Hey, I'm Brett Goodloe, sports medicine faculty at Virginia Commonwealth University in Richmond, Virginia. This topic will cover management of the rim and preparation for label repair, as well as pincer correction in the central compartment. I have no disclosures relative to this presentation. Here's our outline for this topic. We will start with radiographic evaluation, as I think this is pertinent to decision making between a rim preparation versus pincer correction for FAI pathology. We will then go through some technique pearls for central compartment acetabular-sided management. There are several measurements that can aid in decision making for pincer-driven FAI. One that I frequently measure is the acetabular inclination using Tonus Angle. Tonus Angle is measured by a horizontal line from the inferior point of the acetabular source seal, and the angle it creates to the inferior aspect of the source seal to the lateral most aspect of the source seal. In dysplastic hips, this line will be upsloping with measurements greater than 10 degrees, while pincer deformities lead to negative values which define overcoverage. The lateral center edge angle is commonly used by hip arthroscopists and assess the superior lateral coverage of the acetabulum. Typically, pincer deformity is characterized by values greater than 40 degrees. The center edge angle can also guide how much correction is to be performed and can help with preoperative templating to avoid overcorrection. Another important feature to understand with management of the rim is the acetabular version. Determining version on the AP radiograph is commonly done by evaluating the iliopectenial line and the ilioischial line as depicted here. It is important to note that an adequate AP radiograph is required for this evaluation as more inlet views can create false positive crossover signs. As discussed on the last slide, acetabular retroversion includes crossover sign, the presence of ischial spine sign as seen in green, and the posterior wall sign where the posterior wall is medial to the femoral head center. Overall, having a good understanding of radiographic parameters will help you with decision making and game planning for surgery. Additionally, three-dimensional CT can be helpful for planning correction and is routinely used for surgical patients with FAI in my practice. I think similar to other aspects of orthopedic surgery, getting a good view is vital to success for rim management. These views can be obtained differently between right and left hips, and sometimes switching viewing portals can be valuable. This 2018 publication in Arthroscopy Techniques highlights two views that are very effective for addressing acetabular pathology. The bird's eye view is an arthroscopic perspective directly overriding the femoral head with the light source at 3 o'clock on right hips and 9 o'clock on left hips while viewing from the anterolateral portal. The upper deck view places the scope supralabral within the labral capsular junction to allow direct visualization for bony resection and careful attention to the remaining labral tissue. For rim management, this is the outline technique or steps to the procedure. First, we identify the location of the torn labrum. Once this is localized, we develop a plane within the capsular labral junction. Depending on the pathology present, rim preparation is performed versus true pincer resection. Then we follow with labral repair, which usually involves drilling for anchor placement and then securing the labrum. This is another depiction of the steps from the previously defined bird's eye view. Labral tear is identified. The capsule is undermined, leaving the labrum intact. The soft tissue is then cleared off of the bony pincer and then debrided down to an appropriate level with a flat landing strip for anchor placement. So here's a demonstration of a focal pincer lesion on a left hip. It is our preference to view left hips from the mid-anterior portal and work through the anterolateral portal, but a combination of either can be helpful. The red synovial layer deep to the capsule is removed using a suction shaver device with careful attention to not disrupt the labrum. We then follow this with the use of a radiofrequency ablation device above the torn portion of the labrum to further delineate the separation between capsule and labral tissue. Once the appropriate location is identified, we continue to try to separate between the capsule and labrum and fully identify the pincer lesion. In this focal pincer, we start posteriorly, which will allow for improved access for the upcoming burring. As we start to transition more anteriorly as seen here, you can really see the lesion start to reveal itself within the RF device. There are definitely some instances where detachment of the labrum is indicated, but in most cases we try to avoid this if possible. Here you can see that focal pincer lesion, and we start to uncover it anteriorly. Once this focal pincer lesion is identified, we use the burr to perform the acetabuloplasty. Typically, we use the protective sleeve on the burr to protect the labral tissue. The goal of the resection is to remove the bone down to the level of the normal acetabulum anterior or posterior to this area or the pre-templated plan. Here is one more demonstration. This is for global pincer management, this time on a right hip. This is a classic FAI patient with mixed cam pincer deformity and chondralabral separation with a loose flap. Once the extent of the tear is identified, we proceed with capsulolabral separation. Again, establishing the planes is first performed with a shaver device. Meticulous use of the shaver is important as it certainly can excise more capsule than warranted if not careful. We then follow with the radiofrequency ablation device to continue to dissect this tissue. Our preference is an RF device with a bevel, as that seems to be able to set the edge with accuracy. Once the rim is defined, the RF device is used to undermine the capsular tissue proximally to allow for improved access for the upcoming acetabuloplasty. Some surgeons will utilize a traction stitch in the proximal capsular leaflet to place tension on the capsule to help separate these layers and allow for more space for the burr to work. We then follow with the burr in similar fashion to the prior video. Again, the protective sleeve is usually on the labral side to prevent iatrogenic injury. Additionally, you can see how we transition from the bird's eye view to the upper deck view while burring to ensure adequate resection of the pincer lesion. Following the acetabuloplasty, the labrum is repaired and restored. Burring suggests no residual instability, and as the hip is reduced back into place, you can see intimate relationship between the femoral head and labral tissue, restoring the native suction seal. I personally feel that utilizing fluoroscopic imaging can be helpful similar to performing femoroplasty. The fluoroscopy can identify your location on the acetabulum, which is pertinent for global pincers, which requires access to the posterior portions of the acetabulum for adequate resections. For acetabular-sided FAI management, it is important to always be diligent around the surrounding soft tissue, preserving the native labrum when you can, and especially the proximal capsule for later capsular closure. Appropriate indications for acetabular management is important as well as over-resection can potentially lead to hip instability, which is why special attention should be paid to radiographic measurements with preoperative templating. Thank you for your time, and I hope you find this section helpful.

acetabular rim management

labral repair

femoroacetabular impingement

pincer correction

3D CT planning