A Modified “Shuttle” Method Technique for Arthroscopic Hip Capsular Reconstruction in Capsular Deficiency

Figures

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  Fig 1. Intraoperative patient positioning. The patient is placed in the supine position. The left operative extremity elevated 20° and internally rotated. A post-less distraction pad is placed under the patient. The white asterisk indicates the caudal positioning of patient. The white arrow indicates the cranial portion of patient positioning.

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  Fig 2. Intraoperative photograph of a left hip in the supine position, demonstrating the 4 portal locations. ALP, anterolateral portal; ASIS, anterior superior iliac spine; DALA, distal anterolateral accessory portal; GT, greater trochanter; HC, hip center; MAP, mid-anterior portal; PMAP, proximal mid-anterior portal. The red laser crosshairs indicate C-arm position on the patient.

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  Fig 3. Intraoperative arthroscope imaging in a left hip of a patient in the supine position. The arthroscope is viewing from the anterolateral portal portal. Anchor placement (1.4-mm NanoTack anchor; Stryker) is done on the prepared supra-acetabular rim using 45° curved Stryker NanoTack guide (Stryker Endoscopy, Kalamazoo, MI) inserted from the MAP portal through a TransPort Cannula (Stryker Endoscopy, Kalamazoo, MI). One end of the suture limbs from each anchor is brought out the proximal mid-anterior portal and distal anterolateral portal portal.

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  Fig 4. Defect measurement using suture anchor limbs, two hemostats, and arthroscopic knot pusher and viewing from the ALP. The knot pusher is placed through the MAP portal to the most medial anchor denoted by a white asterisk. A hemostat is placed outside the hip at the top of the knot pusher ring. Then the knot pusher is advanced to the most lateral anchor indicated by the white arrow. Another hemostat is placed at the top of the knot pusher ring. The distance between the hemostats is measured and used for graft preparation. ALP, anterolateral portal; DALA, distal anterolateral accessory portal; MAP, mid-anterior portal; PMAP, proximal mid-anterior portal.

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  Fig 5. Allograft for capsule reconstruction. Pictured is a left hip cadaveric specimen in the supine position. The sutures are passed with free needle in proximal limb of graft for subsequent shuttling. Sutures are brought out DALA and PMAP for graft passage. Images show correct graft orientation and that sutures are not twisted. The white asterisk indicates the proximal end of graft, and the white arrow denotes distal end of graft. ALP, anterolateral portal; DALA, distal anterolateral accessory portal; MAP, mid-anterior portal; PMAP, proximal mid-anterior portal.

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  Fig 6. Graft passage. Pictured is a left hip cadaveric specimen in the supine position. The dermal allograft is tightly rolled and inserted with the help of an arthroscopic grasper into the DALA portal canula. The shortened suture tails in the PMAP portal are sequentially pulled to shuttle graft to its position on the supracetabular rim. The white asterisk indicates the proximal end of graft, and the white arrow denotes distal end of graft.

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  Fig 7. Final arthroscopic intraoperative photos of the hip capsular reconstruction viewed from the ALP, anterolateral portal. The black asterisk indicates the interarticular sides of the graft, and the black arrow indicates the extraarticular side of the graft.

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  Fig 8. (A) Supine presurgical axial T2 MRI of the left hip, illustrating capsular defect with synovial fluid extravasation into the pericapsular tissues. (B) Supine postsurgical axial T2 MRI of the left hip after capsular reconstruction now showing well delineated capsule without a defect and no synovial fluid extravasation. In A, the white arrow denotes capsular defect with fluid extravasation, and in B, the white arrow denotes allograft portion of capsular reconstruction with intraarticular fluid containment.