Michael Dienst

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FIGURE 11.3. Anterior hip joint capsule in extension (A) and flexion (B). Flexion leads to a relaxation of the strong anterior il-iofemoral ligament (arrow) and to a significant increase of the in-traarticular joint space of the anterior and medial head and neck area (cadaveric hip joint).

table with an additional traction frame or robotic limb-positioning device. The bony landmarks and the femoral neurovascular bundle are palpated and the longitudinal axis of the femoral neck is determined with the image intensifier. Landmarks and axis of the femoral neck are marked on the skin for orientation during joint access and the surgical procedure. The portal zones are divided into anterior, anterolateral, lateral, and posterolateral (Figure 11.4). From Dorfmann and Boyer's13 and our experience,43,44 a comprehensive overview can be obtained from the an-

FIGURE 11.3. Anterior hip joint capsule in extension (A) and flexion (B). Flexion leads to a relaxation of the strong anterior il-iofemoral ligament (arrow) and to a significant increase of the in-traarticular joint space of the anterior and medial head and neck area (cadaveric hip joint).

pension height of the water bags and the three-way stopcock on the inflow site of the arthroscope.

In general, I combine HA without traction and HA with traction. As indicated below, the combination of both techniques is important to allow a complete diagnostic arthroscopic examination of the hip. From my experience, the traction part should be done before the nontraction scoping because positioning for traction is more demanding. In particular, exact placement of the counterpost is crucial to avoid complications. This placement can be done only under nonsterile conditions.

Technique

For HA without traction, the patient is placed supine on a standard traction table or a standard operating anterolateral anterior anterior

Dienst Portal Hip
lateral

posterolateral posterolateral

FIGURE 11.4. (A, B) Portals to the hip joint. For HA without traction, only portals within the anterior and the anterolateral zone are used (B). The standard portal is the anterolateral portal between the anterosuperior iliac spine and greater trochanter (X); additional portals for outflow and further instruments can be placed more distally and medially (gray area). (A reprinted with permission from Dienst et al.44)

FIGURE 11.4. (A, B) Portals to the hip joint. For HA without traction, only portals within the anterior and the anterolateral zone are used (B). The standard portal is the anterolateral portal between the anterosuperior iliac spine and greater trochanter (X); additional portals for outflow and further instruments can be placed more distally and medially (gray area). (A reprinted with permission from Dienst et al.44)

Dienst Portal Hip

FIGURE 11.5. Intraoperative fluoroscopy for confirmation of entry to the joint and correct portal placement. (A) Puncture of the anterior recess at the transition between the femoral neck and head with a cardiac needle and (B) distension of the joint with 40 ml saline in combination with 10 to 20 kg traction. Correct intraarticular position is demonstrated by displacement of the femoral head. (Reprinted with permission from Dienst et al.44)

FIGURE 11.5. Intraoperative fluoroscopy for confirmation of entry to the joint and correct portal placement. (A) Puncture of the anterior recess at the transition between the femoral neck and head with a cardiac needle and (B) distension of the joint with 40 ml saline in combination with 10 to 20 kg traction. Correct intraarticular position is demonstrated by displacement of the femoral head. (Reprinted with permission from Dienst et al.44)

terolateral portal only. Because the soft tissue mantle is relatively thin and the position of the portal is near the lateral cortex of the femoral neck, maneuverability of the arthroscope is sufficient for moving the arthroscope into the medial recess, gliding over the anterior surface of the femoral head to the lateral recess, and frequently passing the lateral cortex of the femoral neck for inspection of the posterior recess.43

First access to the hip joint periphery can be achieved with or without traction. I prefer a slight force to apply tension to the anterior capsule and to confirm entry to the joint by displacement of the femoral head by distension. The hip is flexed to about 20 degrees, the knee is extended, and 10 to 20 kg traction is applied only for the initial access to the joint. A long needle (diameter: approximately 1-2 mm) is introduced via the anterolateral portal and directed to the transition between the anterior aspect of the femoral head and neck. Here, the capsule is elevated from the neck, which allows easier access of the needle into the joint. Entry to the joint is then confirmed by distension of the joint with up to 40 ml saline, which leads to a visible lateral and caudal displacement of the femoral head under fluoroscopy as the hip is under traction (Figure 11.5A,B). The standard reflux test, return of fluid through the needle, is more inconsistent because of occlusion of the needle by hypertrophic synovium.

A guidewire is then inserted through the needle. The blunt guidewire can be advanced medially until it bounces against the medial capsule. The capsular penetration is then dilated (dilating trochars, cannu-lated trochar) and the arthroscope is introduced in the peripheral compartment under fluoroscopy (Figure 11.6A-C). Traction is then released and the counter-post removed.

The knee is flexed to about 45 degrees and held by either a specially designed long bar at the end of the table or an assistant; the degree of flexion, rotation, and abduction of the hip joint are controlled (Figure 11.7). A second portal is placed under arthroscopic control in the anterior and the anterolateral zone (see Figure 11.4B). Irrigation is used to clear the view via the scope sheath and outflow via the additional portal. Standard and extra-long 25- and 70-degree lenses are used for the diagnostic round.

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