The modified mid-anterior portal for hip arthroscopy

Abstract

The modified mid-anterior portal is a utilitarian hip arthroscopy working portal that permits dual-portal comprehensive surgery for femoroacetabular impingement and related chondrolabral procedures without the need for interportal exchange. Its distal location facilitates labral reparative and reconstructive procedures while minimizing iatrogenic acetabular chondral damage. The relatively lateral location permits instrument navigation not only along the anterosuperior acetabular rim and anterolateral proximal femur typically required for acetabuloplasty and femoroplasty but even to the posterior regions of the hip in cases of global pincer femoroacetabular impingement and posterior extensions of cam morphology and the anteromedial proximal femur while avoiding direct injury to the lateral femoral cutaneous nerve.

Fig 1

MMAP in relation to other common portals in a right hip. One should note their relation to the anterior superior iliac spine and greater trochanter skeletal landmarks. (ALP, anterolateral portal; W, posterolateral portal; X, anterior portal; Y, mid-anterior portal; Z, distal anterolateral accessory portal.)

Fig 2

Favorable angle of approach for acetabular rim preparation (drilling) and suture anchor placement for labral reparative and reconstructive procedures, shown in a right hip.

Fig 3

External view of a supine right hip showing the 70° arthroscope in the ALP and the plastic cannula in the MMAP during arthroscopic osteosynthesis of a femoral head fracture. One should note the use of 2 guide pins for percutaneous insertion of headless screws.

Fig 4

Supine arthroscopic view of right hip from ALP during global acetabuloplasty for severe global pincer FAI. One should note the posterior acetabular rim (AR) and the burr (Flat-top; Smith & Nephew, Andover, MA) resecting a remnant of posterior rim (asterisk) inferior to the direct posterior 9-o'clock location (9). Circumferential labral reconstruction was then performed. All procedures were performed through the MMAP.

Fig 5

Supine arthroscopic view of right hip from ALP after arthroscopic posterior cam decompression. One should note the region of anterolateral (AL) and posterolateral (PL) femoroplasty. The latter is proximal to the retinacular vessels (asterisk) supplying the femoral head (FH).

Fig 6

Supine arthroscopic view of right hip from ALP during arthroscopic internal fixation of anterior column acetabular fracture. The 2 large-fragment cannulated screws (arrow) were inserted through the MMAP. Concurrent arthroscopic femoroplasty, acetabuloplasty, and labral refixation were performed. (AR, acetabular rim; FH, femoral head; L, labrum.)