Visualize and address femoroacetabular impingement via mini-open procedure

Total joint surgeons can address head, labrum and rim morphology with this direct anterior technique.

An orthopedic surgeon from Philadelphia reported success using a mini-open anterior surgical technique he developed for managing femoroacetabular hip impingement, a cause of early arthritis in young patients.

Javad Parvizi, MD, FRCS, a member of the Orthopedics Today Editorial Board, has extensively researched the phenomenon of femoroacetabular impingement (FAI) and sought an effective, straightforward surgical solution. “Nonoperative treatment is almost always unsuccessful,” he said.

During the 25th Annual Current Concepts in Joint Replacement Winter Meeting, Parvizi discussed the three surgical options — surgical dislocation, arthroscopy or the mini-open direct anterior approach — saying he prefers the mini-open surgical technique because he can directly visualize and remove the femoral “bump,” test hip range of motion and almost always repair the labrum.

Hip morphology

Parvizi, who is at the Rothman Institute of Orthopaedics at Thomas Jefferson University said FAI is an unknown condition that leads to early arthritis of the hip in young patients.

Javad Parvizi

Cross-sectional studies should be done in individuals with reduced hip range of motion and hip pain suspected of having impingement, but whose radiographs are negative. These studies typically reveal a triad involving a labral tear, a chondral injury and an abnormal alpha angle. The alpha angle becomes abnormal due to the presence of a bump at the femoral head and neck junction.

“Labral tears are almost always associated with a chondral lesion in these patients,” Parvizi said.

High-resolution MRIs will nearly always confirm the labral tear and chondral lesions, he noted.

Hips with FAI either present with the type of hip cam mechanism that arises from a nonspherical femoral head articulating with the acetabulum or a pincer situation related to a too-deep socket that causes the labrum to tear. To surgically and appropriately correct either problem, the orthopedist needs to identify the nature of the morphological hip abnormality in question, Parvizi said.

The mini-open direct anterior procedure involves a modified Smith-Peterson approach and reflecting the rectus in some cases. “Once the rectus is reflected, the capsule is visible through the incision,” Parvizi said, showing video footage of the “I”-shaped capsulotomy. He said this lets him confirm the impingement and perform the femoral head osteoplasty under direct visualization.

“[This technique] allows you to remove as much or as little bone as you need so you do not weaken the femoral neck unnecessarily,” Parvizi said.

Parvizi checks the labrum for tears and reflects it to trim the acetabular rim and then reattaches the labrum, repairing it with nonresorbable sutures as needed.

Other surgical options

Parvizi’s patients require a 1-night stay, use crutches for 2 weeks postoperative and must be careful with their hips for 6 additional weeks.

Surgical dislocation for FAI, which Reinhold Ganz, MD, popularized, is effective; however it involves a trochanteric flip, which is more involved than the mini-open anterior approach. According to Parvizi, it is also associated with more morbidity and a longer recovery.

“Arthroscopy of the hip, as it stands, has some limitations,” with a limited space in the hip, management of labral tear and chondral lesion using arthroscopy is difficult, Parvizi said. “If underlying labral pathology and rim pathology is not addressed, patients may continue to have a problem.”

For more information:

• Javad Parvizi, MD, FRCS, can be reached at the Rothman Institute, 925 Chestnut St., 5th Floor, Philadelphia, PA 19107; 267-339-3617; e-mail: parvj@aol.com. He has indicated he has intellectual property rights with Smith & Nephew Orthopaedics.

Reference:

• Parvizi J. Femoroacetabular impingement: Saving the joint. #41. Presented at the 25th Annual Current Concepts in Joint Replacement Winter Meeting. Dec. 10-13, 2008. Orlando, Fla.