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In this video, Dr. Byrd discusses how to perform hip arthroscopy. Patient positioning is simple, but critically important for safe, effective hip arthroscopy. A well-padded perineal post is lateralized against the medial thigh. This helps with the optimal tractor vector and moves away from the pudendal nerve.
The hip is slightly abducted and neutral rotation assures a consistent relationship between the trochanter and the joint. Slight flexion may relax the capsule, but excessive flexion is avoided. The surgeon, assistant and scrub nurse are on the operative side of the patient with room for all arthroscopy components directly across.
The C-arm is covered in a sterile drape and positioned between the legs. On this right hip, the greater trochanter is being palpated marking it superior, anterior and posterior margins. The lateral two portals are placed on the superior edge of the greater trochanter at its anterior and posterior boarders. The anterior/superior iliac spine is palpated and a sagittal line drawn distally. Intersection with a transverse line across the tip of the trochanter marks the site for the anterior portal.
With traction applied, pre-positioning is performed with a 17 gage spinal needle. Correct position with a slight angle is first substantiated by simply placing the needle on the front of the hip. The anterolateral portal is established first because it lies most centrally in the safe zone for arthroscopy. The needle is inserted over the anterior boarder of the greater trochanter. With the hip in neutral rotation, and the needle passing parallel to the floor, it should enter the center of the joint. A critical feature of initial needle placement is to avoid perforating the labrum. With distention of the joint, failure of the needle to migrate distally to the femoral head, suggests that it could be within the labral tissue. This signifies the importance of repositioning the needle. Fluid pressure is maintained with the syringe and the needle is withdrawn from the joint. The distention separates the capsule from the labrum.
The 5 mm canula operator assembly is then passed over the guide wire. All subsequent portals are placed with the aid of direct arthroscopic visualization. Positioning for the anterior portal is performed with the 17 gage spinal needle. It enters in the triangle form and by the free edge of the anterior labrum, the femoral head and the edge of the arthroscope. The guide wire is placed, and a 4.5 mm canula is advanced. This time, under direct arthroscopic control. A canula clears the labrum and the articular surfaces are avoided. An anatomic triangle is again evident and the posterolateral portal is placed using the exact same sequence of steps. A separate end-flow is established which allows the luxury of going to the smaller 4.5 mm canulas for the arthroscope. The larger diameter canula is needed only while the inflow is attached to the scope. The next step is to move the arthroscope to the anterior portal and access the position of the anterolateral portal, which was the only one placed without precise arthroscopic visualization. Using a switching stick, the 5 mm canula is placed with a 4.5 mm canula for maximal interchangeability. In a tight hip, this small diameter difference can be substantial.
The arthroscope has been placed in the posterolateral position continuing the initial survey of the joint. It is important to avoid overlooking less common posterior lesions. The 70 degree is replaced with a 30 degree scope, which provides a more direct view of the acetabular fossa and its contents. Lastly, the scope has been returned to the anterolateral portal to complete the initial survey. The 70 degree scope is returned and the plan is to make a small capsulotomy that enhances maneuverability within the hip.
For making the anterolateral capsulotomy, the arthroscope is returned to the anterior portal and the capsular incision is created with a single piece construction arthroscopic knife which is a very versatile instrument in the hip. The knife is passed through the canula and the canula is removed for better control of the blade. Small transverse incisions, just a few mm in each direction substantially improve the freedom of movement for the instruments. More or less capsulotomy may be performed based on the injury. This gives much better maneuverability for the arthroscope and in this case, nodular disease of the synovial tissue within the fossa can be cleared out with a 4.5 mm resector anteriorly. Completion of the debridement is complimented from the posterolateral portal.
