Specialized distractors have been developed that can be applied to a standard operating room table (Fig. 23.1B). These are especially applicable in the outpatient setting where a fracture table would not normally be available. Otherwise, most standard fracture tables can accommodate the few specific needs of hip arthroscopy (Fig. 23.1A). A tensiometer is a helpful tool that can be incorporated into the foot plate. This is especially useful for monitoring the intra-operative ability to maintain adequate distraction. A large-sized perineal post with generous padding more safely distributes the pressure on the perineum and facilitates lateralization of the operative hip.

An image intensifier is used for all cases. This is important for assuring precise portal placement. Simply accessing the joint is often not difficult. More important is care and
precision in portal placement to minimize the risk of iatrogenic damage.

Both the 30-degree and 70-degree arthroscopes are routinely used to optimize visualization. Interchanging the two scopes allows excellent visualization despite the limited maneuverability caused by the bony architecture of the joint and its dense soft tissue envelope. The 30-degree scope provides the best view of the central portion of the acetabulum and femoral head and the superior portion of the acetabular fossa, whereas the 70-degree scope is best for visualizing the outer edges of the joint, the acetabular labrum, the capsule, and the inferior portion of the fossa.

A fluid pump provides significant advantages in the hip. A high flow system can provide optimal flow without having to use excessive pressure. This is important for visualization and safety. Adequate flow is essential for good visualization necessary to perform the procedure effectively and in an expedient manner. Flow cannot be as precisely modulated with a gravity system, creating difficulties both with visualization and extravasation. However, the surgeon must always be cognizant that the pump is functioning properly. Different pumps perform and behave differently and it is important to be familiar with the traits of a given pump before using it on complex hip procedures.

Extra-length cannulas are specifically designed to accommodate the dense soft tissue envelope that surrounds the hip (Fig. 23.5). The extra length has been accomplished by shortening the accompanying bridge which allows these cannulas to be used with a standard arthroscope. For extremely large patients, there are also special extra-long scopes (Fig. 23.6). Cannulated obturators allow passage of the
cannula/obturator assembly over a nitinol guide wire prepositioned in the joint through 6″, 17-gauge spinal needles (Fig. 23.7). The scrub nurse’s Mayo stand contains the instruments routinely needed for each case (Fig. 23.8). The 5-mm cannula is used for initial introduction of the arthroscope while the inflow is attached. The diameter allows adequate flow for the fluid management system attached through the bridge. Once all three portals have been established, the inflow can be switched to one of the other cannulas and the 5-mm cannula replaced with a 4.5-mm cannula. The use of three 4.5-mm cannulas allows complete interchangeability of the arthroscope, instruments, and inflow. The 5.5-mm cannula is available for larger shaver blades.

Extra-length blades are available. Curved designs can be useful for maneuvering within the spherical geometry of the joint. These can be passed through slotted cannulas (Fig. 23.9) which accommodate the curved shaver blades as well as other hand instruments.

Thermal devices demonstrate specific advantages in the hip. The small diameter and flexible designs allow access to recesses within the joint difficult to access with mechanical blades (Fig. 23.10). Also, because of the limits on maneuverability, it can be difficult for the shaver to excise damaged articular cartilage or labrum and create a stable edge. Thermal devices are often much more effective at creating a smooth transition zone, preserving more healthy tissues.