Hip Arthroscopy With Initial Access to the Peripheral Compartment: A Detailed Step-by-Step Technique Description

Abstract

Hip arthroscopy with initial access to the peripheral compartment represents a specific technique to approach the hip that can be particularly useful. This technique is suitable for both the arthroscopic treatment of femoroacetabular impingement syndrome and other pathologies that can be addressed by classic arthroscopy with central compartment initial access. Minimal capsulotomies preserve the fluid pressure in the peripheral compartment, which allows the "ballooning" of the capsule and improved joint exposure with decreased risk of fluid extravasation. In the vast majority of cases, the hip joint can be accessed by any technique depending on the surgeon preference/expertise. Interestingly, access to the central compartment under direct arthroscopic visualization decreases the risk of iatrogenic labral and chondral damage. This is particularly important when access to the central compartment is technically challenging (e.g., acetabular overcoverage, labral hypertrophy, and limited joint distraction). Such a technique is also preferable if the pathology is mainly located in the peripheral compartment. Despite several advantages, hip arthroscopy with initial access to the peripheral compartment is not a commonly performed technique. Our purpose is to perform a step-by-step explanation of a previously described technique.

Fig 1

Image intensifier picture of a right hip with the patient in supine position in a traction table. Starting at the proximal anterolateral portal, an arthroscopic needle is introduced to the anterior femoral head–neck junction under fluoroscopic control.

Fig 2

Peripheral compartment image of a right hip, viewing lateral and distal from the proximal anterolateral portal. A capsular thinning is performed with a shaver in the anterior portal. Minimal capsulotomies preserve fluid pressure to allow the “ballooning” of the capsule and increase cam exposure. (A, anterior; D, distal; Fn, femoral neck; Lc, lateral capsule, P, posterior; Pr, proximal.)

Fig 3

Portals, instruments positions, and arthroscopy image of a right hip viewing lateral and proximal from the proximal anterolateral portal. Lateral femoral osteoplasty is done with the hip in extension, the burr in the anterolateral portal, and a switching stick in the anterior portal to push the capsule laterally. Traction is used to displace the femoral head from the labrum when proximal osteoplasty is needed. (A, anterior; AL, anterolateral portal; An, anterior portal; D, distal; Fh, femoral head; P, posterior; PAL, proximal anterolateral portal; Pr, proximal.)

Fig 4

Right hip, viewing lateral and proximal from the proximal anterolateral portal. Using the switching stick in the anterior portal to push the lateral capsule, central compartment access is established from the anterolateral portal. (A, anterior; D, distal; Fh, femoral head; L, labrum; P, posterior; Pr, proximal.)

Fig 5

Right hip, viewing lateral and proximal from the proximal anterolateral portal. From the anterolateral portal an arthroscopic needle is introduced into the central compartment underneath the hypertrophic labrum. (A, anterior; D, distal; Fh, femoral head; L, labrum; P, posterior; Pr, proximal.)

Fig 6

Right hip, viewing lateral and proximal from the proximal anterolateral portal. Acetabular osteoplasty is performed in the peripheral compartment with the burr in the anterolateral portal to increase the clearance for the central compartment access. (A, anterior; D, distal; L, labrum; P, posterior; Pr, proximal; Rim, acetabular rim.)

Fig 7

Right hip, extra-articular aspect of the capsular defect, viewing from the proximal anterolateral portal. The capsule can be repaired with sutures using a suture-management device plus an arthroscopic canula in the mid-anterior portal. (A, anterior; D, distal; P, posterior; Pr, proximal.)