Check Bundles When Coding Cam/Pincer Lesion Encounters
Sep 07, · Cam lesion Restricted hip movement – especially twisting the hip in and flexing the hip up Deep hip pain, groin pain or buttock pain particularly with twisting type activities ie cutting, pivoting especially on Pain and restriction with deep squatting, getting . Cam morphology (femoroacetabular impingement) Terminology. Cam morphology is also commonly referred to as 'cam deformity', 'cam lesion' or 'cam abnormality', though Epidemiology. There is a significantly higher prevalence of cam morphology in athletes compared to non-athletes. Cam Clinical.
Cam and pincer lesions occur when there is an overgrowth of acetabulum that needs removing, Felt explained. These two conditions are often referred to as femoroacetabular impingement FAI. A cam lesion is a bump on the edge of the femoral head. While these codes have been around awhile, they represent relatively recent medical advances, Felt said.
Final timeout performed. Starting with hip: Surgeon makes anterolateral, mid-anterior accessory, and distal anterolateral accessory portals. Scope inserted to confirm position of portals on fluoroscopy. Shaver used to remove fat and expose capsule. Capsulotomy in line with intertrochanteric line up to the rim 1 cm distal to attachment of reflected head of rectus.
Rim of acetabulum exposed, proceeded with acetabuloplasty using motorized shaver. Adjacent articular cartilage appeared healthy. Surgeon then attended to femoral side. Performed femoroplasty beginning at articular cartilage proximally and terminating at neck base, which created a gentle concave contour. Contour verified with image how long does it take for herbs to grow. Surgeon satisfied with surgical status both on fluoroscopy and arthroscopy.
Capsule closed with: 3 Ultrabond stitches through capsule; Monocryl used in skin; Steri-Strips, local, and sterile dressings over top of surgical area. For this encounter, you should only report and If the payer requires it, you would append modifier 51 Multiple procedures to Your email address will not be published. As a contributor you will produce quality content for the business of healthcare, taking the Knowledge Center forward with your knowhow and expertise.
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Nov 24, · Second, abnormal bumps called cam lesions can develop on the head-neck junction of the hip ball. Current research suggests that these cam lesions develop during adolescence, often when the growth plates are open. Jul 19, · Cam impingement occurs when the femoral head is not perfectly round and cannot rotate smoothly inside the acetabulum. It often results from a bump formed from excess bone growth at the end of the femur. During movement, the bump grinds the cartilage inside the acetabulum. The cam lesion (or femoral neck 'bump') refers to the abnormally-shaped femoral head, which comes into abnormal contact with the edge of the hip socket, thus limiting the range of movement in the hip.
CAM lesions are now seen as a significant pathology that could cause osteoarthritis of the hip joint. Currently there is no gold standard for classifying these lesions.
We aim to show a simple method for classifying these lesions based on shape and position. Using CT 3D reconstruction, 91 preoperative CT scans from patients who had undergone hip arthroscopy for femoroacetabular impingement, were reconstructed to produce 3D images. Two senior hip surgeons have devised a simple four type classification system from previous experience. The system highlights the position and shape of different CAM lesions present in patients.
The two senior surgeons and one junior surgeon reviewed the scans individually to assess whether the system could be used at all levels of surgical experience. The two senior surgeons agreed on which type of CAM lesion was present in all 91 cases. Intra observer reliability scores for the senior surgeons were 0.
The junior surgeon reviewed the scans and disagreed on eight cases. This gave a Kappa co-efficient score of 0. We believe this classification system is simple and reproducible. It will aid surgeons in pre and intra-operative management of CAM lesions. Surgeons will be able to select the optimal portal placement and resect less capsule depending on the exact CAM lesion identified.
This will potentially reduce complications and improve outcomes in junior hip arthroscopy surgeons. Femoroacetabular impingement FAI is an established cause of hip pain and is a possible cause of developing osteoarthritis in the hip [ 1 , 2 ].
CAM and Pincer deformities have been described in the orthopedic literature as two separate entities of hip impingement [ 3 , 4 ]. The CAM deformity has been described as a pistol grip deformity by Stulberg et al. Damage to the acetabular chondral surface from these deformities has been graded [ 3 , 6—7 ], but the position and size of the CAM lesion has been poorly classified.
Current literature has used the alpha angle as a measurement of the deformity [ 4—10 ], but it has been criticised for its inaccuracy [ 11 ]. Notzli et al. The majority of surgeons have since used X-Rays, rather than MR scan to measure this angle. Figure 1 shows how the alpha angle is measured on the AP hip radiograph. Lateral hip radiographs can also be used. It cannot be completely understood from one image and one angle.
The majority of CAM lesions lie in the anterosuperior head neck junction, but studies have shown they appear more anteriorly also [ 12 , 13 ]. Barton et al. The use of 3D CT scanning has enabled the CAM lesion to be accurately visualised [ 10 , 13 ] and it has shown considerable variation in its morphology.
The aim of this study was to map the position of CAM lesions using preoperative 3D CT reconstructions and validate a four type classification that has been created by the authors of this article. Surgeons could then use this system in clinic to aid preoperative surgical planning.
The two senior authors created the classification system from previous experience with preoperative 3D CT reconstruction images for FAI. They have over 5 years of experience in hip arthroscopy between them. They have performed over arthroscopies collectively. They believe all patients fall into these four types. This classification system incorporates different shaped CAM lesions, with varying positions on the femoral head and neck. It does not quantify the size of lesion but this can be produced with computer programs if needed.
We believe this system would improve surgeons planning of CAM resection over the basic alpha angle measurement. Hip arthroscopy is a technically difficult procedure with studies proving experience affects surgical outcomes and complication rates [ 14 , 15 ]. If this is true then we must suspect that surgeons with limited experience are starting to undertake this procedure.
The worry is that complications and revision rates will rise. The main reason for revision hip arthroscopy currently is failure to correct the femoral head neck offset [ 17 , 18 ]. Giving surgeons as much information as possible will help to keep these revision rates down. By classifying the lesion preoperatively, the surgeon can reduce the number of portal placements and damage as little capsule and soft tissue as possible.
Bony resection will be more focussed on correcting the head neck offset. These factors could potentially reduce complications and improve outcomes for junior hip arthroscopy surgeons. Between and , 83 consecutive patients 36 male, 47 female , who underwent arthroscopic surgery for FAI, were entered into the study. Each patient had undergone a CT scan of the affected hip, which was reconstructed to produce a three dimensional image of the joint.
The senior surgeons carried out the process using the local radiology 3D reconstruction system. Below is the four type classification system used: Anterolateral head neck. The reviewers looked at AP and lateral images of the 3D reconstruction to decide which lesion was present.
Anterolateral head neck or anterolateral neck lesions are seen on both the AP and Lateral views. Anterior head neck junction and anterior neck lesions can only be seen on the AP views. Figures 2 and 3 help explain the difference between the four lesions. AP view of hip joint. The red line shows the femoral head neck junction. If the lesion crosses this red line from the neck into the head then it must be the anterolateral head neck lesion or anterior head neck junction lesion.
It cannot be the anterolateral neck or anterior neck lesion. If the lesion is seen on the lateral view in the neck region red rectangle then it must be either the anterolateral head neck type or the anterolateral neck type.
If a lesion is not present in the red rectangle it must be either the anterior head neck junction lesion or anterior neck lesion only. Figures 4—9 show the four types of CAM lesion identified and how they appear on the two views.
Anterolateral Head Neck Lesion. The arrows highlight the lesion on both views. This lesion crosses the head neck junction and is seen on the lateral view so it can only be the anterolateral head neck lesion rather than the anterolateral neck lesion, which does not cross the head neck junction.
See Figure 4. Anterolateral neck lesion. This lesion does not cross the head neck junction, but can be seen on both the AP and lateral views. See figure 6. Anterior neck lesion. This lesion is only seen on the AP view and does not cross the head neck junction.
Anterior head neck junction lesion. This lesion is only seen on the AP view but crosses the head neck junction so is not just the anterior neck lesion seen in Figure 8. Each 3D CT scan was independently reviewed by the two senior surgeons and then by a junior surgeon. The junior surgeon had no experience in hip arthroscopy surgery or interpreting 3D CT scans before the study.
He was given a min tutorial to help classify the CAM lesions. They had access to the images above to aid classification. Two weeks later all three reviewers classified the scans again to produce intra-observer reliability scores. The Cohen kappa coefficient value was calculated to assess the reliability of our classification system. This score is used instead of simple percentages for agreement between reviewers, because it takes into account the element of chance agreement. The score of 1.
Table I. The variation in CAM lesions between the study groups. There were no differences noted between the two senior surgeons when classifying the CT 3D reconstruction scans. They agreed on all 91 hips, which gave a theoretical perfect kappa co-efficient score of 1. The junior surgeon disagreed on eight scans compared with the senior surgeons.
The kappa co-efficient score for inter-observer reliability was 0. The scores in table II show all surgeons could reliably classify the CAM lesions again at a later date. Table II. Intra-observer reliability scores for all surgeons. As you can see there were no specific types of lesion that the surgeons disagreed on significantly Table III.
Table III. The distribution of each CAM lesion when the three surgeons reviewed the scans. This simple four type classification system has been shown to be reliable and accurate during analysis. Kappa co-efficient scores of 0. The fact that no CAM lesions were identified in 16 patients suggests this. It also highlights that CT 3D reconstruction images are sensitive enough to exclude the lesion. The position of the CAM lesion varies within the study population, but four types are reliably described by the senior surgeons.
The most common types seen are the anterolateral head neck lesion and anterolateral neck lesion. The anterior head neck junction lesion is the rarest type seen. The two senior surgeons agreed on all 91 CT scans.