Method of hip arthroscopy for elimination of cam and combined types of femoroacetabular impingement

Abstract

FIELD: traumatology; orthopedics.SUBSTANCE: used for arthroscopy of the hip joint to eliminate Cam or combined types of femoroacetabular impingement. A proximal anterolateral port is created to the peripheral portion of the hip joint, which is used as a viewing port at the beginning of the operation; 4 cm distal and 2 cm lateral to the intersection of the midline of the femur and the perpendicular drawn to it through the apex of the greater trochanter, an anterior port is created, which is used as an instrumental port at the beginning of the operation. The deformation zone is brought to the bone burr, changing the positions of flexion and extension, internal and external rotation of the lower limb, and until the appearance of spring resistance of the fibers of the lateral joint capsule and the ileofemoral ligament, resection of excess bone mass of the anterior surface of the proximal femur within the boundaries of the Cam-deformation is performed. The viewing and instrument ports are changed and the deep fibers of the proximal joint capsule and the ileofemoral ligament are released from the acetabulum. In the presence of Pincer deformity, soft tissues are removed to visualize excess bone mass within the boundaries of the Pincer deformity, and resection of excess bone mass of the anterolateral edge of the acetabulum within the boundaries of the Pincer deformity is performed until radiographic visualization of the absence of intersection of the anterior and posterior edges of the acetabulum. The viewing and instrument ports are replaced. An arthroscope is positioned on the outer edge of the joint capsule fibers, and bone resection of the posterolateral surface of the proximal femur is completed within the boundaries of the Cam deformity by inserting a bone burr from the skin incision of the anterior port into the capsule opening of the proximal anterolateral port, preserving the fibers of the joint capsule and the ileofemoral ligament.EFFECT: method ensures correction of the proximal femur within the boundaries of the Cam-deformation while maintaining the integrity of the structures of the passive capsular-ligamentous stabilizers and eliminates the development of complications in the form of microinstability of the hip joint, anterior dislocation of the femoral head, heterotopic ossification due to maintaining the integrity of the structures of the passive capsular-ligamentous stabilizers and eliminating the development of microinstability of the hip joint, anterior dislocation of the femoral head and heterotopic ossification.1 cl, 1 ex

Description

[0001] The invention relates to medicine, namely to traumatology and orthopedics, and can be used in the treatment of patients with femoroacetabular impingement (FAI).

[0002] According to the FAI morphological classification, there are three types - Cam, Pincer, and combined.

[0003] Cam deformity is characterized by a disruption of the sphericity of the femoral head due to excess bone mass in the femoral neck and head. The radiographic criterion for Cam deformity is the alpha angle, calculated by measuring the angle between a line drawn through the center of the femoral neck and head and a second line drawn from the center of the femoral head to the point where the sphericity of the femoral head ends, where a protruding portion with a radius greater than the radius of the femoral head begins.

[0004] Pincer deformity is excessive overlap of the femoral head by the anterior rim of the acetabulum. Radiographic findings include intersection of the anterior and posterior walls of the acetabulum, or the crossover sign, often with acetabular retroversion. In this case, the crossover sign is visualized, and the posterior wall of the acetabulum is located medial to the center of rotation of the femoral head, which is the center of the spherical portion of the head.

[0005] The combined type combines the features of the two described deformations.

[0006] An effective and least invasive treatment for FAI, regardless of its type, is hip arthroscopy. It can be performed in various ways, depending on the anatomical location of the initial stage of the surgery.

[0007] A method is described with the beginning of the operation from the central section of the hip joint and Pincer resection. For this, traction of the lower limb is performed along the axis with separation of the femoral head and acetabulum. For the operation, as a rule, anterior and anterolateral arthroscopic ports are formed. For convenience of manipulations, one of the capsulotomy variants is performed in the anterolateral section: from port to port, radial or T-shaped, depending on the preferences of the surgeons. This method is the most common in world practice; however, according to publications [1, 2], performing a capsulotomy negatively affects the functional outcome and can increase the risk of complications such as microinstability of the femoral head, anterior dislocation, and heterotopic osification. In addition, the need for long-term traction of the lower limb increases the risk of traction neuropathy.

[0008] Another surgical technique involves initial visualization of the extra-articular surface of the anterolateral hip capsule, followed by a T-shaped capsulotomy and resection of the CAM deformity [3]. The advantages of this hip arthroscopy technique include a good view of the bone resection zones, ease of instrument manipulation, and reduced lower limb traction time. However, the need for an extensive T-shaped capsulotomy carries the same potential risks as the previously described technique.

[0009] The closest to the claimed method is the peripheral method with periportal capsulotomy during hip arthroscopy, presented by CC Chambers et al. (Periportal Capsulotomy: a technique for limited violation of the hip capsule during arthroscopy for femoroacetabular impingement / EJ Monroe, CC Chambers, AL Zhang [et all.] / / Arthrosc Tech. - 2019. - 28;8(2). - e205-e208. DOI: 10.1016 / j.eats.2018.10.015) [4].

[0010] Under fluoroscopic control, the anterolateral portal is first established, followed by the anteromedial portal, 3 cm anterior and slightly distal to the anterolateral portal. An ablator is inserted into the anteromedial portal to expand the capsule access. The access is expanded posterosuperiorly and anteroinferiorly relative to the anterolateral portal. Thus, the length of the anteromedial portal is 8-10 mm. The anterolateral portal is then expanded similarly relative to the anteromedial portal, reaching a length of 6-8 mm. An arthroscope is inserted through the anterolateral portal, a bone burr is inserted through the anteromedial portal, and the pincer deformity is resected. When working with a CAM deformity, for better visualization of the peripheral capsule, it is processed and elevated above the femoral neck using electrocoagulation. To eliminate Cam deformation in all sections of the femoral head, the joint is rotated without changing the viewing and working ports.The ports on the capsule are not closed.

[0011] The given method has a number of disadvantages: despite the absence of capsulotomy in its classical sense, the expansion of the ports is performed using an ablator in directions perpendicular to the course of the fibers of the joint capsule and the ileofemoral ligament, the physical impact of the ablator leads to the destruction of collagen fibers and the formation of two oval defects of the joint capsule with a total length of up to 18 mm, which makes it impossible to restore its integrity and can cause complications such as microinstability of the hip joint, anterior dislocation of the femoral head, heterotopic osification.

[0012] The objective of the invention is to develop a method for arthroscopic correction of femoroacetabular impingement while preserving the capsular-ligamentous stabilizing structures.

[0013] The technical result is to ensure precise correction of the proximal femur within the boundaries of the Cam deformation while maintaining the integrity of the structures of the passive capsular-ligamentous stabilizers and eliminating the development of complications in the form of microinstability of the hip joint, anterior dislocation of the femoral head, and heterotopic ossification.

[0014] The technical result is achieved by the fact that in the method of hip joint arthroscopy for eliminating Cam and combined types of femoroacetabular impingement, including the removal of excess bone mass under X-ray control, a proximal anterolateral port is formed to the peripheral part of the hip joint, which is used as a viewing port at the beginning of the operation; a modified anterior port is formed, retreating 4 cm distal and 2 cm lateral to the point of intersection of the midline of the thigh and the perpendicular drawn to it through the apex of the greater trochanter, which is used as an instrumental port at the beginning of the operation;By changing the positions of flexion and extension, internal and external rotation of the lower limb, the deformity zone is brought to the bone bur and resection of the excess bone mass of the anterior surface of the proximal femur is performed within the boundaries of the Cam deformity until springy resistance of the fibers of the lateral joint capsule and ileofemoral ligament appears; the viewing and instrument ports are changed and release of the deep fibers of the proximal joint capsule and ileofemoral ligament from the acetabulum is performed; in the presence of Pincer deformity, appropriate soft tissues are removed to visualize the excess bone mass within the boundaries of the Pincer deformity, stage-by-stage resection of the excess bone mass of the anterolateral edge of the acetabulum is performed within the boundaries of the Pincer deformity until radiographic visualization of the absence of intersection of the anterior and posterior edges of the acetabulum is performed; the viewing and instrument ports are changed;an arthroscope is installed on the outer edge of the fibers of the joint capsule, bone resection of the posterolateral surface of the proximal femur is completed within the boundaries of the Cam deformity by introducing a bone burr from the skin incision of the modified anterior port into the opening of the capsule of the proximal anterolateral port, preserving the fibers of the joint capsule and the ileofemoral ligament.

[0015] The method is carried out as follows.

[0016] Hip arthroscopy is performed with the patient in the supine position with hip flexion of 30-40 degrees and internal rotation of 20-25 degrees. A soft, wide, truncated cone-shaped support is placed in the perineal area. Under image intensifier guidance, a cannulated needle, a nitinol guidewire, and two 4mm and 6mm dilators are used to sequentially dissect the joint capsule fibers from the outer to the inner edge. A proximal anterolateral port is created to the peripheral hip joint. This port is used as a viewing port at the beginning of the surgery. A modified anterior port is created 4 cm distal and 2 cm lateral to the intersection of the femoral midline and a perpendicular line drawn to it through the apex of the greater trochanter. This port is used as an instrument port at the beginning of the surgery.In the anterior region, without widening the anterior joint capsule opening, by varying the flexion and extension positions, internal and external rotation of the lower limb, the deformity zone is brought to the bone burr, and excess bone mass is resected from the anterior surface of the proximal femur within the Cam deformity boundaries until the appearance of elastic resistance from the fibers of the lateral joint capsule and iliofemoral ligament. The viewing and instrument ports are then exchanged, and the deep fibers of the proximal joint capsule and iliofemoral ligament are released from the acetabulum, creating the necessary space for free manipulation of instruments.If Pincer deformity is present, appropriate soft tissue is removed to visualize excess bone mass within the Pincer deformity. A bone bur is used to gradually resect excess bone mass along the anterolateral acetabular rim within the Pincer deformity until radiographic deconvolution of the anterior and posterior acetabular rims is achieved. The viewing and instrument ports are then reversed. The arthroscope is positioned at the outer edge of the joint capsule fibers. Bone resection of the posterolateral surface of the proximal femur within the Cam deformity is completed by inserting a bone bur from the skin incision of the modified anterior port into the capsule opening of the proximal anterolateral port, preserving all primary joint stabilizers. If a labral suture is necessary, all procedures are performed through the same ports without an additional capsulotomy.

[0017] The developed method allows for precise correction of the bone bases of the FAI without damaging the integrity of the structures of the passive capsular-ligamentous stabilizers.

[0018] Example.

[0019] Patient H., 36, presented with complaints of pain and limited range of motion in the hip joint, which he had been experiencing for 1.5 years. Diagnosis: M16.3. Right-sided dysplastic coxarthrosis, stage 2. Femoroacetabular impingement, labral damage. He underwent conservative treatment with minor clinical benefit in the form of pain relief. Radiographic examination revealed signs of combined femoroacetabular impingement. In addition, magnetic resonance imaging revealed a rupture of the acetabular labrum. On November 2, 2021, surgery was performed using the proposed method. Hip arthroscopy was performed with the patient in the supine position with an initial hip flexion of 30 degrees and internal rotation of 20 degrees, with a soft, wide stop in the form of a truncated cone placed in the perineal area.Under image intensifier guidance, a cannulated needle, a nitinol guidewire, and two 4- and 6-mm dilators were used to sequentially dissect the joint capsule fibers from the outer to the inner edge. A proximal anterolateral portal was created to the distal hip joint. This portal was used as a viewing portal at the beginning of the surgery. A modified anterior portal was created 4 cm distal and 2 cm lateral to the intersection of the femoral midline and a perpendicular line drawn to it through the apex of the greater trochanter. This port was used as an instrument port at the beginning of the surgery.Without widening the anterior joint capsule opening, changing flexion and extension positions, internal and external rotation of the lower limb, and bringing the deformity zone closer to the bone burr, we resected excess bone mass from the anterior surface of the proximal femur within the Cam deformity boundaries. Resection was stopped when spring resistance from the fibers of the lateral joint capsule and ileofemoral ligament was encountered. The viewing and instrument ports were then changed, and the deep fibers of the proximal joint capsule and ileofemoral ligament were released from the acetabulum. Using a coblator and a shaver burr, we removed the appropriate soft tissue to visualize excess bone mass within the Pincer deformity boundaries. A bone burr was used to perform a step-by-step resection of excess bone mass from the anterolateral rim of the acetabulum within the Pincer deformity boundaries.The resection level was controlled using an image intensifier (EIC), and resection was stopped when no intersection of the anterior and posterior acetabular margins was visualized. The viewing and instrument ports were then changed (the port assignments were the same as at the beginning of the surgery). The arthroscope was positioned at the outer edge of the joint capsule fibers, and bone resection of the posterolateral surface of the proximal femur was completed within the boundaries of the Cam deformity by inserting a bone burr from the skin incision of the modified anterior port into the capsule opening of the proximal anterolateral port, preserving the joint capsule fibers and iliofemoral ligament. EIC control of bone resection was performed in hip extension with neutral rotation, as well as flexion with external rotation, neutral rotation, and internal rotation. Bone resection was completed when the Alpha angle was less than 50 degrees in all projections as confirmation of correct bone resection.Traction of the lower limb was applied along the ankle joint. The arthroscope was advanced to the central compartment of the hip joint. Areas of grade 2 chondromalacia of the acetabular roof were identified, along with damage to the chondrolabral complex with a 1 cm avulsion of the glenoid labrum (in the projection of the proximal femur deformity height). Using a penetrating grasper, a loop of FiberWire 1 thread was passed through the thickness of the labrum, a 3.5×19.5 mm channel was formed in the area of ​​the resected bone mass of the anterior rim of the acetabulum for a knotless anchor fixator, the threads were passed through the eye of the PushLock fixator corresponding to the size of the bone canal, the anchor fixator was inserted into the canal, the threads were pulled, the glenoid labrum was repositioned along the acetabulum edge without sagging or hypercorrection, and then the final fixation of the anchor fixator in the canal was performed.The joint cavity was liberally irrigated with saline, then traction was released, and visual inspection of the femoral head within the acetabulum, the stability of the labral suture, and the integrity of the joint capsule were performed. The skin incisions of the arthroscopic ports were sutured and an aseptic dressing was applied.

[0020] No complications were observed during the postoperative period. The patient was discharged for outpatient treatment the day after surgery with the following recommendations: walking with crutches for four weeks; limiting physical activity and avoiding deep squats for three months; taking nonsteroidal anti-inflammatory drugs; taking medications to prevent thrombosis and thromboembolism; therapeutic exercise (exercise therapy), and physiotherapy.

[0021] A follow-up examination was performed on February 28, 2022, and the patient reported no complaints. He was able to walk without additional support. Range of motion in the operated joint (S): 5 / 0 / 120, external / internal rotation with the hip flexed to 90 degrees: 40 / 0 / 20, abduction / adduction: 60 / 0 / 25. There were no neurological or vascular disorders.

[0022] Bibliography

[0023] 1. Puncture Capsulotomy During Hip Arthroscopy for Femoroacetabular Impingement: Preserving Anatomy and Biomechanics / WK Conaway, SD Martin / / Arthrosc Tech. - 2017. - 27;6(6). - e2265-e2269. DOI: 10.1016 / j.eats.2017.08.036.

[0024] 2. Impact of Capsulotomy on Hip Biomechanics during Arthroscopy / H. Lee, W. Lim, S. Lee [et all.] / / Medicina (Kaunas). - 2022. - 9;58(10):1418. DOI: 10.3390 / medicina58101418.

[0025] 3. Longitudinal Capsulotomy in Hip Arthroscopy: A Safe and Feasible Procedure for Cam-Type Femoracetabular Impingement / Q-F. Yin, L. Wang, T. Liang, H. Zhao [et all.] / / Orthop Surg. - 2021. - 13(6): 1793-1801. DOI: 10.1111 / os.1304.

[0026] 4. Periportal Capsulotomy: a technique for limited violation of the hip capsule during arthroscopy for femoroacetabular impingement / E.J. Monroe, C.C. Chambers, A.L. Zhang [et all.] / / Arthrosc Tech. - 2019. - 28;8(2). - e205-e208. DOI: 10.1016 / j.eats.2018.10.015.

Claims

A method of hip arthroscopy for the correction of Cam or combined types of femoroacetabular impingement, including the removal of excess bone mass under radiographic control, characterized in that a proximal anterolateral port is formed to the peripheral part of the hip joint, which is used as a viewing port at the beginning of the operation; 4 cm distal and 2 cm lateral to the point of intersection of the midline of the thigh and the perpendicular drawn to it through the apex of the greater trochanter, an anterior port is formed, which is used as an instrument port at the beginning of the operation;The deformation zone is brought to the bone bur, changing the positions of flexion and extension, internal and external rotation of the lower limb, and until the springy resistance of the fibers of the lateral joint capsule and ileofemoral ligament appears, resection of excess bone mass of the anterior surface of the proximal femur within the boundaries of the Cam-deformation is performed; the viewing and instrument ports are changed and release of the deep fibers of the proximal joint capsule and ileofemoral ligament from the acetabulum is performed; in the presence of Pincer deformity, soft tissues are removed to visualize excess bone mass within the boundaries of the Pincer deformity, resection of excess bone mass of the anterolateral edge of the acetabulum is performed within the boundaries of the Pincer deformity until radiographic visualization of the absence of intersection of the anterior and posterior edges of the acetabulum is performed; the viewing and instrument ports are changed;an arthroscope is installed on the outer edge of the fibers of the joint capsule, bone resection of the posterolateral surface of the proximal femur is completed within the boundaries of the Cam-deformation by inserting a bone burr from the skin incision of the anterior port into the opening of the capsule of the proximal anterolateral port, preserving the fibers of the joint capsule and the ileofemoral ligament.