Introduction

Hip arthroscopy was first performed in our practice with the use of the supine approach on a fracture table for distraction. During our early experiences, problems of getting into the hip joint and complications such as the scuffing of articular cartilage, poor maneuverability, and the inability to achieve the result before extensive extravasation made the procedure difficult. Specific instruments were not developed, and distraction parameters were not established. As a result, the procedure was not predictable for entering the intra-articular space that is now known as the central compartment. In 1931, Burman was the first to use an arthroscope in the hip in a cadaveric study. However, he was unable to enter the central compartment, even with distraction. Our associate James M. Glick, MD, performed 11 procedures between 1977 and 1982, and he had difficulty getting in on two occasions. Because of our experience with the lateral decubitus positioning in total hip replacements, the idea of approaching hip arthroscopy in a similar way was developed. We dissected a cadaver hip to determine the most direct access to the intra-articular space, and we then described the anterior–peritrochanteric and posterior–peritrochanteric trochanteric portals (Figure 10-1); these have subsequently been referred to as the anterolateral and posterolateral portals. In 1986, distraction was introduced by Erikkson with the use of a fracture table to facilitate entry into the central compartment. We developed a rope-and-pulley system with weights as we used for shoulder arthroscopy as our first hip distractor (Figure 10-2). The first patient in whom we performed arthroscopy with the lateral approach was a massively obese woman with hip pain in whom Dr. Glick had previously performed arthroscopy without success in the supine position. In the lateral decubitus position, the obese portions of her thigh drooped down to expose a prominent greater trochanter. The neurovascular structures are safely away from the portals, and the surgeon is very familiar with their location; these portals offer a direct shot into the femoroacetabular joint. Many of the surgeons interested in hip arthroscopy at that time adopted the technique and continue to use it today.

Figure 10–1 The original cadaver dissection performed by James M. Glick and Thomas G. Sampson to develop the portals for the lateral approach.

Figure 10–2 The first hip distractor design. This design makes use of Buck’s traction as a leg holder that is suspended with ropes and pulleys from the ceiling and the wall, with more than 45 lb of weight.

In response to industry’s interest in developing arthroscopic instruments and distractors, the supine approach was once again used and described by Byrd. There have been editorials, journal articles, and book chapters that argue the benefits of one as compared with the other, and it is my opinion that the approach that is used should be based on the training and comfort level of the surgeon. All procedures that involve hip arthroscopy are done with the use of both techniques in equal measure, and complications are not technique specific. A distractor (Hip Positioning System; Smith & Nephew, Andover, MA 01810) has been designed to be used on any operating room table for both techniques, and all instruments designed for hip arthroscopy can be used for patients who are in either position.

The major advancements in getting into the central compartment were a result of distraction and the use of Nitinol wire cannulated trochars (Figure 10-3). Later, the development of longer arthroscopes, slotted (half-pipe) cannulas, and curved and flexible instruments allowed for advanced techniques that have followed a similar path as those used for knee and shoulder arthroscopy.

Figure 10–3 The arthroscope has a shortened hub, and the hip trochar is cannulated for a Nitinol wire. Note that the Mayo stand is above the patient’s shoulder and that it is used to keep the instruments organized for easy access by the surgeon.

Indications

As Thomas Byrd said, “the key to successful results most clearly is proper patient selection.” In our practice, we believe that the patient’s expectations should match the surgeon’s. Hip arthroscopy during the early 1980s was felt to be a procedure looking for indications. Clearly, the list of indications has grown with the advancements of the technique.

Surgical technique

Patient Positioning

The patient is placed on a well-padded operating room table in the lateral decubitus position (Figure 10-4). An axillary roll is positioned, and hip positioners are used to support the pelvis. By preventing the pelvis from rolling back on the perineal post, the risk of pudendal neuropraxias may be reduced.

Figure 10–4 The room setup for the lateral approach. The surgeon stands anterior, although some prefer to be posterior if they perform total hip procedures from the posterior approach. The assistant works from the opposite side, and the scrub technician is to the side of the surgeon. The C-arm lies below the table throughout the case, and a Mayo stand is placed above the patient’s shoulder for instruments. IIT, image intensifier.

The foot is wrapped with padding, and the foot holder is applied, with care taken to avoid skin pinching by the device. The leg is held in abduction by the assistant during the careful placement of the well-padded perineal post. We have determined that the post should have an outer diameter of more than 9 cm for safety; commercially available hip distractors all exceed this size. The genitalia are inspected to ensure that they are free from compression. The foot holder is applied to the distraction arm, and only enough traction is applied to support the leg.

The fluoroscopic C-arm is brought in with the apex under the table and centered at the level of the greater trochanter. Preoperative x-rays are performed to check positioning and hip anatomy. A trial of distraction will be of benefit for two reasons: 1) to check for the distractibility of the joint and 2) to ensure that the foot is properly secured in the foot holder. If the hip does not distract well, this may be the result of a tight or hypertrophic capsule, and a few minutes of traction may allow the hip to relax. Failure to distract may require greater forces of distraction, or it may necessitate capsulotomy. If the foot slips out of the holder during the trial, less padding may help to prevent slippage. Adequate security of the foot in the holder is imperative to prevent an accidental release of the distraction when the instruments are in the central compartment, which may result in iatrogenic articular cartilage damage.

Sticky towels or drapes are placed from the iliac crest to 6 inches below the greater trochanter and from a sagittal line lateral to the anterior superior iliac spine anterior and the sciatic notch posterior.

The anesthesiologist is at the head of the table, the surgeon stands anterior, and the assistant stands posterior. The scrub technician stands next to the surgeon, with the C-arm in between them. A Mayo stand is placed above the patient’s shoulder for easy accessibility to the instruments and for the organization of the arthroscopic cords.

We typically drape with split sheets, and we use a large plastic pouch to catch fluids.

Distraction

For optimal viewing and safe surgery, at least 1.2 cm of distraction is required before the femoroacetabular joint (central compartment) is entered. Three commercially available distractors for the lateral approach are available from Mizuho OSI (Union City, CA 94587-1234), Innomed, Inc. (Savannah, GA, 31404), and Smith & Nephew. The Mizuho OSI and the Smith & Nephew distractors have the advantage in that hip mobility is adjustable during surgery (Figure 10-5).

Figure 10–5 A commercially available lateral hip distractor made by Smith & Nephew.

Not all distractors have a tensiometer to measure the force of distraction. Distraction should be thought of in the same way as a tourniquet. James M. Glick, MD, demonstrated that, with the use of evoked potentials, forces of less than 75 lb for less than 2 hours were safe and did not cause permanent neuropraxias. In our practice, we have performed more than 750 procedures without a tensiometer, with care taken to keep the distraction time to a minimum; we have had no neuropraxias. We try for traction of less than 50 lb and for less than 1 hour to allow for a large margin of safety. It is important to realize that complications may occur from too little or too much traction and that, to accomplish the procedure, the joint surfaces must be separated for the introduction of instruments.

The perineal post should have padding of at least 9 cm in diameter, and it should be positioned eccentrically over the pubic symphysis, with little to no compression to the downside thigh (Figure 10-6).

Figure 10–6 A patient’s right leg being placed in the hip distractor. Note the posterior hip positioner, the large perineal pad, and the foot padding. The axillary roll cannot be seen in this photograph.

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