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Hip Arthroscopy is a conservative surgical approach to cure hip pain. Arthroscopy allows for minimal scarring, faster recovery, and helps to diagnose and treat early causes of arthritis, in many cases preventing it altogether. Hip Arthroscopy surgery is done to treat mechanical symptoms such as popping, painful clicking and catching and demonstrate a reduced range of motion of the hip. Here we have explained the procedures involved in hip arthroscopy.

Acetabular Labral Repair using the PushLock Knotless Anchor System

Introduction:

Diagnosis of acetabular labral tear pathology is mostly clinical and presents in a similar manner as meniscal pathology in the knee. Patients can present with complaints of mechanical symptoms such as popping, painful clicking and catching and demonstrate a reduced range of motion of the hip. Prior treatment guidelines suggested that debridement and resection of the torn labral tissue was appropriate for pain relief. Though effective, this often compromised the function of the acetabular labrum.< Longitudinal, peripheral and intrasubstance tears are amenable to repair. By repairing the torn labrum, the following physiological functions can be preserved:

• Joint Compressive Forces
• Cartilage Consolidation
• Vacuum Sealing Mechanism
• Joint Stability and Congruity

Imaging Studies:

Magnetic resonance arthrography (MRA) is currently the most sensitive method for imaging a labral tear.

Patient Positioning and Traction:

Arthroscopic repair of the acetabular labrum can be performed in either the supine or lateral decubitus position, according to surgeon preference. The perineal post and pad are attached to the operating table with a Clark Rail Adapter on the nonoperative side of the patient and positioned between the legs to provide adequate abduction prior to application of weighted traction. The Hip Distractor System is assembled in a sterile manner and attached to the table with a Clark Rail Adapter on the operative side of the patient near the ankle.

The foam leg sleeve is applied to the operative side using the provided Coban™. The traction pulley is set at a height that allows for 10 - 15˚ of hip flexion. Traction is applied incrementally between 25 and 50 pounds until the vacuum seal of the joint is broken and 8-10 mm of femoral distraction from the acetabulum is achieved. The leg is brought back into slight adduction to gain adequate lateral traction of the femoral head. Prior to portal placement a 14 gauge needle is inserted into the joint to further break the vacuum seal and provide greater distraction of the joint.

Portal Placement:

Repair of the acetabular labral tear is performed through the anterolateral and standard anterior portals in many cases. Establish the anterolateral portal first for the arthroscope using a percutaneous approach with or without fluoroscopic guidance. Once a spinal needle is in place in the joint using a “loss of resistance” method, a long Nitinol wire is advanced through the spinal needle and the needle is removed. A Cannulated Obturator, used in conjunction with the arthroscope sheath, is passed over the wire and into the joint. Once the wire and Cannulated Obturator are removed, the scope can be placed through the sheath and into the joint. Establish the anterior working portal under direct arthroscopic visualization in an outside/in fashion using a spinal needle, being mindful of neurovascular structures in the vicinity. These portals can be atraumatically enlarged to accommodate varying cannula sizes by using the Portal Dilation System. Additionally, in cases of tough capsule resistant to dilation, a Beaver Blade can be inserted through the cannula and capsulotomy performed to accommodate cannulas and instruments.

	After preparing the anchor placement site with a mechanical burr, insert the Metal Offset Guide into the joint. In many cases this is performed through the anterior or anterolateral cannula. The guide should be positioned on the acetabular rim at the point of labral detachment. Remove the trocar to allow the fish-mouth design of the guide tip to remain securely on the acetabular rim. Insert the PushLock drill on power through the guide and advance it into the bone until the drill bit hub "bottoms-out" on the back of the guide handle. Remove the drill and the offset guide, making note of the general location of the pilot hole.
	Insert the long 22° BirdBeak™ w/WishBone Handle, preloaded with #2 FiberWire®, into the cannula. Pass the sharp tip through or around the capsulolabral complex near the pilot hole until the tip is visualized exiting near the acetabular face.
	Release the #2 FiberWire that is now forming a loop and back the BirdBeak tip out of the tissue, but not out of the joint. Reach over the labrum and retrieve the #2 FiberWire loop and pull it out of the cannula.
	Drop both free limbs of the FiberWire outside of the cannula through the retrieved loop and pull the free ends. This will form a “cinch” stitch around the labrum for added stability.
	An alternative step to passing suture around the labrum is advancing a #2 FiberStick™ into the joint gently through a Low Profile SutureLasso™. Remove the lasso, leaving the FiberStick in the joint. Through the cannula, retrieve the FiberStick using the KingFisher™ Suture Retriever/Tissue Grasper. Both limbs of the FiberStick should be exiting the cannula.
	Outside of the joint, pass both limbs of the FiberWire through the tip of the PushLock anchor and slide the anchor down through the cannula. Push the tip into the pilot hole while keeping gentle tension on the suture limbs. Stop advancing the tip of the driver into the pilot hole when the main body of the anchor reaches the cortex. Note, full tissue tension should be achieved at this time and the suture limbs can be relaxed. If the tissue tension is either too great or too relaxed, the anchor tip can be backed out of the pilot hole and proper tension can be achieved by pulling on or relaxing the suture tails.
	Mallet the metal button on the back of the PushLock handle to advance the main anchor body over the driver tip and into the pilot hole, trapping the suture. Stop malleting when the black laser line on the distal anchor insertion shaft is flush with bone. Unscrew the handle from the anchor by turning the handle six complete counterclockwise revolutions then pull back. Insert a FiberWire Suture Cutter into the joint and cut each suture strand flush with bone. Repeat this process if multiple anchors are required.

Dr. Kevin Murphy one of the finest orthopedic surgeons based in Jacksonville, Florida, specializes in sports medicine, upper extremities, hip arthroscopy, knee surgery and shoulder arthroscopy.