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Stepwise Safe Access in Hip Arthroscopy in The Supine Position: Tips and Pearls From A To Z
Stepwise Safe Access in Hip Arthroscopy in The Supine Position: Tips and Pearls From A To Z
Abstract
David R. Maldonado, MD Hip arthroscopy is rapidly growing as a treatment with good outcomes
Philip J. Rosinsky, MD for pathologic conditions such as femoroacetabular impingement
syndrome and labral tears. At the same time, it is one of the most
Jacob Shapira, MD
technically challenging and demanding procedures in orthopaedics
Benjamin G. Domb, MD
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Stepwise Safe Access in Hip Arthroscopy
who are making their early steps in described for both the supine and risk of skin and nerve damage.15
this demanding discipline, with the lateral positions.9,10 The force Second, when using a perineal post,
“tips and pearls” for safe and con- required to achieve adequate dis- the decreased traction force also re-
sistent access to the central com- traction changes throughout the lieves the pressure between the post
partment of the hip. The authors procedure. Initial distraction force and the perineum, thereby lowering
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present their expertise that they have ranges from 444 N in women to the risk of injuries caused by direct
accrued throughout their years of 517 N in men. This force decreases pressure.17 Our results on patient
practice. by an average of 17% after capsu- positioning demonstrated a reduc-
lotomy.11 One of the potential tion in perineal pressure of 15.5%,
complications of using a perineal 28%, and 46% at 5, 10, and 15 of
Patient Positioning post is damage to the pudendal and Trendelenburg compared with 0 (ie,
the perineal nerves.12 A systematic no Trendelenburg), respectively,
Positioning is the key for any ortho-
review by Habib et al13 which without compromising the spatial
paedic procedure, but this is particu-
included 3,405 hip arthroscopies anatomic perception of the sur-
larly true for hip arthroscopy. Supine
found the risk of pudendal nerve geon.18 We propose the use of 8 to
and lateral decubitus positions have
injury to be 1.8%, although all cases 10º of Trendelenburg inclination, a
C38eQrx1fVrTklTr on 04/30/2023
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David R. Maldonado, MD, et al
Fluoroscopy, Is It
Necessary? the operating bed (Figure 2 and avoid this, ensure that the pubic
Video, Supplemental Digital Content symphysis is displayed in a vertical
Radiation exposure is always a con- 1, http://links.lww.com/JAAOS/ position on the monitor. The authors
cern in hip arthroscopy. It has been A496). The authors find the second recommend using this pearl after
reported that the mean intraoperative option more convenient and repro- each time traction is applied to the
radiation dose to patients in hip ducible not only for the purpose of operated leg because it may alter the
arthroscopy is 12.6 mGy, a value that joint access but also for other parts position of the pelvis.5,18
is below the threshold for radiation of the procedure such as femo-
associated complications.20 Alterna- roplasty and subspine decompres- Key Points and Pearls
tively, the lifetime risk of death sion. This allows the C-arm to move
because of malignancy is 0.025% for freely to obtain several views for
(1) Place the C-arm on the non-
the operating room staff because of a bony correction purposes.25
surgical side at an angle that is
cumulative exposure to radiation.21
perfectly perpendicular to the
According to Smith et al, exposure to C-arm and Patient Pelvic patient’s body (Figure 2).
fluoroscopy decreases with time and Position (2) Compensate for the patient’s
practice.19 Although accessing the hip
As mentioned previously, the authors Trendelenburg position by
joint without the use of fluoroscopy
modified the supine position of the cephalically tilting the C-arm.
has been described,22 the authors of
patient by applying Trendelenburg to (3) Check the patient’s pelvic rota-
this review think fluoroscopy is crit-
the operating bed; however, the tion by obtaining an AP pelvis
ical for reproducing safe access and
C-arm must be cephalically tilted to view centered on the pubis.
diminishing the risk of iatrogenic
avoid obtaining inlet views because (4) Once pelvic rotation is checked,
damage to the labrum and the artic-
of the angular displacement. This will move the C-arm forward to the
ular cartilage.23 Alternatively, the use
provide a true AP view.5 surgical side and obtain an AP
of ultrasonography has been pro-
hip view.
posed. Although this concept is
potentially promising, the success of Do Not Get Lost Before You
this method is heavily dependent on Even Start! Correcting Pelvic Venting the Hip Joint
the operator’s experience.24 Rotation
It is critical to obtain a true AP pelvis Importance of Hip Joint
C-arm Location in the view when assessing the hip joint Venting
Operating Room during an arthroscopic procedure. Breaking the seal of the hip joint is
When supine position is selected, the When the surgeon attempts to esti- vital to successfully accessing the
C-arm can be placed either between mate the spinal needle trajectory, the joint arthroscopically. Venting the
the patient legs or on the nonsurgical smallest degree of pelvic rotation can joint neutralizes the normal negative
side of the patient, perpendicularly to lead to unnoticed misdirection. To pressure of the hip joint, thereby
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Stepwise Safe Access in Hip Arthroscopy
Figure 2
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C38eQrx1fVrTklTr on 04/30/2023
Phtographs showing A, Trendelenburg is applied to the surgical table using a perineal post in preparation to a right hip (*)
arthroscopy. The C-arm (black arrow) is placed on the nonsurgical side of the patient, perpendicularly to the operating bed.
The arm in the surgical side is padded and placed just above the level of the umbilicus with 90 flexion of the elbow (white
arrow). B, From another perspective, the C-arm (black arrow) and arm in the surgical side (white arrow) are shown view in
preparation to a right hip (*) arthroscopy. C, The surgical table has been “airplane” away from the surgical side, right hip (*) in
this case. C-arm (black arrow).
enabling to increase the intra- anterolateral portal, their exact iatrogenic injury is relatively high
articular space without the necessity position will rarely coincide.5 and (2) the location of this portal will
of applying an excessive traction determine the placement of the other
force to the leg.23 Key Points and Pearls portals, for example, the midanterior
and distal anterolateral accessory
Venting Technique (1) Check pelvic rotation before (DALA) portal.
Using the ASIS as a landmark, venting.
advance the spinal needle with the (2) For venting purposes, use a Anatomic References
bevel facing toward the femoral head small diameter spinal needle. Traditionally, the greater trochanter
until the capsule is reached. A true The authors find that a 18 G · (GT) is commonly used as an ana-
“12-O’clock” position can be con- 3.5-inch pink spinal needle (BD, tomic landmark to establish the
firmed when the surgeon has a tactile Franklin Lakes, NJ) is reliable anterolateral portal. The antero-
feeling of reaching the capsule, for this step. lateral portal is routinely placed 1 to
although the needle is not over- (3) Pelvic rotation is usually altered 2 cm anterior and 1 to 2 cm superior
lapping the joint (Figure 3 and after venting and the initial to the tip of the GT.26 However, the
Video, Supplemental Digital Content application of traction. Re- GT location and its relationship to
1, http://links.lww.com/JAAOS/ checking pelvic rotation is vital. the hip joint change depending on leg
A496). After confirming the “12- rotation and traction; furthermore,
O’clock” position of the needle the cervico-diaphyseal angle and
with fluoroscopy, gently perforate Hip Arthroscopy Portals neck length also affect GT spatial
the capsule. The presence of an air- location regarding the hip joint. In
arthrogram after removing the stylet Anterolateral Portal addition, in large patients, the
confirms that the suction seal of the The anterolateral portal is classically excessive soft-tissue makes GT pal-
joint has been broken. Traction the first portal to be established in hip pation difficult, leading to misjudg-
should then be applied until at least arthroscopy.8 There are two reasons ment. The authors have found that
10 mm of intra-articular space is which make this portal unique when the ASIS is a more reliable bony
gained. The surgeon must keep compared with the others: (1) it is landmark (Figure 4 and Video,
in mind that while the venting entry not performed under direct visuali- Supplemental Digital Content 1,
point serves as a guide for placing the zation as such because the risk of http://links.lww.com/JAAOS/A496).
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
David R. Maldonado, MD, et al
Unlike the GT, the ASIS is unaffected anterior and posterior aspect of the Figure 3
by leg rotation and its exact location capsule by palpating the capsule
is more readily identifiable by pal- using the spinal needle and con-
pation, irrespective of the patient firming the position by fluoroscopy.
size.5 By palpating the two ASIS, the When the position is confirmed, the
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Stepwise Safe Access in Hip Arthroscopy
Distal Anterolateral
Accessory Portal
C38eQrx1fVrTklTr on 04/30/2023
Photograph showing RH in the supine position. Anterosuperior iliac spine is After completion of the capsulotomy
drawn and marked with the *. AL—12-O’clock—portal; MA portal; DALA portal; P using the anterolateral and the mod-
portal. AL = anterolateral, DALA = distal anterolateral accessory, MA = ified midanterior portal, the decision
midanterior portal, P = posterolateral, RH = right hip of labral treatment should be con-
cluded. Both labral repair and
reconstruction necessitate the place-
Figure 5
ment of anchors in the acetabular
rim. The DALA portal provides the
required “attack angle” because it is
less steep and therefore safer than the
modified midanterior for capsular
elevation and anchor placement.29
The DALA portal has been shown to
decrease the risk of intra-articular
penetration during anchor drilling or
placement.23 In addition, the spatial
relationship and distance relative to
the anterolateral and the modified
midanterior portal should be con-
Photograph showing the right hip showing the ideal location of the 12-O’clock sidered to avoid “cross-hands” dur-
position in the AP view. A, Plastic model. B, Fluoroscopy. ing anchor placement. The three
portals should form an inverted
correction and anchor placement, medial acetabular rim, beyond the equilateral triangle, with the DALA
placing it 3 cm anterior and 4 to 5 cm 2:30-O’clock position, when needed. portal forming the distal apex and
distal to the anterolateral portal.28 the anterolateral and modified mid-
The authors advocate using the anterior forming the proximal apices
midanterior portal; however, it is Key Points and Pearls (Figure 4). In the authors’ hands,
preferable to establish this portal 3 suture managing becomes more
to 4 cm anterior and in line with the (1) Because this portal is made based reproducible by the use of three
anterolateral portal (Figure 4). This on the location of the antero- portals, especially in avoiding su-
portal is useful to initiate the lateral portal, it is critical that tures tangling. Nevertheless, this is
capsulotomy from the 1- to 2- the anterolateral portal is accu- not a requirement and labral repair
O’clock position (Video, Supple- rately situated in the 12-O’clock and even segmental labral recon-
mental Digital Content 1, http:// position. struction can be performed using just
links.lww.com/JAAOS/A496) and (2) Make the incision first before two portals (anterolateral and
for anchor placement in the most advancing the long spinal needle midanterior).30
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
David R. Maldonado, MD, et al
Figure 6
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C38eQrx1fVrTklTr on 04/30/2023
Photograph showing fluoroscopy sequence during the 12-O’clock portal placement in a right hip. Patient in the supine
position. A, Spinal needle is introduced before hip traction. B, Hip is vented, and gentle traction is applied. C, Long spinal
needle is repositioned as close as possible to the femoral head. D, Guidewire is inserted. E, 4.0 mm cannulated dilator is
introduced until the capsule is reached. F, Before advancement of the dilator, the guidewire is partially retrieved.
Key Points and Pearls valid tool for assessing the tra-
Posterolateral Portal jectory of hardware introducing
(1) Although anatomic reference through this portal.
In the authors’ hands, the postero-
points are important, the DALA lateral portal is used particularly for
portal position is mostly based on labral reconstruction and for the Alternative Access
the position of the anterolateral treatment of pertrochanteric patholo- Techniques
and modified midanterior portal. gies, such as gluteus medius tears. This
(2) It is easier to triangulate by portal is placed 3 to 4 cm posterior and These alternatives are (1) inside-
incising the skin before using the in line with the anterolateral portal out—going to the peripheral com-
long spinal needle. (Figure 4). Although the sciatic nerve is partment first32—and (2) outside-in
(3) In the authors’ experience, the potentially at risk during the use of this (extracapsular) which can also be
DALA portal is ideal for anchor portal, this remains a relatively safe used routinely if desired.33 In our
placement, especially from the portal. Thorey et al31 reported a mean experience, these options are partic-
2:30- to 9-O’clock positions. As distance of 3.5 cm from the postero- ularly useful in cases of difficult
previously mentioned, beyond lateral portal to the sciatic nerve. access such as acetabular over-
the 2:30-O’clock position, the coverage (lateral center-edge angle $
angle provided by the mid- 39) and in cases where adequate
anterior portal is usually better Key Points and Pearls joint distraction is not feasible.34
for anchor placement purposes.
(4) Although not mandatory, (1) Avoid using the spinal needle in Inside-out Peripheral
introducing a cannula through the multiple directions; this may Compartment First
DALA portal is extremely useful increase the risk of neuro- Positioning the patient is accom-
in elegant suture management. vascular injury. Fluoroscopy is a plished similarly to the traditional
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Stepwise Safe Access in Hip Arthroscopy
approach. However, as described by (3) T-capsulotomy, inverted the most technically demanding
Dienst et al,32 no traction is applied T-capsulotomy, or H-capsu- procedures in the field of joints
to the surgical leg which is placed in lotomy can be used to improved preservation. Recently, it has been
20 to 30 of flexion. This maneuver visualization if needed. shown that the hip arthroscopy
relieves the tension in the peripheral technically demanding skill is
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compartment, allowing for a more Outside-in (Extracapsular) astonishingly steeper than the pre-
comfortable approach to this com- viously thought. Access to the hip
Unlike the two “inside-out” methods
partment. The authors’ preference is joint is the first challenge that sur-
previously described, this technique
to flex the hip after marking the geons must confront in hip arthros-
is initiated from the extracapsular
anterolateral and midanterior por- copy. Nevertheless, it can be
space. This is particularly useful for
tals, using the same landmarks pre- performed in a safe and reproducible
extreme cases of an overcoverage.
viously mentioned. Using fashion. To achieve this goal, a
The patient is positioned as previ-
fluoroscopy, the long spinal needle is thorough understanding of the hip
ously described; the surgical hip joint
introduced perpendicularly to the anatomy is crucial. Navigating
is vented and the anterolateral and
femoral neck axis and directed distal through the technical concepts and
midanterior portals are marked
to the femoral head-neck junction. pearls brought in this review will
C38eQrx1fVrTklTr on 04/30/2023
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David R. Maldonado, MD, et al
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