Hip Arthroscopy in Adolescents Through an Extra-Capsular Approach.

Hip arthroscopic treatment for femoroacetabular impingement syndrome and labral tears is the gold standard in the adult and adolescent population, as we all know the most common surgical approach to the hip is entering the central compartment with fluoroscopy and with continuous distraction. A periportal capsulotomy in traction must be done to have visibility and instrument maneuverability. These maneuvers avoid scuffing the femoral head cartilage. In adolescents, extreme care must be taken in hip distraction, as the force used can cause iatrogenic neurovascular lesions, avascular necrosis, and lacerations of the genitals and foot/ankle. Experienced surgeons around the world have developed an extracapsular approach to the hip with smaller capsulotomies with a low complication rate. This approach to the hip has brought attention in the adolescent population because it is more secure and simple. Less force of distraction is needed because the capsulotomy is done first. This surgical technique allows observation of the cam morphology while entering to the hip without distraction. We describe an extracapsular approach as an option to treat femoral acetabular impingement syndrome and labral tears in the pediatric and adolescent population.

Quantitative cotyloid fossa thickness and proximity to obturator neurovascular bundle: implications for arthroscopic ligamentum teres reconstruction.

The aim of the present study was to report the in vivo thickness of the cotyloid fossa at the acetabular ligamentum teres (LT) attachment and investigate the clearance of the obturator neurovascular bundle. Fifty-five consecutive patients undergoing a total hip arthroplasty for hip osteoarthritis were included. The thickness of the cotyloid fossa was measured at the acetabular LT attachment using a standard depth gauge. The minimal distance (clearance) of the obturator neurovascular bundle to the center of the acetabular LT attachment was measured in 7 patients (14 hips) who also underwent a computed tomography angiography. The average thickness of the cotyloid fossa at the acetabular LT attachment was 4.1 ± 2.3 (range: 1-10) mm. The obturator vein was closest to the acetabular LT attachment, but the clearance was more than the defined safe zone of 15 mm in all cases. Based on the current findings, it can be assumed that bone anchors might not be suitable for fixation of the graft in LT reconstruction (LTR) and an alternative implant such as a cortical button should be considered. Acetabular fixation of the graft with a 12-mm cortical button is relatively safe concerning injury to obturator neurovascular structures. The results of the present study provide a better understanding of the cotyloid fossa anatomy and might be relevant for surgeons who perform arthroscopic LTR.

Arthroscopic utilization of ChondroFiller gel for the treatment of hip articular cartilage defects: a cohort study with 12- to 60-month follow-up.

ChondroFiller gel is an absorbable collagen implant. It serves as a protective cover for the cartilage defects, allowing chondrocyte migration into the lesion. The implant consists of collagen (Type I) and is derived from veterinary monitored rats. This study evaluates the use of ChondroFiller gel in the treatment of cartilage lesions during hip joint arthroscopy. A prospective study was conducted on a group of 26 adult patients. All patients had an existing femoroacetabular impingement together with acetabular cartilage lesions >2 cm2. All patients underwent hip arthroscopic surgery and the lesions were treated using ChondroFiller gel. The cartilage tissue healing was evaluated postoperatively using MRI. A total of 26 patients, including 5 females and 21 males, all with articular cartilage lesions, were included in the study. Cartilage healing conditions were evaluated for all patients, and the difference between pre- and post-surgery conditions was statistically significant. The follow-up scores have been acquired from 21 out of initial 26 patients (2 were disqualified after receiving THR, 3 could not be reached by researchers) after 3, 4 and 5 years consecutively with 17/21 patients having good/excellent results. The use of ChondroFiller gel during arthroscopy of the hip for acetabular cartilage lesions is an effective treatment technique. Encouraging long-term results have been observed, but further research on larger group of patient is required to better assess the full value of this technique. Patients with pre-existing osteoarthritis (Tönnis 2-3) have poor results.

The Yoga Mat Technique in Postless Hip Arthroscopy.

Hip arthroscopy for the treatment of femoroacetabular impingement syndrome with anti-sliding techniques and without the use of a perineal post to achieve hip distraction has increased greatly in the past 5 to 10 years. To access the hip joint, distraction is mandatory to treat intra-articular disorders such as labral tears, acetabular cartilage defects, loose bodies, ligamentum teres tears, and avascular necrosis of the hip. In hip distraction, counter-distraction is needed, and this is achieved with a bulky and cushioned perineal post. Most of the described techniques in hip arthroscopy worldwide use a perineal post, but iatrogenic pudendal nerve, genital lacerations, hematomas, and groin complications have been reported to occur. In Latin American countries, disposable hip pad devices are expensive, and not all the arthroscopic companies provide them. Our yoga mat technique provides enough countertraction to achieve adequate hip distraction. Labral repair, labral reconstruction, and decompression of femoroacetabular impingement syndrome have been achieved properly, reliably, and reproducibly, and no Trendelenburg position is needed. Postless hip arthroscopy is made simple, and positioning the patient is not difficult. Hip surgeons can adapt this technique to a fracture table, a hip distractor, and a standard operating room table.

Ligamentum teres reconstruction with labrum and capsule repair after posterior acetabular wall fracture: a case report.

The aim of this case study is to present arthroscopic treatment of recurrent hip instability after acute post-traumatic posterior hip dislocation with a fracture of the posterior acetabular wall. A male patient aged 35 suffered a dislocation of the right hip joint with a fracture of the posterior acetabular wall due to an accident. The fracture was stabilized during emergency surgery with a locking compression plate, and the patient was released home in a hip brace. Multiple dislocations of the hip joint followed with the implant being confirmed as stable. Decision was made to qualify the patient for a right hip arthroscopy. During the surgery, ligamentum teres was reconstructed using gracilis and semitendinous muscle grafts, followed by the labrum and joint capsule repair, where the surgery that stabilized the acetabular wall fracture had damaged them. There were no complications following the procedure. Short-term follow-up of 3 months demonstrates the patient has a stable hip, reduced pain and has returned to pre-injury activities.

Hip Arthroscopy and Core Decompression for Avascular Necrosis of the Femoral Head Using a Specific Aiming Guide: A Step-by-Step Surgical Technique.

Avascular necrosis of the femoral (AVN) head is a disabling disease that affects function, mobility, and quality of life in the young adult. Its pathology involves blood circulation disruption of the femoral head and subchondral infarction. This leads to cartilage thinning, femoral head depression, and cartilage breakage, which results in hip osteoarthritis. In the past decade the prevalence of intraarticular pathology has been almost 95%, this revealed with hip arthroscopy (HA). HA and core decompression (CD) of the femoral head can be used effectively and concomitantly to treat AVN with excellent results, HA allows for excellent visualization of the hip joint cartilage, allowing treatment of femoroacetabular impingement syndrome (FAIS) and intra-articular pathology. Our technique demonstrates that retrograde core decompression with allograft and mixed bone matrix is an excellent choice of treatment in the early stages of AVN/ONFH. The femoral head-specific aiming guide is very reliable, is simple to use arthroscopically if placed in the posterolateral portal of the hip, and offers exact pin placement at the necrotic site, as well as less operative time and less radiation to the patient and surgical team.

The Outside-In Technique for Slipped Capital Femoral Epiphysis: A Safe and Reproducible Approach in Hip Arthroscopy.

Femoroacetabular impingement syndrome caused by slipped capital femoral epiphysis (SCFE) can be successfully treated arthroscopically and with the minimally invasive, outside-in surgical technique. The advantages of the technique are that the residual cam-type deformity caused by the slippage can be corrected and reconstructed reliably and reproducibly before distracting the hip joint; and radiation with fluoroscopy is used for only definitive reduction and reconstruction, which is obtained with cannulated screws. In addition, this safe technique allows distraction of the hip after screw placement, without affecting the reconstruction, to address labral tears and chondrolabral delaminations caused by the impingement.

The Tutankhamun Technique in Hip Arthroscopy.

Hip arthroscopy has been increasing tremendously in the past decade and is a very common surgical procedure to repair femoroacetabular impingement. To access the hip joint, distraction is mandatory to treat intra-articular disorders such as labral tears, cartilage loose bodies, and ligamentum teres tears and to evaluate the condition of the femoral head and acetabular cartilage. To distract the hip, counterdistraction is needed, and this is achieved with placement of a bulky and cushioned perineal post. Most of the described techniques in hip arthroscopy use a perineal post, whereas others use beanbags to place the patient's body on the surgical table. Still others do not use a post at all but rather use gravity and a Trendelenburg position to achieve distraction. Our technique does not use a perineal post but instead uses heavy-duty tape over the patient's upper body, which is placed on a normal operating room table to distract the hip while entering the central compartment.

The Mayo Table Technique in Hip Arthroscopy.

Hip distractor devices or hip fracture tables (HFTs) are vital to perform a reliable hip arthroscopy (HA) for the treatment of femoroacetabular impingement, especially when labral tears, chondral-labral delaminations, ligamentum teres tears, and other intraarticular disorders are present. Adequate hip distractors were not available in the early days of HA; most of HFTs being used those days were rigid, cumbersome, and did not allow us to properly perform an arthroscopic dynamic impingement test to evaluate and assess the femoral head and its site of impingement. The mayo table technique was developed because of the lack of appropriate hip instrumentation and an HFT when the author (A.P.S.) started to perform HA. This easy technique allows the surgeon to control hip maximal range of motion and also to assess completely the cam deformity in the posterolateral, superolateral, anterior, and anteroinferior aspects. It also allows the surgeon to revise where the cam is impinging and afterward perform a complete bony resection and decompression. We strongly believe that with the mayo table technique HA can be performed simply and reliably in old rigid and cumbersome HFTs and also hip distractors that do not allow an adequate dynamic assessment of the hip with maximal range of motion.

Prospective study of nerve injuries associated with hip arthroscopy in the lateral position using the modified portals.

To access the central compartment of the hip, distraction is essential in hip arthroscopy (HA); nerve injuries have long been accepted as a complication of this surgical procedure, with an incidence ranging from 0 to 46%. Only one previous article collected data prospectively, and the authors utilized a supine technique, with a modified mid-anterior portal. Our study also used prospectively collected data, from a group of 200 consecutive patients who had HA performed in the lateral position using the paratrochanteric portals. Our results were that four patients (2%) reported symptoms of neurological deficits after surgery, three patients with traction times ranging from 20 to 41 min, their neurological deficits resolved completely over a time from 6 to 9 weeks. The fourth patient who had the longest traction time of 73 min, and also greater than usual traction, his neurological deficit resolved at 12 weeks. Our hypothesis of 200 hip arthroscopies, performed in the lateral position by the modified paratrochanteric portals, the incidence of nerve injuries would be lower than 46%. We found an incidence of 2%, all affecting the perineum and genitals and all occurring in men, no differences between the age, surgery side or type of surgery performed on the patient were found to have statistical differences. Traction times with <31.5 min were related with fewer incidences of neurological symptoms. On the basis of this study, all patients with traction times below 73 min can be confidently reassured that any deficit will recover within 3 months.

Radiographic and anatomic landmarks to approach the anterior capsule in hip arthroscopy.

Hip arthroscopy (HA) is considered to be a very difficult and demanding surgical procedure, special instruments, an image intensifier and a fracture table or hip distractor are required to access the hip joint, the most common and worldwide used HA technique is entering blindly to the central compartment with the use of fluoroscopy and continuous distraction; with the potential danger if performed in unskillful hands of labral penetrations, labral resections and scuffing of the femoral head cartilage. Our technique describes the arthroscopic management of femoroacetabular impingement (FAI), performing a preoperative planning using radiographic and anatomic landmarks to approach the anterior capsule without the use of fluoroscopy. Access to the hip joint is made extra-articularly from the peritrochanteric compartment palpating the greater trochanter and posteriorly penetrating the iliotibial band sliding the arthroscopic sheath and obturator from the trochanteric border to the anterior femoral neck to visualize the anterior capsule bursa and anterior capsule fibers and posteriorly following our previous landmarks perform an anterior oblique Inverted 'T' or 'H' capsulotomy with a radiofrequency wand to access the cam-type impingement and distraction is made under direct controlled arthroscopic vision. Our technique in HA aiming the anterior capsule using radiographic and anatomic landmarks is safe, reliable and reproducible in FAI with big cams, deep sockets and cases with mild arthritis where the capsule is thick, stiff and calcified.

The ligamentum teres-its increasing importance.

The ligamentum teres (LT) has attracted much greater interest over recent years due to the increased use of hip arthroscopy. There have been advancements in our understanding of the LT's biomechanical function and its role in hip and groin pain. Our ability to suspect LT tears by clinical examination and imaging has improved. Publications by many authors concerning LT tear treatment and outcomes continue to increase. This manuscript is a review of the function, mechanism of injury, clinical assessment, imaging, arthroscopic assessment, treatment, outcomes, reconstruction, and unusual conditions of the LT.