Patient Positioning

The supine position and the lateral decubitus position have both been described for hip arthroscopy, and iliopsoas tendon release can be performed with the patient in either one.

We prefer to use the lateral decubitus technique. We position the patient lateral and resting on the nonoperative side on a fracture table with special accessories (Maquet, Rastatt, Germany). A horizontal perineal post with a diameter of 10 cm is positioned horizontally on the operating table; it is then positioned laterally on the patient’s medial thigh and elevated to provide a lateralization vector to the traction force. The lateralization also distances the post from the pudendal nerve. The foot on the surgical side is fixed to the traction device of the fracture table, and the nonoperative side rests free on the table. Before traction is applied, the patient’s genitalia should be inspected to verify that they are free from compression.

The hip is positioned in 20 degrees of flexion to relax the anterior hip capsule. Flexion of more than 20 degrees does not improve the distraction of the hip joint, and it in fact increases the possibility of injury to the sciatic nerve. Abduction is kept neutral to maximize the separation of the iliofemoral joint. Neutral rotation is preferred while establishing arthroscopic portals to maximize the distance between the posterior edge of the greater trochanter and the sciatic nerve.

The C-arm is positioned horizontally under the table to provide an anteroposterior view of the hip. A traction test is performed to confirm effective separation of a minimum of 10 mm between the femoral head and the acetabulum at the image intensifier. After a successful traction test is performed, the hip is flexed 35 degrees, abducted, and externally rotated to confirm the mobility of the setup; this mobility will provide adequate access to the hip periphery. The hip is brought back to a neutral position, and the surgical area is prepared for surgery in the standard fashion.

Iliopsoas Release at the Lesser Trochanter

Arthroscopy of the central compartment is performed first with the use of traction. Three portals are usually established for arthroscopy of the central compartment: an anterolateral portal, a posterolateral portal, and a direct anterior portal. Traction is released to access the peripheral compartment, and accessory portals are usually required to access the hip periphery.

After hip arthroscopy of the central and peripheral compartments is complete, the instruments are taken out of the joint. The hip is positioned in 20 degrees of flexion and external rotation to expose the lesser trochanter at the image intensifier (Figure 18-1). A spinal needle is introduced through an accessory portal (i.e., the superior accessory portal) that is established about 2 cm distal to a horizontal line directed anteriorly from the tip of the greater trochanter and 2 cm anterior to the anterior femur (Figure 18-2). The needle is directed toward the lesser trochanter and navigated by the image intensifier (Figure 18-3). Orientation in the coronal plane is provided by the image intensifier. Orientation in the sagittal plane is provided by palpating the anterior aspect of the femur until the needle is positioned on the lesser trochanter; this will position the needle inside of the iliopsoas bursa. After the spinal needle has been successfully positioned in the iliopsoas bursa, the stylus is removed, and a flexible guidewire (Nitinol) is introduced. The needle is removed, and a cannulated switching stick is passed into the iliopsoas bursa over the flexible guidewire. A 4.5-mm, double-valve, rotatable arthroscopic cannula is passed over the switching stick, which is then removed, and then a 4-mm, 30-degree arthroscope is introduced. The fluid pump is started, and the iliopsoas tendon is identified. A second accessory portal 3 cm to 4 cm distal to the first one is established (i.e., the inferior accessory portal). A spinal needle is triangulated toward the tip of the arthroscope inside of the iliopsoas bursa. The image intensifier can be used to assist with the navigation of the needle. The tip of the needle is identified endoscopically inside of the iliopsoas bursa, and a working portal is established with the use of a flexible guidewire, a cannulated switching stick with a dilator, and a slotted cannula (Hip Access System, Smith and Nephew, Andover, MA). A shaver is introduced through the slotted cannula, which is then removed. The shaver is used to resect synovial tissue from the iliopsoas bursa and to dissect the iliopsoas tendon. The slotted cannula is reinserted with the use of the shaver as a guide. The shaver is removed, and a radiofrequency hook probe is inserted; the slotted cannula is removed, and the radiofrequency probe is used to release the iliopsoas tendon close to its insertion on the lesser trochanter (Figures 18-4 and 18-5). The image intensifier can be used to verify the position of the radiofrequency hook probe before the release of the iliopsoas tendon.

Figure 18–1 This photograph demonstrates a patient positioned for hip arthroscopy on the left side. Only the left foot is fixed to the traction device. Note the extra-padded perineal post in a horizontal position and the image intensifier placed horizontally under the table. The hip is without traction and externally rotated to expose the lesser trochanter at the image intensifier. To the left, a photograph from the image intensifier demonstrates the exposure of the lesser trochanter with external rotation (arrow). Note that the hip is without traction.

Figure 18–2 This photograph demonstrates portal sites. The greater trochanter (GT) and the anterosuperior iliac spine (ASIS) have been outlined. The anterolateral portal and posterolateral portal are at the anterosuperior and posterosuperior corners of the greater trochanter. The direct anterior portal is 1 cm medial to the crossing of a horizontal line from the tip of the greater trochanter and a vertical line from the anterosuperior iliac spine. An anteroinferior accessory portal is located distal to the central compartment portals (i.e., the anterolateral, posterolateral, and direct anterior portals) 1 cm to 2 cm anterior of the anterior aspect of the proximal femur. The black circle indicates our preferred site for the working portal in the case of an iliopsoas tendon release at the lesser trochanter. The white circle indicates our preferred site for the working portal in the case of a transcapsular iliopsoas tendon release.