Loose bodies are common findings in hip arthroscopy. Loose body removal can be challenging because of the inner position of the acetabulum in which the loose bodies tend to accumulate. Moreover, the standard removal procedure of a considerable number of loose bodies may need a long time under limb traction, thereby increasing the risk of complications.
This article describes a new easy method for intra-articular loose body removal. A flexible endotracheal catheter, connected with suction system, is inserted via the anterior or midanterior portal. The catheter can easily be directed toward the inner parts of the joint in proximity of loose bodies. The suction system allows the loose body to be captured in contact with the tip of the catheter, which is then retrieved carrying the loose body outside the cannula.
We performed this technique on 4 consecutive patients with synovial chondromatosis. Patients were evaluated preoperatively and 1 month postoperatively by completing self-administered questionnaires. The technique effectiveness was evaluated in terms of overall surgery time, traction time, radiographic appearance of loose bodies left in situ, and postoperative complications. Mean overall surgery time and central time was 175 and 78 minutes, respectively. All patients showed improvement in the operated hip. All radiographs showed hip joint space free of osteochondral loose bodies. No patients reported paraesthesia, nerve palsy, or other postoperative complications.This technique allows for retrieval of a greater amount of loose bodies in a short time, reducing the possibility of undesirable complications.
The number of hip arthroscopy indications is currently increasing, as well as the complexity of the hip arthroscopy cases currently treated. A large spectrum of procedures, such as chondroplasty, microfractures, acetabular rimming, and labral sutures, are routinely performed by hip arthroscopists.
Loose bodies are common findings in hip arthroscopy.1 Loose body removal is generally described as one of the initial steps of the learning curve. Hip arthroscopy can be challenging because of the position in which the loose bodies tend to accumulate. However, the presence of a considerable number of loose bodies that characterize certain conditions, such as synovial chondromatosis, can discourage the surgeon from completing the procedure in a standard fashion using a grasper because of the length of time needed under limb traction.
This article describes a new method called suction and removal, which are the fundamental steps of this procedure. This is an improvement to daily practice for hip arthroscopists both in terms of surgical time saved and in performing a wide removal of remote or numerous intra-articular loose bodies.
Materials and Methods
This new surgical technique was performed in 4 consecutive patients (3 women and 1 man) from October 2009 to February 2010. The indications for surgery in all cases were disabling pain and a diagnosis of synovial chondromatosis. Mean body mass index was 28.8 and mean age was 54 years. The male patient had previously undergone an arthroscopic treatment at the ipsilateral hip suffering from the same relapsing disease 18 months ago. Patients were evaluated preoperatively and 1 month postoperatively by completing self-administered questionnaires. Data collected included the modified Harris Hip Score,2 the hip outcome score,3 and the non-arthritic hip score.4
At 1 month postoperatively, anteroposterior and cross-table lateral radiographs of the pelvis were taken. The efficacy of the suction and removal technique was evaluated in terms of overall surgery time and central time (traction time), radiographic appearance of possible loose bodies left in situ, and postoperative complication occurrence at 1-month follow-up. Statistical analysis was not performed because of the low number of patients involved.
The basic setup for hip arthroscopy places the patient in the supine position on a fluoroscopic traction table. The arthroscopic and fluoroscopic towers are placed on the opposite side of the surgical extremity, with the C-arm image intensifier centered over the hip to be operated on. A well-padded perineal post is attached to the operating table to provide countertraction resistance.
General anesthesia is preferred to control muscle relaxation. Before starting, the hip is checked for flexion, abduction, adduction, and rotation. Then the extremity is placed in slight abduction and internal rotation. Traction is applied. A C-arm image confirms safe distraction of the joint. Once enough traction is obtained, principal landmarks, including the greater trochanter, anterior superior iliac spine, and neurovascular bundle are identified and marked. Then traction is released until the hip is draped.
Two portals are routinely established: the anterolateral and the midanterior. The anterolateral portal is established first under the aid of the C-arm at the superior margin of the greater trochanter in line with its anterior border. The midanterior portal is performed in an out-in fashion under direct visualization. We generally use standard 70° and 30° arthroscopes. The central compartment is always explored first. A posterolateral portal during loose body removal is sometimes established.
A complete evaluation of the joint is performed. The labrum is visualized and probed, and the femoral head and acetabulum are systematically visualized. Acetabular chondral injuries may be addressed by chondroplasty, drilling, or microfractures of the affected areas to stimulate a fibrocartilaginous response, similar to the techniques used in the knee. These lesions are not uncommon and tend to extend in correspondence of the impingement area.
Loose bodies in degenerative hips of patients with chondromatosis are common. A classical accumulation site is the acetabular fossa. This area is difficult to reach. The suction and removal method to retrieve the loose bodies finds its best indication in these situations.
Holding the 70° arthroscope from anterolateral or midanterior portal, the quantity and the position of the loose bodies are evaluated. If the complexity to perform a direct removal from the standard accesses is confirmed, then a sterile suction endotracheal catheter is inserted via the anterior or midanterior portal (Figure 1). The catheter is connected with the suction system. The catheter is flexible and can easily be directed toward the inner parts of the joint. The suction is then switched, on allowing the loose bodies to be captured in contact with the tip of the catheter (Figure 1). At this point the catheter is retrieved carrying the loose bodies outside the cannula (smaller bodies) in a fishing technique fashion (Figure 2). If the loose body is bigger, it can be retrieved in a region of the joint with an easier access. In this case, a third portal can be useful to introduce a standard suture grasper to retrieve the loose bodies out of the joint after the suction is switched off and the body released from the endotracheal catheter. Figure 3 shows the procedure from outside.
Figure 1: Image of a loose body captured in contact with the tip of the catheter.
Figure 2: Sequence of direct loose body removal with the catheter (smaller loose bodies).
At arthroscopy, capsulectomy and synovialectomy were performed in all cases. Three patients reported acetabular chondral lesions, but they were not treated with microfracture. Rim trimming for pincer femoroacetabular impingement was not performed in any case. Femoral headneck junction osteoplasty was performed in 3 patients. Three patients underwent labral debridement because of a degenerative nonsuturable labral lesion. All patients underwent intra-articular loose body removal using a flexible suction endotracheal catheter. Mean overall surgery time was 175 minutes and mean central time was 78 minutes.
At 1-month follow-up, all patients showed improvements in the operated hip. The mean modified Harris Hip Score improved from 54.45 to 64.63. The mean hip outcome score, calculated only for activities of daily living, improved from 52.83 to 62.91. The mean nonarthritic hip score improved from 52.50 to 60.63. At the control, radiographs of all patients showed hip joint space completely free of intra-articular osteochondral loose bodies. No patients reported paraesthesia, nerve palsy, or other postoperative complications.
The presence of loose bodies within the joints was first recognized at the beginning of the 20th century. A classification based on the origin is usually adopted comprehending osteoarthritis, posttraumatic, or produced by the synovium.5-7 This last condition, also known as synovial chondromatosis, is a disorder of joints, bursae, and tendon sheaths in which chondroid bodies are produced by the synovial membrane. Depending on the pattern of growth, the cartilage bodies can remain in the synovium, become loose bodies in the joint, or be located within the synovial tissue.8,9
Over time, loose bodies grow, and the gross appearance is due to the repetitive deposition of layers of fibrous and cartilaginous tissue. All mature or older loose bodies exhibit multiple layers of fibrous, cartilaginous, and even bony tissue, with deep layers being necrotic and the most superficial layers demonstrating living cells without a vascular supply.5-7
Despite the knowledge of loose bodies, more has been historically investigated about the knee, including the formation, revascularization, and ultimate partial resorption of multiple loose bodies in a hip joint having been previously described.10 Most authors recommend surgical removal of the loose bodies.11,12 Depending on the size of the chondral loose bodies, removal can be performed via an arthrotomy, arthroscopy with mini-open arthrotomy, or arthroscopy. The advantage for the patient undergoing an arthroscopic removal is the minor pain and discomfort during the first postoperative course and the reduced invasiveness of the procedure. Hip arthroscopy is one of the most important surgical advancements of the past decade in orthopedic surgery. One of the first indications that have been described specifically is the removal of loose bodies.13,14
Arthroscopic loose body removal can be a challenging, lengthy procedure, increasing the risk of traction injuries that can be of distraction type, such as sciatic, femoral, or lateral femoral cutaneous nerve neuropraxias or avascular femoral head necrosis, and of compression type against the perineal post, such as pudendal or perineal nerve neuropraxias or scrotal necrosis.15-18 Extraction of loose bodies can also lead to instrument breakage,19 as well as femoral head chondral injury with cartilage scuffing and labral avulsion.15 As short a traction time as possible is mandatory during hip arthroscopy. The technique we describe allows retrieval of greater quantities of loose bodies in a short time, reducing the possibility of undesirable complications. Further studies are necessary to define the impact of this procedure on hip arthroscopy practice.
- McCarthy JC. Hip arthroscopy: Applications and technique. J Am Acad Orthop Surg. 1995; 3(3):115-122.
- Byrd JW, Jones KS. Prospective analysis of hip arthroscopy with 2-year follow-up. Arthroscopy. 2000; 16(6):578-587.
- Martin RL, Philippon MJ. Evidence of validity for the hip outcome score in hip arthroscopy. Arthroscopy. 2007; 23(8):822-826.
- Christensen CP, Althausen PL, Mittleman MA, Lee JA, McCarthy JC. The nonarthritic hip score: reliable and validated. Clin Orthop Relat Res. 2003; (406):75-83.
- Fisher AGT. A study of loose bodies composed of cartilage or of cartilage and bone occurring in joints with special reference to their pathology and etiology. Br J Surg. 1931; 8(32):493-523.
- Phemister DB. The causes of and changes in loose bodies arising from the articular surface of the joint. J Bone Joint Surg. 1924; (6):278-315.
- Freiberg AH, Woolley PG. Osteochondritis dissecans: Concerning its nature and relation to formation of joint mice. J Orthop Surg Am. 1910; (8):477-494.
- Blumlein H, Puls P, Schneider HM, Wunderlich T. Benign and malignant chondromatosis of the joints (A contribution to the clinical aspects and histology of the disease). Z Orthop Ihre Grenzgeb. 1980; 118(1):8-14.
- McFarland EG, Neira CA. Synovial chondromatosis of the shoulder associated with osteoarthritis: conservative treatment in 2 cases and review of the literature. Am J Orthop. 2000; 29(10):785-787.
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- Coolican MR, Dandy DJ. Arthroscopic management of synovial chondromatosis of the knee. Findings and results in 18 cases. J Bone Joint Surg Br. 1989; 71(3):498-500.
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- Cory JW, Ruch DS. Arthroscopic removal of a .44 caliber bullet from the hip. Arthroscopy. 1998; 14(6):624-626.
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Drs Randelli (Filippo), Randelli (Pietro), Banci, and Arrigoni are from Policlinico San Donato, San Donato Milanese, Milan, Italy.
Drs Randelli (Filippo), Randelli (Pietro), Banci, and Arrigoni have no relevant financial relationships to disclose.
Correspondence should be addressed to: Lorenzo Banci, MD, Via Negroli 6, 20133 Milan, Italy (firstname.lastname@example.org).