripheral or Central Access

Transcription

1 4/7/2013 Hip Arthroscopy Peripheral or Central Access Hatem G. Said Assiut University Hospital, Egypt SICOT Editorial Secretary Central or Peripheral Access first 1. Central Compartment 2. Peripheral Compartment Extra-articular 3 Central Comp - Traction 1

2 4/7/2013 Central Access: Traditional Traction Tight space Injury: Cartilage Head / Acetab - Labrum Capsultotomy Op: Adv Technique Central Tech Labral Repair / Debridement Central Tech Labral Repair / Debridement Microfracture Fovea: Deb / trimming Acetabular recession 2

3 4/7/2013 Why Peripheral First? Wide space: Easier Traction complications Dienst Tech Peripheral Compartment First Central Compartment Under vision Peripheral Access: Right Hip Foot Head Masoud & Said

4 4/7/2013 M 32y, HHS 56 Alpha 72 Periph Comp Flexion Right Hip Cam Excision Acetab Neck Right Hip 4

5 4/7/2013 Periph Comp - Pincer Recession: Acetab Neck Left Hip Periph - Flexion Central - Traction Pre-Op Post - Op CE 52 CE 39 5

6 4/7/2013 Central Compartment first Summary Peripheral compartment First Traction Entry under C-arm Capsulotomy Central Compartment Capsulectomy Peripheral comp Less traction time No C-arm Capsular thinning Easier for beginners Central compartment access under vision 6

7 Chondral delaminations What to do JOHN M. O DONNELL Melbourne Australia Disclosures Consulting agreements with Smith and Nephew and Medacta Royalties from Medacta No conflict with this talk Evidence There is no good evidence for many of the things that I am about to say. There is anecdotal evidence, and there are very short term outcome reports. There is evidence for microfracture. 1

8 Classification There is no generally agreed classification of the types of chondral delamination This presentation will use the following Type 1- Intact chondrolabral junction, positive wave sign Type 2-Disrupted chondrolabral junction, articular cartilage pocket Type 3-Cartilage flap Type 4- Full thickness chondral loss Type 1 Type 2 2

9 Type 3 Type 4 Treatment Correct the underlying cause- FAI, instability, dysplasia, and then. Leave the articular cartilage alone, or Excise damaged articular cartilage, or Repair articular cartilage, or Regenerate fibrocartilage 3

10 Excision May be able to remove all the damaged articular cartilage as part of a pincer correction Chondroplasty 4

11 Repair Microfracture + glue, anchors/sutures. Repair Intact CLJ 5

12 Microfracture Wave Microfracture behind articular cartilage Glue 6

13 Regeneration Microfracture Microfracture plus augmentationpatch/amic, MACI, PRP, stem cells Microfracture Microfracture 7

14 Microfracture Healed microfracture Microfracture 6 yrs post-microfracture, cam untreated Microfracture Augment healing PRP 8

15 Microfracture AMIC Collagen membrane Autologous Chondrocyte Graft Warning! Remember, Marc Safran has showed us that this is damaged cartilage. We do not know its healing potential, or its longer term prospects. 9

16 My current practice Type 1- Maintain CLJ, microfracture and glue, OR do nothing except correct FAI. Type 2- Microfracture and glue Type 3- Excise and microfracture, OR glue Type 4- Chondroplasty, microfracture +/- augmentation with PRP, or AMIC 2nd MELBOURNE INTERNATIONAL HA MEETING JAN Thank you 10

17 Hip Arthroscopy for Dysplasia Soshi Uchida M.D., Ph.D. Dept. of Orthop. Surg., Wakamatsu Hospital University of Occupational and Environmental Health Japan (UOEH) Webinar My Talk 1. Clinical outcome of Arthroscopic labral repair and cam osteochondroplasty. 2. Predictor of clinical outcomes. 3. New Surgical Technique Shelf acetabuloplasty Financial Disclosure I do not have a financial interest in any commercial products or service presented in this presentation. Consultant; Biomed Educational; Depuy Mitek Research Grant; Smith & Nephew Teijin 3 Astellas 1

18 Dysplasia Diagnostic Overview Considerable overlap between impingement related issues and dysplasia- related issues. Dynamic Impingement Problems Cam Lesions Pincer Lesions Femoral Retroversion Femoral varus Etc. Overlap Static Overload Problems DDH Uncoverage of the socket Femoral anteversion Valgus orientation etc Bryan Kelly Innovation hip arthroscopy Summary Outcomes for Hip Arthroscopy in Dysplasia Study (Year) Journal Intervention N Outcome McCarthy Orthopaedics Debridement 85% functional improvement Byrd (2003) Arthroscopy Debridement 184 Functional improvement Yamamoto (2005) Arthroscopy Labrectomy 10 Functional improvement Parvitz (2009) J Arthroplasty Debridement 34 Poor and hip operation rate Kalore (2012) CORR Repair Debridement Mei-Dan(2012) Arthroscopy Debridement And osteoplasty Matsuda(2012) Arthroscopy Repair and osteoplasty 106 Poor and high reperation rate 1 Rapid progress OA 2 Rapid progress OA Dysplasia Approach with caution and consider corrective osteotomies when appropriate. Indications unclear as the underlying pathomechanics are not typically corrected with arthroscopy 2

19 Clinical Outcome Following Arthroscopic Management for developmental dysplasia of hip in Japanese patients ~labral repair and osteochondroplasty~ Soshi Uchida 1) 2), Toshiharu Mori 1), Hideo Ohnishi 1), Hidehiko Matsumoto 1) 2), Hajime Utsunomiya 1), Michiharu Hara 1)2), Toshitaka Nakamura 1) 1 1) Dept.of Orthop Surg, School of Medicine, University of Occupational and Environmental Health Japan 2) Dept. of Orthop Surg, Wakamatsu Hospital for UOEH The 3rd Annual Meeting of ISHA Arthroscopic Labral Repair and CAM Osteochondroplasty for Developmental Hip Dysplasia (Uchida et al. ISHA 2011) Between 2009 and 2010, 21 patients were enrolled. Variable Total Mean Age Age 25.1±11 (range;12~45) Gender 4 male 17 female 21 cases Body Mass Index 20.38± 2.62 Mean lateral center-edge angle 19±5 Mean Ventral Center Edge Angle 16±6 Sharp angle 44±9 5 Mean alpha angle 74±15 Dysplasia patients were involved in various physical activities Activity Ballet 2 Valley ball 2 Soccer 2 Rhythmic Gymnast 1 Gymnast 1 Baseball 1 Ranger 1 Golf 1 Track and Field 1 6 3

20 A 22-year-old self defense forces soldier presented to our clinic complaining with left hip pain for the past 6 months. 11 Preope Lt Postope 12 4

21 modified Harris Hip Score Non Arthritic Hip Score 4/8/2013 Results The overall evaluation was excellent in 16 patients. Initial arthroscopy failed in five patients. Two underwent THA. Two underwent RAO. One underwent Shelf. 100 Modified Harris Hip Score Pre Post 6M Post 1Y Post 2Y Non Arthritis Hip Score Pre Post 6M Post 1Y Post 2Y 5

22 Cumulative Survivorship (%) 4/8/2013 Methods Center-edge angle of Wiberg VCA (ventral center angle) Cutt off 15 degree Sensitivity 0.62 Specificity 1.00 Total 1.62 Cutt-off 18 degree Sensitivity 0.57 Specificity 0.93 Total % CE angle CE angle > % P=0.012 log rank test Months after operation CE angle < 18 ROC curve Sensitivity57.1% Specificity92.9% P=0.012 log rank test 6

23 Cumulative Survivorship (%) 4/8/ % VCA angle VCA angle > % VCA angle < P=0.001 log rank test Months after operation ROC curve Sensitivity62.5% Specificity100% Indication of hip arthroscopy for dysplasia Mild to Moderate Dysplasia CE > 20 VCA > 20 No severe instability (lateral migration) No evidence of Osteoarthritis No evidence of severe chondral damage (MRA) No evidence of larger bone cyst. No additional bone abnormality such as Perthes and SCFE Next Solution Shallow Acetabulum Static Load CAM Shear Forces Osteochondroplasty Labral Tear and Cartilage Delamination Labral Repair Osteoarthritis Osteotomy; PAO, RAO, CPO Shelf Acetabulplasty 7

24 New Endoscopic Technique Acetabular Shallowness Labral Tear Cam Impingement Shelf Acetabuloplasty Labral Repair and/or reconstruction Cam Osteochondroplasty 22 He returned to preinjury PO1M activity level at 4 months after surgery Pre op Post op 6 months after surgery Conclusion Arthroscopic labral repair and cam osteochondroplasty has a moderate clinical outcome and reoperation rate depending on the acetabular shallowness and cartilage damage. New arthroscopic shel acetabuloplasty could address both intra-articular pathology and underlying mechanical problem. This arthroscopic procedure is less invasive and could be beneficial treatment for the patients with dysplasia. 8

25 Survivorship (%) 4/8/2013 MAHORN Grade of Cartilage delamination Survivorship % Low grade Grade 0,1, % High grade Grade 3,4, P=0.032 log rank test Months after operation 9

26 Controversies in Hip Arthroscopy Acetabular recsession: To detach Labrum or not? Dr Ali Bajwa MBBS, MRCSEd, MSc Orth, Mphil (Cantab), DSEM, MFSEM(UK), FRCS Tr & Orth Consultant Orthopaedic surgeon Villar-Bajwa Practice, Cambridge, UK Disclosures Co-founder & Director Cambfix Ltd Consultant for Smith & Nephew Research and Development Grants Holder No financial conflict of interest with regards to this presentation 1

27 Lavigne et al 2004 Do we have to remove the labrum? Scenarios with prominent Acetabular margin Labrum intact Chondro-labral disruption Detached labrum 2

28 How and Why? Technical feasibility Advantages 3

29 Acetabular margin visualisation Acetabular rim recession Repair 4

30 Approach Elite National Jockey 5

31 Labral seal integrity 6

32 Limitations Already detached labrum Unstable labrum post resection of large Pincer Calcified rudimentary labrum Conclusion Acetabular recession can be safely and effectively undertaken without detaching the labrum in majority of cases Thank you! 7

33 Psoas Tenotomy: Endoscopic or Arthroscopic? Nicolas BONIN, M.D. LYON, France Nicolas BONIN, M.D. LYON, France Disclosure : Consultant for Smith and Nephew Consultant for Serf / Dedienne Santé Without benefit for the presentation submitted Video Assisted Psoas Tenotomy 2 Approaches BUT 3 Techniques Arthroscopic Trans capsular Central Compartment Hip traction Peripheral Compartment Hip Flexion Endoscopic at Lesser Trochanter 1

34 2 Approaches BUT 3 Techniques Arthroscopic Trans capsular Video Assisted Psoas Tenotomy Central Compartment Hip traction Peripheral Compartment Hip Flexion Endoscopic at Lesser Trochanter Arthroscopic Psoas Tenotomy Central Compartment - Under Hip Traction - Level of Acetabular Brim Contreras ME, Dani WS, Endges WK et al. Arthroscopic treatment of the snapping iliopsoas tendon through the central compartment of the hip: a pilot study. JBJS Br 2010;92-6: Arthroscopic Psoas Tenotomy Central Compartment - Under Hip Traction - Level of Acetabular Brim - At the Psoas u : Clock Face system = 3 o clock right hip / 9 o clock left hip Psoas «u» Psoas Tendon Contreras ME, Dani WS, Endges WK et al. Arthroscopic treatment of the snapping iliopsoas tendon through the central compartment of the hip: a pilot study. JBJS Br 2010;92-6:

35 Arthroscopic Psoas Tenotomy Central Compartment - Under Hip Traction - Level of Acetabular Brim - At the Psoas u : Clock Face system = 3 o clock right hip / 9 o clock left hip ISHA Zone = Between 1&2 Arthroscopy 2008;24-5:534-9 Psoas Tendon Psoas «u» Contreras ME, Dani WS, Endges WK et al. Arthroscopic treatment of the snapping iliopsoas tendon through the central compartment of the hip: a pilot study. JBJS Br 2010;92-6: Arthroscopic Psoas Tenotomy Central Compartment - Under Hip Traction - Level of Acetabular Brim - At the Psoas u : Clock Face system = 3 o clock right hip / 9 o clock left hip ISHA Zone = Between 1&2 - Standard Portal Psoas Tendon Scope in AL Position Schaver and radiofrequency probe in DA or MAP Contreras ME, Dani WS, Endges WK et al. Arthroscopic treatment of the snapping iliopsoas tendon through the central compartment of the hip: a pilot study. JBJS Br 2010;92-6: Arthroscopic Psoas Tenotomy Peripheral Compartment - Hip Flexed 20 to 45 My Favorite Approach - Level of Medial fold (inferior part of the neck) Wettstein M, Jung J, Dienst M. Arthroscopic psoas tenotomy. Arthroscopy 2006;22-8:907 e1-4 3

36 Arthroscopic Psoas Tenotomy Peripheral Compartment - Hip Flexed 20 to 45 - Level of Medial fold (inferior part of the neck) - Portals Proximal Antero lateral Portal 1/3 2/3 Mid Antero inferior Portal Arthroscopic Psoas Tenotomy Peripheral Compartment - Hip Flexed 20 to 45 - Level of Medial fold (inferior part of the Capsulae neck) - Portals - Hip flexion 45 ZO - Capsulotomy MSF FN Rotate Hip to See the relief of Tendon Arthroscopic Psoas Tenotomy 4

37 Arthroscopic Psoas Tenotomy Peripheral Compartment - Hip Flexed 20 to 45 - Level of Medial fold (inferior part of the neck) - Portals - Hip flexion 45 - Capsulotomy 16% communication beetween iliopsoas bursa and hip joint Wettstein M, Jung J, Dienst M. Arthroscopic psoas tenotomy. Arthroscopy 2006;22-8:907 e1-4 Arthroscopic Psoas Tenotomy Arthroscopic Psoas Tenotomy 5

38 Endoscopic Psoas Tenotomy Lesser Trochanter Level - Under Hip External Rotation - 20 Hip Flexion - Fluoroscopy ++ Scope Working Portal Hooked Electrocautery Device Ilizaliturri VM, Jr., Villalobos FE, Jr., Chaidez PA et al. Internal snapping hip syndrome: treatment by endoscopic release of the iliopsoas tendon. Arthroscopy 2005;21-11: Video Assisted Psoas Tenotomy 3 Equivalent Techniques? Arthroscopy 2009;25-2: = Prospective randomized study of 2 different techniques for endoscopic iliopsoas tendon release in the treatment of internal snapping hip syndrome. Ilizaliturri VM Jr et al Group 1 (N=10) = endoscopic iliopsoas tendon release at the lesser trochanter Group 2 (N=9) = endoscopic transcapsular psoas release from the peripheral compartment Results = No Clinical Difference But : Underpowered Study! Pros Cons -Psoas Identification -Traction -Capsulotomy -Intra articular check -Potential Stength loss -Recidive Risk -Heterotopic Ossif. -Safer for Hip arthroplasty patients Central Difficult Yes Standard Yes Less ++ - No Peripheral Endoscopic Medium No Extended Yes Less + - No Easy No No No More - + Yes 6

39 Video Assisted Psoas Tenotomy My Option = Arthroscopic Peripheral Compartment Psoas Tenotomy Intra Articular Checking % to 80% with associated intra articular pathology in native hips If Hip Arthroplasty with a certain diagnosis of Psoas Pain Endoscopic Tenotomy 7