Remplissage and Labral Reconstruction Technique Correlated With Dynamic Hip Examination Using the Kite Technique for Restoration of the Suction Seal in Revision Hip Arthroscopy

Figures

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  Fig 1. Preoperative imaging of a left hip. Preoperatively obtained (A) lateral hip radiograph, (B) axial computed tomography (CT) slice, and (C) 3-dimensional CT reconstruction image showing over-resection of the anterior femoral head−neck junction in the left hip.

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  Fig 2. Labrum and femoral head−neck junction view of a left-sided hip through the mid-anterior portal. (A) Irreparable degenerative labral tissue and (B) previously over-resected anterior femoral head−neck junction shown with a curved red line.

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  Fig 3. Preparation of the labral graft. (A) Preparation of the graft is accomplished with Krackow stitches in a longitudinal fashion and nonlocked continuous suture. (B) Viewing from the anterolateral portal in a left hip, the length of the defect in the labrum is measured by an arthroscopic measurement guide (SCR Guide; Arthrex, Naples, FL), shown with a red arrow, through modified mid-anterior portal. (C) The graft is marked according to the size of the defect in the labrum and (D) cut with scissors.

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  Fig 4. Placement of anchors to the acetabular rim for future graft fixation in a left-sided hip arthroscopy. While viewing from the modified mid-anterior portal (mMAP), (A) drilling with a curved drill guide through the AL portal is shown with a red arrow for anchor placement at 12 o'clock, (B) allowing anchors to be placed at 11 and 12 o'clock. (C) View after passing one of the anchor threads through the labrum remnant. (D) View of the pre-reconstruction preparation from the anterolateral (AL) portal after anchors are placed at 1 and 2 o'clock through the distal anterolateral accessory portal and 11 and 12 o'clock through the AL portal.

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  Fig 5. Creating the proximal mid-anterior portal (PMAP). In a left-sided hip arthroscopy, (A) while viewing through the modified mid-anterior portal (mMAP), the PMAP is located and created with the help of an 18-gauge spinal needle indicated with a red arrow. (B) Taking the threads of mid-body anchors at 12 and 1 o’clock to the PMAP with the help of a suture retriever indicated with a red arrow. (C) Taking the "post" sutures not passing through the labrum remnant of the anterior and posterior anchors to the PMAP with the help of a suture retriever, and (D) the "non-post" sutures of the most anterior and most posterior anchors passing through the labrum remnant to the mMAP with the help of a suture retriever indicated by a red arrow.

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  Fig 6. Graft insertion and fixation in a left-sided patient. The post sutures previously marked on the proximal mid-anterior portal are pulled in a controlled manner, and the graft is advanced from the modified mid-anterior portal to the acetabular rim with the help of an arthroscopic grasper while viewing through anterolateral portal. (B) The posterior part of the graft is placed first, (C) followed by the anterior part of the graft. (D) After proper placement of the graft is confirmed, movement of the graft is prevented with an arthroscopic grasper while the temporary knot (red arrow) is pulled out of the joint and opened. (E) Anterior fixation of the graft is achieved arthroscopically by untying the temporary knot and tying again.

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  Fig 7. Fixation of the graft to mid-body anchors at 1 and 12 o'clock in a left hip arthroscopy. While viewing from the anterolateral (AL) portal, (A) the thread of the anchor at 1 o'clock that was previously passed through the labrum remnant is passed through the proximal portion of the graft with the help of the suture retriever (red arrow) and (B) grasped from the distal portion of the graft with the help of a suture retriever (red arrow). This anchor thread is then (C) pulled through the modified mid-anterior portal (mMAP). (D) The sutures taken to the mMAP are arthroscopically tied with the help of a knot pusher. After applying the same procedure to the 12 o’clock anchor from the AL portal while viewing through the mMAP, (E) anterior and (F) posterior parts of the labral reconstruction are viewed with a 70° scope from the AL portal.

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  Fig 8. Remplissage procedure in a left-sided hip. (A) The view of the over-resection marked with a red curved line in the anterior femoral head−neck junction through modified mid-anterior portal (mMAP) view. (B) The area where the suction seal disappeared during dynamic hip examination in flexion and internal rotation viewing through the mMAP towards the acetabulum. (C) View after insertion of 2 anchors (1.4 mm NanoTack TT; Stryker, Kalamazoo, MI) from the cannula placed in the distal anterolateral accessory (DALA) portal at the most medial and lateral area where the graft will be placed. (D) View after the graft is passed through the DALA portal and placed in the over-resected area by pulling the "post" sutures in the mMAP according to “kite” technique.

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  Fig 9. Placement of the mid-body anchor in a left-sided patient. (A) The location of the mid-body anchor, which is planned to be placed in line with the convexity of the femoral head and acetabulum, is shown with a red asterisk. (B) The view from modified mid-anterior portal (mMAP) after placing the third anchor, while the thread belonging to the knotless anchor (1.8 mm Knotless Hip FiberTak; Arthrex, Naples, FL) is indicated with a red arrow. (C) View of the femoral graft after the remplissage procedure through mMAP.

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  Fig 10. Testing the suction seal in a left-sided hip. While viewing through the modified mid-anterior portal, the reestablishment of the suction seal in different hip positions is evaluated with a dynamic hip examination. Dynamic hip examination at (A) extension with slight traction, (B) 30° flexion and released traction, and (C) 70° flexion and released traction.