Hip Arthroscopy with Acetabular Osteoplasty and Labral Repair

CHAPTER 1

So there's the top of the troc right there. So what I'll do isI'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, thenstraight across.This way - you always want to see that pubic hair linecuz that'll giveyou 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 theinside of that labrum,it's going to be like a bucket handle tear it's going to followus around, and we’ll be blind.So we we got to try some how toget on the outside of that labrum,So it's maybe 2-3 mm difference, you know,whether or not you’re dragging the labram aroundwith you, or whether he getsa 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 siliconepad on her post.It's her tensioning in the boot before we ever seetraction 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 atincreased working distance we wantto be right in line with the joint.If we're too perpendicular to the joint,then it’s very difficult for us towork with that portal as a utility portal.We can view, but it's very difficultto 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 uplike this, andwhen 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 andthat 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 itdoesn'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 goingto tether, right here at the skinis 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 orhe can be having a straight wire like thisand he's cutting across it this way.So if it tethers - make sure that you hold andpull out the obturator with the wire.So if it tethers, we know that the wire is wrappedaround the head.If he tries to pull the wire back, he'll break it right there. Ifhe loosens up the obturator and brings the wireand the obturator back,it'll come right back in. The big thing is if it tethers, you donot want to force it through,because it's a teeny little opening - it’s onlyenough 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 goingto show you here.So I would say the cross-sectional line is more likethat, so I think you're right on with that point, yep.Looking at this triangle right here.See the capsule? It forms a triangle. Andnot unlike the shoulder where you have a safe triangleto get in, right aboveyour subscap, and get the femoral head on your right,labrum on your left,this red stuff up here is the capsulethat we're trying to get through.And we are trying to get through right in the center of that cuz I'mgoing to have to put other obturators in,he needs to be right in the center of that.You can see this whole area opening upwith 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 notvertical, 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 inwith your obturator or with your cannula - justcome in with your - just to there, yeah.Then take your knife, and justdo a little slit on the capsule. So we make a little slit inthe capsule just to relax it,so we're not putting too much pressure onthe head. And the head will see some indentationit'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 stayvertical 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 tomake this not only viewing but also for utilityfor passing anchors, sutures, whatnot - I’m going to take the Mytech.And you see, we try to keep it down evenbelow 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 cutthis 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 littledefect going up here, that's the acetabular notch right there.You can see a little bit of discolorationthat 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 viewingjust the opposite direction, so anterolateral,inferiorly. Now we’re going to switch backcuz most of what we want todo is up near - from this portal here all the way up to ouranterior portal, so we’re going to flip backto the other side.So you can see, this whole thing isdisrupted 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 candrill through it,and we can pass our sutures and things through itwithout getting constricted.Most important, our anchors have to go to this portal.So we're angling toward the acetabular rimto 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 aboutone-third to one-half of the way,and it's going to make me a quadrilateralspace right hereto work through.This is going to be for passing sutures and doingour acetabular recession.This is that blood supply I told you about right here.Right at the capsulolabral junction wherethe labrum meets the capsule right here.That's where our main blood supply comes in, sowe don't want to take a knife and come through there.We want tocome up above it, so I've got some capsule in here,all this stuffhere - and we're going to use that to augmenther labrum for her labralrepair, so my sutures don't pull through.

CHAPTER 2

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 andeasy, come down.Take off 5, counterclockwise. So we use intermittent traction nowbecause 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 furtherthan that there, and I'm going to bring you up here.So here's yourlabrum. 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 justwant to scarify it, okay? She's got soft bone.You’re never going to get those anchors to hold.So that's already done. Soright 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 shuttlesand the passthroughs for this is thatthey 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 abig hole in this labrum.There's no way you could put a vertical mattress in.So now, we're going to pull our back limbthat went through our bone, soif I pull this limb, I can giggly it through this whole labrum andcut 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 ourfingers so it can cut right through that labrum.So we need to getit moving first cuz it's -remember, that anchor is deep inside bone, so I dothe back limb here.Pull it up on this side first to get it moving tomake a tract, and then I pull this through.It comes back much easier.And we want our knot on our back limbso it's recessed back here off ofthe 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 decimatethe whole labrum if you passjust one pass through. It’s disgusting.I think we're going to go to smaller anchors,which they're trying to donow - your 1-7 - I'm mean we’ll be out when?You guys keep promising me.Because the problem is not going to be inthe suture or the anchorusually 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 likethat, 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 edgeof 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 tissuein here as I can - as it allows me to. I'm going to goslightly 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 anacetabular recession. So now, instead of being here,it's back here.If I just drill holes and put it on, it can be evert, evenif it's off a millimeter or two.We use the femoral head to reduce the rimreduce the labrum back to the rimand then we tension it so thatwe 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 likethis if we over tension it. Why?Because of traction, reduced the femoral headback into the socket. We did two different things.One is we're putting thelabrum right back to its new recessed rim,and two is we're not allowingit to evert with over-tensioning whenwe're tying it down cuz it's veryeasy for me to over-tension it and pull the labrumright up like that.

So this is a sliding knot, a modified Weston.It really takes it down, and we borrowedsome of that capsule to augment our labrumso that this doesn't pull through.And now Drew is going to show me a reductionto take all the tractionoff 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 yourhead 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 distentionof 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 startcoming over lateral now. If we look up,this thing coming down is goingto be your iliopsoas.So in between this medial synovial fold right hereand her labrum right here isstraight up above is going to be her iliopsoas.This bulge I’m underneath, it’s a little bit frayedcoming down there.And some people will have an exposure of the tendonwith 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 doingT capsulorrhaphies - you cut across all thisblood 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 spotis right down here - right at the capsulolabral junctionis where the bloodsupply is, but you can see the huge feeders comingoff that - look and look - youcan see them going right into the labrum - look at,see it? Yep.So why would you cut across that? It makes no sense to mewhy 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 thingis the zona orbicularis.That's what the capsule ties into,and it allows that we can rotate thispatient 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.