Tips & Techniques

A Simple Way to Improve Visualization and Increase Working Space in Arthroscopy: The Pull-String Technique

Chul-Hyun Cho, MD, PhD; Young-Kuk Lee, MD; Sung-Won Sohn, MD; Ki-Cheor Bae, MD; Kyung-Jae Lee, MD

  • Orthopedics
  • January 2011 - Volume 34 · Issue 1: 22-25
  • DOI: 10.3928/01477447-20101123-14
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A new pull-string technique uses polydioxanone to improve visualization and maintain adequate working space in arthroscopic procedures.
>Cover illustration © Jennifer E. Fairman
Cover illustration © Jennifer E. Fairman

Arthroscopic procedures play an increasingly important role in the diagnosis and treatment of joint problems. Good visualization and sufficient working space are critical for successful surgeries, including anatomic reconstruction. However, most surgeons have experienced poor visualization and insufficient working space during arthroscopic procedures. Repeated obstruction of the visual field prolongs procedure duration, increases fluid extravasation, and increases the difficulty of the procedure. To deal with this problem, we describe a pull-string technique using polydioxanone to improve visualization and maintain adequate working space in arthroscopic procedures.

Materials and Methods

The pull-string technique can be used in any arthroscopic procedure, such as shoulder, knee, elbow, wrist, or ankle surgery, to improve visualization and create sufficient working space. This article describes our technique in the context of arthroscopic rotator cuff repair using the double-row suture-bridge technique.

Of 143 patients undergoing arthroscopic rotator cuff repair from 2007 to 2008, 15 patients who experienced difficulty during arthroscopic procedures because of poor visualization and insufficient working space were operated on with the use of this technique. Mean patient age was 54.5 years (range, 37-72 years). Average follow-up was 16 months (range, 12-23 months). There were 8 medium-sized, 5 small-sized, and 2 partial-thickness rotator cuff tears. All patients were evaluated using the American Shoulder Elbow Surgeons scoring system.1

Surgical Technique

With the patient in the lateral decubitus position and having received general anesthesia, a standard arthroscopic glenohumeral examination is performed through the posterior and anterior portals to evaluate lesions of the shoulder joint. The arthroscope is then placed in the subacromial space through the posterior portal and a bursectomy is performed using an arthroscopic shaver to improve visualization.

The size of the torn tendon is evaluated and arthroscopic acromioplasty is performed through the lateral portal. A posterolateral portal is created as a viewing portal for rotator cuff repair. If repeated obstruction of the visual field is met by soft tissue swelling during arthroscopic repair, this technique is usually used to create good visualization and sufficient working space.

Although the location of the 18-gauge spinal needle for passing of the polydioxanone is determined by the location of the rotator cuff tear and the area of exposure required for lateral-row reattachment, we generally set the needle 4 to 5 cm below the anterolateral corner of the acromion (Figure 1).

Figure 1A: An 18-gauge spinal needle for passing the polydioxanone Figure 1B: An 18-gauge spinal needle for passing the polydioxanone
Figure 1: An 18-gauge spinal needle for passing the polydioxanone is generally set 4 to 5 cm below the anterolateral corner of the acromion. External (A) and arthroscopic (B) views.

Through the spinal needle, number 1 polydioxanone is passed to the subacromial space and pulled out through the lateral portal using an arthroscopic grasper (Figure 2). The cannula is then removed from the lateral portal to place the polydioxanone on the outside of the cannula. The cannula is reinserted after fixing the polydioxanone with hemostat forceps.

Figure 2A: A No. 1 polydioxanone is passed to the subacromial space Figure 2B: Arthroscopic grasper
Figure 2: Through the spinal needle, a No. 1 polydioxanone is passed to the subacromial space and pulled out through the lateral portal using an arthroscopic grasper. External (A) and arthroscopic (B) views.

The rotator cuff footprint of greater tuberosity is prepared after trimming the margins of the torn rotator cuff with an arthroscopic shaver. A 5.0-mm suture anchor is inserted in the articular cartilage margin of the humeral head and 2 to 4 medial knots are made depending on the size of the rotator cuff. The knots of the medial row are simulated to plan the appropriate lateral attachment. At this point, the hemostat holding the polydioxanone is pulled, which creates good visualization and enough working space through lateral traction of the deltoid muscle, allowing more room for the lateral reattachment anchor to enter the lateral distal portion of the greater tuberosity (Figure 3). Once good visualization has been secured, lateral reattachment screws are fixed at that exact point and the complete double-row suture-bridge (Figure 4).

Figure 3A: External view Figure 3B: Arthroscopic view
Figure 3C: Pretensioning diagram Figure 3D: Posttensioning diagram
Figure 3: After the polydioxanone is placed on the outside of the lateral portal cannula, pulling the hemostat holding the polydioxanone creates good visualization and enough working space through lateral traction of the deltoid muscle. External (A) and arthroscopic (B) views. Pretensioning (C) and posttensioning (D) diagrams.

Figure 4A: Pretensioning view at the posterolateral portal Figure 4B: Posttensioning view at the posterolateral view
Figure 4C: View at the lateral portal Figure 4: After obtaining good visualization and sufficient working space, the lateral reattachment screws are fixed at that exact point and the double-row suture-bridge technique is completed. Pretensioning view at the posterolateral portal (A). Posttensioning view at the posterolateral view (B). View at the lateral portal (C).

Results

The average American Shoulder Elbow Surgeons score improved from 42.9 preoperatively to 90.8 postoperatively. Overall outcome using this system (excellent, 90-100; good, 80-89; fair, 70-79; poor, <70) revealed 10 excellent (67%) and 5 good (33%). All patients had satisfactory results after rotator cuff repair using our technique. Also no intraoperative and postoperative complications existed.

Discussion

With the development of new arthroscopic instruments and techniques, arthroscopic surgery produces better outcomes than open surgery. In arthroscopy, good visualization and sufficient working space are fundamental to success. Some techniques, such as obtaining correct patient positioning with traction devices, application of an infusion pumping system, hypotensive anesthesia, use of an electrocautery device, and interchangeable plastic cannula system, increase the likelihood of surgical success.2-4

Despite these techniques, most surgeons have at some time experienced difficulty during arthroscopic procedures because of poor visualization and insufficient working space. Repeated obstruction of the visual field prolongs procedure duration, increases fluid extravasation, and increasingly complicates the procedure. Sometimes it is even necessary to convert an arthroscopic procedure to an open one. Surgeons without much experience in arthroscopic surgery may be especially likely to face prolonged procedures because of intensive or combined pathologies and because performing arthroscopy in too narrow a space does not allow accurate assessment.

The pull-string technique uses polydioxanone and an 18-gauge spinal needle to create good visualization and sufficient working space. It is simple and may be applied in any desired anatomic location any time to enlarge the working space to ensure good visualization.

Our technique is most helpful in the lateral reattachment of the greater tuberosity in rotator cuff repair using the double-row suture-bridge technique.5,6 It can be used in arthroscopic knee surgery also. When ligamentum mucosum disturb visualization during an arthroscopic procedure such as anterior cruciate ligament reconstruction, our technique not only improves visualization but also preserves ligamentum mucosum (Figure 5). It also works well in anterior capsular release in elbow stiffness due to osteoarthritis. If the polydioxanone is pulled anteriorly through the medial portal and the lateral portal, the additional space created leads to a safer, more exact anterior capsular release. We have also found that our pull-string technique works well during removal of osteophytes from the olecranon fossa, a procedure in which it is easy to obstruct visualization and end up working in a narrow space with synovial swelling. In addition, we have begun using the technique in triangular fibrocartilage complex repair of the wrist and anterior impingement of the ankle.

Figure 5A: Ligamentum mucosum disturb visualization Figure 5B: Posttensioning view at the lateral portal
Figure 5C: External view Figure 5: Ligamentum mucosum disturb visualization during arthroscopic anterior cruciate ligament reconstruction. pre-tensioning view at the lateral portal (A). Good visualization is obtained by pull-string technique. Posttensioning view at the lateral portal (B). External view (C).

Conclusion

The pull-string technique improves visualization and provides sufficient working space in an area that is difficult to access. It is a simple, inexpensive, and effective technique that allows exacting procedures and reduces procedure duration.

References

  1. Richards RR, An KN, Bigliani LU, et al. A standardized method for the assessment of shoulder function. J Shoulder Elbow Surg. 1994; 3(6):347-352
  2. Yip DK, Wong JK. A simple device in shoulder arthroscopy: the suture assistant. Arthroscopy. 2005; 21(9):1151.
  3. Aydin AT, Ozcanli H, Soyuncu Y, Dabak TK. A new noninvasive controlled intra-articular ankle distraction technique on a cadaver model. Arthroscopy. 2006; 22(8):905.
  4. Selby RM, O’Brien SJ, Kelly AM, Drakos M. The joint jack: report of a new technique essential for elbow arthroscopy. Arthroscopy. 2002; 18(4):440-445.
  5. Kim KC, Rhee KJ, Shin HD, Kim YM. Arthroscopic fixation for displaced greater tuberosity fracture using the suture-bridge technique. Arthroscopy. 2008; 24(1):120.
  6. Park MC, Elattrache NS, Ahmad CS, Tibone JE. “Transosseous-equivalent” rotator cuff repair technique. Arthroscopy. 2006; 22(12):1360.e1-5.

Authors

Drs Cho, Sohn, Bae, and Lee (Kyung-Jae) are from the Department of Orthopedic Surgery, Dongsan Medical Center, School of Medicine, Keimyung University, and Dr Lee (Young-Kuk) is from the Department of Orthopedic Surgery, Beauty Korea Hospital, Daegu, Korea.

Drs Cho, Lee (Young-Kuk), Sohn, Bae, and Lee (Kyung-Jae) have no relevant financial relationships to disclose.

Correspondence should be addressed to: Chul-Hyun Cho, MD, PhD, 194 Dongsan-Dong, Joong-Gu, Daegu, Korea, 700-712 (oscho5362@dsmc.or.kr).

doi: 10.3928/01477447-20101123-14

doi: 10.3928/01477447-20101123-14

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