http://upload.orthobullets.com/topic/3100/images/hip arthrscopy.jpg
http://upload.orthobullets.com/topic/3100/images/portals.jpg
http://upload.orthobullets.com/topic/3100/images/zona_orbicularis.jpg
http://upload.orthobullets.com/topic/3100/images/peripheral_compartment_medial_view.jpg
http://upload.orthobullets.com/topic/3100/images/zona_orbicularis_arthroscopic_image.jpg
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
Portals
  • Anterolateral portal 
    • function
      • primary viewing portal
      • anterolateral hip joint access
    • location and technique
      • located 2 cm anterior and 2 cm superior to anterosuperior border of greater trochanter
      • typically established first under fluoroscopic guidance
  • Posterolateral portal
    • function
      • posterior hip joint access
    • location and technique
      • located 2 cm 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
  • Distal anterolateral portal
    • function
      • provides access to the peripheral compartment in the region of the femoral neck
    • location and technique
      • used in conjunction with the anterolateral portal to visualize the peripheral compartment
      • 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
      • portal is established 3 to 5 cm distal to the anterolateral portal, just anterior to the lateral aspect of the proximal femoral shaft and neck
    • structures visualized within the peripheral compartment
      • femoral head
      • labrum
      • zona orbicularis   
        • provides a landmark for the iliopsoas tendon 
      • medial synovial fold
      • femoral neck
      • peripheral capsular attachments
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
 

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Questions (4)

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

QID:3685
1

Iliopsoas

82%

(1892/2302)

2

Pectineus

5%

(120/2302)

3

Sartorius

2%

(53/2302)

4

Adductor brevis

2%

(42/2302)

5

Rectus femoris

8%

(185/2302)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

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:

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

QID:797
1

Use of traction

92%

(1070/1162)

2

Lateral positioning

3%

(31/1162)

3

Supine positioning

1%

(7/1162)

4

Deep venous thrombosis

1%

(16/1162)

5

Heterotopic ossification

3%

(34/1162)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

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.


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

QID:220
1

Anterior peritrochanteric portal with limb in internal rotation

0%

(4/806)

2

Anterior peritrochanteric portal with limb in flexion

1%

(6/806)

3

Posterior peritrochanteric portal with limb in internal rotation

52%

(423/806)

4

Posterior peritrochanteric portal with limb in external rotation

45%

(364/806)

5

Distal lateral portal with limb in neutral rotation

0%

(2/806)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

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.


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(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? Review Topic

QID:234
FIGURES:
1

Injury to the Pudendal nerve from Portal A

1%

(23/2409)

2

Injury to the Femoral nerve from Portal B

1%

(21/2409)

3

Injury to the Lateral Femoral Cutaneous Nerve from Portal A

95%

(2280/2409)

4

Injury to the Common Peroneal nerve from Portal C

0%

(7/2409)

5

Injury to the a sensory branches of the sciatic nerve from Portal B

3%

(68/2409)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

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:

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