Surgery Hip Arthroscopy

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The technique illustrated is with the patient in the supine position. The important principles for performing safe, effective, reproducible arthroscopy are the same whether the patient is in the lateral decubitus or supine orientation. Portal placements, relationship of the extra-articular structures, and arthroscopic anatomy are all the same regardless of positioning.

Equipment

A standard fracture table or custom distraction device is needed to achieve effective joint space separation. A tensiometer can be helpful to monitor the traction forces intraoperatively. The C arm is important for precise placement of the instrumentation within the joint. Extra-length arthroscopy instruments are also available to accommodate the dense surrounding soft tissue.

Anesthesia

The procedure is commonly performed under general anesthesia. It can be performed under epidural anesthesia but requires an adequate motor block to ensure optimal distractibility of the joint.

Intra-articular (Central) Compartment Setup

The perineal post is heavily padded and lateralized against the medial thigh of the operative hip (Fig. 45-1). This aids in achieving the optimal traction vector (Fig. 45-2) and reduces pressure directly on the perineum, lessening the risk of neurapraxia of the pudendal nerve. Neutral rotation achieves a constant relationship between the topographic landmarks and the joint. Slight flexion may relax the capsule, but excessive flexion should be avoided as this places undue tension on the sciatic nerve and may block access for the anterior portal. Typically, about 50 pounds of force is needed to distract the joint. In general, the goal is to use the minimal force necessary to achieve adequate distraction and keep traction time as brief as possible. Two hours is usually recognized as a reasonable limit for traction.

Portals

Three standard portals are used for this portion of the procedure (Figs. 45-3 and 45-4). Two of these (anterolateral and pos-terolateral) are placed laterally over the superior margin of the greater trochanter at its anterior and posterior borders. The anterior portal is placed at the site of intersection of a sagittal line drawn distally from the anterior superior iliac spine and a transverse line across the tip of the greater trochanter. With careful orientation to the landmarks in relation to the joint, these portals are a safe distance from the surrounding major neu-rovascular structures (Figs. 45-5 to 45-7; Table 45-3).9

Diagnostic Procedure

After applying traction, a spinal needle is placed from the anterolateral position and the joint is distended with fluid. The anterolateral portal is then established under fluoroscopic control for introduction of the arthroscope (Fig. 45-8). Careful

Maquet Extension
Figure 45-1 The patient is positioned on the fracture table so that the perineal post is placed as far laterally as possible toward the operative hip resting against the medial thigh. (Courtesy of Smith & Nephew Endoscopy, Andover, MA.)
Hip Arthroscopy Positioning

Figure 45-2 The optimal vector for distraction is oblique relative to the axis of the body and more closely coincides with the axis of the femoral neck than the femoral shaft. This oblique vector is partially created by abduction of the hip and partially accentuated by a small transverse component to the vector created by lateralizing the perineal post. (Courtesy of Smith & Nephew Endoscopy, Andover, MA.)

Figure 45-2 The optimal vector for distraction is oblique relative to the axis of the body and more closely coincides with the axis of the femoral neck than the femoral shaft. This oblique vector is partially created by abduction of the hip and partially accentuated by a small transverse component to the vector created by lateralizing the perineal post. (Courtesy of Smith & Nephew Endoscopy, Andover, MA.)

Hip Arthroscopy Portals

Figure 45-3 The site of the anterior portal coincides with the intersection of a sagittal line drawn distally from the anterior superior iliac spine and a transverse line across the superior margin of the greater trochanter. The direction of this portal courses approximately 45 degrees cephalad and 30 degrees toward the midline. The anterolateral and posterolateral portals are positioned directly over the superior aspect of the trochanter at its anterior and posterior borders. (From Byrd JWT: Hip arthroscopy utilizing the supine position. Arthroscopy 1994;10:275-280.)

Figure 45-3 The site of the anterior portal coincides with the intersection of a sagittal line drawn distally from the anterior superior iliac spine and a transverse line across the superior margin of the greater trochanter. The direction of this portal courses approximately 45 degrees cephalad and 30 degrees toward the midline. The anterolateral and posterolateral portals are positioned directly over the superior aspect of the trochanter at its anterior and posterior borders. (From Byrd JWT: Hip arthroscopy utilizing the supine position. Arthroscopy 1994;10:275-280.)

Lateral femoral cutaneous nerve Femoral artery and nerve

Dessin Fortnite Imprimer Saison Cinq

Figure 45-4 The relationship of the major neurovascular structures to the three standard portals is demonstrated. The femoral artery and nerve lie well medial to the anterior portal. The sciatic nerve lies posterior to the posterolateral portal. Small branches of the lateral femoral cutaneous nerve lie close to the anterior portal. Injury to these is avoided by using proper technique in portal placement. The anterolateral portal is established first since it lies most centrally in the safe zone for arthroscopy. (Courtesy of J.W. Thomas Byrd, MD, Nashville, TN.)

Figure 45-4 The relationship of the major neurovascular structures to the three standard portals is demonstrated. The femoral artery and nerve lie well medial to the anterior portal. The sciatic nerve lies posterior to the posterolateral portal. Small branches of the lateral femoral cutaneous nerve lie close to the anterior portal. Injury to these is avoided by using proper technique in portal placement. The anterolateral portal is established first since it lies most centrally in the safe zone for arthroscopy. (Courtesy of J.W. Thomas Byrd, MD, Nashville, TN.)

Femoral nerve

Superior gluteal nerve

Lateral femoral cutaneous nerve

Lesion Cubital Fracturas

Figure 45-5 Anterior portal pathway. The portal penetrates the sartorius and rectus femoris before entering the anterior capsule. Its course is almost tangential to the axis of the femoral nerve, lying only slightly closer at the level of the capsule. (Courtesy of Smith & Nephew Endoscopy, Andover, MA.)

Portal pathway Sartorius muscle

Ascending branch, lateral circumflex femoral artery

Rectus femoris muscle

Figure 45-5 Anterior portal pathway. The portal penetrates the sartorius and rectus femoris before entering the anterior capsule. Its course is almost tangential to the axis of the femoral nerve, lying only slightly closer at the level of the capsule. (Courtesy of Smith & Nephew Endoscopy, Andover, MA.)

Superior gluteal nerve

Superior Gluteal Nerve Path

Gluteus medius muscle

Figure 45-6 Anterolateral portal pathway. The portal penetrates the gluteus medius, entering the lateral capsule at its anterior margin. The superior gluteal nerve lies well cephalad to this site. (Courtesy of Smith & Nephew Endoscopy, Andover, MA.)

Gluteus medius muscle

Figure 45-6 Anterolateral portal pathway. The portal penetrates the gluteus medius, entering the lateral capsule at its anterior margin. The superior gluteal nerve lies well cephalad to this site. (Courtesy of Smith & Nephew Endoscopy, Andover, MA.)

Gluteus Medius Sciatic Nerve

Figure 45-7 Posterolateral portal pathway. The portal penetrates the gluteus and minimus, entering the lateral capsule at its posterior margin. Its course is superior and anterior to the piriformis tendon and is closest to the sciatic nerve at the level of the capsule. (Courtesy of Smith & Nephew Endoscopy, Andover, MA.)

Figure 45-7 Posterolateral portal pathway. The portal penetrates the gluteus and minimus, entering the lateral capsule at its posterior margin. Its course is superior and anterior to the piriformis tendon and is closest to the sciatic nerve at the level of the capsule. (Courtesy of Smith & Nephew Endoscopy, Andover, MA.)

Table 45-3 Distance from Portal to Anatomic

Structures Based on an Anatomic Dissection of

Portal Placements in Eight Fresh Cadaver Specimens

Average

Range

Portals

Anatomic Structure

(cm)

(cm)

Anterior

Anterior superior iliac spine

6.3

6.0-7.0

Lateral femoral cutaneous

0.3

0.2-1.0

nerve*

Femoral nerve

Level of Sartorius1"

4.3

3.8-5.0

Level of rectus femoris

3.8

2.7-5.0

Level of capsule

3.7

2.9-5.0

Ascending branch of lateral

3.7

1.0-6.0

circumflex femoral artery

Terminal branch

0.3

0.2-0.4

Anterolateral

Superior gluteal nerve

4.4

3.2-5.5

Posterolateral

Sciatic nerve

2.9

2.0-4.3

*Nerve had divided into three or more branches, and measurement was made to the closest branch.

"•"Measurement made at superficial branch of Sartorius, rectus femoris, and capsule.

fSmall terminal branch of ascending branch of lateral circumflex femoral artery identified in three specimens.

From Byrd JWT, Pappas JN, Pedley MJ: Hip arthroscopy: An anatomic study of portal placement and relationship to the extraarticular structures. Arthroscopy 1995;11:418-423.

attention is necessary to avoid perforating the labrum or scuffing the articular surface.10 Using the 70-degree scope, the anterior and posterolateral portals are then placed under direct arthroscopic view as well as fluoroscopy for precise entry into the joint. Diagnostic and operative arthroscopy is then achieved by interchanging the arthroscope and instruments between the three established portals. Use of both the 70- and 30-degree scopes provides optimal viewing despite limitations of maneuverability within the joint (Figs. 45-9 to 45-12).

Peripheral Compartment Positioning

After completing arthroscopy of the intra-articular compartment, the instruments are removed, the traction released, and the hip flexed approximately 45 degrees (Fig. 45-13).

This relaxes the capsule, providing access to the peripheral compartment.

Portal Placement

Two portals are routinely used to access the peripheral compartment. These include the anterolateral portal and an ancillary portal established 4 to 5 cm distally.

Diagnostic Procedure

The anterolateral portal is redirected onto the anterior neck of the femur (Fig. 45-14). The ancillary portal is then established distally under direct arthroscopic and fluoroscopic guidance (Fig. 45-15). The arthroscope and instruments are interchanged, also using the 30- and 70-degree scopes for inspection (Figs. 4516 and 45-17).

Figure 45-8 The arthroscope cannula is passed over a guidewire that was inserted through a pre-positioned spinal needle. Fluoroscopy aids in avoiding contact with the femoral head or perforating the acetabular labrum. (Courtesy of Smith & Nephew Endoscopy, Andover, MA.)

Smith Nephew Andover

Anterior wall

Anterior labrum

Greater trochanter

Trochanter With Cannula

Femoral head

Hip Arthroscopic Hemi Cannula

Anterior portal (camera)

Anterolateral portal (camera)

Anterolateral Hip Portal

Figure 45-10 A, Arthroscopic view from the anterior portal. B, Demonstrated are the lateral aspect of the labrum (L) and its relationship to the lateral two portals. (A, Courtesy of Smith & Nephew Endoscopy, Andover, MA.)

Figure 45-9 A, Arthroscopic view of a right hip from the anterolateral portal. (Courtesy of Smith & Nephew Endoscopy, Andover, MA.) B, Demonstrated are the anterior acetabular wall (AW) and the anterior labrum (AL). The anterior cannula is seen entering underneath the labrum and the femoral head (FH) is on the right. (Courtesy of J.W. Thomas Byrd, MD, Nashville, TN.)

Figure 45-10 A, Arthroscopic view from the anterior portal. B, Demonstrated are the lateral aspect of the labrum (L) and its relationship to the lateral two portals. (A, Courtesy of Smith & Nephew Endoscopy, Andover, MA.)

Figure 45-12 A, The acetabular fossa can be inspected from all three portals. B, The ligamentum teres (LT), with its accompanying vessels, has a serpentine course from its acetabular to its femoral attachment. (A, Courtesy of Smith & Nephew Endoscopy, Andover, MA. B, Courtesy of J.W. Thomas Byrd, MD, Nashville, TN.)

Figure 45-11 A, Arthroscopic view from the posterolateral portal. B, Demonstrated are the posterior acetabular wall (PW), posterior labrum (PL), and the femoral head (FH). (A, Courtesy of Smith & Nephew Endoscopy, Andover, MA. B, Courtesy of J.W. Thomas Byrd, MD, Nashville, TN.)

Figure 45-12 A, The acetabular fossa can be inspected from all three portals. B, The ligamentum teres (LT), with its accompanying vessels, has a serpentine course from its acetabular to its femoral attachment. (A, Courtesy of Smith & Nephew Endoscopy, Andover, MA. B, Courtesy of J.W. Thomas Byrd, MD, Nashville, TN.)

Smith Nephew Andover
Figure 45-13 The operative area remains covered in sterile drapes while the traction is then released and the hip flexed 45 degrees. Inset: Illustrates position of the hip without the overlying drape. (Courtesy of Smith & Nephew Endoscopy, Andover, MA.)
Smith And Nephew Sports Medicine
Figure 45-14 From the anterolateral entry site, the arthroscope cannula is redirected over the guidewire through the anterior capsule, onto the neck of the femur. (Courtesy of Smith & Nephew Endoscopy, Andover, MA.)
Smith And Nephew Sports Medicine
Figure 45-15 With the arthroscope in place, prepositioning is performed with a spinal needle for placement of an ancillary portal distally. (Courtesy of Smith & Nephew Endoscopy, Andover, MA.)
Hip Arthroscopy Portal Placement

Figure 45-17 A, Peripheral compartment viewing medially. B, Demonstrated are the femoral neck (FN), medial synovial fold (MSF), and the zona orbicularis (ZO). (A, Courtesy of Smith & Nephew Endoscopy, Andover, MA. B, Courtesy of J.W. Thomas Byrd, MD, Nashville, TN.)

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