hip arthroscopy in the athlete · portals / anatomy . compartments cc . central compartment ....
TRANSCRIPT
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Marc R. Safran, MD Professor, Orthopaedic Surgery
Associate Director, Sports Medicine Stanford University
Annual Meeting of the California Orthopaedic Assn 2013
Rancho Palos Verdes, CA
Hip Arthroscopy:
Portals & Anatomy
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Introduction Evolving Field Technique / Portals IntraArticular
– Central – Peripheral
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Introduction Burman, 1931
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Introduction Burman, 1931 More Commonly Performed
Since 1980’s – Eriksson & Glick – McCarthy & Villar – Dorfman & Boyer – Dienst – Byrd & Philippon
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Introduction Burman, 1931 More Commonly Performed
Since 1980’s – Eriksson & Glick – McCarthy & Villar – Dorfman & Boyer – Dienst – Byrd & Philippon
Diagnostic Treatment Expanding Indications
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Hip Arthroscopy Growing Number of Hip Arthroscopies
0
20,000
40,000
60,000
80,000
100,000
120,000
2003 2006 2007 2008 2009
10%
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Introduction Many Feel Hip
Arthroscopy Futile Difficult
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Slow Acceptance
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Slow Acceptance Surrounding N-V Structures Technically Difficult
– More Constrained Joint – Thick Soft Tissue Envelope – Dense Capsule Hard to Distract
– Limited Maneuverability w/i Joint Learning Curve
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Current Techniques Loose Body Removal Labral Debridement Labral Repair Ligamentum Teres Debridement Microfracture Acetabuloplasty Chielectomy Capsulorraphy Labral Reconstruction Lig Teres Reconstruct
Psoas Tendon Release
Abductor Repair IT Band Release Trochanteric
Bursectomy Acet Rim Fx ASIF Femoral Head ASIF Sciatic Nerve IschioFem Impinge
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Overview General
Considerations Compartments Equipment Anesthesia Position Portals / Anatomy
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Compartments CC
Central Compartment
Drawing Courtesy of Michael Dienst, MD
PC Peripheral Compartment
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Compartments Central Compartment Artificial Joint Space Traction Req‘d
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Compartments Central Compartment Artificial Joint Space Traction Req‘d
Peripheral Compartment Need Traction Off Relax Ligaments
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General Considerations Keep Traction As Short As Possible < 2 hours
Keep Traction Force To As Little As Needed May Be Able To Lower Force After Make Portals
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Equipment Fracture Table Fluoroscopy Hip Arthroscopy
System – Long Scopes – Special Cannulas – Long Instruments
E-Flex 300 & 700 Lens
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Anesthesia General Anesthesia Paralyzed Lumbar Plexus
Block Epidural +
Hypotension
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Patient Positioning
Supine
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Patient Positioning
Lateral
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Patient Positioning Supine
Fracture Table Padded Post - Lat Neutral Rot / F-E Abduct 10 – 250 20 - 50 lbs Tensiometer?
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Relieve IA Pressure Pull Traction Prep – Betadine Spinal Needle
– Stay Close To Femoral Head
– Long End Of Needle Away Fm Femoral Head
Equilibrate w/ Ambient Pressure
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Relieve IA Pressure
Pull Traction Prep – Betadine Spinal Needle Equilibrate w/
Ambient Pressure ? Saline
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Making The Portal
Visualize Entry Protect Labrum / Articular Cartilage
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Visualize Entry Protect Labrum / Articular Cartilage
Making The Portal
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Visualize Entry Protect Labrum / Articular Cartilage
Making The Portal
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Portals Anterior AnteroLateral PosteroLateral
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First Portal Safe & Easy Ant Margin of
Greater Troch Close to Sup
Fem Head Anteversion
Anterolateral Portal
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Penetrate Gluteus Medius Muscle Superior Gluteal
Nerve Closest – 4.4 cm fm
Portal – Branches
Posteriorly
Anterolateral Portal
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Anterolateral Portal
View w/ 70° Lens View w/ 30° Lens
Drawing Courtesy of Michael Dienst, MD
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700 Lens Anterolateral Portal
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300 Lens Anterolateral Portal
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Aid To Make Additional Portals
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I Prefer 2nd Portal Some Prefer as 1st Entry Site – Vary Junction of ASIS &
Greater Troch 450 Prox 300 Med
Anterior Portal
From Byrd
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6.3 cm Distal to ASIS Penetrates
Sartorius & Rectus Femoris
Anterior Portal
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Lat Fem Cutaneous Nn High Risk >3 branches @ Portal Move Lat Does Not
Reduce Injury Risk Reduce Risk Moving
Medially – (Fem NV)
Injury Cutting Deep Vigorous
Instrumentation – Loose Bodies
Temp or Permanent Primal Pictures
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Anterior Portal Cut Skin Only –
LFCN
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Anterior Portal Femoral Nerve
– Tangential To Portal
– 3.2 cm from Portal – Slightly Closer @
Capsular Level
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Anterior Portal Lateral Femoral
Circumflex Artery – 3.7 cm Inf to Portal – May be w/i mm of
Portal @ Capsular Level
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Anterior Portal
View w/ 70° Lens View w/ 30° Lens
Drawing Courtesy of Michael Dienst, MD
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Anterior Portal Observe Entry w/ 700 Scope fm A-L Exchange Trochar To Look At A-L
Portal - Labrum
700 Lens
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Anterior Portal 300 Lens
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First Portal Made Under Fluoro Only
Others Made Under Arthroscopic Visualization
Before Scoping Hip, Check 1st Portal From Other Portal To Be Sure No Injury to Labrum
Making The Portal
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Last Portal Posterior Margin
of GT Converge Toward
Center of Joint Be Sure LE- NR
PosteroLateral Portal
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Sciatic Nerve Risk From Byrd
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PosteroLateral Portal Superior
Gluteal Nerve
4.4 cm from
Portal Branches
Posteriorly
Superior Gluteal Nerve
P-L Portal
Superior Gluteal Nerve
P-L Portal
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PosteroLateral Portal
Drawing Courtesy of Michael Dienst, MD
View w/ 70° Lens View w/ 30° Lens
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700 Lens PosteroLateral Portal
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300 Lens PosteroLateral Portal
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Normal Variants Labral Cleft
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Normal Variants Triradiate Physeal Scar
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Normal Variants SupraAcetabular Fossa
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Normal Variants Stellate Crease
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Mean Accessible Area Graphical Representation of MASA
Femoral Head
Medial View Superior View Courtesy of Michael Gerhardt, MD
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Graphical Representation of MASA Acetabulum & Labrum
Courtesy of Michael Gerhardt, MD
Mean Accessible Area
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Central Compartment Arthroscopic View
Limitations Posteroinferior & Medial Most Difficult to Reach
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Flex Hip To Relax Anterior Capsule / Ligaments
Peripheral Compartment
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Portal 7.5 cm Distal to
Ant-Lat Portal Or
4 -5 cm Proximal To Ant-Lat Portal
Peripheral Compartment
From Byrd
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Peripheral Compartment
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Peripheral Compartment
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Peripheral Compartment
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Other Portals
For Lesser Troch / IP Release &/or
Peritrochanteric Space
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Troch Bursectomy
Foot
Head
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Complications: Incidence
Overall = 1.4 – 5.5% – < 0.5% Permanent
Clark / Villar >1,000 Arthroscopies = 2.8% Surgeon’s Experience
– Steep Learning Curve
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Hip A/S – Complications Related To
–MD Experience –Fluid Mgt
Most Related To Traction –Too Much –Too Little
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Conclusion Steep Learning
Curve Start with Easy
Cases Fun
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Conclusion Expanding Indications Enhanced
Understanding Better Technology Better Tools Minimal Relative
Morbidity Direct Access To The
Problem
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Thank You