Visual Sweep And Anatomy

The acetabulum and its structures are viewed first and visually divided into thirds. Initially, the femoral head cannot be entirely viewed with the hip distracted; however, the hidden portions will be observed when looking in the pericapsular area later in the procedure (Figures 9.22 through 9.26).

With the 30-degree scope, start observing the ac-

FIGURE 9.24. Arthroscopic view of a normal posterior cleft at the labral cartilaginous junction.

etabular notch and the fat pad. Petechial hemorrhage is normal due to the traction forces pulling negative pressure on the vessels.

Atrophy of the fat pad is abnormal. Look for loose bodies and rice bodies and notch osteophytes or masses. Advance the scope deep to view the liga-mentum teres. Look for tears or avulsions. The transverse acetabular ligament is hard to see unless the patient has hyperlaxity.

Rotate the scope posterior and inferior and pick up the posterior labrum at the articular margin, noting the posterior third. Look behind the labrum for loose bodies, then follow the labrum lateral and anterior, noting a normal cleft in the posterior articular margin with a small labral cartilage sulcus. This is not an old avulsion fracture or evidence for subluxation posteri

FIGURE 9.25. Arthroscopic view of an articular cartilage blister forming, the beginning of a peel-off lesion at the posterior labral cartilaginous junction.

FIGURE 9.23. Arthroscopic view of an atrophic fat pad in the notch of the acetabulum.

FIGURE 9.25. Arthroscopic view of an articular cartilage blister forming, the beginning of a peel-off lesion at the posterior labral cartilaginous junction.

orly. Note any labral fraying or tears and articular changes.

Look at the mid third and note any labral cartilage separations or fraying and degenerative changes. The surface may be smooth or have a cobblestone appearance in early degeneration.

As the scope is rotated to the anterior third, the labrum may give a backlighting of the joint as the light reflects off the anterior capsule through the labrum. Look for hypertrophy of the labrum in patients with dysplasia. The acetabular cartilage may be soft or may appear blistered or delaminated in dysplastics with anterior groin pain and instability or popping. Look anterior beyond the labrum in the sulcus for synovitis and loose bodies. Move the scope to the superior sul-cus of the joint to see the nonarticular side from anterior to posterior. Look for evidence of cysts and spurring and labral tears. During all these maneuvers, a probe or switching stick is used to probe.

Next observe as much of the femoral head with the same method and if necessary rotate the leg while in traction. At this point, I switch to a 70-degree scope to look deeper into the notch and have a better view of the femoral head fovea with its ligamentum teres attachment.

After viewing from the anterolateral portal, the same procedure is carried out from the posterior portal if one is not satisfied with the initial viewing. The corrective surgery is then performed, and the traction is completely released to allow the hip to be moved in rotation and flexion.

With the hip in slight flexion and neutral rotation, the intracath is inserted through the anterolateral portal, aiming along the femoral neck toward the head-neck junction (Figure 9.27). While observing under fluoroscopy, a small pop is felt as the needle passes through the capsule and the effusion dribbles out of the needle. Pass a Nitanol wire and bounce it off the inferior capsule to confirm it is intraarticular (Figure 9.28). Advance the arthroscopic sheath over the wire and begin viewing the anterior, inferior, and posterior pericapsular space.

First, note the femoral head seated in the labrum as it transforms into the transverse acetabular ligament (Figure 9.29). The zona orbicularis crosses the field, and one may see the vincula-like vessel

FIGURE 9.27. Fluoroscopic view with the C-arm showing the FIGURE 9.28. Arthroscopic view of a Nitanol wire in the inferior arthroscope position in the inferior pouch and a cannula near the pouch. Note the reactive synovitis. head-neck junction laterally.

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Essentials of Human Physiology

Essentials of Human Physiology

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