Introduction Overview increasingly common procedure as advances in technology and familiarity expands technically difficult procedure due to deep location of hip joint and high congruity (as compared to knee and shoulder) significant learning curve Epidemiology incidence 250% increase in hip arthroscopies performed in US from 2007 to 2011 Indications intra-articular pathology femoroacetabular impingement lesions labral tears diagnosis and staging of AVN loose bodies chondral defects ligamentum teres injury synovial disease septic arthritis extra-articular pathology AIIS subspine impingement capsular tears or instability iliopsoas tendon pathology gluteal tears trochanteric bursal debridement ischiofemoral impingement deep gluteal syndrome piriformis debridement/release proximal hamstring tears Contraindications advanced DJD hip ankylosis severe dysplasia joint contracture severe osteoporotic bone significant protrusio acetabuli Prognosis lower morbidity than open arthrotomy with expeditious post-operative course Setup, Positioning, and Joint access Setup dedicated hip arthroscopy instruments required 70-degree arthroscope long cannulas and guides flexible instrumentation fluoroscopy positioned so both fluoroscopic and arthroscopic towers visible Positioning may be done supine or in lateral decubitus position regular fracture traction table or commercially made tables/attachments available perineal post, if used, must be well padded traction placed through operative leg to distract joint for safe entry often requires around 50 pounds of traction bed may be placed in Trendelenburg to lessen force required Access needle insertion at anterolateral portal site spinal needle placed into hip joint (central compartment) with aid of fluoroscopy to avoid femoral head and labrum can load joint with saline to distend alternatively, joint can be vented to create air arthrogram guidewire, cannula, and arthroscope inserted into joint subsequent portals placed under direct visualization and/or fluoroscopy portal use dictated by pathology being treated Portals Anterolateral portal (AL) function primary viewing portal anterolateral hip joint instrumentation location and technique located 2 cm anterior and 2 cm superior to anterosuperior border of greater trochanter established first under fluoroscopic guidance structures at risks superior gluteal nerve Anterior portal (AP) function central compartment visualization and instrumentation location and technique often second portal created starting point originally described at intersection between superior ridge of greater trochanter and line drawn longitudinally from ASIS subsequently moved variable distance lateral to this line to avoid lateral femoral cutaneous nerve flexion and internal rotation of hip loosens capsule and may assist scope insertion interportal capsulotomy made connecting anterior portal to anterolateral portal iliofemoral ligament fibers cut structures at risk lateral femoral cutaneous nerve ascending branches of lateral femoral circumflex artery femoral neurovascular bundle Distal anterolateral portal (DALA) function provides access to the peripheral compartment in the region of the femoral neck location and technique starting point 3 to 5 cm distal to the anterolateral portal 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 structures at risk ascending branch of lateral femoral circumflex artery Mid-anterior portal (MAP) functions imilar to anterior portal location and technique various different portals described all made lateral to anterior portal and medial the anterolateral portals Posterolateral portal (PL) function posterior hip joint access and instrumentation location and technique located 1 cm posterior and 1 cm proximal to the posterosuperior tip of the greater trochanter leg in neutral rotation structures at risk sciatic nerve Compartments Central compartment consists of acetabular fossa and femoral head articular surfaces ligamentum teres acetabular rim and labrum AIIS and capsule requires traction for access and instrumentation Peripheral compartment portion of hip joint lateral to the labrum no traction required consists of femoral head-neck junction iliopsoas tendon zona orbicularis landmark for the iliopsoas tendon medial synovial fold Lateral compartment trochanteric and peri-trochanteric area no traction required consists of IT band and bursa gluteus medius/minimus tendons Deep gluteal space extra-articular posterior hip space no traction required consists of piriformis and sciatic nerve hamstring origin at ischial tuberosity Rehabilitation Rehab protocols vary by procedure and surgeon physical therapist involvement prior to procedure to discuss expectations immediate post-operative full or brief protected weight-bearing foot-flat partial weight-bearing with progression to full weight bearing early range of motion strengthening is started after full ROM is achieved iliopsoas tendinitis common Return to full activity earlier reports of faster recovery following arthroscopic procedures compared with open Complications Chondrolabral injuries iatrogenic chondral injuries most commonly reported complication due to scope or instrumentation placement avoid by instrumentation under direct visualization Hip instability iatrogenic hip instability due to capsular insufficiency risk factors imprecise capsulotomy lack of capsular closure avoided with careful initial capsulotomy capsular closure or plication Neurovascular injury traction related associated with amount of traction force required pudendal nerve injury most common overall neurovascular complication neuropraxia or compression injury due to perineal post for traction avoided with post-less surgery peroneal nerve injury traction or compressive neuropraxia due to traction or compression from ill-fitting boot avoided with intermittent release of traction total traction time under 2 hours adequate muscle paralysis (requires less traction force) portal related superior gluteal nerve anterolateral portal sciatic nerve posterolateral portal increased risk with external rotation of hip lateral femoral cutaneous nerve anterior portal avoid any instrumentation medial to ASIS ascending branch of lateral femoral circumflex artery distal anterolateral portal Fluid extravasation risk factors prolonged surgical time high pump pressure prevention low-pressure pump settings iliopsoas tenotomy/lengthening performed last Heterotopic ossification prevention routine NSAIDs post-operatively Conversion to total hip arthroplasty risk factors obesity age greater than 60 female gender tobacco use low case volume surgeon pre-existing hip osteoarthritis
QUESTIONS 1 of 8 1 2 3 4 5 6 7 8 Previous Next (OBQ18.115) A 29-year-old female presents with worsening activity-related groin pain and occasional mechanical symptoms. Physical exam and radiographic evaluation demonstrate femoroacetabular impingement with an associated labral tear. She has exhausted all conservative measures and elects to undergo arthroscopic surgery. Figure A demonstrates a left hip with the proposed arthroscopic portal sites marked. In the postoperative period, the patient reports diminished sensation over the anterolateral thigh. The neurologic injury responsible for this finding most likely occurred as a result of which aspect of the surgery? QID: 213011 FIGURES: A Type & Select Correct Answer 1 Axial traction 3% (69/2267) 2 Extra-articular fluid extravasation 1% (12/2267) 3 Poorly fitted post-operative hip abduction orthosis 2% (41/2267) 4 Utilization of the "AL" portal intra-operatively 21% (475/2267) 5 Utilization of the "AP" portal intra-operatively 73% (1645/2267) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ16HK.7) A 30 year old patient is referred to you complaining of 5 months of activity-related hip pain. It has not improved after a brief period of rest followed by 2 months of physical therapy. Her primary physician ordered an MRI which shows an anterolateral labral tear. Which of the following pre-surgical factors is a general contraindication for hip arthroscopy? QID: 211185 Type & Select Correct Answer 1 Alpha angle of 60 degrees 9% (175/1943) 2 Femoral head-neck offset ratio of 0.2 5% (95/1943) 3 Tobacco use 9% (175/1943) 4 Tönnis angle of 5 degrees 7% (130/1943) 5 Tönnis grade 3 70% (1357/1943) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ11.262) The zona orbicularis is the arthroscopic landmark for access to which of the following structures? QID: 3685 Type & Select Correct Answer 1 Iliopsoas 84% (3913/4683) 2 Pectineus 5% (222/4683) 3 Sartorius 2% (97/4683) 4 Adductor brevis 2% (79/4683) 5 Rectus femoris 7% (346/4683) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ07.136) Complications from hip arthroscopy are most commonly related to which of the following? QID: 797 Type & Select Correct Answer 1 Use of traction 92% (3212/3487) 2 Lateral positioning 2% (81/3487) 3 Supine positioning 1% (38/3487) 4 Deep venous thrombosis 1% (52/3487) 5 Heterotopic ossification 3% (92/3487) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ06.209) During hip arthroscopy, the sciatic nerve is most at risk with which of the following portal techniques? QID: 220 Type & Select Correct Answer 1 Anterior peritrochanteric portal with limb in internal rotation 1% (27/3269) 2 Anterior peritrochanteric portal with limb in flexion 1% (24/3269) 3 Posterior peritrochanteric portal with limb in internal rotation 50% (1627/3269) 4 Posterior peritrochanteric portal with limb in external rotation 48% (1561/3269) 5 Distal lateral portal with limb in neutral rotation 0% (8/3269) L 4 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (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? QID: 234 FIGURES: A Type & Select Correct Answer 1 Injury to the Pudendal nerve from Portal A 1% (47/5598) 2 Injury to the Femoral nerve from Portal B 1% (40/5598) 3 Injury to the Lateral Femoral Cutaneous Nerve from Portal A 96% (5389/5598) 4 Injury to the Common Peroneal nerve from Portal C 0% (16/5598) 5 Injury to the a sensory branches of the sciatic nerve from Portal B 2% (88/5598) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic
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