Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.
Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
Arthroscopy. 2019 Apr;35(4):1280-1293.e1. doi: 10.1016/j.arthro.2018.10.118. Epub 2019 Mar 14.
To perform a systematic review that assesses the current literature on suture anchor placement for the purpose of identifying factors that lead to suture anchor perforation and techniques that reduce the likelihood of complications. It was hypothesized that suture anchor placement in hip arthroscopy would generally be safe, with the exception of the complications of articular cartilage violation and psoas tunnel perforation. Perioperative factors, related to patient, surgeon, and technical variables, may influence the safety of suture anchor insertion.
Three databases (PubMed, Ovid MEDLINE, and Embase) were searched, and 2 reviewers independently screened the resulting literature. The inclusion criteria were clinical and biomechanical studies examining the use of suture anchors in hip arthroscopy. The methodologic quality of all included articles was assessed using the Methodological Index for Non-Randomized Studies criteria and the Cochrane risk-of-bias assessment tool. Results are presented according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using descriptive statistics.
We included 14 studies in this review, comprising 4 case series (491 patients; 56.6% female patients; mean age, 33.9 years), 9 controlled cadaveric or laboratory studies (111 cadaveric hips and 12 synthetic acetabular bone blocks; 42.2% female hips; mean age, 60.0 years) with a mean Quality Appraisal for Cadaveric Studies score of 11, and 1 randomized controlled trial (37 hips; 55.6% female hips; mean age, 34.2 years). Anterior cortical perforation into the psoas tunnel by suture anchors led to pain and impingement of pelvic neurovascular structures. The anterior acetabular positions (3- to 4-o'clock position) had the thinnest bone, smallest rim angles, and highest incidence of articular perforation. Drilling angles from 10° to 20° measured off the coronal plane were acceptable. The midanterior and distal anterolateral portals were used successfully, with 1 study reporting difficulty placing anchors at anterior locations through the distal anterolateral portal. One study showed that curved suture anchor drill guides allow for a better trajectory away from the articular cartilage. Small-diameter (≤1.8-mm) all-suture anchors had a lower in vivo incidence of articular perforation with similar stability and pullout strength to other anchor types in biomechanical studies.
Suture anchors at anterior acetabular rim positions (3- to 4-o'clock position) should be inserted with caution. Large-diameter (≥2.3-mm) suture anchors increase the likelihood of articular perforation without increasing labral stability. Inserting small-diameter (≤1.8-mm) all-suture anchors from 10° to 20° drilling angles may increase safe insertion angles from all cutaneous portals. Direct arthroscopic visualization, the use of fluoroscopy, distal-proximal insertion, and the use of nitinol wire can help prevent articular violation.
Level IV, systematic review of Level I to IV studies.
进行系统评价，评估目前关于缝合锚钉放置的文献，以确定导致缝合锚钉穿透的因素和降低并发症发生概率的技术。假设髋关节镜下缝合锚钉放置通常是安全的，但关节软骨损伤和腰大肌隧道穿透的并发症除外。围手术期因素，与患者、外科医生和技术变量有关，可能会影响缝合锚钉插入的安全性。
检索了三个数据库（PubMed、Ovid MEDLINE 和 Embase），并由两名独立的审稿人筛选文献。纳入标准为研究缝合锚钉在髋关节镜下使用的临床和生物力学研究。所有纳入文献的方法学质量均采用非随机研究方法学指数（Methodological Index for Non-Randomized Studies，MINORS）标准和 Cochrane 偏倚风险评估工具进行评估。结果按照 PRISMA（系统评价和荟萃分析的首选报告项目）指南呈现，使用描述性统计。
本综述纳入了 14 项研究，包括 4 项病例系列研究（491 例患者；56.6%为女性患者；平均年龄 33.9 岁）、9 项对照尸体或实验室研究（111 具尸体髋关节和 12 块合成髋臼骨块；42.2%为女性髋关节；平均年龄 60.0 岁），以及 1 项随机对照试验（37 例髋关节；55.6%为女性髋关节；平均年龄 34.2 岁）。缝合锚钉前皮质穿透进入腰大肌隧道会导致骨盆神经血管结构疼痛和撞击。前髋臼位置（3 点至 4 点位置）的骨最薄、边缘角度最小，关节穿透发生率最高。从冠状面测量的 10°至 20°的钻孔角度是可以接受的。中前和远前外侧入路使用成功，有 1 项研究报告称通过远前外侧入路在前部位置放置锚钉有困难。一项研究表明，弯曲的缝合锚钉钻导可使轨迹远离关节软骨。在生物力学研究中，小直径（≤1.8mm）全缝线锚钉的关节穿透发生率较低，稳定性和拔出强度与其他锚钉类型相似。
应谨慎在前髋臼边缘位置（3 点至 4 点位置）插入缝合锚钉。大直径（≥2.3mm）缝合锚钉增加关节穿透的可能性，而不会增加盂唇稳定性。从 10°至 20°的钻孔角度插入小直径（≤1.8mm）全缝线锚钉可能会增加所有皮入口的安全插入角度。直接关节镜可视化、透视使用、远近插入和使用镍钛诺丝可以帮助防止关节损伤。
IV 级，对 I 级至 IV 级研究进行系统评价。
