A Method for Capsular Management and Avoidance of Iatrogenic Instability: Minimally Invasive Capsulotomy in Hip Arthroscopy

Most surgeons create a T-shaped or interportal capsulotomy to ensure good visibility when performing hip arthroscopy. This entails transecting the iliofemoral ligament, which may or may not be repaired at the end of the procedure. Cases of iatrogenic hip instability and pain after hip arthroscopy suggest that the iliofemoral ligament plays a crucial role in the stability of the hip joint, and thus preservation should be a goal in hip arthroscopy. We describe a minimally invasive iliofemoral ligament–sparing capsulotomy, guided by the reflected head of the rectus tendon, that can be easily repaired after arthroscopic rim trimming, labral refixation, and offset correction

Femoral Derotation Osteotomy Technique for Excessive Femoral Anteversion

Excessive femoral anteversion may lead to increasing stress placed on the anterior acetabulum and soft tissues, which can predispose to intra-articular hip pathology. By addressing the excessive femoral anteversion in combination with intra-articular hip pathology, the results will be durable over time. This technique details how to perform a femoral derotation osteotomy for excessive femoral anteversion after addressing intra-articular pathology with hip arthroscopy in one surgical intervention. This allows the surgeon to address both the underlying pathoanatomy and the resultant intra-articular sequelae

Imaging of Abductor Tears: Stepwise Technique for Accurate Diagnosis

This article presents the authors' technique for evaluation of possible abductor tears with magnetic resonance imaging (MRI). By using T2 fat-saturated coronal and axial slices of the hip and T1 coronal images of the pelvis, the authors show how to visualize all tears of the abductor tendons and signs of chronic abductor deficiency. After diagnosis has been made, signs that may help the surgeon determine if open or arthroscopic surgery would be best used are reviewed. Finally, the author reviews indications for a gluteus medius repair with concomitant gluteus maximus reconstruction

Endoscopic Transtendinous Repair for Partial-Thickness Proximal Hamstring Tendon Tears

Partial tears of the proximal hamstring tendon can successfully be managed with tendon repair in cases of failed conservative management. As in partial-thickness gluteus medius repair, a transtendinous technique can be used to repair partial-thickness undersurface tears of the hamstring origin. This report details an endoscopic transtendinous approach for the treatment of partial-thickness hamstring tendon tears

The Modified Resisted Internal Rotation Test for Detection of Gluteal Tendon Tears

Greater trochanteric pain syndrome (GTPS) has received increasing attention in recent years. Most patients with GTPS present with trochanteric bursitis and respond to nonoperative treatment. However, a subset of patients may have persistent lateral hip pain or recalcitrant GTPS resulting from an undiagnosed gluteal tendon tear. Recalcitrant GTPS may be a debilitating condition in this patient subset. There is a need for an accurate and evidence-based physical examination maneuver to aid in earlier diagnosis of gluteal tendon tears and timely intervention in these patients. Most studies evaluating gluteal tendinopathy fail to assess surgical indications and instead focus on identifying trochanteric bursitis, which may or may not require surgical treatment. The modified resisted internal rotation test has been used in our practice to detect gluteus medius tendon tears in the recalcitrant GTPS patient population. Fundamental anatomic, biomechanical, electromyographic, and clinical data have been reviewed to make this an evidence-based clinical test for early detection of this pathology

Endoscopic Repair of Proximal Hamstring Avulsion

Hamstring muscle injuries are common in athletes and mostly consist of sprains at the myotendinous junction, which often respond well to conservative treatment. Proximal hamstring avulsion injuries, though less common, can be severely debilitating. This injury is often seen in water skiers but has been described in many other sports and in middle-aged patients. Complete avulsions in young and active individuals do not respond well to conservative treatment and may require surgical repair. In contrast, many partial tears may be treated nonoperatively. However, when symptoms continue despite a trial of extensive therapy, surgery may be warranted. Traditional surgery for proximal hamstring repair is performed with the patient in the prone position with an incision made longitudinally or along the gluteal fold, followed by identification of the torn tendons and fixation to the ischial tuberosity. We describe a novel surgical technique for endoscopic repair of proximal hamstring avulsion injuries

Arthroscopic Labral Reconstruction of the Hip Using Local Capsular Autograft

Labral reconstruction is becoming an important treatment modality for hips with nonsalvageable labra. Nonsalvageable labra can be present in cases of intrasubstance damage, revision surgery after debridement, labral calcification, and hypoplasia. Previous methods of reconstruction have been performed in an open manner and arthroscopically using ligamentum teres, iliotibial band, and gracilis autograft. We present an alternate method of arthroscopic labral reconstruction using capsular autograft. The technique uses readily available capsular tissue during arthroscopy with no donor-site morbidity. This technique may be valuable in appropriately selected patients with labral deficiency

Technique of Arthroscopically Assisted Transtrochanteric Drilling for Femoral Head Chondral Defects

Microfracture is a marrow-stimulation technique in which damaged cartilage is drilled or punched, perforating the subchondral bone and generating a blood clot within the defect that matures into fibrocartilage. Microfracture for the treatment of small cartilage defects of the hip has shown good results. Arthroscopic procedures are less invasive than open procedures and have a reduced incidence of complications such as infection or avascular necrosis of the femoral head. Furthermore, arthroscopic procedures allow for a shorter recovery time, resulting in not only lower overall treatment costs but also higher patient satisfaction. Medial and parafoveal cartilage defects of the femoral head can be challenging to effectively microfracture using standard arthroscopy portals because of the acute angles required for instrument manipulation. This report describes a technique for microfracturing these challenging areas of the femoral head using a 2.7-mm K-wire and drilling in a transtrochanteric direction using arthroscopic and imaging guidance to target the area of chondral damage

Arthroscopic Capsular Reconstruction of the Hip With Acellular Dermal Extracellular Matrix: Surgical Technique

Atraumatic instability of the hip has become an increasingly studied occurrence in recent years. There are several established surgical techniques that help restore stability of the native hip joint. In some cases, these procedures are not an option. As the phenomenon has become recognized more frequently, a greater number of revision surgeries are warranted in patients with ligamentous laxity. A durable solution for irreparable microinstability needs to be formulated to address this vulnerable patient demographic. We describe the surgical technique for capsular reconstruction with acellular dermal extracellular matrix

Forget the Greater Trochanter! Hip Joint Access With the 12 O’clock Portal in Hip Arthroscopy

Most surgeons rely on the greater trochanter as the reference point to establish the anterolateral portal. Nevertheless, we believe that the anterosuperior iliac spine is a more reliable landmark. Unlike the greater trochanter, it is unaffected by leg rotation and is more easily identified by palpation. Abiding by the central tenet of medicine to “do no harm,” the technique described herein presents in detail the concept of the 12 o’clock portal placement, a hip joint access method based on identifying specific anatomic points under fluoroscopy and by palpation. To accomplish this goal, this Technical Note presents a step-by-step approach, including tips and pearls for patient positioning and fluoroscopic guidance. We believe this method ensures a reproducible and safe way to start hip arthroscopy in the supine position