Global Pincer Impingement: Scope All the Way: Go Big or Go Home! - - PowerPoint PPT Presentation

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

• Crossover sign
• Upper region of

acetabulum

• Ischial spine sign
• Posterior wall sign
• Commonly treated

arthrscopically with good results

Focal Pincer Impingement

• More severe
• Deep socket with generalized
• vercoverage
• Acetabular protrusio
• Coxa profunda
• CEA of >40 degrees
• Traditionally treated with open hip

dislocation

Global Pincer Impingement

FOCAL CEA 25-39 Crossover sign

Pincer FAI

GLOBAL CEA >40 Medial Acetabular Floor

• Hip distraction
• Larger force needed
• Central compartment access
• Difficult access from anterolateral portal
• Posterior rim access

Challenges to Treatment of Global Lesions

• 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 Technique

Arthroscopic Pincer Resection

• Be prepared to deal with labrum
• Pre-existing tears
• Iatrogenic detachment
• Knotless labral repair

Labrum Considerations

• CEA < 35 degrees
• Anterior margin

ratio (Gross, et al Arthroscopy 2012) = 5

• Neutral posterior

wall sign

Radiographic Endpoints

• 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

Outcomes

• 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

Conclusions

Thank You