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Arthroscopic Acetabular Labral Repair

Scott D. Martin, MD
Brigham and Women's Hospital

Anesthesia

  1. The patient is taken to the operating room and positioned supine on the operating table.
  2. The patient is placed under general anesthesia with endotracheal tube intubation.

Positioning

  1. The patient is then placed against a silicone-padded perineal post, in foam boots and placed in traction.
  2. A positive vacuum sign is noted after which traction is let off.
  3. The patient is then draped and prepped in usual sterile manner using aseptic technique.

Portal Placement

  1. The anterolateral portal is established using fluoroscopic guidance with the gauge cannulated needle and the joint insufflated.
  2. A 5-0 obturator and cannula are then placed.
  3. The anterior portal is established next under direct arthroscopic viewing.
  4. This is followed by the mid anterior portal and Dienst portal.
  5. A diagnostic arthroscopy is performed to assess the surrounding structures, including the labrum, Ligamentum Teres, Pulvinar and Femoral head.

Acetabular osteoplasty and Labral Repair

  1. The acetabular rim is then recessed using fluoroscopic guidance, starting laterally and working medially from approximately the 12 o'clock to the 3 o'clock position using a #4-0 round abrader on reverse.
  2. Labral repair is undertaken by visualizing the transverse ligament, then cleaning the inferior recess and acetabular notch of any loose bodies.
  3. Accessory mid-anterior and Dienst portals are then used to introduce the Smith and Nephew knife rasp to elevate the capsule approximately 5-8 mm above the capsulolabral junction, then cut down to the acetabular brim.
  4. Anchors are then placed with 2.3 osteoarticular Smith and Nephew anchors.
  5. The sutures are shuttled through the labrum using vertical mattress sutures and each anchor and suture is passed the same under direct fluoroscopic guidance along with direct viewing.
  6. Knots are tied on the capsular recess side using a modified Weston with multiple half hitches, using vertical mattresses.
  7. Sutures are shuttled using wire suture shuttle relay and the anchors are composite 2.3 osteoarticular anchors loaded with #2 FiberWire sutures, again knots were kept on the capsular recess side.
  8. In addition, the labrum is tensioned down with the traction let off so as not to evert the labrum and also to reconstitute the labrum back to its newly recessed acetabular rim.
  9. Tissue is then tested for stability of repair by probing.
  10. The hip joint is put through range of motion to assess stability.

Wound Closure

  1. Traction is then let off.
  2. The instruments are removed and the scope is placed in the peripheral compartment.
  3. Medial and lateral gutters are assessed for presence of loose bodies.
  4. The medial and lateral synovial folds are assessed for lesion.
  5. The Zona orbicularis is assessed for lesions.
  6. The capsular reflection is assessed for separation off of the femoral neck.
  7. The scope and instruments are removed.
  8. The portals are closed using 3-0 nylon sutures with interrupted stitches and then covered with Adaptic along with sterile gauze along with Op-Site dressings.
  9. The patient is awakened, extubated, and transferred to recovery room bed and checked post-operatively for any surgical complications.