Diagnostic Hip Arthroscopy
In this short, fundamental case, Dr. Scott D. Martin takes us through a diagnostic hip arthroscopy where he diates the main viewing portal; examines the labrum, femoral head, and transverse ligament; probes and debrides the labrum; explores the medial structures and peripheral compartment; continues the labral debridement; checks the capsular reflection; surveys the joint; and closes.
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This article is the companion to the JoMI article "Portal Placement for Hip Arthroscopy" by Scott D. Martin, MD.
Dilate Main Viewing Portal
- High Flow Rate
- Puncture-Capsule Orifice
- Pulvinar, Condyloid Notch, and Ligamentum Teres
Examine Labrum, Femoral Head, and Transverse Ligament
- Discoloration of Labrum
- Articular Cartilage Bubbling
- Labral Fraying
- Assessment of Labral Damage
- Shave Labral Fray
Explore Medial Structures
- Medial Gutter, Medial Synovial Fold, and Zona Orbicularis
- Range of Motion
- Labral Seal
Explore Peripheral Compartment
- Opening Capsule via Increased Flow Rate
Continue Labral Debridement
Check Capsular Reflection, Survey Joint, and Close
- Lateral Synovial Fold and Vasculature
TranscriptionsPlease note that, unless otherwise stated, these transcriptions have been auto generated and therefore we can not guarantee their complete accuracy.
We are just going to dilate up our portal here. Let me have the mitech now. Go down to 50. Uh 50. So heat is bad for the hip so we really run high-flow when we are running this thing.
We are going to dilate this out cause he's going to... you can back up a little bit... this is going to be our main viewing portal now. We use puncture capsulorrhaphy, so we're just coming through with the puncture instead of just doing it T capsulorrhaphy where we open up the whole thing. We want this perfectly circular, any little overhanging edges are going to be magnified 19 times here. It’s like trying to operate with a washcloth sticking in your eyes.
This is our pulvinar right here with her ligamentaires right here. It's on the left. It’s this structure right here. Do you have a probe? So this is our ligamentaires right here. That's the main ligament between the femoral head and the acetabulum. This is her pulvinar. Little bit of bleeding. The whole thing is Cottonwood notch. The pulvinar is this fatty stuff right here. This tissue right here has a vessel in it for the head, which is just a branch of the obturator artery supplies about 10 to 15% of blood supply to the head. Back our cam up to give us a little bit more excursion on this probe. You can see this little yellow discoloration right here so see how everything is so white in there yellow discoloration of the labrum.
The femoral head looks good. All the way down to bottom. Transverse ligament is where the labrum goes real wide here to narrow. That's it right there, beginning of the transverse ligament. That's the six position for this hip. Then 12 o’clock would be about where we're coming through right here.
She's got a little bit of bubbling over articular cartilage right here. I am going let my fellow take a feel here, and then we’re going to look all the way around. Yep go ahead.
Besides some fraying of the labrum where we came in on, I don't see a lot on this. A lot of times if they have a big labral tear and as you come in and just everywhere. She's only 24 so she's got some pretty good tissue, but did you see all this yellow discoloration. But still we would never just debride for that you would cause more damage than you would correct. If you look at the femoral head it looks really nice. Little bit of fraying in labrum right here. This area right here. I know I saw it coming in. I mean it's just it's very mild. It's a combination of that with the little bit of bubbling. Come on in here and give us a spot. So we're going to probe this, make sure that there's nothing through and through on both sides here.
What we have been doing some patients that they're really bubbled out is we microfracture behind them, but you can see how pretty smooth this is here. Then as it comes over here the kind of labral junction is a little bit bubbled. A little bit at fraying of labrum but you know overall not terrible. Then the question would be whether not the put some anchors and sutures in. I think it's pretty superficial.
Take that out. Let me have the operator for blue. Follow. Just going to switch out here. Can I have a shaver please? You can see this right here, this fraying on the edge here. Right there. Then that little area right there, but the rest of labrum looks good. And see the fraying goes all the way down to there. Might be why you caught it. Keep it right there.
When they're right on the edge like this you know and they're not ripped off of the condo-labral junction. Pretty tough to justify elevating that whole thing down. Now if she had a big pinch of big overhang I would do that I would take the whole thing down but she doesn't, just has some fraying. What you are going to do is let this come over us. I'll take the mytecho. Okay operator the blue.
So Drew I’m going to show you when these aren't straight up and down I’m going to show you what happens you're always working back on yourself. Hold these portals. So I am torquing it to get it in there. Just going to touch it. I am just dabbing it through the to the edge. When your head goes in it will compress that right back down. That's all you need okay.
We used to hit it with the ultrasonic chisel, which is heat and the problem with that is really don't feel it's good for the labrum. Now hold it right there. Bring this back. Well we did a study and we looked at the heat that's generated by these thermal probes and it can go up to average 71 degrees centigrade. you only need 51 degrees to kill chondrocytes. When you get bubbles from doing any cutting or blading, those temperatures can go up over 100 degrees and that’s centigrade. Yeah so it's a huge amount of energy when the bubbles burst they disperse all that energy right in the spot where your operating.
Okay up to 70 on the pump. So everything off that side. Get ready to flex her. Back up a little bit. Yep 70 in the pump in case I come out. I put maybe with slight abduction and internal rotation so I have the femoral neck parallel to the floor. Going in. Traction off. All of it. Support yeah right there and lock it there.
Now this is a medium gutter right here. This is the medial synovial fold right there. That thing up on top is called a Zona orbicularis. The capsule attaches to it kind of like if you think of a hot air balloon. The balloon attached to a ring this is the ring for the hip so we can move the hip it doesn't tether the capsule. See all the excursion and the ring is staying going up and down but it's not rotating but yet everything's attaching to it. That's just 45 50 degrees of rotation.
This is her labral seal. Can we dull the overheads? This is that medial synovial fold that we just talked about. This is her medial gutter right there. Tighten now wire. I’m going to come back on a little bit on it, Drew.
Let me see the five five. Now we're dilating up to five fives which will really give us good flow. This is the peripheral compartment, so not as constrained little bit easier for us to work with and most importantly we don't need traction. So you see how that collapses see that. Then you try to get in there forget it. Yeah so watch what happens when I turn the fluid off and suck them out. This collapses right down. So if we're trying to get in and it's like that without any fluid and it's very difficult sometimes to get into peripheral compartment, whereas if we dilate it up you see the capsule going up. I'll block this here. Opens it up quite a bit, huge difference. That's why when we were going to go into the peripheral compartment we increased our flow rate and we increase the pump pressure to 70 so we could really dilate this capsule up.
This is almost medial so she still has a little bit right there. I’m going to clean that up. Let me have a shaver. Media coming over to you, 12 o’clock position here. Yeah.
Mytech now. Now let me have a switching stick. This is coming all the way over laterally to where we were working. Keep our flow up. That's the area that we were debriding.
Watch your flow way up. Okay rotate her in a little bit. Now rotate her out. Right there that's the area we debrided. Can you suck a little bit?
Okay. So you can see we still have a good seal. See the seal right there. Suck a little bit. And no big bumps, so we'll move around.
All that is just soft tissue and her blood supply coming in through the lateral synovial fold. This is all the way underneath. Suck a little bit. Where this capsule reflection is that’s her lateral synovial fold and the redness right there branches of the posterior superior retinacular vessel which is right underneath this. Where its arborizing right there that little vessel underneath. And we have about 70 on our pressure so you let the blood pressure down or the pump pressure down a lot of times you can actually see a pump. This is a capsule reflection not the femoral neck right here, and we're just about done.
So because she's young we won't use any marking in her joint. We will just inject her portals. Marcaine the numbing medication can be cytotoxic for cartilage.
This is that medial synovial fold I was telling you about right there. And I am taking this out. Okay let’s suck it out. Alright yeah good.
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