General Technique

Dorn Spinal Therapy

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The technique described here has proved to be effective and reproducible.4-6

Portals

Three standard portals are used for hip arthroscopy: anterior, anterolateral, and posterolateral (Figures 10.10, 10.11).7 The site of the anterior portal coincides with the intersection of a sagittal line drawn distally from the anterior superior iliac spine and a transverse line across the superior margin of the greater trochanter. The direction of this portal courses approximately 45 degrees cephalad and 30 degrees toward the midline. The anterolateral and posterolateral portals are positioned directly over the superior aspect of the trochanter at its anterior and posterior borders.

Trochanter Cannulas

FIGURE 10.8. The scrub nurse's Mayo stand contains basic instruments necessary for initiating the arthroscopic procedure including a marking pen; no. 11 blade scalpel; 6-inch, 17-gauge spinal needles; 60-ml syringe of saline with extension tubing; a Nitanol guidewire; three 4.5-, two 5.0-, and one 5.5-mm cannulas with can-nulated and solid obturators; a switching stick; a separate inflow adapter; and modified probe.

FIGURE 10.8. The scrub nurse's Mayo stand contains basic instruments necessary for initiating the arthroscopic procedure including a marking pen; no. 11 blade scalpel; 6-inch, 17-gauge spinal needles; 60-ml syringe of saline with extension tubing; a Nitanol guidewire; three 4.5-, two 5.0-, and one 5.5-mm cannulas with can-nulated and solid obturators; a switching stick; a separate inflow adapter; and modified probe.

Anterior Portal

The pathway of the anterior portal penetrates the muscle belly of the sartorius and the rectus femoris before entering the anterior capsule (Figure 10.12). At the portal level, the lateral femoral cutaneous nerve has usually divided into three or more branches. Consequently, the portal usually passes within several millimeters of one of these branches. Because of the multiple branches, the nerve is not easily avoided by altering the portal position. Rather, it is protected by using meticulous technique in portal placement. Specifically, the nerve is most vulnerable to a deeply placed skin incision that lacerates one of the branches. Therefore, the initial stab wound should be made carefully through the skin only.

The average minimum distance from the anterior portal to the femoral nerve is 3.2 cm. The relationship of the ascending branch of the lateral circumflex femoral artery is variable but averages 3.6 cm inferior to the anterior portal.

Trochanter Major Sagittal

FIGURE 10.10. The site of the anterior portal coincides with the intersection of a sagittal line drawn distally from the anterosuperior iliac spine and a transverse line across the superior margin of the greater trochanter. The direction of this portal courses approximately 45 degrees cephalad and 30 degrees toward the midline. The antero-lateral and posterolateral portals are positioned directly over the superior aspect of the trochanter at its anterior and posterior borders.

Posterolateral Portal The Hip

FIGURE 10.11. The relationship of the major neurovascular structures to the three standard portals. The femoral artery and nerve lie well medial to the anterior portal. The sciatic nerve lies posterior to the posterolateral portal. Small branches of the lateral femoral cutaneous nerve lie close to the anterior portal. Injury to these is avoided by using proper technique in portal placement. The anterolateral portal is established first because it lies most centrally in the safe zone for arthroscopy.

FIGURE 10.11. The relationship of the major neurovascular structures to the three standard portals. The femoral artery and nerve lie well medial to the anterior portal. The sciatic nerve lies posterior to the posterolateral portal. Small branches of the lateral femoral cutaneous nerve lie close to the anterior portal. Injury to these is avoided by using proper technique in portal placement. The anterolateral portal is established first because it lies most centrally in the safe zone for arthroscopy.

Lateral Femoral Cutaneous N.

Femoral N.

Portal Pathway

Sartorius M.

Sartorius M.

Ascending Br., Lat. Circumflex Femoral A.

Rectus Femoris M.

FIGURE 10.12. Anterior portal pathway/relationship to lateral femoral cutaneous nerve, femoral nerve, and lateral circumflex femoral artery. (Courtesy of Smith & Nephew Endoscopy, An-dover, MA.)

Anterolateral Portal

The anterolateral portal penetrates the gluteus medius before entering the lateral aspect of the capsule at its anterior margin (Figure 10.13). The superior gluteal nerve lies an average of 4.4 cm superior to the portal.

Posterolateral Portal

The posterolateral portal penetrates both the gluteus medius and minimus before entering the lateral capsule at its posterior margin (Figure 10.14). Its course is superior and anterior to the piriformis tendon. The portal lies closest to the sciatic nerve at the level of the capsule, with the distance averaging 2.9 cm. An average distance of 4.4 cm separates the portal from the superior gluteal nerve.

Portal Placement

The anterolateral portal lies most centrally in the safe zone for arthroscopy and thus is the portal placed first.7 Subsequent portal placements are assisted by direct arthroscopic visualization. This initial portal is placed by fluoroscopic inspection in the anteroposterior (AP) plane. However, orientation in the lateral plane is equally important. With the leg in neutral rotation, femoral anteversion leaves the center of the joint just anterior to the center of the greater trochanter. Thus, the entry site for the anterolateral portal at the anterior margin of the greater trochanter corresponds with entry of the joint just anterior to its midportion. This correct entry site of the joint is

Sciatic Nerve

Gluteus Mininmus M.

Gluteus Medius M.

Sciatic Nerve

Sciatic Nerve Pathway

Portal Pathway

Gluteus Medius M.

Piriformis Tendon

FIGURE 10.14. Posterolateral portal pathway/relationship to the sciatic nerve and superior gluteal nerve. (Courtesy of Smith & Nephew Endoscopy, Andover, MA.)

Piriformis Tendon

Portal Pathway

FIGURE 10.14. Posterolateral portal pathway/relationship to the sciatic nerve and superior gluteal nerve. (Courtesy of Smith & Nephew Endoscopy, Andover, MA.)

achieved by keeping the instrumentation parallel to the floor during portal placement (Figure 10.15).

When distracting the hip, a vacuum phenomenon usually is present (Figure 10.16A). Prepositioning for the anterolateral portal is performed with a 6-inch, 17-gauge spinal needle under fluoroscopic control (Figure 10.16B). The joint is then distended with approxi

Tendons The Elbow

FIGURE 10.13. Anterolateral portal pathway/relationship to superior gluteal nerve. (Courtesy of Smith & Nephew Endoscopy, Andover, MA.)

Smith And Nephew Offset Gauge

FIGURE 10.15. With the patient supine, the hip is in neutral rotation with the kneecap pointing toward the ceiling. A needle placed at the anterior margin of the greater trochanter (anterolateral position) is maintained in the coronal plane by keeping it parallel to the floor as it enters the joint. Due to femoral neck anteversion, the entry site will be just anterior to the joint's center. If the entry site is too anterior, it becomes crowded with the anterior portal. If it is too posterior, it becomes difficult to properly visualize the entry site for the anterior portal. (From Byrd,8 with permission of Arthroscopy.)

FIGURE 10.13. Anterolateral portal pathway/relationship to superior gluteal nerve. (Courtesy of Smith & Nephew Endoscopy, Andover, MA.)

FIGURE 10.15. With the patient supine, the hip is in neutral rotation with the kneecap pointing toward the ceiling. A needle placed at the anterior margin of the greater trochanter (anterolateral position) is maintained in the coronal plane by keeping it parallel to the floor as it enters the joint. Due to femoral neck anteversion, the entry site will be just anterior to the joint's center. If the entry site is too anterior, it becomes crowded with the anterior portal. If it is too posterior, it becomes difficult to properly visualize the entry site for the anterior portal. (From Byrd,8 with permission of Arthroscopy.)

Uncovering Femoral HeadUncovering Femoral Head

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