Abstract
Labral tear of the hip joint is an important factor causing joint pain and locking, as well as mobility disturbance. Although femoroacetabular impingement syndrome often results in anterior labral tears, posterior labral tears are present in a subset of patients, especially those with a history of posterior hip dislocation. Posterior labral repair under arthroscopy usually requires switching between the viewing approach and the operating approach, but this undoubtedly increases the operative time and the destruction of soft tissue. This article introduces a technique for rapid posterior labral suture by rotating the arthroscopic camera without switching the surgical approach.
Technique Video
There are long-established techniques for the diagnosis and treatment of anterior-superior labral injury caused by femoroacetabular impingement syndrome.1,2 However, tears of the posterior upper labrum are still difficult to suture. This is due to the blind visual field of the observation approach, and it is often necessary to switch the observation and operation approaches repeatedly, which undoubtedly increases the difficulty of surgery and postoperative complications. This article describes a technique that can quickly complete the posterior upper labral suture without switching approaches, which has the advantages of low operational difficulty, a clear surgical field, and no additional complications.
Surgical Technique
Patient Positioning and Portal Establishment
Perineal column traction and C-arm fluoroscopy are not used during the operation. The patient is placed in the supine position with silicone pads under the buttocks to increase the friction between the patient’s body and the operating table. After traction, the surgical accesses are labeled, including the anterolateral (AL) portal, mid-anterior portal, and distal anterolateral accessory portal (Fig 1).
Fig 1.
Preoperative preparation of right hip, free of perineal column traction and C-arm fluoroscopy. The patient is placed with the head low and the feet high.
Step 1: Approach Establishment and Transverse Capsulotomy
The exchange rod is inserted into the joint cavity through the AL approach. The puncture cone is rotated back and forth to enlarge the joint capsule, and the arthroscopic camera (Synergy; Arthrex, Naples, FL) is inserted. A transverse incision of the joint capsule is alternately performed with a radiofrequency device and shaver (Smith & Nephew, London, England) (Fig 2, Video 1).
Fig 2.
Approach establishment and transverse capsulotomy in right hip. (A) Contact between arthroscopic camera and radiofrequency device outside joint capsule. (B) The joint capsule is transversely dissected.
Step 2: Pincer Arthroplasty and Labral Assessment
Pincer arthroplasty is performed with a spherical burr (Arthrex) (Fig 3). Then, the labral tear is fully evaluated, including location, type, and scope.
Fig 3.
Pincer arthroplasty with a spherical grinding drill, from the view of AL portal (supine position, right hip).
Step 3: Technique for 2-Step Camera Rotation Switching Bird’s-Eye View for Posterior Labral Suture
When it is found that the labral tear is located at the position of the acetabulum before the 12-o’clock position and visual blindness is observed below the labrum through the AL approach (Fig 4), there is no need to switch surgical approaches. The surgeon first rotates the arthroscopic camera clockwise in his or her hand. Under the arthroscopic view, the field of view changes from directly opposite the labrum to directly above the acetabulum, which is called the “bird’s-eye view.” The suture hook passes through the posterior upper side of the torn labrum in the bird’s-eye view and emerges from below its anterior side (Fig 5A). The light source line of the camera should be rotated so that the arthroscopic view is aligned with the exit of the suture hook, and the suture hook across the labrum can be clearly seen (Fig 5B). The polydioxanone wire is released from the suture hook, and a No. 2-0 Ethibond wire (DePuy Synthes, Warsaw, IN) is introduced using the through-line technique. After the high-strength wire is formed into a lasso loop in vitro, a 2.9-mm knot-free anchor (Arthrex) is used to fix the labrum (Fig 6).
Fig 4.
Conventional technique is used to evaluate the suture of the posterior labrum tear. (A) Injury to the labrum at 10 o’clock observed from the anterolateral (AL) approach by traditional observation. (B) It is difficult to observe the exit of suture hook when suture hook is placed through MA portal to suture the labrum, from the view of AL portal (supine position, right hip).
Fig 5.
The bird 's-eye view establishment by two-step camera rotation switching. (A) The suture hook is located, entering through the mid-anterior portal. (B) The exit of the suture hook is clearly visible from the bird's eye view, from the view of AL portal (supine position, right hip).
Fig 6.
Labrum suture (A) Suture the labrum with lasso-loop technique. (B) Place the knot-free anchor, from the view of AL portal (supine position, right hip).
Step 4: Cam Arthroplasty and Capsular Suture
After the neck of the femoral head is fully formed with a spherical grinding drill, the incised joint capsule is sutured.
Discussion
Exploration and treatment of the labrum comprise an important step in hip arthroscopy to preserve the sealing effect of the joint, increase range of motion, and delay degeneration.3,4 Labral tears are most commonly seen at the anterior upper surface of the acetabulum, in the 11- to 3-o’clock position.5 However, in patients with a history of traumatic posterior dislocation of the hip and a cam or pincer deformity placed laterally, posterior-superior labral tears are equally common.6
When the AL approach is used for observation and the mid-anterior approach is used for operating, there is a visual blind area in the treatment of posterior labral injury. It is usually necessary to change the surgical approach. The repetitive procedure undoubtedly increases surgical time, soft-tissue damage, and even the risk of infection. We have described a surgical technique that can quickly complete posterior labral suture without switching surgical approaches. Ortiz-Declet et al.7 proposed the concept of the bird’s-eye and “upper deck” views for pincer arthroplasty. Through different positioning of the light source, they solved the problem of visualizing the acetabular edge in pincer arthroplasty.
We have described a suture method for posterior labral tears without switching approaches. The whole suture process requires only a short amount of time to complete a suture, which can effectively shorten the operative time and yield less secondary soft-tissue injury than the operation after switching approaches, and is worthy of popularization and application (Table 1).
Table 1.
Advantages and Limitations of Technique
| Advantages |
| Reduction in surgical time |
| Less soft-tissue trauma |
| Avoidance of risk of infection due to repeated shuttling of instruments |
| Simple technique |
| Best visualization of posterior labral suture |
| Not subject to suture instruments |
| Limitations |
| Good sense of 3-dimensional space required |
| Full understanding of operating principles of arthroscopy required |
| Easy to cause damage during labral suturing |
| Confusing visual field under microscope after rotation of camera |
Disclosures
Authors (R.N., Y.Z., D.L.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Funding
The authors declare the following financial interests/ personal relationships which may be considered as potential competing interests: D.J. reports that financial support was provided by the Scientific Research Fund project of the Education Department of Yunnan Province (No. 2024J0182); the PhD Start-up Fund project of the First Affiliated Hospital of Kunming Medical University (No. 2019BS008); and the Major Science and Technology Project of Yunnan Provincial Department of Science and Technology, Yunnan Provincial Orthopedic and Sports Rehabilitation Clinical Medicine Research Center (No. 202102AA310068). K.W. reports that financial support was provided by Medical Reserve Talent for Health Commission of Yunnan Province (No. H-2019071).
Supplementary Data
Complete description of technique for posterior labral suture of hip joint by 2-step camera rotation switching bird’s-eye view. The patient is placed supine on the operating bed, and the affected lower limb is retracted by a perineal column–free traction technique. The arthroscope is implanted through the anterolateral (AL) portal without C-arm fluoroscopy, and the joint capsule is transversely dissected after radiofrequency implantation through the mid-anterior (MA) portal. Pincer arthroplasty is performed with a spherical grinding drill after exposure of bone hyperplasia at the upper margin of the acetabulum. The location, type, and scope of the labral injury on the acetabular surface should be fully assessed. When it is found that the labral tear is located at the position of the acetabulum before the 12-o’clock position and visual blindness is observed below the labrum through the AL portal, the technique of 2-step camera rotation switching bird’s-eye view is used for the labral suture. Finally, hip flexion at 40° is performed to complete the joint capsule longitudinal incision, cam arthroplasty, and capsular suture.
References
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Associated Data
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Supplementary Materials
Complete description of technique for posterior labral suture of hip joint by 2-step camera rotation switching bird’s-eye view. The patient is placed supine on the operating bed, and the affected lower limb is retracted by a perineal column–free traction technique. The arthroscope is implanted through the anterolateral (AL) portal without C-arm fluoroscopy, and the joint capsule is transversely dissected after radiofrequency implantation through the mid-anterior (MA) portal. Pincer arthroplasty is performed with a spherical grinding drill after exposure of bone hyperplasia at the upper margin of the acetabulum. The location, type, and scope of the labral injury on the acetabular surface should be fully assessed. When it is found that the labral tear is located at the position of the acetabulum before the 12-o’clock position and visual blindness is observed below the labrum through the AL portal, the technique of 2-step camera rotation switching bird’s-eye view is used for the labral suture. Finally, hip flexion at 40° is performed to complete the joint capsule longitudinal incision, cam arthroplasty, and capsular suture.