Basic Hip Arthroscopy Part 1: Patient Positioning and Portal Placement

Abstract

Over the past decade, hip-preservation strategies have gained momentum, resulting in a notable increase in the use of hip arthroscopy for diagnostic and therapeutic interventions in hip-related pathology. In this 3-part series, the authors will aim to comprehensively review the fundamentals of hip arthroscopy in the setting of femoroacetabular impingement. While considering the advantages and disadvantages of post versus postless hip arthroscopy, this Technical Note will review the preferred patient and portal positioning approach used by the senior authors.

Fig 1

Surgical-site image demonstrating adequate patient positioning before a right hip arthroscopy. As depicted, the anterior superior iliac spine (ASIS) should be parallel to the widest part of the pink pad/surgical table.

Fig 2

Surgical-site image demonstrating the surgical limb in a traction boot tightly wrapped around with Coban wrap. The limb is positioned in extension, 10° to 15° of leg adduction (ADD), and 20° to 30° of foot internal rotation (IR) to achieve adequate distraction. Adequate distraction (8- to 10-mm space creation) is assessed intraoperatively with the use of fluoroscopy through a mini-C-arm.

Fig 3

(A) Draping starts by placing a nonsterile “U” drape with the open “U” portion of the drape facing cephalad as depicted in this surgical-site image of a right hip. The lateral vertical edge of the “U” drape should be attached to the skin at the edge of its junction with the surgical table, whereas the medial vertical portion should attach to the proximal and medial most aspect of the patient’s thigh and continued vertically in a cephalad manner. Lastly, the curved portion of the “U” drape should sit wrapped around the patient’s thigh. (B) After scrubbing the right surgical limb, four 10 × 10-inch sterile drapes are placed on the inside surface of the previously positioned “U” drape in hopes of establishing sterile boundaries (inside of solid black line). The superior and inferior 10 × 10 drapes should be positioned perpendicular to the patient’s surgical limb at the level of the umbilicus and midthigh, respectively, thus allowing for adequate surgical exposure. (C) An antimicrobial Ioban wrap (Ioban; 3M) is placed over the previously established sterile surgical area boundaries. Note that the anterior-superior iliac spine (ASIS) lies at the level of the widest part of the pink pad and surgical table. (D) Surgical-site image of a sterilely draped right hip showing intra-articular needle verification for disruption of the hip’s native negative pressure. On joint entrance, hip venting is performed for allowance of an additional centimeter of surgical hip distraction.

Fig 4

Surgical-site image of patient positioning in a perineal post-assisted hip arthroscopy of the right hip. Notice the parallel location of the anterior superior iliac spine (ASIS) with the widest portion of the surgical table.

Fig 5

Cadaveric dissection of a right hip demonstrating the regional neurovascular bundle. The lateral cutaneous femoral nerve (LCFN) lies 19 mm medial to a line drawn vertically from the anterior superior iliac spine (ASIS).

Fig 6

Surgical-site image of a sterilely draped right hip. Recognition of the anatomic structures is of critical importance for adequate portal placement. A spinal needle and subsequent trocar, aiming away from the chondrolabral junction and toward the acetabular sourcil and femoral head articular cartilage, have been inserted in the location of the anterolateral portal just proximal and anterior to the greater trochanter (GT) of the femur. In addition, the modified midanterior portal (mMAP) is located at the intersection of a vertical line extending from the anterior superior iliac spine (ASIS) and a horizontal line drawn from the anterolateral (AL) portal. Lastly, the distal anterolateral accessory (DALA) entry point is marked 6 to 7 cm distal to the location of the AL portal.

Fig 7

Side-to-side arthroscopic and surgical-site images showing the correct location of the modified midanterior portal (mMAP). Two 5.5-mm cannulas are seen at the locations of the anterolateral (AL) and modified midanterior portals. In addition, an equidistant triangle should connect the superficial entry points for the AL, mMAP, and distal anterolateral (DALA) portals (dashed line triangle). Intra-articularly, the mMAP should be located within the safe confines of the arthroscopic triangle between the labrum, the femoral head, and the hip capsule (solid line triangle). (GT, greater trochanter.)