Principles of Hip Arthroscopy

Preoperative Preparation

• Thromboembolic deterrent (TED) stockings are placed on both lower extremities 2 in below the level of the fibular head to avoid compression of the peroneal nerve.

• Hair on the operative extremity is trimmed medially to 1 in medial to the anterior superior iliac spine (ASIS), posterolaterally to the midbuttock, proximally to 2 in proximal to the inguinal crease and distally to 6-8 in distal to the inguinal crease.

• All preoperative imaging studies (XR, CT, and/or MRI) should be available for viewing in the OR.

Anesthesia

• Before surgery, the anesthesia plan is discussed with the appropriate anesthesia provider.

• Endotracheal intubation rather than a laryngeal mask airway is recommended.

• Muscular paralysis is induced.

• The goal is systolic blood pressure of ˜100 mm Hg.

Patient Positioning, Fluoroscopy, Traction, and Draping

• Hip arthroscopy can be done with the patient in a supine or lateral position. We prefer supine positioning using a commercially available fracture table or table extension to provide traction.

• On the contralateral (non-operative) extremity, large pads are placed on the heel and dorsal and plantar aspects of the foot. On the operative extremity, a single pad is placed on the dorsal foot, and the foot and ankle are wrapped with self-adherent (Coban, 3M, St. Paul, MN) wrap to prevent slippage in the boot.

• Both feet are placed in the traction boots so that the heels are all the way down in the boot. The boot is closed as tightly as possible and secured with cloth tape.

• The patient is positioned so the operative extremity is against a well padded perineal post and then distally, so that the perineum abuts the post as well.

• The nonoperative extremity is abducted to 45 to 60 degrees and the operative extremity to 10 degrees. Both extremities should be placed in neutral rotation (patella facing ceiling) and alignment in the sagittal plane (no flexion or extension). Some surgeons prefer 15-20 degrees of internal rotation to place the femoral neck parallel to the ground and 10-20 degrees of hip flexion (Fig. 30-1).

• A clear nonsterile U-drape is placed from inferior to superior, on the far side of the umbilicus, medial to the ASIS, and as far posteriorly along the buttock as possible, and a clear nonsterile sheet is placed transversely at the level of the umbilicus.

Figure 30-1 | Patient positioned supine for right hip arthroscopy. Note the perineal post is lateralized toward the operative hip. The operative hip is positioned in 10 degrees of abduction, as well as neutral rotation and neutral flexion/extension. The nonoperative hip is abducted 45-60 degrees to allow the fluoroscopic monitor to be positioned to assist with the surgery.

• The fluoroscopy machine should come between the patient’s legs.

• Traction with just body weight is placed on the nonoperative extremity to help lateralize the operative extremity. Gross traction is placed on the operative extremity, followed by fine traction to subluxate the hip (usually10 to 50 lb of traction for 8-10 mm of hip joint distraction).

Approach and Arthroscopic Portals

• The anatomic structures are not outlined and no arthroscopic portals are made until traction is applied (Fig. 30-2).

Figure 30-2 | Right hip with surgical marker outlining the greater trochanter, ASIS, and #1 intersection of line going distal from ASIS and line going transverse at the tip of the greater trochanter, #2 anterior portal, #3 anterolateral portal, #4 posterolateral portal, #5 modified anterior or mid-anterior portal, #6 distal anterolateral portal, and #7 distal portal for endoscopic iliopsoas lengthening at the lesser trochanter.

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