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Updated: Mar 24 2023

Hip Arthroscopy

Images
https://upload.orthobullets.com/topic/3100/images/hip arthrscopy.jpg
https://upload.orthobullets.com/topic/3100/images/portals.jpg
https://upload.orthobullets.com/topic/3100/images/zona_orbicularis.jpg
https://upload.orthobullets.com/topic/3100/images/peripheral_compartment_medial_view.jpg
https://upload.orthobullets.com/topic/3100/images/zona_orbicularis_arthroscopic_image.jpg
  • Introduction
    • Overview
      • increasingly common procedure as advances in technology and familiarity expands
      • technically difficult procedure due to deep location of hip joint and high congruity (as compared to knee and shoulder)
        • significant learning curve
    • Epidemiology
      • incidence
        • 250% increase in hip arthroscopies performed in US from 2007 to 2011
    • Indications
      • intra-articular pathology
        • femoroacetabular impingement lesions
        • labral tears
        • diagnosis and staging of AVN
        • loose bodies
        • chondral defects
        • ligamentum teres injury
        • synovial disease
        • septic arthritis
      • extra-articular pathology
        • AIIS subspine impingement
        • capsular tears or instability
        • iliopsoas tendon pathology
        • gluteal tears
        • trochanteric bursal debridement
        • ischiofemoral impingement
        • deep gluteal syndrome
        • piriformis debridement/release
        • proximal hamstring tears
    • Contraindications
      • hip ankylosis
      • joint contracture
      • severe osteoporotic bone
      • significant protrusio acetabuli
    • Prognosis
      • lower morbidity than open arthrotomy with expeditious post-operative course
  • Setup, Positioning, and Joint access
    • Setup
      • dedicated hip arthroscopy instruments required
        • 70-degree arthroscope
        • long cannulas and guides
        • flexible instrumentation
      • fluoroscopy positioned so both fluoroscopic and arthroscopic towers visible
    • Positioning
      • may be done supine or in lateral decubitus position
        • regular fracture traction table or commercially made tables/attachments available
      • perineal post, if used, must be well padded
      • traction placed through operative leg to distract joint for safe entry
        • often requires around 50 pounds of traction
        • bed may be placed in Trendelenburg to lessen force required
    • Access
      • needle insertion at anterolateral portal site
      • spinal needle placed into hip joint (central compartment) with aid of fluoroscopy to avoid femoral head and labrum
      • can load joint with saline to distend
        • alternatively, joint can be vented to create air arthrogram
      • guidewire, cannula, and arthroscope inserted into joint
      • subsequent portals placed under direct visualization and/or fluoroscopy
        • portal use dictated by pathology being treated
  • Portals
    • Anterolateral portal (AL)  
      • function
        • primary viewing portal
        • anterolateral hip joint instrumentation
      • location and technique
        • located 2 cm anterior and 2 cm superior to anterosuperior border of greater trochanter
        • established first under fluoroscopic guidance
      • structures at risks
        • superior gluteal nerve
    • Anterior portal (AP)
      •  function
        • central compartment visualization and instrumentation
      • location and technique
        • often second portal created
        • starting point originally described at intersection between superior ridge of greater trochanter and line drawn longitudinally from ASIS
          • subsequently moved variable distance lateral to this line to avoid lateral femoral cutaneous nerve
        • flexion and internal rotation of hip loosens capsule and may assist scope insertion
        • interportal capsulotomy made connecting anterior portal to anterolateral portal
          • iliofemoral ligament fibers cut
      • structures at risk
        • lateral femoral cutaneous nerve
        • ascending branches of lateral femoral circumflex artery
        • femoral neurovascular bundle
    • Distal anterolateral portal (DALA)
      • function
        • provides access to the peripheral compartment in the region of the femoral neck
      • location and technique
        • starting point 3 to 5 cm distal to the anterolateral portal
        • traction is removed and the hip is placed in either neutral flexion and extension or in 45 degrees of flexion to relax the anterior capsule
        • fluoroscopy and direct arthroscopic visualization is used to guide portal placement
      • structures at risk
        • ascending branch of lateral femoral circumflex artery
    • Mid-anterior portal (MAP) 
      • functions
        • imilar to anterior portal
      • location and technique
        • various different portals described
        • all made lateral to anterior portal and medial the anterolateral portals
    • Posterolateral portal (PL)
      • function
        • posterior hip joint access and instrumentation
      • location and technique
        • located 1 cm posterior and 1 cm proximal to the posterosuperior tip of the greater trochanter
        • leg in neutral rotation
      • structures at risk
        • sciatic nerve
  • Compartments
    • Central compartment
      • consists of
        • acetabular fossa and femoral head articular surfaces
        • ligamentum teres
        • acetabular rim and labrum
        • AIIS and capsule
      • requires traction for access and instrumentation
    • Peripheral compartment
      • portion of hip joint lateral to the labrum
      • no traction required
      • consists of
        • femoral head-neck junction
        • iliopsoas tendon
        • zona orbicularis
          • landmark for the iliopsoas tendon
        • medial synovial fold
    • Lateral compartment
      • trochanteric and peri-trochanteric area
      • no traction required
      • consists of
        • IT band and bursa
        • gluteus medius/minimus tendons
    • Deep gluteal space
      • extra-articular posterior hip space
      • no traction required
      • consists of
        • piriformis and sciatic nerve
        • hamstring origin at ischial tuberosity
  • Rehabilitation
    • Rehab protocols vary by procedure and surgeon
      • physical therapist involvement prior to procedure to discuss expectations
      • immediate post-operative full or brief protected weight-bearing
        • foot-flat partial weight-bearing with progression to full weight bearing
      • early range of motion
      • strengthening is started after full ROM is achieved
        • iliopsoas tendinitis common
    • Return to full activity
      • earlier reports of faster recovery following arthroscopic procedures compared with open
  • Complications
    • Chondrolabral injuries
      • iatrogenic chondral injuries most commonly reported complication
      • due to scope or instrumentation placement
      • avoid by
        • instrumentation under direct visualization
    • Hip instability
      • iatrogenic hip instability due to capsular insufficiency
      • risk factors
        • imprecise capsulotomy
        • lack of capsular closure
      • avoided with
        • careful initial capsulotomy
        • capsular closure or plication
    • Neurovascular injury
      • traction related
        • associated with amount of traction force required
        • pudendal nerve injury
          • most common overall neurovascular complication
          • neuropraxia or compression injury
          • due to perineal post for traction
          • avoided with
            • post-less surgery
        • peroneal nerve injury
          • traction or compressive neuropraxia
          • due to traction or compression from ill-fitting boot
          • avoided with
            • intermittent release of traction
            • total traction time under 2 hours
            • adequate muscle paralysis (requires less traction force)
      • portal related
        • superior gluteal nerve
          • anterolateral portal
        • sciatic nerve
          • posterolateral portal
          • increased risk with external rotation of hip
        • lateral femoral cutaneous nerve
          • anterior portal
          • avoid any instrumentation medial to ASIS
        • ascending branch of lateral femoral circumflex artery
          • distal anterolateral portal
    • Fluid extravasation
      • risk factors
        • prolonged surgical time
        • high pump pressure
      • prevention
        • low-pressure pump settings
        • iliopsoas tenotomy/lengthening performed last
    • Heterotopic ossification
      • prevention
        • routine NSAIDs post-operatively
    • Conversion to total hip arthroplasty
      • risk factors
        • obesity
        • age greater than 60
        • female gender
        • tobacco use
        • low case volume surgeon
        • pre-existing hip osteoarthritis
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