Hip Arthroscopy

Hip arthroscopy

 

Indications

 

Labral tear

Cam / pincer impingement

Loose bodies / trauma / synovial proliferation

 

Hip Scope Loose BodyHip Scope Loose Body RetrievalHip Loose Body

Removal loose body post trauma

 

Hip arthroscopy technique

 

Position

 

Supine

Lateral

 

Traction

 

Need 10 mm of distraction to enter joint and avoid chondro-labral damage

- full muscle relaxation

- traction table

- post versus postless

- occasionally need venting with needle to break vacuum suction

 

Hip Arthroscopy Set upPostless traction bed

Traction bed with post                                                       Post less traction bed using friction pad under patient

 

Portals

 

Hip scope portalsHip scope portals 2

 

PALA - Proximal anterolateral viewing portal

- entry point anterolateral aspect greater trochanter

- image intensifer

- insert just above head to avoid translabral penetration (between acetabulum and labrum)

- typically 20 degrees posterior depending on patient size

- guide wire / dilators / cannula

 

Anterolateral Portal 2Anterolateral Portal 3PALA

PALA

 

PALA 1PALA 2PALA 3

Insertion of PALA under image intensifier

 

Mid Anterior portal

- stay lateral to line drawn down from ASIS to prevent NV injury

- aim for tip of camera on image intensifier

- judge anterior posterior using femoral head / acetabulum

- enter capsule between labrum and femoral head

 

Anterior Portal 1Hip mid anteriorAnterior Portal 2

 

Hip Scope Anterior Portal 1Hip Scope Anterior Portal 2Mid anterior portal

Mid anterior portal
 

Distal anterolateral portal

- between midanterior and proximal anterolateral

- useful for some acetabular anchors

- used to perform T capsulotomy

 

Posterolateral Portal

- 2 cm posterior to GT

- level with superior border GT

- not commonly used

- removal of loose bodies

 

Posterior PortalHip Scope Nerves at Risk 2

Posterolateral portal

 

Interportal capsulotomy

 

Critical to allow instrumentation

- divide capsule between PALA and midanterior portals

- use combination of knife / diathermy

- preserve capsule for later repair

 

Interportal capsulotomy 1Interportal capsulotomy 2

Interportal capsulotomy through PALA                  Interportal capsulotomy through midanterior

 

Labral Repair

 

Assess for Labral Tears

 

Labral tearHip scope normal acetabular Labrum

 

Expose acetabulum

- place proximal capsule suspension sutures

- elevate and protect proximal capsule for later repair

- use cautery to expose acetabulum while not injuring labrum

 

Acetabulum 1Acetabulum 2

 

Acetabular rim trim / Acetabuloplasty

 

Rim trim 3Rim trim 2Rim trim 1

Pincer resection

 

Os resection 1Os resection 2

Os acetabuli resection

 

Labral repair

 

Options

- knotted versus knotless anchors

- straight versus curved

 

Must avoid intra-articular penetration

 

Labral repairLabral repair 2

 

LR 3LR 2LR 1LR 4

 

LR 1LR 2LR 3

 

Labral debridement

- for degenerative / irreparable / ossified labrum / failed labral repair

 

Hip Arthroscopy Initial ViewHip Arthroscopy Post Labral Resection

Labral debridement

 

CAM resection

 

Capsule

- distal capsule suspension sutures / parachute technique

- T capsulotomy - better for large Cam lesions, needs repair

 

Distal capsule suspensionCapsule suspension

Placing distal capsule sutures to allow parachute technique / distal capsule suspension to expose Cam

 

T CapsulotomyT Capsulotomy 2T Capsulotomy 3

T capsulotomy to expose large Cam at head neck junction

 

Leg position

 

Anterior Cam

- hip flexed to 45 degrees

- image intensifer rotated 20 degrees posterior and 20 degrees distal to allow Dunn view

 

Cam resection 1Cam resection 2Cam resection 3

 

Cam 1Cam 2Cam 3

Anterior cam resection with hip flexed

 

Cam 1Cam 2

Intra-operative Cam resection using Dunn view

 

Lateral Cam

- hip in extension / internal rotation

 

FAI Cam Resection 1FAI Cam Resection 2FAI Cam Resection 3

Lateral cam resection with hip in extension

 

Capsular Repair

 

T capsule 1T capsule closure2T Capsule closure 3

T capsule closure

 

Capsular repair 1Capsular repair 2

Interportal capsule closure

 

Complications

 

Infection 1/1000

 

DVT / PE - uncommon

 

Intra-articular anchors

 

Pudenal nerve injury

- secondary to use of post and excessive traction time / duration

- numbness in the groin / sexual dysfunction

 

Lateral femoral cutaneous nerve injury

- secondary to portals

- numbness outside of thigh

 

Hip Scope Nerves at Risk

 

Numbness dorsum feet

- due to traction boots

 

Abdominal compartment syndrome

- extravasation of fluid

- associated with high pressures / prolonged surgery / psoas tendon release

- can be fatal

 

Hip fracture

- 1/1000

- excessive Cam resection

 

Hip dislocation

- 1/1000

- increased risk with ligamentous laxity / DDH / reduced LCEA / capsulotomy

 

Heterotopic ossification - 1%

 

HOHetertopic ossification 1

Heterotopic ossification anterior capsule

 

Capsular retear / deficiency

- may cause microinstability  / pain

- most studies point towards superior outcomes with capsular repair

 

Capsular deficiency

Anterior capsular deficiency on MRA post hip arthroscopy