Table of Contents
- Case Overview
- Preoperative X-rays and MRI Images
- Intraoperative C-Arm Imaging
- Overall Outcomes After Hip Arthroscopy
- Future Research
- Patient Follow Up
Hip arthroscopy with femoral neck or acetabular osteoplasty with or without labral repair can be used for treatment of femoroacetabular impingement (FAI). Patients may present with insidious onset of hip pain and mechanical symptoms and pain worse with activity and sitting. On physical exam hip flexion and internal rotation may be reduced and anterior impingement testing will produce groin pain in the majority of patients with FAI. Imaging may demonstrate lesions responsible for cam-type or pincer-type impingement, and MRI may demonstrate labral tear or cartilaginous lesions. Arthroscopic surgical treatment is indicated for patients who have failed conservative treatment.
The patient is a 39-year-old female with significant right hip pain that persists despite conservative treatment with non-impact loading exercise, activity modification, and steroid injection. She is most bothered by getting out of deep chairs and pivoting activities. She had an MRI showing labral tear.
- Describe the onset of symptoms. Was it insidious or was there a preceding event?
- What is the location of pain?
- What is the quality of the pain? Are there any mechanical symptoms, such as a pop, snatch, catch, lock, or subluxation/instability?
- Is there exacerbation with sitting?
- Is pain activity-related?
- What relieves the pain?
- Do you walk with a limp?
- Do you have limitations to walking a distance or climbing stairs?
- Hip range of motion may be similar in the affected and unaffected hip.
- Assess flexion and internal rotation, comparing the affected and unaffected hip. The unaffected hip may exhibit reduced flexion and internal rotation or pain with range of motion.
- Assess for Trendelenburg sign by having patient stand on one leg on the affected side. The test is positive if the pelvis drops on the contralateral side. This occurs in 33% of patients with femoroacetabular impingement (FAI).
- Perform anterior impingement test by passively flexing the adducted hip and slowly internally rotating. This test reproduces anterior groin pain in 88% of patients with FAI.
- Perform FABER (flexion-abduction-external rotation) test.
- Perform resisted straight leg raise.
- Perform log roll test. Pain is reproduced in 30% of patient with FAI with log roll test.
- Perform posterior impingement test by placing the hip in extension and external rotation. Hip pain is reproduced in 21% of patients with FAI with posterior impingement test.
- Perform a complete exam of the affected limb and lumbar spine to rule out bursitis, nerve entrapment, and referred pain.1, 2
An AP pelvis view allows comparison of affected and unaffected femora. Assess symmetry to ensure that a true AP view has been captured. This can be assessed by checking that the coccyx overlaps the symphysis pubis, with no more than 2 cm of separation between the two structures. The joint should be assessed for reduction in joint space and degenerative changes. Compare the anterolateral neck contour with the unaffected side. Lack of superior neck concavity indicates reduced head-neck offset. Flat or increased radius of anterosuperior or anterior head indicates an aspherical head. Several measurements may be analyzed:
- Lateral Center Edge Angle: the angle formed by a vertical line drawn from the center of the femoral head and a line drawn from the lateral rim to the center of the head. An angle less than 20 degrees indicates dysplasia.
- Acetabular Index: the angle formed by the acetabular roof or sourcil. An angle greater than 10 degrees indicates dysplasia.
- Acetabular Version: traces lines from anterolateral acetabular edge along anterior and posterior projections of acetabular rim. An anterior wall that is more lateral than the posterior wall (“posterior wall sign”) indicates retroversion. An anterior wall that crosses the posterior wall (“cross-over sign”) indicates bony excess at anterior rim and relative retroversion.
- A cross-table lateral view is important for assessment of FAI, allowing a view of the anterolateral femoral neck.
- Alpha-angle: Formed between a line along the midline of the femoral neck and a line from the center of the femoral head to the point where excess bone deviates from normal femoral head sphericity. An angle greater than 60 degrees indicates FAI.
- Head-Neck Offset: Begin with a line bisecting longitudinal axis of femoral neck. Draw a parallel line that is tangential to the anterior aspect of the femoral neck and measure the distance to a parallel line tangential to the anterior femoral head. Normal distance is greater than 9 mm or a ratio to head diameter greater than 0.17.
MRI and CT can be used for further assessment of the acetabulum and proximal femur. These studies may provide superior assessment of acetabular version and soft tissue impingement or help with preoperative planning. MR Arthrogram may also assist with diagnosis of a cam lesion of the femoral neck, assess the labrum, or cartilage. Radial sequencing is best, an abnormal labrum will appear blunted or with increased signal at its base.3, 4 Pincer impingement, due to acetabular retroversion, will initially show labral failure followed by small, thin lesions to the posteroinferior acetabular cartilage as a result of a contracoup mechanism.5 This may be redemonstrated with a cross-over sign, the posterior wall sign, or a negative sourcil angle on radiographs. MRI will demonstrate blunted labrum, kissing lesion on femoral neck, wear of the posterior acetabular cartilage, or a retroverted acetabulum. Cam impingement, due to lesions of the femoral neck demonstrates initial failure of the cartilage followed by labral tearing. Assessing for decreased head-neck offset on the lateral x-ray, excess bone contours on the femoral neck, and an increased alpha-angle may aid in the diagnosis. On MRI the labrum may demonstrate tearing at its base, an abnormal femoral head-neck contour may be evident, or cartilage delamination may be evident. Patients will present with both cam and pincer impingement in 80% of cases, though one form is usually dominant.2
FAI is due to either a cam impingement, so-called “pistol grip deformity,” or pincer impingement, due to excess acetabular coverage. Etiology of cam impingement is unclear, but the reduction in femoral neck offset can cause hip pain and eventually lead to labral tears and chondral damage over time. Decreased femoral head-to-neck diameter ratio allows the femoral neck to abut on the anterior acetabulum and labrum in deep hip flexion. Chronic, repetitive impingement may lead to arthritic changes or labral tears in the presence of minor or altogether absent trauma.6
Initial non-surgical management for FAI includes activity modification and anti-inflammatory medication. Progression to surgical treatment should be considered for patients who fail conservative management. Surgical treatment of femoral neck lesions or labral tears may be treated by open or arthroscopic debridement and labral repair or resection. Indications for open treatment include non-spherical femoral head, decreased head-neck offset, pincer impingement, and posterior hip impingement lesions. The Bernese periacetabular osteotomy is an open acetabular reorientation procedure with the goal of decreasing acetabular retroversion. Chondral injuries of the acetabulum may be treated by chondroplasty, drilling, or microfracture, which aim to stimulate fibrocartilage regrowth. Acetabular anteversion and posterior osteophyte impingement may be treated with rim excision of the acetabulum. Arthroscopic clinical outcomes appear similar to open surgical clinical outcomes for the treatment of FAI.2, 3
Surgical repair for FAI seeks to return adequate joint space to allow hip range of motion without abutment of the femoral head or neck against the acetabulum. Excision of the lesions that reduce this space is performed to potentially slow the degenerative process and resolve impingement pain and other symptoms. Arthroscopy provides a less-invasive alternative to the traditional open surgery with similar clinical outcomes.4, 7
Patients should be aware that the degree of chondral damage at the time of the procedure correlates with the expected outcome. Older patients and those with relatively less joint space at the time of intervention are more likely to require subsequent total hip replacement. Increased satisfaction is observed in patients with ≥ 2 mm and those treated with repair of damaged labrum.8 A relative contraindication, therefore, is severe joint space narrowing (< 2 mm). Chondral damage of the femoral head indicates advanced disease and is associated with worse outcomes. Complications may result from several aspects of arthroscopic repair of FAI. Portal placement in proximity to the superior gluteal or femoral neurovascular bundles, or the lateral femoral cutaneous nerve can put these structures at risk during the procedure. Traction during the procedure can lead to sciatic nerve injury, which can be mitigated with gentle application of traction. Avascular necrosis risk increases with greater than 30% resection of the femoral neck. As with all excision procedures, fracture may result from the removal of excess bone.4
FAI may represent an early step on the path to hip osteoarthritis. Arthroscopic treatment of FAI focuses on the repair of cam type lesions of the femoral neck and pincer type lesions of the acetabulum. The goal of these procedures is to alleviate symptoms and arrest the progression of osteoarthritic change in the hip. Compared with open surgery, these interventions have demonstrated similar clinical outcomes while utilizing a less-invasive approach. Patients should be aware that arthroscopic repair of FAI is most successful when employed for the treatment of early disease. Ideal candidates report reduced hip pain and clinical impingement tests demonstrate resolution of symptoms following the procedure in a majority of patients. Those undergoing the procedure with advanced degenerative change of the hip joint are far more likely to go on to have total hip replacement following arthroscopy. Investigators have also demonstrated improved clinical outcomes among patients treated with labrum-sparing procedures compared with those who have undergone labral-excising procedures.9, 10
Studies have demonstrated improved clinical outcomes, resolution of symptoms, return to athletic performance, and elimination of clinical signs of impingement, which remain stable up to 3 years after treatment. Pain scores show a 74% reduction and patients rate their hips as “Excellent” or “Good” 75% of the time at 1 year postoperatively.7 Patients may experience optimal outcomes with adherence to a tiered postoperative rehabilitation routine that includes initially protected weight-bearing and range of motion.11
Future research should address long-term clinical outcomes with comparison between open surgical and arthroscopic approaches. In particular there should be studies to elucidate the patient or procedural factors associated with need to proceed to total hip replacement following initial surgical treatment of FAI. The success of subsequent hip arthroscopy also requires assessment.
The patient returned to clinic doing well without signs of infection, nerve injury, or joint instability following hip arthroscopy with labral repair and acetabular osteoplasty. She will remain non-weight bearing on crutches until six weeks postoperatively, at which time she will be advanced to weight bearing as tolerated.
- Knife Rasp, Smith and Nephew.
- 2.3 Bioraptor Osteoarticular suture anchors, Smith and Nephew.
- #2 FiberWire sutures, Arthrex.
The authors have no disclosures to make.
Informed consent was obtained from the patient to be featured in this video article. The patient is aware that it will be available on the internet. A copy of the consent is maintained in her medical records.
- Clohisy JC, Knaus ER, Hunt DM, Lesher JM, Harris-Hayes M, Prather H. Clinical presentation of patients with symptomatic anterior hip impingement. Clin Orthop Relat Res. 2009;467(3):638-644. doi:10.1007/s11999-008-0680-y.
- Guanche CA, Bare AA. Arthroscopic treatment of femoroacetabular impingement. Arthroscopy. 2006;22(1):95-106. doi:10.1016/j.arthro.2005.10.018.
- Ilizaliturri VM Jr, Orozco-Rodriguez L, Acosta-Rodríguez E, Camacho-Galindo J. Arthroscopic treatment of cam-type femoroacetabular impingement: preliminary report at 2 years minimum follow-up. J Arthroplasty. 2008;23(2):226-234. doi:10.1016/j.arth.2007.03.016.
- Philippon MJ, Stubbs AJ, Schenker ML, Maxwell RB, Ganz R, Leunig M. Arthroscopic management of femoroacetabular impingement: osteoplasty technique and literature review. Am J Sports Med. 2007;35(9):1571-1580. doi:10.1177/0363546507300258.
- Maheshwari AV, Malik A, Dorr LD. Impingement of the native hip joint. J Bone Joint Surg Am. 2007;89(11):2508-2518. doi:10.2106/JBJS.F.01296.
- Tanzer M, Noiseux N. Osseous abnormalities and early osteoarthritis: the role of hip impingement. Clin Orthop Relat Res. 2004;429:170-177. doi:10.1097/01.blo.0000150119.49983.ef.
- Larson CM, Giveans MR. Arthroscopic management of femoroacetabular impingement: early outcomes measures. Arthroscopy. 2008;24(5):540-546. doi:10.1016/j.arthro.2007.11.007.
- Philippon MJ, Briggs KK, Yen YM, Kuppersmith DA. Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: minimum two-year follow-up. J Bone Joint Surg Br. 2009;91(1):16-23. doi:10.1302/0301-620X.91B1.21329.
- Larson CM, Giveans MR. Arthroscopic debridement versus refixation of the acetabular labrum associated with femoroacetabular impingement. Arthroscopy. 2009;25(4):369-376. doi:10.1016/j.arthro.2008.12.014.
- Kelly BT, Weiland DE, Schenker ML, Philippon MJ. Arthroscopic labral repair in the hip: surgical technique and review of the literature. Arthroscopy. 2005;21(12):1496-1504. doi:10.1016/j.arthro.2005.08.013.
- Stalzer S, Wahoff M, Scanlan M. Rehabilitation following hip arthroscopy. Clin Sports Med. 2006;25(2):337-357. doi:10.1016/j.csm.2005.12.008.
Cite this article
Martin SD. Hip arthroscopy with acetabular osteoplasty and labral repair. J Med Insight. 2023;2023(14). doi:10.24296/jomi/14.
Table of Contents
- The patient is taken to the operating room and positioned supine on the operating table.
- The patient is placed under general anesthesia with endotracheal tube intubation.
- The patient is then placed against a silicone-padded perineal post, in foam boots and placed in traction.
- A positive vacuum sign is noted, after which traction is let off.
- The patient is then draped and prepped in usual sterile manner using aseptic technique.
- The anterolateral portal is established using fluoroscopic guidance with the gauge cannulated needle, and the joint insufflated.
- A 5-0 obturator and cannula are then placed.
- The anterior portal is established next under direct arthroscopic viewing.
- This is followed by the mid anterior portal and Dienst portal.
- A diagnostic arthroscopy is performed to assess the surrounding structures, including the labrum, ligamentum teres, pulvinar, and femoral head.
- 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.
- Labral repair is undertaken by visualizing the transverse ligament, then cleaning the inferior recess and acetabular notch of any loose bodies.
- 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.
- Anchors are then placed with 2.3 osteoarticular Smith and Nephew anchors.
- 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.
- Knots are tied on the capsular recess side using a modified Weston with multiple half hitches, using vertical mattresses.
- 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.
- 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.
- Tissue is then tested for stability of repair by probing.
- The hip joint is put through range of motion to assess stability.
- Traction is then let off.
- The instruments are removed, and the scope is placed in the peripheral compartment.
- Medial and lateral gutters are assessed for presence of loose bodies.
- The medial and lateral synovial folds are assessed for lesion.
- The zona orbicularis is assessed for lesions.
- The capsular reflection is assessed for separation off of the femoral neck.
- The scope and instruments are removed.
- 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.
- The patient is awakened, extubated, and transferred to recovery room bed and checked postoperatively for any surgical complications.
So there's the top of the troc right there. So what I'll do is I'll put my finger down here, and I know that that's the posterolateral portal, and then she's tiny, so I’d bring her down to here. Yeah, then straight across. This way - you always want to see that pubic hair line cuz that'll give you exactly where the joint is. I’d say we’ll be somewhere in here, about here. Now she has a pretty big tear, so our big problem is when he goes in, the area of the tear extends right into our portal, so if we get on the inside of that labrum, it's going to be like a bucket handle tear it's going to follow us around, and we’ll be blind. So we we got to try some how to get on the outside of that labrum, So it's maybe 2-3 mm difference, you know, whether or not you’re dragging the labram around with you, or whether he gets a clean stick here. Good inclination - looks pretty good. So one turn on that side - we’re going to do traction. Another 5, cuz that took everything off. Yep, a lot of this is viscoelasticity in the system, so it's not really traction on the joint. It's her tensioning up against our silicone pad on her post. It's her tensioning in the boot before we ever see traction here. Does 10, 5 more. Okay, good. Yep. And he wants to be in about 15- to 20-degree inclination, for us to be able to work, because remember, we're coming into very constrained joint, so at increased working distance we want to be right in line with the joint. If we're too perpendicular to the joint, then it’s very difficult for us to work with that portal as a utility portal. We can view, but it's very difficult to use it as an utility portal. Nah, just to get the - change the inclination on your needle. Yeah, yeah, I always think about picking your hand up like this, and when you change directions, you got to come all the way back out. Keep your hand up even more. Keep posteriorly. And then as you’re ready to perforate the capsule, you got to just watch the inclination and that your - you've got at least 15 degrees. Yep. X-ray. You need a little more closer to the edge, maybe. Yeah, I think you need to be right off of that head. Or we’re going to be fighting with this. John have some fluid ready. That's a little too far off the head. Well did you perf? No, not yet. It looks like you're almost in. It looks like you're in Alice. Does it feel like you're in? This won't be like the last one. No - so just try some fluid if you think you're in.
Let's see what your outflow is. Yep, now do your nitinol wire. That’s okay - she was soft to stick, right? Go with your nitinol wire. So if it’s in, the nitinol wire should hit your medial wall. So he's bumping against the medial wall of the acetabulum. Good, yep, make your incision. Take one spot there. Good. He still could be through her tear cuz it's a big tear, so it doesn't stay on the edge of the acetabular rim, it goes like this, and so it's very easy for us to get inside of it. So there's some nitinol wire. There’s two places that he's going to tether, right here at the skin is going to be probably the toughest one on her cuz her capsule's thin. Older patients, I'm telling you, the capsule gets very thin, and younger patients, like if they’re 15, it’s unbelievable how thick it is. You got to keep your hand up. Remember, you went in with about 10 degrees, you want to be colinear - just make sure your colinear. Make sure your obturator is locked out in the cannula. Yep, so he has to make sure that that wire doesn't start to bend or he can be having a straight wire like this and he's cutting across it this way. So if it tethers - make sure that you hold and pull out the obturator with the wire. So if it tethers, we know that the wire is wrapped around the head. If he tries to pull the wire back, he'll break it right there. If he loosens up the obturator and brings the wire and the obturator back, it'll come right back in. The big thing is if it tethers, you do not want to force it through, because it's a teeny little opening - it’s only enough for that wire. If it's bent, it won't go through - it'll break. You should be in. Yep, so we’re going to… Okay.
This is just a big - yeah, this is a big floppy labrum. A lot different from that last patient. Yeah, big difference. So you want that cross-sectional line in line with this. So I’m just going to show you here. So I would say the cross-sectional line is more like that, so I think you're right on with that point, yep. Looking at this triangle right here. See the capsule? It forms a triangle. And not unlike the shoulder where you have a safe triangle to get in, right above your subscap, and get the femoral head on your right, labrum on your left, this red stuff up here is the capsule that we're trying to get through. And we are trying to get through right in the center of that cuz I'm going to have to put other obturators in, he needs to be right in the center of that. You can see this whole area opening up with the apex of the triangle being medial. So you went just a little more superior... Yep. A little more distal, and then you can go a little more lateral. Yep. Basically. Okay. Go ahead and make a small slit. Need to take a picture of that. Yep. And so every time that wire moves and it's not vertical, and it goes off to the side on at angle, you know that you're pushing in the wrong direction. Try to stay colinear with that. Yep. Because these wires will break. Remember, you’re not coming in with your obturator or with your cannula - just come in with your - just to there, yeah. Then take your knife, and just do a little slit on the capsule. So we make a little slit in the capsule just to relax it, so we're not putting too much pressure on the head. And the head will see some indentation it's like a ping pong ball - the only thing is it - because it's elastic deformation, it'll come back - plastic deformation, it'll come back. So if you came back the end of the case, the defect would be gone. She doesn't have one yet, but she will. Yeah, but just a little - like a millimeter here and then a millimeter medial. So see unlike the other one, see how your knife is able to stay vertical without you angling it? Yep. Yep, so this way, if I got to retrieve my suture or anything else, I can use this as a utility portal. Nice stick. Perfect stick. And when you're starting from out here, and you're trying to hit a 5-mm patch inside, a very small region for error. So he's right on it. Now we're going to open this up... come on over here, Drew. To make a viewing portal. So we're going to make this not only viewing but also for utility for passing anchors, sutures, what not - I’m going to take the Mytech. And you see, we try to keep it down even below the capsule, so the cartiledge doesn’t take a hit. And we use high flow rate. Now some people take a knife, and they just cut this all the way. I don't think that's a good idea. A couple reasons: one is heterotopic ossification, which we see quite a bit on referrals.
Let's go right here, take a look over. So this is a transverse ligament. Right here we can see the labrum is right here, and then that little defect going up here, that's the acetabular notch right there. You can see a little bit of discoloration that yellow discoloration we talked about. And that looks good. Our pulvinar, our ligamentum teres again, right here on the right. Pulvinar there. And this anterior portal is good for viewing just the opposite direction, so anterolateral, inferiorly. Now we’re going to switch back cuz most of what we want to do is up near - from this portal here all the way up to our anterior portal, so we’re going to flip back to the other side. So you can see, this whole thing is disrupted here - all the way from where we came in. So we have to get the peripheral compartment. Let me have the obturator?
So now I’m going to make some accessory portals. It's going to be a mid-anterior portal. And if you look at this, it’s going to be a - almost an isosceles triangle. I’ll take the needle. So we have to go with a bigger cannula here, so that we can drill through it, and we can pass our sutures and things through it without getting constricted. Most important, our anchors have to go to this portal. So we're angling toward the acetabular rim to get this one in. So we could put our anchors right in the rim.
So this is called Dienst portal - I come from the ASIS right here, and I come down about one-third to one-half of the way, and it's going to make me a quadrilateral space right here to work through. This is going to be for passing sutures and doing our acetabular recession. This is that blood supply I told you about right here. Right at the capsulolabral junction where the labrum meets the capsule right here. That's where our main blood supply comes in, so we don't want to take a knife and come through there. We want to come up above it, so I've got some capsule in here, all this stuff here - and we're going to use that to augment her labrum for her labral repair, so my sutures don't pull through.
Now this is where we got to be really careful elevating this up. Okay Drew, tap, tap. Tap that. And we try to elevate it up with just a sliver. So this the rim that we’re talking about right here. These fibers right here are the deep head of the rectus. Round debrider. 4-0. Okay, Drew. You’re going to feel it right here, right here. Okay, you’re going to just flatten that out. She’s got soft bone. This right here. And then that deep head of the rectus is right here. So come from here, just nice and easy, come down. Take off 5, counterclockwise. So we use intermittent traction now because we're up in the peripheral compartment, so counterclockwise, we're going to need that. You can take off five, and then take a spot when you start. You want to come out here. You can back up now. So we don't need it to go any further than that there, and I'm going to bring you up here. So here's your labrum. Here's your chondrolabral junction. You’re coming all the way up here. Soft bone - soft bone - you’re digging in big guy. You don't want to do that. You just want to scarify it, okay? She's got soft bone. You’re never going to get those anchors to hold. So that's already done. So right here, come up here. You feel it? Yep. Keep dropping our hand. There you go. And then you can take a spot. Keep working. Keep working though. We’ll take a spot with you working. Yep, come in a little bit more, good. Right there. Spot there. Keep working. Now if she were younger - see how easy this is coming off? That's on reverse. I would be very aggressive at taking that all the way off. With her age, I think it's a mistake.
Angle a little bit more. Let me have a spot there. Tap first - drill. Then the anchor. Hit it a little bit hard. Right there, good. Nice and easy. Go down easy. Go all the way down. Good, yep, pull it out.
So this is my own technique that - no bigger than an IV needle. and the problem with the suture shuttles and the passthroughs for this is that they create a lot of damage. They are big, number 1. Back. Take the needle out. Okay, hold that cannula. This one - I’m in. Okay, Sam went through. Okay, now needle. Now remember you’re going to hold both sides. You’re going to hold this up and that up. This is a saddle technique. Pull up on this one - tight. That's the way. I’m going to go oblique. Felt good. Okay. Good. Yep, yep. Now your loop is going to go through. This a vertical mattress. My suture grasper. Pull out. Pull back. Yep. Needle out. Okay. Send that through. This is our own technique. Minimal perforation. If I use some of the sharp penetrators, it would have a big hole in this labrum. There's no way you could put a vertical mattress in. So now, we're going to pull our back limb that went through our bone, so if I pull this limb, I can giggly it through this whole labrum and cut it in half, right here. They don't call it a FiberWire for nothing. It's made out of the same substance as Kevlar vests, but it can cut our fingers so it can cut right through that labrum. So we need to get it moving first cuz it's - remember, that anchor is deep inside bone, so I do the back limb here. Pull it up on this side first to get it moving to make a tract, and then I pull this through. It comes back much easier. And we want our knot on our back limb so it's recessed back here off of the joint surface. So a lot of people use bird's beaks. I don’t know if you've seen those. But they're big and they really decimate the whole labrum if you pass just one pass through. It’s disgusting. I think we're going to go to smaller anchors, which they're trying to do now - your 1-7 - I'm mean we’ll be out when? You guys keep promising me. Because the problem is not going to be in the suture or the anchor usually once you get it in. Pulling it out when you’re putting it in can be a problem. Once you get it in, the rate limiting factor is the healing of a labrum back. Now I’m going to let all of our traction down. We let the femoral head reduce the labrum back to the rim. So I got to get that to flip now. There it goes. So that's nice and tight. Now we want this to look like that, the question is: can I do it all in vertical mattresses? I don't know.
Drill up. We’re going to - you have your second one opened up, right? There’s one. We’ll come right here for our other one - right on the edge of the rim right here. Go ahead, tap, tap. Drill. All the way down. Good, yeah. Okay, suture grasper. Okay, you're going to pull up both sides. So he's got the back end here. There's my one limb. There's my other rim. And he's giving me some tension, so I can grab as much tissue in here as I can - as it allows me to. I'm going to go slightly obliquely - try to pick up more tissue. Let's take off five. So what we want to do is, we want the hip, the femoral head, to reconstitute the labrum back to the acetabular rim, and we just did an acetabular recession. So now, instead of being here, it's back here. If I just drill holes and put it on, it can be evert, even if it's off a millimeter or two. We use the femoral head to reduce the rim reduce the labrum back to the rim and then we tension it so that we don't evert it. We do it with the traction all the way down, labrum is all the way back. We're not going to evert the labrum up like this if we over tension it. Why? Because of traction, reduced the femoral head back into the socket. We did two different things. One is we're putting the labrum right back to its new recessed rim, and two is we're not allowing it to evert with over-tensioning when we're tying it down cuz it's very easy for me to over-tension it and pull the labrum right up like that.
So this is a sliding knot, a modified Weston. It really takes it down, and we borrowed some of that capsule to augment our labrum so that this doesn't pull through. And now Drew is going to show me a reduction to take all the traction off now. So I'm tensioning it, and then I won't tighten it down til he has everything off.
So all traction is off, right? Yep. Okay. Excellent. Now go ahead and put the traction back on.
So there's our rim down. Okay, so it's not so floppy now. Let's have a probe. Nice and stable there. Nice and firm there. That’s not going anywhere. Now, this is normally lax. This is more medial. These are the areas here. If you were going to put another one, it would only be if this extended out laterally, which it didn't cuz there's my junction right there, see it? So I like that - I like that a lot. And everything is buried. When your head goes in, all this will be compressed, and then we’ll look at it from the peripheral compartment. Now I’ll take the obturator for the blue. Up to 70 on our pump. So we go 70 so we insufflate this joint to provide as much distention of this capsule as we can. Traction off the other side. Everything off this side. So now we’re in the peripheral compartment. Look back, there's our labrum right there. That's your capsule reflection off the neck. Flex her up. So we flex her up to about 40 - 45 degrees. And right there is your medial plica in it. See it right there? If you get tumors, that’s where they like to hide out. So this is looking all the way medial right here. So you can range her a little bit, and we're all the way medial, so we’ll start coming over lateral now. If we look up, this thing coming down is going to be your iliopsoas. So in between this medial synovial fold right here and her labrum right here is straight up above is going to be her iliopsoas. This bulge I’m underneath, it’s a little bit frayed coming down there. And some people will have an exposure of the tendon with no capsule here. It’s pretty neat. You can look right up it. Look at a blood vessel right there. So, and this is my other reason for not doing T capsulorrhaphies - you cut across all this blood supply that's coming in through the capsule, and that then goes into the labrum. If I cut across here, now that's not down here, but the main spot is right down here - right at the capsulolabral junction is where the blood supply is, but you can see the huge feeders coming off that - look and look - you can see them going right into the labrum - look at, see it? Yep. So why would you cut across that? It makes no sense to me why you take a knife and cut that off. You have to come up above it. So there’s our medial synovial fold. We’ll come the other side here. Okay and this thing coming right here - this round thing is the zona orbicularis. That's what the capsule ties into, and it allows that we can rotate this patient without the capsule getting tethered. So there's our repair, there's our suture, see it? Got a great seal all the way around. You can follow it all the way around. Looks good. What are we up to? What number? 36.