Hip Arthroscopy - Knee & Sports

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