Hip Arthroscopy

Author: David Abbasi

Topic updated on 01/20/13 1:24pm

Introduction

Technically difficult because of deep location of hip joint
Lower morbidity than open arthrotomy with easier post-operative course
Indications
- FAI
- labral tears
- AVN (diagnosis and staging)
- loose bodies
- synovial disease
- chondral injuries
- ligamentum teres injuries
- snapping hip
- mechanical symptoms
- impinging osteophytes
Contraindications
- advanced DJD
- hip ankylosis
- joint contracture
- severe osteoporotic bone
- significant protrusio acetabuli

Positioning and Scope insertion

Position
- may be done supine or in lateral decubitus position
Joint distension
- can load joint with saline to distend joint
  - typically done under flouroscopic guidance
- requires traction in line with the femoral neck
  - well padded perineal post
  - ~50 pounds of traction
Scope insertion
- anterolateral scope placed first
  - arthroscope insertion over guidewire
- anterior portal placed second
  - then placed under fluoroscopic guidance with the hip flexed and in internal rotation
- posterior portal placed last
- zona orbicularis provides landmark for iliopsoas

Portals

Anterolateral portal
- function
  - primary viewing portal
  - anterolateral hip joint access
- location and technique
  - located 2 cm anterior and 2cm superior to anterosuperior border of greater trochanter
  - typically established first under flouroscopic guidance
Posterolateral portal
- function
  - posterior hip joint access
- location and technique
  - located 2cm posterior to the tip of the greater trochanter
Anterior portal
- function
  - anterior hip joint access
- location and technique
  - located at intersection between
    - superior ridge of greater trochanter
    - ASIS
  - flexion and internal rotation of hip loosens capsule and assists scope insertion

Rehabilitation

Immediate post-operative period
- NWB or PWB for ~ one week
- with gradual progression to full weight bearing
Rehabilitation
- strengthening is started after full ROM is achieved
Return to full activity
- at ~ 3 months

Complications

Direct injuries
- can occur from scope or cannula placement
- most commonly reported complication
  - chondral injuries
Neurovascular injury
- traction related
  - pudendal nerve injury
    - most common neurovascular complication
    - due to traction post in groin for traction
    - neuropraxia or compression injury
  - peroneal nerve injury
    - traction neuropraxia
  - may prevent traction injuries with
    - intermittent release of traction
    - adequate anesthesia
- anterolateral portal
  - risks superior gluteal nerve
- posterolateral portal
  - risks sciatic nerve
    - increased risk with external rotation of hip
- anterior portal
  - risks lateral femoral cutaneous nerve injury
  - risks femoral neurovascular bundle
  - risks ascending branch of lateral femoral circumflex artery

Please Rate Educational Value!

4.0

Average 4.0 of 7 Ratings

Qbank (4 Questions)

TAG

(OBQ11.262) The zona orbicularis is the arthroscopic landmark for access to which of the following structures? Topic

Review Topic

1. Iliopsoas
2. Pectineus
3. Sartorious
4. Adductor brevis
5. Rectus femoris

PREFERRED RESPONSE ▶

DISCUSSION: 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.

Illustrations: A

REFERENCES:

1. Ito H, Song Y, Lindsey DP, Safran MR, Giori NJ. The proximal hip joint capsule and the zona orbicularis contribute to hip joint stability in distraction. J Orthop Res. 2009 Aug;27(8):989-95. PMID:19148941 (Link to Abstract)

2. Kelly BT. Techniques for arthroscopy of the hip. In: Kibler WB, ed. Orthopaedic Knowledge Update: Sports Medicine 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2009:101-108.

Question Authors:

Michael Hughes MD, Patrick McCulloch MD, Dave Marcu MD,

Please Rate Educational Value!

2.0

Average 2.0 of 9 Ratings

TAG

(OBQ07.136) Complications from hip arthroscopy are most commonly related to which of the following? Topic

Review Topic

1. Use of traction
2. Lateral positioning
3. Supine positioning
4. Deep venous thrombosis
5. Heterotopic ossification

PREFERRED RESPONSE ▶

DISCUSSION: 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.

REFERENCES:

1. Garrick eds. OKU Sports Medicine 3, 2004.

2. Byrd JW, Jones KS. Prospective analysis of hip arthroscopy with 10-year followup. Clin Orthop Relat Res. 2010 Mar;468(3):741-6. Epub 2009 Apr 21. PMID:19381742 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, John Badylak MD,

Please Rate Educational Value!

4.0

Average 4.0 of 5 Ratings

TAG

(OBQ06.209) During hip arthroscopy, the sciatic nerve is most at risk with which of the following portal techniques? Topic

Review Topic

1. Anterior peritrochanteric portal with limb in internal rotation
2. Anterior peritrochanteric portal with limb in flexion
3. Posterior peritrochanteric portal with limb in internal rotation
4. Posterior peritrochanteric portal with limb in external rotation
5. Distal lateral portal with limb in neutral rotation

PREFERRED RESPONSE ▶

DISCUSSION: 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.

REFERENCES:

1. McCarthy JC: Hip arthroscopy; Applications and technique. JAAOS 1995;3:115-122. PMID:10790660 (Link to Abstract)

2. McCarthy JC, Lee J: Hip arthroscopy: Indication, outcomes, and complications. Instr Course Lect. 2006;55:301-8. Review. PMID:16958465 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Derek Moore,

Please Rate Educational Value!

4.0

Average 4.0 of 10 Ratings

TAG

(OBQ06.223) 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? Topic

Review Topic

FIGURES: A

1. Injury to the Pudendal nerve from Portal A
2. Injury to the Femoral nerve from Portal B
3. Injury to the Lateral Femoral Cutaneous Nerve from Portal A
4. Injury to the Common Peroneal nerve from Portal C
5. Injury to the a sensory branches of the sciatic nerve from Portal B

PREFERRED RESPONSE ▶

DISCUSSION: 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.

Incorrect Answers:
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.

Illustrations: A

REFERENCES:

1. Byrd JW. Hip arthroscopy in athletes. Instr Course Lect. 2003;52:701-9. Review. PMID:12690895 (Link to Abstract)

2. Robertson WJ, Kelly BT. The safe zone for hip arthroscopy: a cadaveric assessment of central, peripheral, and lateral compartment portal placement. Arthroscopy. 2008 Sep;24(9):1019-26. PMID:18760209 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, John Badylak MD, Dave Marcu MD,

Please Rate Educational Value!

3.0

Average 3.0 of 12 Ratings

Cases

	Heterotopic bone greater trochanter / abductors (C1461) General - Treatment Consult - Hip Arthroscopy HPI - 36 yr old with hx of pelvic trauma as a child. No previous hip surgery. What are next steps?	3/27/2013 100 responses 4
	Global pincer? (C1315) Sports - Treatment Consult - Hip Arthroscopy HPI - 29 yr of female with hip pain for many years. Right worse than left How would you obtain access to joint?	11/6/2012 108 responses 5
	External hip impingement? (C1429) Sports - Treatment Consult - Hip Arthroscopy HPI - 17 yr female. Pulled "muscle" she was told when she was younger running track. P... Next step?	2/26/2013 86 responses 4

See More Cases

Videos

	Hip arthroscopy portal placement Sports - Surgical Techniques - Hip Arthroscopy Video shows basic setup and hip arthroscopy portal placement	12/16/2012 397 views 4
	Arthroscopic Hip Iliopsoas release for Internal Snapping Hip Sports - Surgical Cases - Hip Arthroscopy Left hip arthroscopy shows release of the iliopsoas tendon for treatment of inte...	2/12/2012 915 views 1
	Hip Arthroscopy for Cam Lesion in Femoroacetabular Impingement Sports - Surgical Cases - Hip Arthroscopy Hip Arthroscopy: Chondroplasty and Osteoplasty for Cam Lesion in Femoroacetabula...	12/29/2011 308 views 3

See More Videos

Posts

Key Article: Risk of Sciatic Nerve Traction Injury During Hip Arthroscopy - Is It the Amount or Duration?: An Intraoperative... Includes Poll

Jessica J.M. Telleria, MD; Marc R. Safran, MD; John N. Gardi, PhD, D.ABNM,...

Sports - Journal Club - Hip Arthroscopy

12/4/2012

1 responses

See More Posts

Groups

	ABOS II: Hip Arthroscopy General - Oral Boards Review	7/29/2011 0 responses
	Hip Arthroscopy And Preservation Interest Group Sports - Surgical Cases	1/29/2012 133 responses

See More Groups

Evidence & References Show References

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Ito H, Song Y, Lindsey DP, Safran MR, Giori NJ. The proximal hip joint capsule and the zona orbicularis contribute to hip joint stability in distraction. J Orthop Res. 2009 Aug;27(8):989-95. PMID:19148941 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Kelly BT. Techniques for arthroscopy of the hip. In: Kibler WB, ed. Orthopaedic Knowledge Update: Sports Medicine 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2009:101-108.

Undefined

Byrd JW, Jones KS. Prospective analysis of hip arthroscopy with 10-year followup. Clin Orthop Relat Res. 2010 Mar;468(3):741-6. Epub 2009 Apr 21. PMID:19381742 (Link to Abstract)
Byrd JW. Hip arthroscopy in athletes. Instr Course Lect. 2003;52:701-9. Review. PMID:12690895 (Link to Abstract)
Garrick eds. OKU Sports Medicine 3, 2004.
McCarthy JC, Lee J: Hip arthroscopy: Indication, outcomes, and complications. Instr Course Lect. 2006;55:301-8. Review. PMID:16958465 (Link to Abstract)
McCarthy JC: Hip arthroscopy; Applications and technique. JAAOS 1995;3:115-122. PMID:10790660 (Link to Abstract)
Robertson WJ, Kelly BT. The safe zone for hip arthroscopy: a cadaveric assessment of central, peripheral, and lateral compartment portal placement. Arthroscopy. 2008 Sep;24(9):1019-26. PMID:18760209 (Link to Abstract)

Topic Comments

Subscribe status: On Off

Recent on Bottom | Recent on Top

Page:1

Hip Arthroscopy

Qbank (4 Questions)

Question Comments

Question Comments

Question Comments

Question Comments

Cases

Videos

Posts

Groups

Evidence & References Show References

Topic Comments