Updated: 4/21/2020

Hip Arthroscopy

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Questions
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Evidence
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Videos
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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
  • 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  
  • Contra-indications
    • 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 risk
      • 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) 
    • function
      • similar 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
 

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Questions (7)
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(OBQ11.262) The zona orbicularis is the arthroscopic landmark for access to which of the following structures? Review Topic | Tested Concept

QID: 3685
1

Iliopsoas

84%

(3191/3808)

2

Pectineus

5%

(178/3808)

3

Sartorius

2%

(77/3808)

4

Adductor brevis

2%

(66/3808)

5

Rectus femoris

7%

(273/3808)

L 2 C

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

QID: 797
1

Use of traction

92%

(2453/2653)

2

Lateral positioning

2%

(64/2653)

3

Supine positioning

1%

(23/2653)

4

Deep venous thrombosis

1%

(38/2653)

5

Heterotopic ossification

2%

(64/2653)

L 1 C

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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 | Tested Concept

QID: 220
1

Anterior peritrochanteric portal with limb in internal rotation

1%

(21/2767)

2

Anterior peritrochanteric portal with limb in flexion

1%

(21/2767)

3

Posterior peritrochanteric portal with limb in internal rotation

49%

(1348/2767)

4

Posterior peritrochanteric portal with limb in external rotation

49%

(1352/2767)

5

Distal lateral portal with limb in neutral rotation

0%

(7/2767)

L 4 D

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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 | Tested Concept

QID: 234
FIGURES:
1

Injury to the Pudendal nerve from Portal A

1%

(43/4952)

2

Injury to the Femoral nerve from Portal B

1%

(34/4952)

3

Injury to the Lateral Femoral Cutaneous Nerve from Portal A

96%

(4766/4952)

4

Injury to the Common Peroneal nerve from Portal C

0%

(9/4952)

5

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

2%

(84/4952)

L 1 C

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Evidences (14)
VIDEOS (25)
CASES (3)
Topic COMMENTS (2)
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