Preprocedural Planning
Full informed consent addressing the specific pathology present and procedure to be performed should be obtained in every case.
A detailed history, a thorough physical examination, and careful critical assessment of diagnostic imaging results are extremely important in planning for hip arthroscopy. Depending on the indication, plain radiography, computed tomography (CT) with or without three-dimensional (3D) reconstruction, magnetic resonance imaging (MRI), MRI arthrography, or various combinations thereof may be part of a preoperative workup.
Equipment
Traction tables are most commonly used for positioning and assist in gaining access to the hip joint. Tables specifically designed for hip arthroscopy are commercially available. The hip table and positioning should allow flexion, extension, abduction, and internal and external rotation. Instruments and implants suitably sized for the hip should be readily available to the surgeon. A 70º arthroscope is typically used for the procedure, and a 30º scope should be available.
Patient Preparation
Anesthesia
General or regional anesthesia can be used. General anesthesia is often used with anesthetic paralysis to assist with distraction of the hip joint. Femoral nerve blocks have been investigated as an adjunct for postoperative pain relief. [22, 23]
Positioning
Hip arthroscopy has been done in both the lateral decubitus position and the supine position; to date, the latter has been more commonly employed. [17]
Traction is placed on both the well leg and the leg to be operated on. Careful padding and secure fixation of the ankle in the traction device are important both for preventing peripheral nerve injury and for ensuring that traction force can be dependably applied without slipping. Close attention should be paid to positioning the traction post laterally against the medial thigh; this provides a more ideal traction vector for hip access and removes pressure on the pudendal nerve (thereby avoiding neurapraxia).
As noted, the patient should be positioned on the table in such a way as to permit flexion, extension, abduction, and rotation (internal and external). There should be sufficient room for C-arm positioning, and the C-arm and arthroscopy monitors should be readily visible. In many cases, 50 lb (22.7 kg) of traction is required to distract the hip. Prolonged traction (ie, >2 hours) may place the patient at increased risk for neurovascular complications, typically neurapraxias. [3, 7, 14, 9]
Monitoring & Follow-up
Standard intraoperative monitoring is indicated. Dropping temperature, falling blood pressure, and increasing abdominal firmness can be signs of intra-abdominal compartment syndrome; these parameters should be checked at regular intervals throughout the procedure. After the operation, follow-up at regular intervals is warranted for wound care, advancement of weightbearing, and rehabilitation, depending on the specific procedure that was performed.
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Hip arthroscopy. Labral tear with adjacent chondrolabral separation and wave sign.
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Hip arthroscopy. Drilling for anchor placement in acetabulum after acetabuloplasty.
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Hip arthroscopy. Suture anchor in place ready for labral repair.
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Hip arthroscopy. First anchor placed for labral repair.
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Hip arthroscopy. Labral repair with wraparound technique.
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Hip arthroscopy. Labral repair status post takedown and acetabuloplasty.
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Hip arthroscopy. Cam lesion with adjacent cartilage damage.
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Hip arthroscopy. Motorized burr recreating femoral head offset; resection of cam.
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Hip arthroscopy. Cam resection.
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Hip arthroscopy. Cam resection.
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Location of lateral femoral cutaneous nerve.
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Hip arthroscopy. Portal placement.
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Cross-section at hip, showing locations of femoral nerve, artery, and vein. Courtesy of Wikimedia Commons.
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Location of femoral neurovascular structures and lateral femoral cutaneous nerve in relation to acetabulum. Courtesy of Wikimedia Commons.
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Frontal view of hip area, showing femoral vein, nerve, and artery, along with tensor fasciae latae. Courtesy of Wikimedia Commons.
