Arthroscopy

Indications

 

Removal of loose / foreign bodies

 

Hip Scope Loose BodyHip Scope Loose Body RetrievalHip Loose Body

 

Synovial biopsy / subtotal synovectomy / synovial chondromatosis

Management of labral tears / CAM Lesions

Osteochondritis dissecans / chondral lesions

Treatment of pyarthrosis

 

Position

 

Supine 

Lateral decubitus

II and traction

 

Hip Arthroscopy Set up

 

Distraction

 

Forces

- both longitudinal & lateral in direction with vector parallel to femoral neck

- force required to distract femoral head varies considerably 

- range from 25 lb to 200 lb in unanesthetised adult volunteers

- majority performed with 50 lb (225 N) or less 

- important to limit periods of distraction with higher forces

 

Aids

1.  GA & skeletal muscle relaxation

2.  Negative intra-articular pressure

- released via joint capsule puncture with spinal needle + saline

- reduces force for distraction by 1/2

- "vacuum effect"

 

Portals

 

Anterolateral

- viewing portal

 

Anterior

- working portal

 

Posterolateral

- working portal

 

Portal Placement

 

Hip Arthroscopy DistractionHip Arthroscopy InsufflationHip Arthroscopy Trochar InsertionHip Arthroscopy Cannular

 

Anterolateral portal / viewing portal

 

Anterolateral Portal 1Anterolateral Portal 2Anterolateral Portal 3

 

Insertion point

- 2 cm anterior to GT

- superior aspect of GT

 

Inserted under fluoroscopic guidance

- spinal needle directed medially & superiorly at 45° in each plane

- aim towards sourcil but under labrum

- joint distraction increases space in joint

- joint distended with normal saline

- guide wire inserted / blunt trochar / cannula

 

Dangers

- LFCN - may result in partial or complete neuropraxia

 

Hip Arthroscopy Anterolateral InstrumentationHip Scope Air Arthrogram

 

Anterior portal / working portal

 

Anterior Portal 1Anterior Portal 2Hip Scope Nerves at Risk

 

Intersection of perpendicular lines

- superior aspect of GT and inferiorly from ASIS

 

Inserted under direct vision

- guide wire / trochar / cannula

 

Dangers

- femoral NV bundle is 3 to 4 cm medial to insertion site 

- if placed inferior to neck ascending branch of lateral femoral circumflex artery is at risk

 

Hip Scope Anterior PortalHip Scope Anterior Portal 1Hip Scope Anterior Portal 2

 

Posterolateral Portal

 

Insertion point

- 2 cm posterior to GT

- level with superior border GT

 

Uses

- insert drainage portal

- improves visualisation

 

Danger

- sciatic nerve especially if foot ER during insertion

 

Posterior PortalHip Scope Nerves at Risk 2

 

Examination

 

Central compartment

- femoral head in acetabulum

- examine chondral surfaces

- examine labrum / debride / repair

 

Hip Arthroscopy Central Compartment

 

Peripheral

- head neck junction

- hip flexed, traction removed

- capsulotomy often required

- removal of CAM lesions

 

Hip Arthroscopy Peripheral Compartment

 

Complications

 

Nerves

 

LFCN - anterolateral portal

Pudendal - traction

Sciatic - from traction / posterolateral portal

 

Pressure necrosis

 

Foot, scrotum, or perineum 

 

Cartilage

 

Scuffing of articular surfaces 

 

Infection

 

Rare