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abstractFull article available online at Healio.com/Orthopedics. Search: 20121217-10

Hip arthroscopy is being used with increasing frequency as the understanding of ar-throscopic management of groin pain improves. To access the hip joint arthroscopi-cally, traction must be placed on the leg. In most cases, countertraction is provided with a padded post in the groin. Complications of traction are often attributed to the post and include perineal or pudendal neuropraxias and skin complications.

The purpose of this study was to investigate the safety of a traction technique that avoids a perineal post. A supine position is used with the foot in a standard traction boot. The patient is moved down the table such that his or her perineum is located 7 to 10 cm proximal to the traction post. The post is also located 5 to 10 cm lateral to mid-line. The operative table is placed in 15° to 20° of Trendelenburg. With this position, enough friction is generated between the patient’s upper body and bed to allow suc-cessful hip distraction without the post contacting with the perineum. One hundred seventy patients (111 men and 59 women) were followed prospectively and evaluated for possible side effects of this traction technique immediately postoperatively and 1 and 14 days and 3 and 6 months postoperatively. Patients were examined at each visit. No significant complications related to traction occurred during follow-up.

The described technique has been used in more than 2000 hip arthroscopies without a documented groin or perineal complication. It allows easy positioning and access to the central compartment.

The authors are from the Department of Orthopaedics (OM-D, MOM), University of Colorado, Boulder, Colorado; and the Melbourne Orthopaedic Group (DAY), Melbourne, Victoria, Australia.

The authors have no relevant financial relationships to disclose.Correspondence should be addressed to: Omer Mei-Dan, MD, Department of Orthopaedics, University

of Colorado, 12631 E 17th Ave, Mail Stop B202, Aurora, CO 80045 (omer.meidan@ucdenver.edu).doi: 10.3928/01477447-20121217-10

Hip Arthroscopy Distraction Without the Use of a Perineal Post: Prospective StudyOmer mei-Dan, mD; mark Owen mccOnkey, mD, FrcSc; DaviD alexanDer yOung, mBBS, FracS(Orth)

A

BFigure: The patient is positioned in 15° of Tren-delenburg with the foot in a well-padded boot (A). The post is located 10 cm from the perineum (dot-ted line) and off-center such that it rests against the proximal medial thigh (B).

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n Feature Article

Hip arthroscopy is a surgical tool increasing in popularity as the understanding of hip disability in

the young athletic population grows. The diagnostic and therapeutic uses are numer-ous and most commonly directed at intra-articular cartilage and labral pathology.

The orthopedic literature reports an acceptable incidence of complications, usually below 1.5%, but higher rates have been reported.1-7 The most common re-ported complications in hip arthroscopy include those related to traction, fluid management, bony complications, and surgical instruments.2,4,6,8,9

To access the central hip compartment, traction must be placed on the patient’s operative leg to allow joint distraction and entry of the surgical instruments. Hip ar-throscopy can be performed in the supine or lateral position, typically with the leg in a boot and a padded post in the groin to act as countertraction. Complications related to traction are relatively common and are often related to the pressure of the post on the groin. One study reported 20 neuropraxias in a series of 1000 patients; 14 of the neuropraxias involved the peri-neal or pudendal nerves.6 Byrd9 reported a complication rate of 1.34% after 1491 hip arthroscopies, including 6 pudendal neu-ropraxias and 1 case of scrotal necrosis. The literature demonstrates that although complications are rare, they are common-ly due to the traction post pressure in the perineum.

To attempt to eliminate skin, deep soft tissue, and neurological injuries to the groin during hip arthroscopy, the se-nior author (D.A.Y.) developed a trac-tion method without the use of a perineal post 20 years ago and has used it in more than 2000 arthroscopies, with no groin or perineal complications reported. This technique is currently used by all of the authors at their respective institutions.

The purpose of this study was to pro-spectively assess the safety of this tech-nique. The hypothesis, based on long-term experience, was that no side effects

or complications would occur using the described technique.

Materials and Methods This study was approved by the institu-

tional review board before the start of data collection and documentation. All patients presenting with painful natural or resur-faced hips and scheduled for hip arthros-copy were eligible for enrollment. A total of 170 consecutive patients undergoing hip arthroscopy for various indications were enrolled. No patients were excluded from the study cohort. The procedures were performed by 2 authors (O.M.-D., D.A.Y.) at their respective clinics.

Each patient was questioned regarding perineal and inner thigh skin, deep soft tis-sue, and neurological side effects. An eval-uation was performed at the completion of surgery and then after the patient awoke and was able to cooperate and report on his or her physical status. The majority of patients (152/170) stayed overnight and were discharged the following day after an additional examination. They were asked specifically about perineal and inner thigh pain.

All patients were followed up 7 to 14 days postoperatively. History and physi-cal examination focused on potential side effects, including traction side effects. Patients were then followed up at 3, 6, and 12 months postoperatively.

surgical techniqueHip arthroscopy is performed with the

patient in the supine position on a trac-tion table and bony prominences of the foot and ankle well padded. The authors use a Denyer manual table (XRT3000 manual operating table, OE/1059 traction frame; Denyer Int, Victoria, Australia) with an on-floor traction frame (D.A.Y.) or the Skytron Elite 6500 table (Skytron, Grand Rapids, Michigan) with traction arms (MAXI traction accessory; Smith & Nephew, Andover, Massachusetts) (O.M.-D.), but virtually any traction table would work with the described technique.

The patient is moved down the table such that the perineum is located 7 to 10 cm proximal to the location of the traction post (Figures 1A, B). The radiolucent post (Figure 1C) should also sit 5 to 10 cm off center toward the operative side (Figures 1D-F). The operative limb is placed in a standard traction boot with a well-padded narrow post placed between the patient’s legs (Figure 1B). Instead of a wide-diam-eter hip arthroscopy post, a standard post commonly used for hip or femur fractures is used.

Once the setup is complete, the opera-tive table is placed in approximately 15° to 20° of Trendelenburg (upper body tilted down) (Figure 1D). The limb is adjusted after Trendelenburg is established to en-sure that the operative limb is positioned in 0° to 5° of flexion and abduction, rela-tive to the pelvis. Fifteen degrees of hip in-ternal rotation is applied (measured at the foot), bringing the femoral neck to 0° of version to allow for optimal portal place-ment. The nonoperative limb is placed in 30° to 40° of abduction, slight flexion, and external rotation to allow space for the fluoroscopy unit to obtain lateral im-ages of the hip while maintaining minimal stress on the nonoperative limb. Using this technique, with the patient in 15° to 20° of Trendelenburg, enough resistance is creat-ed by gravity and friction between the pa-tient’s upper body and the bed to allow for successful hip distraction without the post coming into contact with the perineum.

When positioning is complete, the leg is prepped in a standard sterile fashion for hip arthroscopy. A needle is inserted into the hip with the aid of fluoroscopy to break the suction seal of the hip joint and allow distraction. Traction is gradually placed on the operative limb. The post sits at the me-dial aspect of the patient’s proximal thigh but will remain 3 to 8 cm away from the groin, depending on the amount of traction applied and patient’s morphology. During the application of traction and intraopera-tively, the surgeon can monitor with his hand the space between the post and the

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patient’s perineum, making sure no con-tact occurs. A clear plastic drape is used to allow the surgical team to note any move-ment in the patient’s position that may put skin or perineal tissues at risk. The surgeon can access the space between the perineum and post to ensure a fist-sized gap remains throughout the case.

When surgery is complete in the central compartment and traction is no longer needed, the bed is taken out of Trendelenburg and put back to a horizon-tal position. Repositioning the table to flat from Trendelenburg functionally lowers the hip relative to the surgeon so the table is elevated to the previous working height, and peripheral compartment work is per-formed with the bed flat.

results Between 2011 and 2012, a total of 170

patients (111 men and 59 women) were enrolled in the study. Mean patient age was 34 years (range, 16-66 years). Mean weight was 76 kg (range, 57-106 kg), and mean height was 175 cm (range, 155-190 cm). Seven patients had an artificial joint (resurfacing or total hip arthroplasty). One patient had both hips operated on during 1 surgery while under the same anesthesitic. No perineal or thigh-related complica-tions were observed at any patient follow-up examination.

discussionTo address intra-articular hip disease

arthroscopically, traction must be applied to the lower extremity. Hip arthroscopy can be performed in the supine or lateral position, but all techniques for providing traction on the leg rely on the use of a post in the perineum to act as countertraction (Figure 2).1,10-12 The described technique involves no special equipment and takes no longer to set up than standard supine hip arthroscopy. It allows for safer ac-cess to the central hip compartment by decreasing the likelihood of injury to the delicate tissues of the perineum. Also, us-ing this technique, the surgeon can be less

concerned with traction time because no direct compression is being applied on any body organs, nerves, or vessels.

The majority of complications due to hip arthroscopy are preventable and are usually related to patient positioning or fluid management. In a series of 1491 pa-tients, a complication rate of 1.34% was reported.9 Of the 20 complications docu-mented, 7 were likely related to traction against the perineal post, including 6 tem-porary pudendal nerve palsies and 1 case of scrotal necrosis.9 Clarke and Villar2

reported 15 (1.4%) complications in a se-ries of 1054 hip arthroscopies. The likely traction-related complications included temporary neuropraxias involving the femoral and sciatic nerves and a vaginal tear. In another study, Sampson6 reported a consecutive series of 1000 patients treat-ed with hip arthroscopy. Of the 20 neuro-praxias reported, 10 involved the perineal nerve and 4 involved the pudendal nerve. The study reported no skin complications.

Complications related to the use of a perineal post are not limited to the hip

Figure 1: Photograph showing the patient positioned in 15° of Trendelenburg with the foot in a well-padded boot (A). The post is located 10 cm from the perineum (dotted line) and off-center such that it rests against the proximal medial thigh (B). Photograph showing the radiolucent perineal post prior to being wrapped with soft roll (C). Position of the post off-center using the authors’ preferred tables: the manual table with on-floor traction frame (XRT3000 manual operating table, OE/1059 traction frame; Denyer Int, Victoria, Australia) (A-C, F) or the Skytron elite 6500 table (Skytron, Grand Rapids, Michigan) with traction arms (MAXI traction accessory, Smith & Nephew, Andover, Massachusetts) (D, E).

1A 1B

1C

1D 1E 1F

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n Feature Article

arthroscopy literature. At least 2 reports have described pudendal nerve palsies af-ter intramedullary nailing of the fractured femur.13,14 In 1 study, the authors reported that the amount of traction force used dur-ing nailing correlated significantly with the likelihood of pudendal nerve palsy.13

Other authors have described hip dis-traction for arthroscopy without a perineal post. Flecher et al15 described a traction technique involving external fixation. They used a specifically designed distractor us-ing a total of 4 pins, 2 placed in the acetab-ulum and 2 placed in the proximal femur, which allowed for up to 50 kg of distrac-tion force. They reported no traction- related complications, but the technique has several disadvantages. The need to make more incisions and to drill into the femur and pelvis are drawbacks for the pa-tient in terms of early pain scores and cos-mesis and potentially place the patient at risk for iatrogenic stress riser–related frac-ture. Furthermore, the use of disposable traction pins increases cost and operative time; the authors required an average of 18 minutes to insert the distraction pins.15

Merrel et al16 described a technique in which the patient is positioned supine with a positioning beanbag placed circumferen-tially around the chest and upper abdomen. This construct is then taped to the bed, al-lowing distraction. They reported no issues with distraction or access in 30 patients.16

Contrary to the aforementioned tech-niques, the current technique requires no additional surgical instrumentation, ad-ditional skin cuts, compromising of soft tissues, or bone drilling. It also has the advantage of not limiting access or con-stricting the abdomen or thorax. The setup time is shorter, with no extra equipment or preparation needed, such as using a bean-bag or taping of the patient. Concern may be raised regarding positioning a patient in Trendelenburg for surgery. The effect of the steep Trendelenburg position (20°-45° of Trendelenburg) has been studied because the technique is necessary for some mini-mally invasive intra-abdominal procedures. Case reports exist of laringeal edema,17 mild brachial plexopathy,17 and posterior isch-emic neuropathy18 after minimally invasive urological procedures, but these involved

prolonged (4-10 hours) steep Trendelenburg positioning. These complications have been seen using a position more extreme than that used with the current technique and for durations longer than is required for hip arthroscopy. To the current authors’ knowl-edge, no complications related to position-ing at an angle of 15° of Trendelenburg for short periods of time (less than 2 hours) have been reported. To decrease any risks associated with Trendelenburg position-ing, the surgeon must take the patient out of the Trendelenburg position once surgery is complete in the central compartment and work in the peripheral compartment begins.

The senior author observed a single minor complication using this technique prior to the initiation of the current study. The patient sustained a medial thigh skin rash postoperatively because the surgeon did not wrap the post with a soft roll, re-sulting in skin irritation due to contact with the post’s outer rubber surface.

With the current technique, no in-creased difficulty with access to the hip joint exists because distraction is not an is-sue. Positioning is quick and easy and re-quires no special equipment. In theory, distraction without a post should eliminate perineal pressure–related complications to the pudendal and perineal nerves, as well as the delicate tissues of the perineum.

references 1. Byrd JWT. Surgical techniques: hip ar-

throscopy. J Am Acad Orthop Surg. 2006; 14(7):433-444.

2. Clarke MT, Villar RN. Hip arthroscopy: com-plications in 1054 cases. Clin Orthop Relat Res. 2003; (406):84-88.

3. Griffin DR, Villar RN. Complications of ar-throscopy of the hip. J Bone Joint Surg Br. 1999; 81(4):604-606.

4. Ilizaliturri VM Jr. Complications of ar-throscopic femoroacetabular impingement treatment: a review. Clin Orthop Relat Res. 2009; (467):760-768.

5. Lo YP, Chan YS, Lien LC, Lee MS, Hsu KY, Shih CH. Complications of hip arthroscopy: analysis of seventy three cases. Chang Gung Med J. 2006; 29(1):86-92.

6. Sampson TG. Complications of hip arthros-copy. Tech Orthop. 2005; 20(1):63-66.

Figure 2: For hip arthroscopy in the lateral position, the padded post is placed directly against the patient’s perineum to allow proper distraction (picture courtesy of Dr Mat Brick) (A). For hip arthroscopy in the supine position, the padded post is placed directly against the patient’s perineum to allow proper distraction (B, C).

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2C2B

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7. Scher DL, Belmont PJ Jr, Owens BD. Case report: osteonecrosis of the femoral head af-ter hip arthroscopy. Clin Orthop Relat Res. 2010; (468):3121-3125.

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9. Byrd JWT. Complications associated with hip arthroscopy. In: Byrd JWT, ed. Operative Hip Arthroscopy. New York, NY: Thieme; 1998:171-176.

10. Kelly BT, Weiland DE, Schenker ML, Philip-pon MJ. Arthroscopic labral repair in the hip: surgical technique and review of the litera-ture. Arthroscopy. 2005; 21(12):1496-1504.

11. Parvizi J, Leunig M, Ganz R. Femoroacetab-ular impingement. J Am Acad Orthop Surg. 2007; 15(9):561-570.

12. Philippon MJ, Schenker ML, Briggs KK, Kuppersmith DA, Maxwell RB, Stubbs AJ. Revision hip arthroscopy. Am J Sports Med. 2007; 35(11):1918-1921.

13. Brumback RJ, Ellison TS, Molligan H, Mol-ligan DJ, Mahaffey S, Schmidhauser C. Pu-dendal nerve palsy complicating intramedul-lary nailing of the femur. J Bone Joint Surg Am. 1992; 74(10):1450-1455.

14. Kao JT, Burton D, Comstock C, McClellan RT, Carragee E. Pudendal nerve palsy after femoral intramedullary nailing. J Orthop Trauma. 1993; 7(1):58-63.

15. Flecher X, Dumas J, Argenson J-N. Is a hip distractor useful in the arthroscopic

treatment of femoroacetabular impinge-ment? Orthop Traumatol Surg Res. 2011; 97(4):381-388.

16. Merrell G, Medvecky M, Daigneault J, Jokl P. Hip arthroscopy without a perineal post: a safer technique for hip distraction. Arthros-copy. 2007; 23(1):107e1-107e3.

17. Phong SV, Koh LK. Anaesthesia for robot-ic-assisted radical prostatectomy: consid-erations for laparoscopy in the Trendelen-burg position. Anesth Intensive Care. 2007; 35(2):281-285.

18. Weber ED, Colyer MH, Lesser RL, Subrama-nian PS. Posterior ischemic optic neuropathy after minimally invasive prostatectomy. J Neuroophthalmol. 2007; 27(4):285-287.

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