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The zona orbicularis is the arthroscopic landmark for access to which of the following structures?
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The zona orbicularis is the arthroscopic landmark for access to the iliopsoas. Arthroscopic release of the iliopsoas can be performed for treatment of an internal snapping hip, which is usually caused by the iliopsoas snapping over the iliopectineal eminence or the femoral head.
The referenced study by Ito et al performed hip distraction on 7 cadaveric specimens and then sequentially released soft tissue structures to determine which structures were most important for hip stability during distraction. They found that the proximal to middle part of the capsule, which includes the zona orbicularis, had the most influence on hip stability during distraction.
The zona orbicularis is a ring of capsular tissue shown in the MRI in Illustration A and the hip arthoscopy image in Illustration B. Identification of the zona orbicularis can guide the surgeon to the iliopsoas tendon that is immediately deep to this structure. The video clip shows pericapsular release of the iliopsoas tendon. Note that some surgeons choose to release the iliopsoas off the lesser trochanter itself rather than going through the capsule.
Ito H, Song Y, Lindsey DP, Safran MR, Giori NJ
J. Orthop. Res.. 2009 Aug;27(8):989-95. PMID: 19148941 (Link to Abstract)
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Complications from hip arthroscopy are most commonly related to which of the following?
Use of traction
Deep venous thrombosis
Hip arthroscopy is currently effective for the treatment of loose bodies, labral tears, chondral injuries, AVN, synovial disease, ruptured ligamentum teres, impinging osteophytes, and unexplained mechanical symptoms. The set-up is typically supine or lateral, and traction is applied. The complications are rare but are associated with traction injuries, iatrogenic chondral injuries, and neurovascular injury due to aberrant portal placement. Transient neuropraxia of the groin (pudendal) or dorsum of the foot (peroneal) are most common as these are the points where the traction is applied. The Byrd is the first to describe 10 year follow-up of hip arthroscopy patients and only 2 complications were reported.
Byrd JW, Jones KS
Clin. Orthop. Relat. Res.. 2010 Mar;468(3):741-6. PMID: 19381742 (Link to Abstract)
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During hip arthroscopy, the sciatic nerve is most at risk with which of the following portal techniques?
Anterior peritrochanteric portal with limb in internal rotation
Anterior peritrochanteric portal with limb in flexion
Posterior peritrochanteric portal with limb in internal rotation
Posterior peritrochanteric portal with limb in external rotation
Distal lateral portal with limb in neutral rotation
The posterolateral portal is made 2-3cm posterior to the tip of the greater trochanter. The hip should never be externally rotated during this portal entry as this brings the sciatic nerve closer to the portal. Internal rotation would move the portal farther away from the sciatic nerve- this concept is similar to internally rotating during a posterior approach to the hip for a total hip arthroplasty.
McCarthy presents a review of hip arthroscopy basic priniciples.
J Am Acad Orthop Surg. 1995 May;3(3):115-122. PMID: 10790660 (Link to Abstract)
McCarthy JC, Lee JA.
Instr Course Lect. 2006;55:301-8. PMID: 16958465 (Link to Abstract)
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A 29-year-old male undergeoes hip arthroscopy using the three portals shown in Figure A. Postoperatively he develops numbness in the distribution shown in yellow. This complication was most likely caused by which of the following?
Injury to the Pudendal nerve from Portal A
Injury to the Femoral nerve from Portal B
Injury to the Lateral Femoral Cutaneous Nerve from Portal A
Injury to the Common Peroneal nerve from Portal C
Injury to the a sensory branches of the sciatic nerve from Portal B
Paresthesias in the distribution marked in yellow in Figure A are consistent with an injury to the Lateral Femoral Cutaneous Nerve (LFCN). The LFCN is at greatest risk of injury with placement of the anterior portal (Portal A in Figure). A properly positioned anterior portal still may cause injury to the LFCN, and therefore the portal incision should be through skin followed by blunt dissection; also known as the "nick and spread" technique. The anterolateral (B) or distal lateral (C) portals may also result in LFCN injury, but the anterior portal is the greatest risk.
Byrd reviewed the indications for hip arthroscopy in athletes. It reviews portal placement and complications.
Robertson et al examined the safety of 11 different hip arthroscopy portals and noted that the greatest risk still comes from the proximity of the anterior portal to the lateral femoral cutaneous nerve. However, a slightly more lateral location seems to provide substantial benefits.
Answer 1: Transient nerve injury affecting the groin (pudendal nerve) is usually due to traction against the perineal post used to distract the hip.
Answer 2: An anterior portal that is too far medial risks injury to the femoral nerve.
Answer 4: Transient nerve injury affecting the dorsum of the foot (peroneal) are usually due to traction used to distract the hip.
Answer 5: The sciatic nerve does not have sensory branches innervating the distribution in Figure A.
Instr Course Lect. 2003;52:701-9. PMID: 12690895 (Link to Abstract)
Robertson WJ, Kelly BT
Arthroscopy. 2008 Sep;24(9):1019-26. PMID: 18760209 (Link to Abstract)
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HPI - 52 yo female anethesiologist complains of worsening R hip pain for several months. No specific injury although states that she "tweaked" it on several occasions. She is an avid, competitive tennis player
How would you treat this patient?
HPI - 17 yr female. Pulled "muscle" she was told when she was younger running track. Presented to me with hip pain.
HPI - 29 yr of female with hip pain for many years. Right worse than left
How would you treat this patient's RIGHT hip?
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