Updated: 6/15/2019

Hip Arthroscopy

Topic
Review Topic
0
0
Questions
6
0
0
Evidence
9
0
0
Videos
24
Cases
3
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
  • 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 (6)

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

QID: 3685
1

Iliopsoas

83%

(2839/3405)

2

Pectineus

5%

(163/3405)

3

Sartorius

2%

(71/3405)

4

Adductor brevis

2%

(60/3405)

5

Rectus femoris

7%

(253/3405)

L 2

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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

93%

(2023/2183)

2

Lateral positioning

3%

(55/2183)

3

Supine positioning

1%

(17/2183)

4

Deep venous thrombosis

1%

(31/2183)

5

Heterotopic ossification

2%

(49/2183)

L 1

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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

1%

(18/2412)

2

Anterior peritrochanteric portal with limb in flexion

1%

(20/2412)

3

Posterior peritrochanteric portal with limb in internal rotation

48%

(1160/2412)

4

Posterior peritrochanteric portal with limb in external rotation

50%

(1194/2412)

5

Distal lateral portal with limb in neutral rotation

0%

(4/2412)

L 4

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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%

(38/4606)

2

Injury to the Femoral nerve from Portal B

1%

(32/4606)

3

Injury to the Lateral Femoral Cutaneous Nerve from Portal A

96%

(4429/4606)

4

Injury to the Common Peroneal nerve from Portal C

0%

(9/4606)

5

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

2%

(84/4606)

L 1

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ARTICLES (13)
VIDEOS & PODCASTS (25)
CASES (3)
Topic COMMENTS (2)
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