In this case, Dr. Scott D. Martin takes us through a diagnostic hip arthroscopy where he dilates 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.
Table of Contents
- High Flow Rate
- Puncture-Capsule Orifice
- Pulvinar, Condyloid Notch, and Ligamentum Teres
- Discoloration of Labrum
- Articular Cartilage Bubbling
- Labral Fraying
- Assessment of Labral Damage
- Shave Labral Fray
- Medial Gutter, Medial Synovial Fold, and Zona Orbicularis
- Range of Motion
- Labral Seal
- Opening Capsule via Increased Flow Rate
- Lateral Synovial Fold and Vasculature
So we’re just gonna dilate up our portal here. Let me have the Mitech now. 60 - you want to go down a little? Go down to 50. 50 or 40? 50. So heat is bad for the hip, so we really run high-flow when we are running this thing.
I’m gonna dilate this out cuz this is gonna - you can back up a little bit - this is gonna be our main viewing portal now. We wanna - we use puncture capsulorrhaphy, so we're just coming through with the puncture instead of just doing - doing a T capsulorrhaphy where we open up the whole thing. And we want this perfectly circular cuz any - any little overhanging edges are gonna be magnified 19 times here. It’s like trying to operate with a washcloth sticking in your eyes.
This is her pulvinar right here with her ligamentum teres right here. It's on the left. It’s this structure right here. Do you have a probe? So this is her ligamentum teres right here. That's the main ligament between the femoral head and the acetabulum. This is her pulvinar. Little bit of bleeding. Whole thing is called a cotyloid notch cuz the pulvinar is this fatty stuff right here. This tissue right here has a vessel in it for the head, which is a - just a branch of the obturator artery - just 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. So you can see this little yellow discoloration, right here? So see that - how everything is so white and then there’s yellow discoloration of the labrum.
The femoral head looks good. And all the way down to bottom. Transverse ligament is where the labrum goes real wide here to narrow. That's - right there is the beginning of the transverse ligament. That's the 6 o’clock 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’m gonna let my fellow take a feel here, and then we’re gonna look all the way around. Yep, go ahead.
Besides some fraying of the labrum where we came in, I don't - I don’t see a lot on this. A lot of times if they have a big labral tear, as you come in, it’s just everywhere. She's only 24 so she's got some pretty good tissue, but do you see all this yellow discoloration? But still, we would never just debride for that cuz you’d cause more damage than you’d correct. If you look at the femoral head, it looks really nice. Little bit of fraying in labrum right here. This area right here. No, I saw it coming in. I mean, it's just - it's very mild. It's a combination of that with a little bit of bubbling. Can you come on in here and give us a spot? So we're gonna probe this and make sure that there's nothing through and through on both sides here.
What we have been doing on some patients, if 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 with a little bit at fraying of her labrum - but, you know, overall - not terrible. Then the question would be whether not to put some anchors and sutures in. I - I think it's pretty superficial.
So I’m gonna take that out. Let me have the obturator for blue. Follow. I’m just gonna switch out here. Can I have a shaver please? You can see this right here - this fraying on the edge here. Right there - in 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 chondrolabral 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. She just has some fraying. What you’re gonna do is let this come over us. I'll take the Mitek-o. Okay, obturators are blue.
So Drew, I’m gonna show you - when these aren't straight up and down, I’m gonna show you what happens. You're always working back on yourself with these portals. So I’m torquing it to get it in there. Just going to touch it. I’m just dabbing it to resist 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 we really don't feel that it's good for the labrum. Now hold that right there, Drew, as I 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 like 71 degrees centigrade. You only need 51 degrees to kill chondrocytes. And 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 you're 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. So 40 - yeah - right there and have her in. Lock it there.
Now this is a medial 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, and it doesn't tether the capsule. So 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, you know, 45, 50 degrees of rotation.
So this is her labral seal. Can we dull the overheads? This is that medial synovial fold that we ta - just talked about. This is her medial gutter, right there. Tighten now wire. I’m gonna come back out a little bit, 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. See? So if we're trying to get in and it's like that without any fluid in it, 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. So that's why when we were gonna go into the peripheral compartment, we increased our flow rate, and we increased our 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 gonna clean that up. Let me have a shaver. Medial coming over to the 12 o’clock position here. Yeah.
Mitek 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.
There you watch your flow - way up. Okay, rotate her in a little bit. Now rotate her out. Okay, right there - that's the area we debrided. Can you - can suck a little bit there?
So you can see, we still have a good seal. So see the seal right there? Suck a little bit. And no big bumps, so we'll move around.
And all that is just soft tissue and her blood supply coming in through the lateral synovial fold. This is all the way underneath. Right there. Suck a little bit. Where this capsule reflection is - that’s her lateral synovial fold, and the redness right there branches off 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 or so. If 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’ll 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’m gonna take this out now. Okay. Alright, now let’s suck it out. Alright, yep. Good.