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  • 1. Portal Placement
  • 2. Labral Repair
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Hip Arthroscopy with Acetabular Osteoplasty and Labral Repair

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

Transcription

CHAPTER 1

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.

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 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.