I would be presenting on his behalf, he had to leave, but I'm Jarvis Barsky, I'm one of his junior partners. But the title of his presentation, Worst Day in the OR, from 2020, is This is Not a Drill. These are his disclosures, I don't have any. So I'll start with the case. It's a 32-year-old female who had a history of greater than one year of right hip pain, and she failed several conservative modalities, including injections. Indications included a positive impingement sign, increased vapor distance. She had a tonus grade zero, and an alpha angle of 63 degrees, and some evidence of mixed impingement. An MRI demonstrated a labral tear. I won't go too much into the radiographs, but this was her preoperative AP pelvis. So we started the case. He uses epidural anesthesia. He sort of uses the traditional method, supine, he uses a well-padded perineal post. He used two portals and an inter-portal capsulotomy. So the diagnostic exam in this case revealed a labral disruption from 11 o'clock to one, with some disruption at the chondrolabral junction, and he's shown some synovitis in the joint. So started with a rim trimming based upon preoperative templating, about three millimeters removed from the acetabular side. As far as labral refixation, he uses two, three hydroxyapatite anchors. For this case, he was piercing the labrum and did arthroscopic knot tying techniques. Uses a straight tooth drill guide for trajectory to ensure appropriate protection of the acetabular cartilage, and a two, three millimeter fluted drill. So he put in the three o'clock anchor first and then moved to the 12 o'clock position, but when pre-drilling at the 12 o'clock position, I heard an audible snap and the fluted portion of the drill bit had broken off and was completely buried in the bone. So with that, there was nothing kind of protruding out, able to grasp at that point, it was completely embedded. So there was a discussion had as to remove the drill bit or just leave it there in place, but kind of considering the options quickly, there's obviously traction time and some other factors. He hadn't even really completed the labral repair. So some risk factors to include include its location in the acetabular rim, which option has more risk of harm associated with it and potential future complications. Just one option compromised the primary procedure of the labral repair and compromised some of the other soft tissue or bony structures more than the other. So that's what was going on in his head. But how often does this happen? How often does a drill bit break off and an instrument become lodged in bone? So looking at the literature, there is some evidence out there, none of this is from hip arthroscopy specifically, mostly trauma literature, but the first case I have here is just a series of about 8,000 procedures from a single institution over a two-year period and their overall rate of instrument breakage was less than 0.2%. But drill bits did account for the greatest proportion of the breakages and a second paper I have here also is a single institution registry and about 12,000 cases, they found a slightly higher rate, about 0.35%. And again, drill bits accounted for the highest amount of complications. In the second study, only about two of the 23 drill bits were removed. They didn't report any symptoms and follow-up, but it was a retrospective. I often would see drill bit breakage in the setting of olecranon fractures where you were using a home run screw kind of passing the fracture site, often a 150mm 3-5 screw and there was a lot of interference from other screws in that scenario and that's when I would see it. But every time it was just sort of left in place, but the olecranon is much different than the hip. This is a case report from an acetabular ORIF where a drill bit was left in place and as you can see, the patient underwent a subsequent procedure and the drill bit had sort of migrated out into the anterior soft tissue, so you can imagine it could create a lot of problems around the hip, both intra-articulately and extra-articulately if it becomes dislodged. So some considerations from this specific case, it was a 12 o'clock anchor, so a very vertical trajectory and especially given gravity once the patient's standing, there's no threads on the fluted drill, so nothing to stop migration, especially with activity and motion. And in this case, there was about 2cm of the buried drill bit, so that's a substantial amount of metal that could come out. And then just another thing to consider is traction time, as I said, he had only really just started the case and you had to be mindful of that because he was using a post and sort of a traditional setup. So he decided that he was gonna remove it, and actually there is, this is not just his case that happens, this is from actually Dr. Stubbs published a technique on how to go about removing this, so he recommended in this technique to start on the extra-articular side of the failed hole, you know, to avoid damage to having an intra-articular blowout and then the adjacent holes to be parallel, adjacent to and in the same orientation as the drill guide. And then he recommended using a microfracture awl to gently sort of lever the broken piece out and then obviously consider additional portals and then once you have this, once you eventually remove the foreign body and you have a larger hole, you can upsize your suture anchor and potentially still gain fixation at that point. So getting back to his case, so the sequence of how things unfolded were this, first he actually finished, was able to finish the labor repair, although he had that 2-3 hole but he just sort of worked adjacent to it, he ended up using a total of three anchors and so he was happy with the repair and then he finished the remainder of the central compartment work before letting traction down. At that point, while he was doing the osteoplasty, they opened up the microfracture awl sets and other things and the back table got organized so he wasn't wasting traction time at that point. And then once the osteoplasty was complete, he placed traction back on and then used primarily the 30 degree microfracture awl and a grasping instrument to work the drill bit piece loose and eventually to extract it. Then he used fluoro to visualize complete extraction. He didn't do it in this case but, and sort of as was mentioned by Dr. Stubbs, an option is to fill the defect with a larger anchor and use those sutures or sometimes a technique he's used for femoral head cysts is to use a hydroxyapatite anchor to fill in the defect and then just unload it so that you at least have some sort of fill and structural integrity. And then in this case, he released traction, it was under two hours and proceeded with capsular closure. Post-operatively, he didn't change anything, used 20 pounds of flat foot weight bearing for three weeks and event, there's not very long term follow up but she has proceeded with regular, she was happy with her results so far. So some takeaways, although rare, instrument breakage is a potential complication that you can see with drills. If it breaks, you have to consider location within the joint, risk of loosening migration and feasibility of removing it without creating further damage. You need to be aware of your traction time, especially if you're using a post on a traditional setup and it's always useful to have appropriate, not only associated implants like microfracturals but also have a full complement of anchors available in case you're going to have to fill a larger defect. So how did it change his practice? Pre-operatively and after each use, the surgical scrub now sort of more, pays more attention to drill bit and potential plastic deformation of it. Also there's been some, he's had a few cases where suture anchor insertion devices have broken off the tines you can see on some of these smaller all suture anchors could become dislodged or broken so the scrub afterwards will kind of thoroughly inspect those to make sure there's not any missing metal. And then if it's a larger case, it's a revision where several anchors are being inserted including augmentations or reconstructions or if the patient's a large muscular patient and you're really torquing on the drill guide with potentially some plastic deformation, you'll just have a lower threshold to sort of swap that out and just ask for new ones to try to prevent this. All right, that's it. Thank you. Anyone have any other broken instrument stories that they want to share? I broke the head off a burr once. Really? Did you really? Yeah. I use a curved burr and this actually changed the practice of the company. So I use a... But they've never seen that before. Yeah, it was not awesome. So it was a pre-bent burr and there's a little bit of slop in the tube. And so we were doing a case and kind of hit some hard bone and the head popped off the burr and started floating around in there. And it's kind of like those oh shit moments where you take a deep breath and you say nobody move and then we were able to extract it pretty easily. But what it did is it changed the implant design of the, which I didn't get any IP for which I should have. But within the tube now they put a centering collar on the actual burr to keep it from wiggling too much to prevent that. I use a self-retrieving suture passer sometimes for either capsular closure or labral passage. And it has a nitinol needle. And it's not that strong actually, the nitinol needle. And it has a little triangle at the end. And I've had one of those pop off, actually twice. The little triangle. And it is, because it's a self-retriever, it'll still retrieve the suture by the way. I have no idea how but it does. So you're passing and if it's your last stitch it can go unrecognized because you put it down, you tie your knots, you're good to go and then you get an x-ray in the peripheral compartment and there's a freaking black triangle on your x-ray. And I will tell you it always ends up inside the tissues like in the middle of your labrum or in the middle of your capsule. And it's a total pain in the ass to go get. But I will tell you now if there's any, if you use any of those devices, be very careful. If it's hard to pass, just fire the needle at the end and look at the triangle to make sure it's there. Any of those self-retrieving passers, make sure, because that thing will break. I think one of my first five cases in practice I had a beaver blade tip break off. It's not fun but I think we were able to retrieve it. I actually had one of my partners next door and he just kind of walked me through it. But sometimes you just need like an orthogonal view just to kind of get yourself a little bit more oriented. But if it's in the joint, I think that if you make a posterior lateral portal, anything that breaks usually kind of falls in that posterior compartment and that usually takes care of it. Just put a posterior lateral portal, put a cannula in and usually if it's small enough it'll just kind of suck out. If it's big enough you might need a grasper but I think almost always you can get it in a posterior lateral portal.

Jarvis Barsky

hip pain

hip arthroscopy

drill bit breakage

instrument removal