Femoroacetabular Impingement Hip Arthroscopy



Femoroacetabular Impingement Hip Arthroscopy


Yi-Meng Yen





Indications



  • Failure of nonoperative treatment for symptomatic femoroacetabular impingement


  • Acetabular and femoral deformity amenable to arthroscopic intervention


Instruments and Equipment



  • Fluoroscopy


  • Hip distraction extension or fracture table (Figure 33.1)


  • 70° arthroscope


  • Hip-length 14-gauge needles, nitinol wires, cannulated arthroscopic cannulas (4.5, 5.0, 5.5 mm)


  • Hip-length arthroscopic instruments (arthroscopic blade, graspers, biters, probe)


  • Hip-length suture anchors and instruments, drill


  • Hip-length electrocautery/radiofrequency (RF) device, arthroscopic shavers, and burrs


  • Hip-length suture-passing device (Figure 33.2)


Patient Positioning



  • Supine with nonoperative arm extended and operative side placed over the chest and secured


  • Feet and ankle are padded with foam boats or Webril and padding and placed into the traction apparatus


  • C-arm can be used from the bottom of the bed or perpendicular to the patient. The author prefers the perpendicular approach (Figure 33.3)
























Surgical Approach



  • Initial fluoroscopic imaging



    • With fluoroscopy, a true anteroposterior (AP) image of the operative hip, 90° Dunn-lateral, 45° Dunn-lateral, frog-leg lateral, and false profile views of the hip are obtained preoperatively and saved (Figure 33.4)


  • Traction



    • Traction is typically limited to less than 2 hours regardless of whether a padded post is used for distraction. This limits stretch of the neurovascular structures


    • Gentle countertraction is placed on the contralateral hip to stabilize the pelvis


    • The operative hip is placed at approximately 30° flexion and 30° of abduction with internal rotation to keep the patella facing the ceiling. Gross traction is applied in this position


    • The leg is brought in a position of 10° flexion and neutral abduction/adduction, and distraction is confirmed by fluoroscopy. The hip is kept in this position for work in the central compartment. Fine traction can be utilized to obtain further distraction (Figure 33.5)


  • Draping



    • Preparation of the surgical field is typically done with a chlorhexidine alcohol-based solution


    • Sterile drapes are used to square off the surgical field and a large isolation drape with Ioban is used to cover the field and the patient (Figure 33.6)


  • Portals



    • The anterior superior iliac spine (ASIS) should be palpated and marked. The outline of the greater trochanter should be traced out


















    • Typical portals for hip arthroscopy include the anterolateral (AL), mid-anterior (MA), anterior, posterolateral (PL), and distal anterolateral accessory (DALA) (Figure 33.7)


    • The author prefers the use of the AL and MA portal, with utilization of the PL and DALA portals on a case-by-case basis


    • The AL portal is located 1 cm proximal to the tip of the greater trochanter and on level with the anterior portion of the femur. In cases where there is significant retroversion of the femur, this portal can be moved ventrally


    • The MA portal is typically located on a line midway between a line drawn distal to the ASIS and the AL portal. A line 45° to the AL portal is drawn and the intersection of this line to the midway line is the location of the AL portal. Typically between 6 and 7 cm separates the 2 portals


  • Hip entry



    • The hip-length 14-gauge needle should enter the skin at the AL portal (Figure 33.8). The typical trajectory that is desired is 10° to 15° cranial and 10° to 15° posterior in order to enter the hip joint as lateral as possible (Figure 33.8A). The space between the femoral head and acetabulum is targeted with the needle tip faced away from the labrum when entering the capsule. This is done with fluoroscopic guidance



      • The needle trocar is removed, and 5 cc of air is injected as an air arthrogram to confirm joint entry and, in some cases, break the suction seal of the hip and allow continued traction (Figure 33.8B)


      • The ideal location of the needle is as distal as possible without injuring the femoral head. If the needle needs to be readjusted, the needle should be completely withdrawn and reinserted


      • A nitinol wire is inserted through the needle and confirmed to stop at the cotyloid fossa. If the wire stops short of the fossa, it is likely that the portal placement is either too anterior or too posterior and should be repositioned (Figure 33.8C)