Dry Arthroscopic Hip Labral Repair to Minimize Use of Irrigation Fluid

Abstract

Hip arthroscopy is a technically demanding procedure that can require a substantial volume of irrigation fluid. Techniques should be explored to optimize fluid use while ensuring satisfactory surgical instrumentation and labral repair. In this technical note, we present a method for performing a dry arthroscopic labral repair. This technique can be used in the treatment of a variety of labral pathologies, including primary labral repair with knotless or hand-tied anchors, revision labral repair, and labral reconstruction, without the need for irrigation fluid. Additionally, we discuss supplemental techniques that can be used during other portions of the arthroscopic hip procedure to limit irrigation fluid use.

The utilization of hip arthroscopy for the treatment of intra-articular and periarticular hip pathology has been increasing over the past decade.1, 2, 3, 4 Additionally, it is well known that hip arthroscopy is a technically challenging procedure with a steep learning curve.^5,6 A recent natural disaster in the fall of 2024 catastrophically damaged a major irrigation fluid supplier in the United States, drastically affecting the national supply of irrigation fluid for use.⁷ These events have happened before, with a similar occurrence in 2018, which left the health care industry with a critically low supply of intravenous fluid.⁸ An internal review of our orthopaedic procedures at the beginning of the recent saline solution shortage found hip arthroscopy to be one of the sports medicine procedures associated with the highest irrigation (arthroscopic) fluid utilization. In the current setting of an irrigation fluid shortage and a recent historical precedent, it is imperative that we find ways to appropriately ration our fluid use to limit waste and provide patients with efficient, timely, and quality care. In this article, we discuss a method to perform a dry arthroscopic labral repair without the use of irrigation fluid, as well as other fluid optimization measures. This technique is demonstrated in Video 1, and a list of key pearls and pitfalls identified while developing the procedure is presented in Table 1.

Table 1.

Pearls and Pitfalls of Arthroscopic Labral Repair With Limited Irrigation Fluid

Pearls

The PL portal should be created under direct visualization.

Venting should be performed through an open scope cannula spigot to maintain the working space.

The tip of the scope should be cleaned off as needed. Additionally, brief flushes of water through the scope cannula may clear the field of view.

Additional methods of fluid conservation should be applied as possible (permissive hypotensive anesthesia, epinephrine in saline solution, decreased pump pressure).

Pitfalls

Challenging visualization requires surgeons to be comfortable with hip arthroscopy.

The use of a PL portal may not be routine; therefore, surgeons should be comfortable with the use of this portal.

Intermittent stops in workflow may be needed to clean off the scope. This may be of particular relevance for traction time–intensive procedures such as labral reconstruction.

Dry arthroscopy and fluid optimization will be inherently more challenging in the setting of increased operative field bleeding, such as that seen with intraoperative hypertension or suboptimal hemostasis.

PL, posterolateral.

Surgical Technique

Patient Positioning and Hip Joint Access

The patient is positioned supine on a hip distraction table with the feet placed in well-padded boots (Fig 1). We prefer the use of a padded perineal post to obtain hip distraction, but post-less distraction can also be used for this technique. The lateral hip is then prepared and draped in standard sterile fashion.

Fig 1.

Patient positioned supine on traction table with padded perineal post and right hip draped.

The anterior superior iliac spine is marked superficially, and a line is drawn distally to the lateral border of the patella to mark the medial aspect of our working safe zone to prevent iatrogenic neurovascular injury. The anterior, superior, and posterior borders of the greater trochanter are marked (Fig 2). Under fluoroscopic guidance, the anterolateral (AL) portal is established approximately 2 cm anterior to the superior aspect of the greater trochanter with the use of a 17-gauge access needle (Portal Entry Kit; Stryker Sports Medicine, Greenwood Village, CO), and an air arthrogram is performed. Once needle placement and trajectory are satisfactory, the needle is removed from the cannula and a nitinol guidewire is placed into the hip joint. A TransPort Hip Access System cannula (Stryker Sports Medicine) is inserted over the nitinol wire to safely gain access to the hip. The 70° arthroscope is then inserted, and the midanterior portal (MAP) is created under direct visualization. A second TransPort Hip Access cannula is introduced into the MAP, and an interportal capsulotomy is created with a Samurai Blade (Stryker Sports Medicine), being sure to leave a cuff of medial capsule for both retraction and repair. All the aforementioned procedures can be performed in the absence of irrigation fluid.

Fig 2.

Right hip prepared and draped for hip arthroscopic procedure. The anterior, superior, and posterior borders of the greater trochanter (caret) are outlined. The midanterior portal (MAP), anterolateral portal (AL), and distal anterolateral portal (DALA) are the main working portals. The posterolateral portal (PL) is typically an accessory portal, but with this technique, it is used for suction with limited use of irrigation fluid. The asterisk indicates the anterior superior iliac spine.

Labrum Exposure

Once the capsulotomy is complete, the capsulolabral junction is dissected with the use of both an arthroscopic shaver and a radiofrequency ablation device (Fig 3). Irrigation fluid use is required for this portion of the case for the instruments to work appropriately. Several techniques can be used to limit irrigation fluid use during this portion of the case, including permissive hypotensive anesthesia (systolic pressures in the 90s [in millimeters of mercury], as medically appropriate), decreased arthroscopic pump pressure (visualization possible at 15-30 mm Hg), epinephrine mixed in saline solution bags, and use of multi-case pump tubing systems (ReDuce Pump Tubing; Arthrex, Naples, FL). Once the capsulolabral dissection is complete, traction sutures can be placed in the proximal capsular leaflet using No. 1 Vicryl suture (Ethicon, Somerville, NJ) loaded into a suture-passing instrument (Slingshot; Stryker Sports Medicine). This suture-passing instrument is placed through the MAP to pass a traction suture in a simple fashion and out the MAP to be tensioned against the skin at the portal site with a clamp. This can be repeated for a total of 2 to 3 times from medial to lateral as needed, placing the lateral-most suspension suture through the AL portal. Once this step is complete, the acetabular rim should be well exposed. Depending on the pathology present, the surgeon can proceed with pincer or subspine decompression as well as acetabular rim preparation for labral repair.

Fig 3.

Arthroscopic images of right hip. An arthroscopic shaver (A) and radiofrequency ablation device (B) are used to dissect the capsule (carets) from the labrum (asterisks). These arthroscopic instruments are placed in the midanterior portal. The camera is in the anterolateral portal.

Posterolateral Portal Placement for Labral Repair

Once the acetabular rim exposure and decompression are complete, the irrigation fluid system can be turned off to conserve fluid. A posterolateral portal is established with the use of a 17-gauge access needle (Portal Entry Kit) under direct visualization with the arthroscope in the AL portal (Fig 4). Once the needle has entered the intra-articular space, it is attached to a suction adapter (Suction Swab Adapter; Arthrex) and irrigation fluid is drained. To prevent collapse of the joint space with suction, a spigot on the arthroscopic cannula is opened to allow for a low, steady-state flow of air through the joint.

Fig 4.

(A) Arthroscopic image of posterolateral portal access with 17-gauge needle to be used for suction during labral repair portion of case in right hip. The camera is in the anterolateral portal. Labrum marked with asterisk. (B) External view of portal placement and instrument utilization in right hip. The suction device is in the posterolateral portal, and the camera is in the anterolateral portal.

Labral Repair Without Irrigation Fluid Use

The labrum can now be repaired in a standard fashion with our dry arthroscopy technique. Labral repair can be performed with both knotless and hand-tied anchors, as well as with an inside-out (inverting) or outside-in technique. For far lateral labral repair, fluoroscopy can be used to assist in anchor placement to ensure that anchor placement remains extra-articular (Fig 5). This technique can also be performed in the revision setting for revision labral repair or reconstruction once adequate exposure has been obtained. Once the labral repair is complete (Fig 6), the 17-gauge suction needle is removed from the posterolateral portal and traction can be taken off the operative extremity and the hip can be reduced to assess the ability of the repaired labrum to maintain a suction seal.

Fig 5.

Intraoperative fluoroscopic image of right hip arthroscopy. The camera is in the anterolateral portal, and the drill guide is in the distal anterolateral accessory portal. For far lateral labral repair (10- to 11-o’clock position), drilling is performed without the use of irrigation fluid.

Fig 6.

Arthroscopic image of repaired labrum (asterisk) in right hip without irrigation fluid use with 4-anchor repair. The camera is in the anterolateral portal.

Peripheral Compartment Work

With the hip reduced and the labral repair complete, the surgeon can begin distal exposure and perform peripheral compartment work as needed. For this portion of the case, use of irrigation fluid will be required for appropriate use of the arthroscopic instruments (e.g., arthroscopic burr). Again, the previously described techniques regarding conservation of irrigation fluid use can be applied to optimize fluid usage. Once peripheral compartment work is complete, the traction sutures can be removed, and the hip capsule is closed with a suture-passing instrument (Slingshot) and tied with an arthroscopic knot-tying technique.

Discussion

Hip arthroscopy for the treatment of a variety of intra- and extra-articular pathologies has been increasing over the years.1, 2, 3, 4 In the setting of the current irrigation fluid shortage, surgeons are pressed to develop techniques to continue to provide patients with appropriate treatment options. Unfortunately, this is not the first time we have experienced a fluid shortage in the past decade.⁸ It is prudent that we innovate and adapt our current techniques so that we can continue to care for our patients not only in the current fluid shortage setting but also in the future, should another similar event occur, while also optimizing intraoperative resource utilization and decreasing unnecessary medical waste generation.

Labral repair with limited irrigation fluid is possible for primary labral repair, revision labral repair, and labral reconstruction. There are notable advantages and disadvantages to using this technique, as well as risks and limitations (Table 2). This technique can be applied in a variety of settings including all-suture and hard-body anchors, inside-out and outside-in anchor placement, and knotless or hand-tied sutures. The versatility of this technique allows the surgeon to apply his or her preferred labral repair approach while optimizing irrigation fluid use. In addition to limiting fluid use during the labral repair, we have found supplementary techniques during other portions of the procedure, which include mixing of epinephrine into the irrigation fluid, decreased pump pressure (visualization possible at 15-30 mm Hg), permissible hypotensive anesthesia (systolic pressure in the 90s [in millimeters of mercury], as medically appropriate), and consideration of the use of multi-case pump tubing systems.

Table 2.

Advantages and Disadvantages Including Risks and Limitations of Arthroscopic Labral Repair With Limited Irrigation Fluid

Advantages

Optimization and conservation of irrigation fluid in times of limited resources

Decreased perioperative waste generation (i.e., saline solution bags)

Disadvantages, risks, and limitations

Potentially technically challenging, particularly in setting of suboptimal hemostasis

Aspects of hip arthroscopy will innately require irrigation, such as radiofrequency ablator and efficient shaver use

Disclosures

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: A.J.K. reports board membership with American Journal of Sports Medicine, International Cartilage Repair Society, and Springer; reports a consulting or advisory relationship with Arthrex; and owns equity or stocks in Arthrex. M.H. reports a consulting or advisory relationship with DJO Surgical, Moximed, and Vericel; receives funding grants from Elsevier; and reports board membership with Journal of Cartilage and Joint Preservation. All other authors (J.G.I., A.L.T., B.C.C.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Supplementary Data

Video 1

Technique for arthroscopic labral repair with limited irrigation fluid use. On external images of portal placement, the asterisk indicates the anterior superior iliac spine, and the caret indicates the greater trochanter. Right hip is shown, with visualization from the anterolateral portal.