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The Use of a Ureteric Stone Basket for Removing Loose Bodiesat Hip Arthroscopy

Patrick Weinrauch, M.B.B.S., M.Eng., F.R.A.C.S., F.A.Orth.A.,Sharon Kermeci, B.Nur., Grad.Cert.Clin.Sci.(PNSA), and Austin Lang, M.B.B.S.

Abstract: We present the use of a ureteric stone basket for arthroscopic removal of loose bodies from the hip joint. Thetechnique is easy to perform and reduces the time required for loose body retrieval while minimizing the risk of iatrogenicdamage to the cartilage surfaces of the joint.

emoval of symptomatic loose bodies from the hip

Roften provides patients with immediate reductionin mechanical symptoms and potential longer-termbenefits in joint preservation.1-3 Although symptomaticloose body removal may be conducted by open hiparthrotomy, hip arthroscopy techniques and instru-mentation have facilitated relatively simple and mini-mally invasive extraction techniques with decreasedblood loss, reduced risk of neurovascular injury,and faster recovery time.2-4 Arthroscopic removal ofsymptomatic loose bodies from the hip joint is now thestandard of care. Loose bodies are also sometimesidentified as an incidental finding at hip arthroscopy forearly to moderate osteoarthritis. Removing loose bodiesin this situation is also likely to improve patient satis-faction and potentially longer-term clinical outcomes.Most loose bodies within the hip joint in either central

or peripheral compartments are easy to extract byarthroscopic methods. However, there are certain loosebodies that are difficult to remove because of their largesize and hard consistency, making them difficult notonly to grasp but also to extract.5 A number of differentmethods are described for removing loose bodies withinthe hip that generally rely on the use of grasping

From Brisbane Hip Clinic, St. Andrew’s Specialist Centre, St. Andrew’sar Memorial Hospital, Spring Hill, Australia.The authors report that they have no conflicts of interest in the authorship

nd publication of this article.Received January 16, 2013; accepted April 17, 2013.Address correspondence to Patrick Weinrauch, M.B.B.S., M.Eng.,.R.A.C.S., F.A.Orth.A., Brisbane Hip Clinic, St. Andrew’s War Memorialospital, 457 Wickham Terrace, Level 7, Suite 2, Spring Hill, Queensland000, Australia. E-mail: pweinrauch@brisbanehipclinic.com.au� 2013 by the Arthroscopy Association of North America2212-6287/1347/$36.00http://dx.doi.org/10.1016/j.eats.2013.04.007

Arthroscopy Techniques, Vol 2, No 3

forceps, a chondrotome blade, suction-assisted removal,or similar techniques.4,5 There are limitations in thesetechniques, however, including restriction in instru-ment maneuverability because of the deep location ofthe joint and dense surrounding tissues, difficulties ingrasping the loose body because of its hard nature andsize, and the floating nature of loose bodies that canevade grasping by forceps.5,6 We present a simple,reproducible, and safe technique for removing loosebodies during hip arthroscopy using a ureteric stoneretrieval basket.

TechniqueThe techniqueof using aureteric stone basket to extract

loose bodies from the hip joint is independent of thesurgeon’s chosenmethod of performing hip arthroscopywith the patient in either the supine or lateral position.We choose to performhip arthroscopywith thepatient inthe supine position using the camera in the posteriortrochanteric portal with an anterior instrument portal,but the technique would work just as well for surgeonsusing the lateral position with a variety of portal loca-tions.Our technique consists of the patient under generalanesthesia with muscle paralysis placed supine ona standard traction table with a well-padded perinealpost. The operative-side lower limb is placed in slightflexion and abduction and 10� of internal rotation withthe traction vector applied along the femoral neck.Traction is applied until adequate joint distraction forsurgical instrument clearance is confirmed by ultrasoundimaging. Traction is released while surgical draping isconducted and reapplied before development of thecentral compartment portals. A posterior trochantericportal is developed with ultrasound guidance, and directarthroscopic vision is used to develop the anteriorinstrument portal. A standard 70� arthroscope lens is

(August), 2013: pp e311-e313 e311

Fig 1. Introduction and expansion of basket. Fig 3. Capture and firm grasp of loose body.

e312 P. WEINRAUCH ET AL.

used for all procedures, with a 30� arthroscope usedwhen required.On visualization of the loose body, a ureteric stone

retrieval basket (Nitinol Stone Basket model B9002;Applied Medical, Rancho Santa Margarita, CA) isintroduced to the joint through either portal (Video 1).Typically, the anterior working portal can be used toretrieve all central-compartment loose bodies. Accuratepositioning of the flexible stone basket wire can beassisted by placing the instrument through a rigidcannulated device such as a switching stick (Smith &Nephew, Andover, MA) or through a chondrotomesheath (4.5-mm Full-Radius Curved Concave Blade,180 mm long; Smith & Nephew) (Figs 1-4). We finda curved extended-length chondrotome sheath most

Fig 2. Manipulation around loose body.

useful in this regard because rotation of the sheath willassist in delivering the stone basket closer to the loca-tion of the loose body. Given the flexibility of the basketwire, the device can be delivered easily to regionswithin the hip joint that are otherwise difficult to accesswith rigid instruments. Precise approximation of thebasket device to the loose body is not necessary,however, because of the expandable volume of thebasket when opened. Opening of the basket achievesencapsulation of the loose body without risk of damageto the adjacent hyaline chondral surfaces. Retraction ofthe basket delivers and secures the loose body to theend of the cannulated instrument, allowing forextraction. Because the stone basket is quite large whenopened, the technique is particularly useful for loose

Fig 4. Secure, simple extraction of loose body from joint.

LOOSE BODY REMOVAL WITH URETERIC STONE BASKET e313

bodies that are large and have a hard consistency.Extension of capsular and skin incisions may berequired to deliver the loose body out of the joint,particularly if the loose body is very large.

DiscussionWe present a novel technique for removing loose

bodies from the hip joint using arthroscopic methods.We have found this method simple to conduct withreduced operative time and minimal risk of iatrogenichyaline chondral injury. Because the technique avoidsthe necessity to grip the surface of the loose body that isrequired with typical forceps grasping techniques, wehave found it particularly useful for larger sized andhard-consistency loose bodies. Typically, these are themore difficult loose bodies to remove by regularmethods. There is a reduced requirement for instru-ment maneuverability compared with forceps anddecreased technical difficulty to capture the floating andmobile loose body.The described technique is sometimes limited by the

strength of the basket wire when delivering very largeloose bodies from the joint and soft tissues. In these

situations we recommend extending both the capsuleand skin incisions. If the basket wire is stretched duringextraction of such a loose body, the mechanism maynot open or close completely and a second basket maybe required for subsequent loose body removal.

References1. Byrd JW. Hip arthroscopy for posttraumatic loose frag-

ments in the young active adult: three case reports. Clin JSport Med 1996;6:129-133, discussion 133-134.

2. Svoboda SJ, Williams DM, Murphy KP. Hip arthroscopy forosteochondral loose body removal after a posterior hipdislocation. Arthroscopy 2003;19:777-781.

3. Keene GS, Villar RN. Arthroscopic loose body retrievalfollowing traumatic hip dislocation. Injury 1994;25:507-510.

4. Randelli F, Randelli P, Banci L, Arrigoni P. Intra-articularloose body removal during hip arthroscopy. Orthopedics2010;33:476.

5. Kumar VP, Satku K. Arthroscopic retrieval of loose bodies.Arthroscopy 1994;10:696-697.

6. Sampson TG. Complications of hip arthroscopy. Clin SportsMed 2001;20:831-835.