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Hip Arthroscopic Portal Bridge Retraction Technique for Improved Peripheral Compartment Visualization
Hip Arthroscopic Portal Bridge Retraction Technique for Improved Peripheral Compartment Visualization Brian E. McGrath, M.D., and Joseph B. Kuechle, M.D., Ph.D.
Abstract: Hip arthroscopy has been shown to be an effective technique in managing an increasingly widening set of indications for hip pathology. In any arthroscopic procedure, obtaining good visualization is one of the most critical components to performing a successful operation. Whereas other authors have described various techniques for improving visualization, we describe an additional simple but effective technique in this report. We describe the use of a retracting suture bridge between portal sites that allows for improved visualization of the peripheral compartment in hip arthroscopy, as well as other arthroscopic procedures.
H
ip arthroscopy has been shown to be an effective technique in managing an increasingly widening set of indications for hip pathology, including symptomatic labral tears, femoral acetabular impingement, chondral injuries, and more.1 In any arthroscopic procedure, obtaining good visualization is one of the most critical components to performing a successful operation. In hip procedures, this has been one of the more significant challenges that has contributed to the steep learning curve when attempting to master its practice.2 The hip joint, when compared with other joints, is invested in significantly thicker soft tissues and has a smaller area for maneuvering. Whereas the rate of complications of arthroscopic femoral acetabular impingement treatment are low, technical difficulties of visualization contribute to this number.3 Capsular tissue as well as surrounding musculature can obscure visualization, causing an inappropriate trajectory for placement of suture anchors for labral repair, poorly tightened knots, and capsule closure techniques, leading to loss of fixation of labral repairs and instability of the hip. Iatrogenic chondral or labral injury is seen in up to 6% of hip arthroscopy cases and can be due to inadequate visualization.4 Adequate visualization of
From the Department of Orthopedics, University at Buffalo, Buffalo, New York, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received November 15, 2013; accepted May 9, 2014. Address correspondence to Brian E. McGrath, M.D., 4949 Harlem Rd, Ste 101, Buffalo, NY 14226, U.S.A. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 2212-6287/13799/$36.00 http://dx.doi.org/10.1016/j.eats.2014.05.011
cam lesions can be a challenge to inexperienced surgeons in the peripheral compartment, and without visualization, those that are missed on preoperative imaging also can be missed intraoperatively.5,6 We describe a simple but effective technique to improve visualization for arthroscopic hip procedures in the peripheral compartment.
Surgical Technique The patient is anesthetized then placed on the traction table in either the supine or lateral position. A wellpadded perineal post and boot are placed. After standard sterile preparation and draping techniques, landmarks are drawn on the patient for portal positioning, including the anterior superior iliac spine and the superior, posterior, and anterior borders of the trochanter, as shown in Video 1. After traction is applied and joint distraction is confirmed by fluoroscopic visualization, the anterior lateral portal is placed by advancing a 17-gauge spinal needle at a site just anterior to the trochanter and in line with the proximal end of the trochanter with a slight superior direction, while avoiding perforation of the labrum. Further distraction of the joint is noted with correct placement of the needle on fluoroscopy. The standard arthroscopic portal is inserted over a guidewire. The anterior portal is created under direct visualization using a 70 Arthrex Synergy arthroscope (Arthrex, Naples, FL) from the anterolateral portal. The spinal needle is advanced at a site 1 cm lateral to the intersection of the sagittal line, marking the anterior superior iliac spine, and the transverse line, marking the proximal end of the greater trochanter, while avoiding the anterior labrum. A transverse capsulotomy is performed using a beaver
Arthroscopy Techniques, Vol 3, No 4 (August), 2014: pp e501-e503
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visualization, as shown in Figure 2. Not only does this technique allow for a greater depth of view because there is less interposing tissue but the field of view itself is enlarged, as shown in Figure 3.
Discussion
Fig 1. A hip in a lateral position showing the positions of various portal sites with the lasso connecting the portals, including the anterior (A), anterolateral (AL), posterolateral (PL), superior acetabular (SA), and midefemoral neck (MF) portals. The 2 ends of the suture can be clamped with a Kelly clamp and retracted to increase intra-articular visualization.
blade between the anterior and anterolateral portals. Other portal sites used include a posterior trochanteric portal, a superior acetabular portal, and a midefemoral neck portal located 4 cm distal and one-third of the way between the anterolateral and anterior portals. The novel aspect of our technique is the use of a heavy monofilament or braided suture between the various portal sites. We use No. 5 Arthrex Blue FiberWire. This simple technique involves placing this retractor suture through the portals and then shuttling to exit the adjacent portal. A switching-stick technique is used to replace the cannulas, leaving the suture retractor external to the cannula and freeing the portal for its full use. The free ends are then clamped outside of the patient, and improved visualization can be achieved by applying tension to the portal bridge retracting suture. The portal bridge retractor can be passed between any adjacent portal sites, as shown in Figure 1. Retracting on this simple loop greatly improves
The small amount of retraction afforded by the application of the portal bridge retractor technique can make a significant impact on visualization and thereby improve results for patients. This technique is indicated for procedures such as labral repairs and cam and pincer lesion debridement. It is not recommended for patients in whom there are concerns about skin quality because the retraction is performed directly at the portal sites without the cannulas. In addition, excessive retraction can cause suture breakage, skin breakdown at the portal sites, or erosion through the musculature (Table 1). This technique is ideal in that it involves very little added cost or time. The portal bridge retractor technique is inexpensive because it requires no special device to deploy; rather, it entails only the cost of the suture material. It saves time because added visualization allows for quicker procedures and the time involved in placing the retractor is minimal. With increased time performing the procedure, there is increased risk regarding sciatic nerve neurapraxia and perineal skin damage.4 The technique also decreases the complication of fluid extravasation caused by increasing the pump pressure to increase the arthroscopic working space to improve visualization.7 Arthroscopic surgery involving any joint can benefit from the use of a portal bridge retractor as we have described in this report. This retractor can be used in areas such as the anterior knee to help retract the anterior fat pad, the subacromial space, or the medial soft tissue in elbow arthroscopy to help protect the ulnar nerve. Other authors have described techniques such as placement of additional portals or use of a switching stick for retraction.8 Our technique is similar
Fig 2. (A) Before and (B) after passage of suture passing through 2 portals, outside of cannulas. Improved visualization is achieved by increasing the field of view of the arthroscopic camera.
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Fig 3. Arthroscopic images of view through hip anterolateral portal into peripheral compartment (A) before retraction and (B) after retraction with improved visualization.
to the “hanger-lifting” and “coiling up” techniques described for the knee in that retraction with those technique using a stiff wire provides additional space for viewing and manipulating intra- and extra-articular structures.9 Overall, our simple and effective technique is inexpensive, easy to use, and widely applicable, allowing for improved visualization of the peripheral compartment in hip arthroscopy, as well as other arthroscopic procedures. Table 1. Key Points, Indications, Contraindications, and Pitfalls Key points The suture bridge technique is a simple tool to improve visualization. The bridge can be used between any portal sites. An additional assistant may be required to help with retraction. Indications Labral repair Cam lesion debridement Pincer lesion debridement Contraindications Poor skin quality Pitfalls Excessive retraction can cause suture breakage, skin problems at portal sites, or erosion through musculature
References 1. Bedi A, Kelly BT, Khanduja V. Arthroscopic hip preservation surgery: Current concepts and perspective. Bone Joint J 2013;95:10-19. 2. Konan S, Rhee SJ, Haddad FS. Hip arthroscopy: Analysis of a single surgeon’s learning experience. J Bone Joint Surg Am 2011;93:52-56 (suppl 2). 3. Ilizaliturri VM Jr. Complications of arthroscopic femoroacetabular impingement treatment: A review. Clin Orthop Relat Res 2009;467:760-768. 4. Harris JD, McCormick FM, Abrams GD, et al. Complications and reoperations during and after hip arthroscopy: A systematic review of 92 studies and more than 6,000 patients. Arthroscopy 2013;29:589-595. 5. Matsuda DK. The case for cam surveillance: The arthroscopic detection of cam femoroacetabular impingement missed on preoperative imaging and its significance. Arthroscopy 2011;27:870-876. 6. Maeno S, Hashimoto D, Otani T, Masumoto K, Hui C. The “coiling-up procedure”: A novel technique for extraarticular arthroscopy. Arthroscopy 2010;26:1551-1555. 7. Ladner B, Nester K, Cascio B. Abdominal fluid extravasation during hip arthroscopy. Arthroscopy 2010;26:131-135. 8. Suslak AG, Mather RC III, Kelly BT, Nho SJ. Improved arthroscopic visualization of peripheral compartment. Arthrosc Tech 2012;1:e57-e62. 9. Maeno S, Hashimoto D, Otani T, et al. Hanger-lifting procedure in knee arthroscopy. Arthroscopy 2008;24:1426-1429.
Abstract: Hip arthroscopy has been shown to be an effective technique in managing an increasingly widening set of indications for hip pathology. In any arthroscopic procedure, obtaining good visualization is one of the most critical components to performing a successful operation. Whereas other authors have described various techniques for improving visualization, we describe an additional simple but effective technique in this report. We describe the use of a retracting suture bridge between portal sites that allows for improved visualization of the peripheral compartment in hip arthroscopy, as well as other arthroscopic procedures.
H
ip arthroscopy has been shown to be an effective technique in managing an increasingly widening set of indications for hip pathology, including symptomatic labral tears, femoral acetabular impingement, chondral injuries, and more.1 In any arthroscopic procedure, obtaining good visualization is one of the most critical components to performing a successful operation. In hip procedures, this has been one of the more significant challenges that has contributed to the steep learning curve when attempting to master its practice.2 The hip joint, when compared with other joints, is invested in significantly thicker soft tissues and has a smaller area for maneuvering. Whereas the rate of complications of arthroscopic femoral acetabular impingement treatment are low, technical difficulties of visualization contribute to this number.3 Capsular tissue as well as surrounding musculature can obscure visualization, causing an inappropriate trajectory for placement of suture anchors for labral repair, poorly tightened knots, and capsule closure techniques, leading to loss of fixation of labral repairs and instability of the hip. Iatrogenic chondral or labral injury is seen in up to 6% of hip arthroscopy cases and can be due to inadequate visualization.4 Adequate visualization of
From the Department of Orthopedics, University at Buffalo, Buffalo, New York, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received November 15, 2013; accepted May 9, 2014. Address correspondence to Brian E. McGrath, M.D., 4949 Harlem Rd, Ste 101, Buffalo, NY 14226, U.S.A. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 2212-6287/13799/$36.00 http://dx.doi.org/10.1016/j.eats.2014.05.011
cam lesions can be a challenge to inexperienced surgeons in the peripheral compartment, and without visualization, those that are missed on preoperative imaging also can be missed intraoperatively.5,6 We describe a simple but effective technique to improve visualization for arthroscopic hip procedures in the peripheral compartment.
Surgical Technique The patient is anesthetized then placed on the traction table in either the supine or lateral position. A wellpadded perineal post and boot are placed. After standard sterile preparation and draping techniques, landmarks are drawn on the patient for portal positioning, including the anterior superior iliac spine and the superior, posterior, and anterior borders of the trochanter, as shown in Video 1. After traction is applied and joint distraction is confirmed by fluoroscopic visualization, the anterior lateral portal is placed by advancing a 17-gauge spinal needle at a site just anterior to the trochanter and in line with the proximal end of the trochanter with a slight superior direction, while avoiding perforation of the labrum. Further distraction of the joint is noted with correct placement of the needle on fluoroscopy. The standard arthroscopic portal is inserted over a guidewire. The anterior portal is created under direct visualization using a 70 Arthrex Synergy arthroscope (Arthrex, Naples, FL) from the anterolateral portal. The spinal needle is advanced at a site 1 cm lateral to the intersection of the sagittal line, marking the anterior superior iliac spine, and the transverse line, marking the proximal end of the greater trochanter, while avoiding the anterior labrum. A transverse capsulotomy is performed using a beaver
Arthroscopy Techniques, Vol 3, No 4 (August), 2014: pp e501-e503
e501
e502
B. E. MCGRATH AND J. B. KUECHLE
visualization, as shown in Figure 2. Not only does this technique allow for a greater depth of view because there is less interposing tissue but the field of view itself is enlarged, as shown in Figure 3.
Discussion
Fig 1. A hip in a lateral position showing the positions of various portal sites with the lasso connecting the portals, including the anterior (A), anterolateral (AL), posterolateral (PL), superior acetabular (SA), and midefemoral neck (MF) portals. The 2 ends of the suture can be clamped with a Kelly clamp and retracted to increase intra-articular visualization.
blade between the anterior and anterolateral portals. Other portal sites used include a posterior trochanteric portal, a superior acetabular portal, and a midefemoral neck portal located 4 cm distal and one-third of the way between the anterolateral and anterior portals. The novel aspect of our technique is the use of a heavy monofilament or braided suture between the various portal sites. We use No. 5 Arthrex Blue FiberWire. This simple technique involves placing this retractor suture through the portals and then shuttling to exit the adjacent portal. A switching-stick technique is used to replace the cannulas, leaving the suture retractor external to the cannula and freeing the portal for its full use. The free ends are then clamped outside of the patient, and improved visualization can be achieved by applying tension to the portal bridge retracting suture. The portal bridge retractor can be passed between any adjacent portal sites, as shown in Figure 1. Retracting on this simple loop greatly improves
The small amount of retraction afforded by the application of the portal bridge retractor technique can make a significant impact on visualization and thereby improve results for patients. This technique is indicated for procedures such as labral repairs and cam and pincer lesion debridement. It is not recommended for patients in whom there are concerns about skin quality because the retraction is performed directly at the portal sites without the cannulas. In addition, excessive retraction can cause suture breakage, skin breakdown at the portal sites, or erosion through the musculature (Table 1). This technique is ideal in that it involves very little added cost or time. The portal bridge retractor technique is inexpensive because it requires no special device to deploy; rather, it entails only the cost of the suture material. It saves time because added visualization allows for quicker procedures and the time involved in placing the retractor is minimal. With increased time performing the procedure, there is increased risk regarding sciatic nerve neurapraxia and perineal skin damage.4 The technique also decreases the complication of fluid extravasation caused by increasing the pump pressure to increase the arthroscopic working space to improve visualization.7 Arthroscopic surgery involving any joint can benefit from the use of a portal bridge retractor as we have described in this report. This retractor can be used in areas such as the anterior knee to help retract the anterior fat pad, the subacromial space, or the medial soft tissue in elbow arthroscopy to help protect the ulnar nerve. Other authors have described techniques such as placement of additional portals or use of a switching stick for retraction.8 Our technique is similar
Fig 2. (A) Before and (B) after passage of suture passing through 2 portals, outside of cannulas. Improved visualization is achieved by increasing the field of view of the arthroscopic camera.
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PORTAL BRIDGE RETRACTION TECHNIQUE
Fig 3. Arthroscopic images of view through hip anterolateral portal into peripheral compartment (A) before retraction and (B) after retraction with improved visualization.
to the “hanger-lifting” and “coiling up” techniques described for the knee in that retraction with those technique using a stiff wire provides additional space for viewing and manipulating intra- and extra-articular structures.9 Overall, our simple and effective technique is inexpensive, easy to use, and widely applicable, allowing for improved visualization of the peripheral compartment in hip arthroscopy, as well as other arthroscopic procedures. Table 1. Key Points, Indications, Contraindications, and Pitfalls Key points The suture bridge technique is a simple tool to improve visualization. The bridge can be used between any portal sites. An additional assistant may be required to help with retraction. Indications Labral repair Cam lesion debridement Pincer lesion debridement Contraindications Poor skin quality Pitfalls Excessive retraction can cause suture breakage, skin problems at portal sites, or erosion through musculature
References 1. Bedi A, Kelly BT, Khanduja V. Arthroscopic hip preservation surgery: Current concepts and perspective. Bone Joint J 2013;95:10-19. 2. Konan S, Rhee SJ, Haddad FS. Hip arthroscopy: Analysis of a single surgeon’s learning experience. J Bone Joint Surg Am 2011;93:52-56 (suppl 2). 3. Ilizaliturri VM Jr. Complications of arthroscopic femoroacetabular impingement treatment: A review. Clin Orthop Relat Res 2009;467:760-768. 4. Harris JD, McCormick FM, Abrams GD, et al. Complications and reoperations during and after hip arthroscopy: A systematic review of 92 studies and more than 6,000 patients. Arthroscopy 2013;29:589-595. 5. Matsuda DK. The case for cam surveillance: The arthroscopic detection of cam femoroacetabular impingement missed on preoperative imaging and its significance. Arthroscopy 2011;27:870-876. 6. Maeno S, Hashimoto D, Otani T, Masumoto K, Hui C. The “coiling-up procedure”: A novel technique for extraarticular arthroscopy. Arthroscopy 2010;26:1551-1555. 7. Ladner B, Nester K, Cascio B. Abdominal fluid extravasation during hip arthroscopy. Arthroscopy 2010;26:131-135. 8. Suslak AG, Mather RC III, Kelly BT, Nho SJ. Improved arthroscopic visualization of peripheral compartment. Arthrosc Tech 2012;1:e57-e62. 9. Maeno S, Hashimoto D, Otani T, et al. Hanger-lifting procedure in knee arthroscopy. Arthroscopy 2008;24:1426-1429.