Surgical Pearls – Hip Arthroscopy to Address Labral Pathology
Michael Kang, MD, from the Insall Scott Kelly Institute for Orthopaedics and Sports Medicine, shared his tips for managing labral pathology with hip arthroscopy with attendees at the Insall Scott Kelly 13th Annual Sports Medicine and Total Knee & Hip Course, sponsored by the International Congress for Joint Reconstruction.
Highlights of his presentation include the following advice:
Imaging. Magnetic resonance imaging (MRI) has a 90% sensitivity for diagnosing labral pathology. Dr. Kang prefers a 1.5 T MRI, with an isolated hip coil. Many patients who are referred to him have had a pelvic MRI, which he says is inadequate. He also likes to order plain radiographs to detect impingement.
Tractioning. Dr. Kang uses a cushioned post and starts with the hip in neutral abduction with 10 degrees of flexion and 20% of internal rotation. He will adduct the leg until the seal is broken to lateralize the head.
Portal placement. An anterolateral portal is placed first, and then Dr. Kang places a mid-anterior portal.
Exposure. Dr. Kang says the exposure is very important – so important that he will spend about 30 minutes on the exposure. He will then perform an extensive anterior capsulotomy, starting at the mid-anterior portal and then going over to the anterolateral portal. He will then switch portals and complete the capsulotomy from the anterolateral to the mid-anterior portal.
Identify the pathology. A number of chondral injuries can occur with labral pathology, and these must be indentified and treated. Microfracture is appropriate for grade IV chondral lesions, Dr. Kang said, while chondrolplasty, with a shaver or cautery device, can be used to treat grade II or III lesions.
Adddress bony abnormalities, especially in femoroacetabular impingement. Cam and pincer impingement must also be managed. Fluoroscopic guidance allows for better resection of pincer lesions on the acetabulum. Dr. Kang said that in his practice, he will take down the labrum and reattach it if the pincer rim resection is greater than 5 mm. If it is less than 3 mm, he leaves the labrum intact, performs a rim trimming, and proximalizes the labrum. Fluoroscopic guidance can also be used in resection of cam lesions, but there is also the potential to use CT scan for better delineation of where the bump is located. Once the cam resection is done, the hip can be dynamically tested with the hip reduced.
Postoperative course. Following hip arthroscopy for labral pathology, Dr. Kang’s patients are protected from weight-bearing for 2 weeks. They also take a non-steroidal anti-inflammatory drug for those 2 weeks. Excessive external rotation is limited for 2 weeks to protect the anterior capsulotomy and prevent excessive hip instability. Hip flexion is limited to isometric strengthening for 6 weeks.