Overview of Surgical Technique for Basic Hip Arthroscopy

Kurt P. Droll, MSc, M.D., FRCSC
Assistant Professor
Northern Ontario School of Medicine
Lakehead and Laurentian University
Thunder Bay, ON

Introduction
Arthroscopic surgery of the hip is becoming an increasingly well-recognized clinical procedure for the evaluation and treatment of many hip disorders. Hip arthroscopy is technically demanding, however, requiring careful preoperative positioning, special instrumentation, and a thorough understanding of the anatomical relationships about the hip joint. This brief article will serve to outline the basic techniques for performing a successful hip arthroscopy.

 

Patient Positioning

DROLLFigure_1
Figure 1: Patient positioning for hip arthroscopy in the supine position. Photo courtesy of Dr. Paul Beaulé.

Hip arthroscopy can be performed with the patient in either the supine (this author's preferred position) or lateral position1,2. A modified fracture table or a distraction device fitted to a radiolucent table and an image intensifier are necessary. A perineal post is used to provide counter-traction and needs to be well-padded to protect against neuropraxia. In the supine position, the nonoperative leg is abducted approximately 40 degrees and traction applied to prevent the pelvis from shifting during distraction of the operative leg. For evaluation of the central, intra-articular compartment, the operative leg is positioned in extension, abduction and neutral rotation (see Figure 1). With traction applied to the operative leg, the leg is adducted against the perineal post which acts as a fulcrum and results in distraction of the femoral head both laterally and distally. The necessary joint distraction, approximately 7 to 10 mm, is thus achieved and is confirmed with fluoroscopic examination (see Figure 2). For evaluation of the peripheral, extra-articular compartment, the operative leg is taken out of traction and the hip placed in 45 degrees of flexion in order to relax the anterior capsule and facilitate visualization. While the orientation of the patient may be different in the lateral position, the arthroscopic techniques remain the same.

Equipment
Due to the dense soft tissue envelope, arthroscopic access to the hip joint requires specialized extra-long instruments. Cannulated obturators, trocars and cannulas (e.g. 4.5, 5.0, 5.5 mm) are used to access the hip joint. The cannulas are long enough to protect the soft tissues around the hip. Most of the intra-articular structures in the hip can be visualized by varying the portals and the angle of the arthroscope. Both 70 and 30 degree arthroscopes are routinely used. Arthroscopic working instruments such as shavers, burrs, and hand instruments are frequently utilized and are introduced into the joint via the cannulas. A fluid management system is essential for optimizing visualization as a pump maintains a constant intra-articular pressure and the hip capsule becomes distended with saline solution.

Portals

DROLLFigure_2
Figure 2: Intra-operative fluoroscopic evaluation of the hip joint demonstrating satisfactory joint distraction.

While several portals have been described, there are three standard portals utilized: anterior, anterolateral or anterior paratrochanteric and posterolateral or posterior paratrochanteric. The location of the anterior portal is 1 cm distal to the intersection of a sagittal line drawn distally from the anterior superior iliac spine and a transverse line drawn across the superior margin of the greater trochanter. The direction of this portal is approximately 45° cephalad and 30° towards the midline. The anterolateral and posterolateral portals are located at the proximal extent of the trochanter along its anterior and posterior margins (see Figure 3).

Once the location of the portals has been determined, the anterolateral portal is established first. A 17-gauge spinal needle is advanced under fluoroscopic guidance through the hip capsule. The hip joint can be further distended with the introduction of 40 cc of saline. A guidewire is placed through the needle and into the joint, at which point the needle is removed. A stab incision facilitates the introduction of the obturator/cannula assembly which enters the hip joint in a controlled fashion. Pitfalls in establishing this portal are entering too cephalad or too caudal thereby risking injury to the labrum and femoral head articular cartilage respectively. The anterior portal is the second portal established and this is performed under direct visualization via the arthroscope. Care needs to be taken to not stray too medial as this may place the neurovascular structures at risk. The posterolateral portal is placed under direct visualization as well, bearing in mind the proximity of the sciatic nerve. Keeping the leg in neutral rotation and extension will facilitate optimal posterior portal placement and, in turn, assist in avoiding injury to the sciatic nerve.

Examination

DROLLFigure_3
Figure 3: Portal locations are determined by palpable anatomic landmarks. ASIS=anterior superior iliac spine, GT=greater trochanter, AP=anterior portal, ALP=anterolateral portal, PLP=posterolateral portal. Photo courtesy of Dr. Paul Beaulé.

Through the use of the established portals, a systematic evaluation of the hip joint is possible. Structures such as the femoral head, acetabulum, fossa, ligamentum teres and the anterior, lateral, and posterior labrum can all be reliably visualized. Techniques including debridement, repair, and thermal ablation are used to address the pathology3,4,5. At the completion of the procedure, traction is immediately released and the portals are closed with a simple suture and a sterile dressing is applied.

References

 

  1. Glick J.M., Sampson T.G., Gordon R.B., Behr J.T., Schmidt E. Hip arthroscopy by the lateral approach. Arthroscopy. 1987;3:4-12.
  2. Byrd J.W. Hip arthroscopy: the supine position. Instr Course Lect. 2003;52:721-730.
  3. McCarthy J., Noble P., Aluisio F.V., Schuck M., Wright J., Lee J.A. Anatomy, pathologic features, and treatment of acetabular labral tears. Clin Orthop. 2003;406:38-47.
  4. Byrd J.W. Hip arthroscopy for posttraumatic loose fragments in the young active adult: three case reports. Clin J Sports Med. 1996;6:129-133.
  5. Bare A.A., Guanche C.A. Hip impingement: the role of arthroscopy. Orthopaedics. 2005;28:266-273.

 

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