What are the steps for hip arthroscopy?

Steps for Hip Arthroscopy

Hip arthroscopy is a surgical procedure that requires a systematic approach to ensure complete visualization of the joint space and effective treatment of hip pathologies.

Patient Positioning and Setup

• Position the patient in lateral decubitus position with the involved leg held in an abducted and flexed position with traction by pulleys hung overhead 1
• Hip abduction and flexion relaxes the capsule while traction separates the joint to facilitate insertion of the arthroscope 1
• Ensure proper positioning to avoid complications related to patient positioning 2

Portal Establishment

• Use fluoroscopic guidance for accurate portal placement 3
• Establish portals using a direct lateral approach over the greater trochanter 1
• Standard portals include:
  • Anterolateral portal (primary viewing portal)
  • Anterior portal (primary working portal)
  • Posterolateral portal (accessory portal) 3

Diagnostic Arthroscopy Procedure

1. Initial Joint Distraction

   • Apply appropriate traction to create adequate joint space for instrument insertion 1
   • Monitor distraction using fluoroscopy to prevent excessive traction 3

2. Systematic Joint Examination

   • Begin with examination of the central compartment (acetabulum, femoral head, labrum) 3
   • Assess for chondral lesions, labral tears, and loose bodies 1
   • Evaluate the peripheral compartment (femoral neck, head-neck junction) for cam deformities 3

3. Treatment of Identified Pathologies

   • Address labral tears through repair or debridement 4
   • Perform osteoplasty for femoroacetabular impingement (FAI) 4
   • Remove loose bodies if present 1
   • Manage chondral lesions appropriately 4

Post-Procedure Management

• Monitor for potential complications:
  • Neurovascular injuries from instrument introduction 2
  • Fluid extravasation during the procedure 2
  • Traction-related complications 2

Indications and Contraindications

• Primary Indications:

  • Diagnosis of unresolved hip pain following failure of conservative treatment 1
  • Removal of loose bodies 1
  • Exploration and debridement following fracture and/or dislocation 1
  • Femoroacetabular impingement (FAI) with concurrent chondro-labral lesions 4

• Relative Contraindications:

  • Advanced articular damage and secondary hip osteoarthritis 4
  • Extensive cartilage damage 4

Imaging Considerations

• Radiographs are typically the first imaging modality for assessment of hip pain 5
• For suspected labral tears with or without impingement, MR arthrography is usually appropriate (rated 9/9) 5
• For evaluation of articular cartilage, MRI without IV contrast or MR arthrography is usually appropriate (rated 9/9) 5
• CT arthrography may be an alternative for cartilage evaluation (rated 8/9) 5

Common Pitfalls and Avoidance Strategies

• Inadequate Visualization: Ensure proper portal placement and joint distraction 3
• Neurovascular Injury: Thorough understanding of hip anatomy is essential to avoid damage to surrounding structures 2
• Fluid Extravasation: Monitor irrigation pressure and limit procedure time 2
• Traction-Related Complications: Use appropriate padding and limit traction time 2
• Patient Selection: Carefully evaluate for advanced osteoarthritis, which may lead to poor outcomes 4