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Transcript
PORTAL PLACEMENT
FOR ENDOSCOPIC
HAMSTRING REPAIR
Filiep Bataillie, MD
Sophie Bataillie, student
Kristoff Corten, PhD
BELGIUM
I have financial relationship with the following company:
Filiep Bataillie is consultant for Arthrex
DEEP GLUTEAL AREA
•
•
Open surgery in the deep
gluteal area is limited by the
retraction of the Gluteus
Maximus, with danger to harm
the Inferior Gluteal nerve, the
Sciatic nerve and the Posterior
Femoral Cutaneous nerve
Endoscopic surgery can give a
better visualization than open
surgery, with an easy access
to the Sciatic nerve and the
proximal part of the hamstrings
Posterior
Femoral
Cutaneous
nerve
Sciatic
nerve
Quadratus
Femoris
Ischial
Tuberosity
PORTAL PLACEMENT
•
There are no data concerning the safety of portal
placement in endoscopic surgery of the deep gluteal
area
•
5 cadaveric specimens were operated endoscopically
in the gluteal area, using three portals
•
The location of each portal with regards to the Sciatic
nerve, Posterior Femoral Cutaneous nerve and Inferior
Gluteal nerve was documented
PORTAL PLACEMENT
•
A preliminary cadaver study with dissections was
conducted to define the most optimal and safe portal
placement
Ischial Tuberosity
Conjoined
Tendon
Semitendinosus
Biceps Femoris
Reflected
Gluteus Max.
Inferior
Gluteal
Nerve
Sciatic Nerve
Semimembranos
us
Posterior view of right specimen
Posterior
Cutaneous
Nerve
THE FOURTH
COMPARTMENT
• Landmarks
• Ischial Tuberosity
• Gluteus Maximus
• Greater Trochanter
• Prone
• Leg free draped and 10° flexion
THE PORTALS
•
Inferior Portal:
•
Line through the
middle of the Ischial
Tuberosity
•
2 cm under the inferior
border of the Ischial
Tuberosity
THE PORTALS
•
Medial Portal:
•
2 cm medial to the line
through the middle of
the Ischial Tuberosity
•
1 cm under the inferior
border of the Ischial
Tuberosity
2 cm
THE PORTALS
•
Lateral Portal:
•
2 cm lateral to the line
through the middle of
that Ischial Tuberosity
•
1 cm under the inferior
border of the Ischial
Tuberosity
2 cm
MATERIAL & METHODS
•
5 cadaveric specimens
•
Prone
•
70° scope
•
Use of RF probe
•
Measurement of distance
to the nerves
•
Open dissection after the
endoscopic intervention
DISTANCES TO THE
NERVES
•
The lateral portal is directly posterior to the Sciatic and
Posterior Femoral Cutaneous nerve. Care must be
taken during the skin incision and the blunt dissection
with the trocar.
•
The lateral and medial portals are safe with a minimum
distance of more than 5 cm to any of the nerves.
DISTANCES TO THE
NERVES
•
Distance of the lateral portal to the nerves is highly
dependent on the operative manouvres. Endoscopic
control is possible and mandatory.
•
The distance of lateral border of the proximal insertion
of the Semimembranosus to the Sciatic nerve is
between 1,5 and 3 cm
•
Sciatic nerve dissection can be safely done to 6 cm
distal from the inferior border of the ischial tuberosity
CONCLUSIONS:
SAFETY OF THE PORTALS
•
The location of the medial and inferior portal is safe, if
directed to the Ischial Tuberosity
•
The inferior scope portal needs to be created first
because it allows for direct visibility of the creation of
the lateral portal, which can be in proximity to the
sciatic and posterior cutaneous nerve
•
The lateral portal is safe if directed towards the Ischial
Tuberosity and under endoscopic control
CONCLUSIONS:
SEQUENCE OF THE PORTALS
•
Start with the inferior portal or the scope portal, directly
touch the Ischial Tuberosity with the obturator and try
to make some space by limited blunt dissection
•
Second portal is the medial portal. After small blunt
dissection, introduce the RF probe and find the Sciatic
nerve and the Posterior Femoral Cutaneous nerve
•
Lateral portal is made under direct endoscopic control
from the inferior portal
CONCLUSIONS:
•
The gluteal area is a safe zone for endoscopic surgery
with a good knowledge of the anatomy of the nerves
•
The sequence of the portals is important, starting
inferior, followed by medial and ending lateral
•
Direction of all instruments has to be to the Ischial
Tuberosity. Under Endoscopic control the direction can
be changed
•
The release of the sciatic nerve can be done through
this approach as well as surgery to the proximal
hamstrings
•
Miller S, Gill J et al. The proximal origin of the hamstrings and surrounding
anatomy encountered during repair: a cadaveric study. JBJS 2007; 89(1):
44-48
•
Guanche CA. Endoscopic Hamstring Repair and Ischial Bursectomy.
Operative Hip Arthroscopy. 2013: 331-338
•
Guanche CA. Hamstring injuries. Hip and pelvis injuries in sports
medicine 2010: 181-191
•
Robertson WJ. The Safe Zone for Hip Arthroscopy: A Cadaveric
Assessment of Central, Peripheral, and Lateral Compartment Portal
Placement. Arthroscopy. 2008:1019-1026