Arthroscopic Treatment of Pigmented Villonodular Synovitis of the Hip Using Puncture Capsulotomy
Key findings
- Arthroscopic treatment of pigmented villonodular synovitis in the hip joint is technically challenging because of the difficulty in obtaining exposure for a complete synovectomy
- A novel arthroscopic technique developed at Massachusetts General Hospital makes use of puncture capsulotomy, which obviates the need for capsular repair and preserves the iliofemoral ligament
- Surgical pearls include maintaining irrigation at a constant temperature using a high outflow rate, ablating the blood supply to any lesion that has an obvious stalk and refraining from using a shaver
In initial studies, arthroscopic treatment of pigmented villonodular synovitis (PVNS) in the hip joint has had positive results. However, the procedures described to date require invasive capsulotomy.
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Scott D. Martin, MD, director of the Joint Preservation Service within the Department of Orthopaedics Sports Medicine Center at Massachusetts General Hospital, has developed a technique that allows for excision of PVNS during hip arthroscopy using only puncture capsulotomy. He and Ali Parsa, MD, surgery fellow, of the same department, describe the novel procedure in Arthroscopy Techniques.
Puncture Capsulotomy
At each of several portals (specified below), the surgeon uses an obturator to create a puncture in the hip joint capsule. A flexible radiofrequency device is inserted through the puncture, and the surgeon intermittently ablates the interior surface of the capsule, in a limited fashion, to create a circular entrance.
Visualization
Full visualization throughout the central and peripheral compartments, including the gutters, is critical in order to achieve meticulous surgical excision and ablation of all the PVNS and surrounding synovium. Therefore, the following accessory portals are established as needed:
- Anterolateral and proximal anterolateral portals are used to enter the peripheral compartment. The proximal anterolateral portal, established 3 cm proximal to the anterolateral portal, is also helpful for visualizing the lateral synovial fold and gutter
- A distal anterolateral portal, established 4 cm distal and 1 cm anterior to the anterolateral portal, is particularly helpful for inspection of the medial synovial fold and gutter, where lesions are often found
- Anterior, mid-anterior and Dienst portals are particularly helpful for accessing lesions in the anterosuperior capsular recess extending out laterally. The Dienst portal is placed one-third of the distance between the anterior superior iliac spine and the anterolateral portal
- A posterolateral portal is used to access lesions in the acetabular notch and pulvinar
The recommended order of inspection is:
- Medial synovial fold and gutter
- Capsular reflections off the femoral neck and acetabulum
- Lateral synovial fold and gutter
Excision and Synovectomy
Any lesions encountered must be completely excised and ablated while carefully maintaining hemostasis. First, a radiofrequency ablator is used to simultaneously cut and ablate the base of the tumor, and it is retrieved in toto using a tissue grasper. Afterward, a radiofrequency ablator and flexible ultrasonic chisel are used for ablation synovectomy of the tumor bed.
After the removal of the arthroscope and other instruments, the portals are closed using 3-0 nylon sutures.
Surgical Pearls
The authors make the following recommendations:
- Irrigation must be kept at a constant temperature using a brisk outflow rate. If the lavage temperature is allowed to rise it can cause chondral injury, and temperatures above 50 °C can cause chondrolysis
- If a nodular lesion is identified that has an obvious stalk, it is critical to ablate the blood supply to that lesion and the surrounding synovium. Bleeding could limit the arthroscopic view; worse, if the blood supply is not ablated there is an increased risk of tumor recurrence
- A shaver must not be used, as it can disseminate tumor cells
Advantages and Disadvantages
Dr. Martin and Dr. Parsa acknowledge that even puncture capsulotomy is a difficult technique, but it has numerous benefits:
- Highest preservation of capsular anatomy and biomechanics
- No need for capsular repair (except portal entrances); accordingly, no risk of overtensioning the capsular repair or loose capsular repair
- Minimal exposure of extra-articular structures to the hip joint environment
- No confounding of postoperative symptoms with recurring hip pain due to PVNS regrowth because concomitant intra-articular pathology is addressed
- Lower traction time because less operative time is spent on capsulotomy and capsular repair
- Faster postoperative recovery
More complete details of the technique are available in the article and an accompanying video.
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