Peripheral Compartment Approach to Hip Arthroscopy

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CHAPTER 11 Peripheral Compartment Approach to Hip Arthroscopy

Michael Dienst

Introduction

Arthroscopy without traction of the peripheral compartment (PC) has become an integral part of hip arthroscopy. It has contributed to a better understanding of the functional anatomy and pathogenesis of new concepts such as femoroacetabular impingement and other pathologic conditions of the hip joint. With the tremendous improvement of its technique and the development of better instrumentation, a completely new field of therapeutic options has evolved.

The acetabular labrum is the key structure during portal placement and therapeutic arthroscopy within the hip joint. The labrum seals the joint space between the lunate cartilage and the femoral head by maintaining a vacuum force of about 120 N to 200 N, which keeps the femoral head within the socket. To overcome the vacuum force and the passive resistance of the soft tissues, traction is needed to separate the head from the socket, to elevate the labrum from the head, and to allow the arthroscope and other instruments access to the narrow “artificial space” between the weight-bearing cartilage of the femoral head and the acetabulum. However, if traction is applied, the joint capsule with the iliofemoral, ischiofemoral, and pubofemoral ligaments is tensioned, and the joint space peripheral to the acetabular labrum decreases. Thus, to maintain the space of the PC for better visibility and maneuverability during arthroscopy, traction should be avoided.

The hip is divided arthroscopically into two compartments that are separated by the labrum (Figure 11-1). The first is the central compartment (CC), which comprises the lunate cartilage; the acetabular fossa; the ligamentum teres; and the loaded articular surface of the femoral head. This part of the joint can be visualized almost exclusively with traction. The second is the PC, which consists of the unloaded cartilage of the femoral head; the femoral neck, with the medial, anterior, and posterolateral synovial folds (i.e., Weitbrecht ligaments); and the articular capsule with its intrinsic ligaments, including the zona orbicularis. This area can be better seen without traction.

image

Figure 11–1 Arthroscopic compartments of the hip joint.

With permission from Michael Dienst, MD.

In addition to its importance in therapeutic hip arthroscopy, the PC can be used as an intermediate space to control the placement of portals to the CC. In our practice, we have been using this technique successfully for more than 4 years; it has a smaller risk of iatrogenic lesions of the acetabular labrum and the femoral head cartilage.

Indications

Arthroscopy without traction of the PC should be performed in all cases. For the treatment of unclear hip pain, the PC needs to be scanned for pathologic changes. Most hip disorders present with primary or secondary lesions in the PC, such as the following:

• Peripheral lesions of the acetabular labrum, such as intralabral or perilabral ossifications, labral cysts, and ganglia
• Primary (e.g., rheumatic) or reactive synovitis within the perilabral sulcus and gutters
• Loss of head–neck offset in femoroacetabular impingement
• Impinging osteophytes at the head–neck junction
• Hypertrophy of the synovial folds at the head–neck junction
• Loose bodies in degenerative joint disease or after trauma
• Tumor-like lesions or benign tumors such as chondromas and osteochondromas with synovial chondromatosis or pigmented villonodular synovitis

In addition, the PC allows access to periarticular structures such as the following:

• The psoas tendon sheath and the psoas tendon
• Periarticular cysts
• Heterotopic ossifications of the periarticular muscles

History and physical examination

There are no symptoms or functional tests during physical examination that are specific for pathologies within the PC. In addition, most hip disorders present with primary or secondary changes of the PC rather than of the CC only.

The most important thing to do during the primary preoperative workup is to determine whether the source of pain is intra-articular or extra-articular. This determination can be made by going through a thorough diagnostic checklist (see Chapter 3: Imaging: Plain Radiographs and Chapter 6: The Technique and Art of the Physical Examination of the Adult and Adolescent Hip).

Imaging and diagnostic studies

Radiologists and surgeons need to consider that the hip joint is not limited to the direct articulation between the cartilage of the femoral head and the lunate cartilage of the acetabulum. The PC joint extends to the intertrochanteric line anteriorly and to the femoral neck posteriorly. Thus, the assessment of roentgenograms, computed tomography scans, and magnetic resonance images has to include this part of the joint.

Consequently, radiographs need to be evaluated for the contour of the head–neck junction, the overcoverage of the anterolateral acetabular rim, and perilabral ossifications in cases that involve femoroacetabular impingement. Here, one has to differ between the primary signs of impingement (i.e., loss of offset) and osteophytes, which are signs of osteoarthritis and secondary changes. In general, the removal of osteophytes does not lead to the same good results as the reshaping of the head–neck junction in femoroacetabular cam impingement. In addition, osteophytes are indicators of cartilage degeneration within the CC, which is important for the patient’s prognosis. The soft tissues around the femoral neck have to be analyzed for subtle or more prominent ossifications that indicate osteochondromas within the PC. With magnetic resonance imaging, the space underneath the articular capsule needs to be scanned for an effusion; inflammation; thickening; villous or nodular hypertrophy of the synovium; loose bodies; and chondromas. The latter often accumulate in the pouch underneath the transverse ligament and in the gutter medially to the femoral neck. Depending on their cartilaginous or bony structure, size, and location, one has to decide whether to perform the removal through the arthroscope or via open surgery. The labrum needs to be analyzed for the degree of degeneration, tears at the labrum–cartilage junction, intralabral or perilabral cysts, and ossifications. These are important indicators for determining whether the labrum can be saved, trimmed or resected, or temporarily detached for the trimming of the bony rim. Some of this intra-articular work can be done under traction from the CC, and some can be done without traction via the PC. Radial magnetic resonance cuts can be helpful for the better imaging of the contour of the head–neck junction in different positions. For cases in which the loss of offset extends posterolaterally, only very experienced arthroscopic surgeons are capable of reshaping the head–neck junction sufficiently.

Diagnostic injections of the hip joint with local anesthetics are very helpful for the differentiation of intra-articular causes of pain from those that are extra-articular. Under fluoroscopy or ultrasound, the needle is introduced via the proximal anterolateral portal to the anterolateral head–neck junction and into the PC. Here, the space between the capsule and the bone allows for safe and effective fluid aspiration or injection. The straight anterior puncture or injection without imaging has a high risk of periarticular misplacement.

Surgical technique

Positioning and Switching Between the Compartments

Hip arthroscopy with and without traction can be performed with the patient in the lateral or supine position. From our experience, the decision of whether to use the lateral or supine position is more a matter of individual training and habit of use. However, because of the almost exclusive use of the proximal and distal anterolateral and anterior portals during hip arthroscopy without traction, we prefer the supine position.

To allow for a complete diagnostic arthroscopic examination of the hip, both techniques with and without traction are combined for arthroscopy of the CC and the PC; this requires specific attention to positioning, table equipment, and draping. The order of arthroscopy with and without traction depends on different parameters (Figure 11-2). In “standard” cases with good distraction and visibility, we prefer to access the PC first to control portal placement to the CC. However, there are cases in which the distraction of the hip is insufficient and visibility in the PC decreased. Here, a release of different parts of the joint capsule can be performed to increase the PC space and improve distraction. We usually start with a release of the zona orbicularis that extends into the iliofemoral ligament in cases of severe capsular thickening or fibrosis, and this is followed by therapeutic procedures such as the reshaping of the head–neck junction. At this point, traction is again applied. If distraction is improved, portals to the CC can be placed under arthroscopic control. However, if distraction is still not sufficient, arthroscopy of the PC only should be considered to avoid iatrogenic damage of the acetabular labrum and the femoral head cartilage during portal placement to the CC.

image

Figure 11–2 Flowchart for switching between the central compartment and the peripheral compartment. ASC, arthroscopy; CC, central compartment; PC, peripheral compartment.

With permission from Michael Dienst, MD.

For arthroscopy of the PC, a good range of movement is important to relax parts of the capsule and to increase the intra-articular volume of the area that needs to be inspected and addressed. In addition, only without traction can the impingement maneuver and other functional tests be reproduced under various degrees of flexion, rotation, and abduction. Another advantage of the nontraction technique is the possibility of “hiding” the hyaline cartilage of the femoral head under the socket by flexion to avoid damage when working in the PC.

During the past several years, we have removed the foot from the traction module to allow for the maximum range of movement. However, this technique is time consuming and strenuous for the assistant who is holding the leg. In addition, switching back into the CC under traction is difficult, because the foot needs to be readapted to the traction module. Especially for femoroacetabular impingement cases, there is a need to alternate between both compartments with and without traction. Thus, we changed our technique. For arthroscopy of the PC, the foot is kept in the traction module. The traction is released, and the traction module with the foot is slid in with the extension bar. With this technique, the hip and knee can be flexed up to 90 degrees, abducted to about 30 degrees, and rotated 20 degrees internally and externally (Figure 11-3). When reentering the CC, the extension boom is drawn out, and the hip and knee are extended. Before traction is applied, the room nurse has to check for possible soft-tissue entrapment at the perineum.

image

Figure 11–3 Supine position for hip arthroscopy without traction. Flexion and rotation in the hip can be achieved by shortening the extension boom and unlocking the rotation jig; abduction can be achieved by unlocking the jig at the base of the extension boom. The assistant is supporting the position.

With permission from Michael Dienst, MD.

Portals to the Peripheral Compartment

Basically, portals are established where they are needed. With our current knowledge, most pathology in the PC can be addressed via anterior and lateral portals. It is still difficult to access the posteromedial parts of the PC for both viewing and working. The posteromedial peripheral space is significantly smaller and additionally hidden from the posterior part of the greater trochanter. Thus, this part of the PC can sometimes be better seen and accessed via the CC under traction. The distal part of the posteromedial space of the PC cannot be seen from the CC but rather from the perilabral sulcus and the space directly peripheral to the posterior part of the transverse ligament. Here, loose bodies and chondromas can be reached via the posterolateral portal.

A comprehensive overview of the PC can be obtained from the proximal anterolateral portal only (Figure 11-4). At this level, the soft-tissue mantle is relatively thin, and the position of the portal is near the lateral cortex of the femoral head. Therefore, the maneuverability of the arthroscope is sufficient for moving it into the medial recess, gliding over the anterior surface of the femoral head to the lateral recess, and passing the lateral cortex of the femoral neck for the inspection of the posterolateral recess. With the need for better access to the lateral and posterolateral head and neck area for therapy of the cam type of femoroacetabular impingement and the removal of chondromas from the medial area underneath the transverse ligament in patients with synovial chondromatosis, a two-portal technique for the PC is usually preferred.

image

Figure 11–4 Portals to the peripheral compartment of the hip.

From Dienst M (Ed). Hip arthroscopy. Elsevier Urban & Fischer, Munich; 2009.

Proximal Anterolateral Portal

The position and direction of the proximal anterolateral portal are different for the anterolateral portal to the CC in that the incision lies more proximally and anteriorly. Usually the perfect spot for the skin incision can be found by palpating a soft spot one third of the distance along a line drawn from the anterior superior iliac spine to the tip of the greater trochanter. Here, one can feel the anterior margin of the gluteus medius. On its way to the joint capsule, the needle only penetrates the tensor fasciae latae. Under fluoroscopy, the needle is directed perpendicular to the femoral neck axis to the anterolateral transition from the femoral head to the neck (Figure 11-5). The proximal anterolateral portal is predominantly used as a viewing portal. However, in patients with femoroacetabular cam impingement, this portal becomes important for the removal of the lateral and posterolateral extension of the head–neck bump.

image

Figure 11–5 Fluoroscopic view of the position of the arthroscope introduced over the femoral head–neck junction perpendicular to the neck axis via the proximal anterolateral portal. A radiofrequency probe is inserted via the anterior portal.

With permission from Michael Dienst, MD.

Anterior Portal

With the use of the same skin incision as was used for the anterior portal to the CC, the needle is directed more inferiorly and not so far medially, aiming for the anterior junction of the femoral head and neck. It is important to perforate the anterior capsule lateral to the psoas tendon and proximal to the zona orbicularis to stay away from the femoral nerve and to have sufficient mobility of the instrument, respectively. The anterior portal is mostly used for the introduction of instruments. The mediolateral position of the skin incision for the anterior portal to the PC depends on the localization of the pathology. In femoroacetabular cam impingement, it is beneficial to place this portal 2 cm to 3 cm lateral to the vertical line from the anterosuperior iliac spine. Thus, the more lateral extension of the head–neck bump can be better accessed. For chondromatosis cases, we prefer a more medial position on the line of the anterosuperior iliac spine to reach the medial recess underneath the transverse ligament, where chondromas often hide.

Special Equipment for Arthroscopy of the Peripheral Compartment

Operating Table and Devices

The PC can be viewed with an arthroscope on a regular basic operating table with the patient in the supine or the lateral position. However, the need for arthroscopy of the CC in many cases requires the option of distracting the hip joint. The big advantage of a standard fracture table is its stable application of traction. For the combination with arthroscopy without traction, the extension booms must have the option of gliding in and out during arthroscopy to flex and extend the hip and knee joints (see Figure 11-3). The position of abduction and rotation needs to be adjustable. In particular, the option for lengthening and shortening the extension booms depends on the height of the patient. It is important to check before disinfection and draping if enough hip flexion can be achieved or if additional lengthening or shortening adapters are needed. During the past several years, alternative devices have been developed. In general, they provide similar functions with somewhat less effective traction but somewhat better motion during the nontraction part of the procedure.

Lenses and the Arthroscopy Shaft System

With respect to the thicker soft-tissue mantle, it is beneficial to use regular-length arthroscopes with shafts that have additional working length. This is usually achieved by mounting the water inflow farther backward. Extra-long arthroscopes are more sensitive to torque, and replacements are often not immediately available if intraoperative damage occurs. The more experienced the surgeon is, the more frequently the 70-degree lens is used. The PC is usually completely visualized with an arthroscope with a 70-degree lens; however, when working in the acetabular fossa with traction, the 30-degree lens often has advantages. The 70-degree lens offers the great advantage for inspection from different perspectives.

Access System

For the PC, the same principles apply as those used for the CC. The key to successful hip arthroscopy is a precise and atraumatic access system. This can be managed with cannulated, specific hip arthroscopy instrumentation only. Shafts, closed/slotted/half-pipe cannulas, and possibly also shaver systems need to be cannulated and compatible with the basic guidewire access system. In particular, the half-pipe cannulas provide for the atraumatic and rapid introduction and exchange of instruments. Aiming devices are beneficial for both beginning and advanced arthroscopic hip surgeons to reduce access trauma and operating time.

Instruments

Diagnostic and therapeutic hip arthroscopy can be effective only if specific hip arthroscopy instrumentation is available. Unstable cartilage or labrum flap tears can often be identified with extra-long straight and curved probes only. For synovectomy and a capsular release within the PC, short and extra-long shaver blades of different sizes and tip configurations are necessary. Thus, only with extra-long curved blades can the medial gutters beneath the transverse ligament or the posterolateral perilabral sulcus be accessed and freed of loose bodies or synovial hypertrophy. Particularly for the treatment of femoroacetabular cam impingement, special extra-long burrs are required to address the anterolateral head–neck junction. Extra-long straight, curved, and potentially movable radiofrequency tips are mandatory for effective synovectomy and control of bleeding.

Diagnostic Round and Arthroscopic Anatomy of the Peripheral Compartment

To increase the mobility of instruments and to improve inspection and access to the medial and lateral areas of the femoral neck, a release of the anterolateral articular capsule and mainly of the zona orbicularis is often necessary. We prefer to resect the zona orbicularis only, from medial to lateral. In narrow compartments and in patients with a significant loss of rotation, parts of the iliofemoral ligament are also removed.

Similar to arthroscopies of other joints, the key to an accurate and complete diagnosis of lesions within the hip joint is a systematic approach. A sequence of examination should be developed and carried out in the same way in every hip, progressing from one part to another of the joint cavity.

The PC can be divided into seven zones: 1) the anterior neck area; 2) the medial neck area; 3) the medial head area; 4) the anterior head area; 5) the lateral head area; 6) the lateral neck area; and 7) the posterior area. During a diagnostic round trip, the PC can best be viewed starting from the anterior surfaces of the femoral neck (Figure 11-6).

image

Figure 11–6 Diagnostic round trip of the peripheral compartment. A, Anteromedial neck area. fh, Femoral head; fn, femoral neck; msf, medial synovial fold; zo, anteromedial capsule with the zona orbicularis. B, Medial head area. aml, Anteromedial horn of the labrum; fh, femoral head; mc, medial capsule; pls, perilabral sulcus; TL, transverse ligament. C, Anterior head area. b, Base of the labrum; fe, free edge of the labrum; fh, cartilage of the femoral head; pls, perilabral sulcus. D, Anteroinferior neck area. ac, Anterior capsule; cr, anteroinferior reflection of the capsule; fn, anterior surface of the femoral neck. E, Posterolateral area. fn, Lateral border of the femoral neck; pc, posterior capsule; plf, posterolateral synovial fold with the end vessels of the medial circumflex artery; zo, lateral zona orbicularis. F, Lateral head area. fh, Cartilage of the femoral head; IL, lateral portion of the labrum; pls, perilabral sulcus; c, capsule.

With permission from Michael Dienst, MD.

The Anterior Neck, Medial Neck, and Medial Head Areas

The anteromedial part of the zona orbicularis and the anterior and medial synovial folds are inspected. The medial synovial fold, which is not adherent to the femoral neck, can be found very consistently, and it represents a helpful landmark, especially if visibility within the PC is limited by synovial disease or loose bodies.

By rotating the scope cranially, the anterior capsular recess and the anterior margin of the femoral head can be inspected. Here, in line with the medial synovial fold, the psoas tendon is lying anterior to the capsule. Sometimes the tendon shines through a thin articular capsule, or it may even be accessed directly via a hole that connects the hip joint and an iliopectineal bursa. Caudally, a complete view of the inferior reflexion of the articular capsule can be achieved. Moving the scope medially over the medial synovial fold, the medial neck area can be examined. By rotating the 70-degree lens, the medial margin of the femoral head, the medial transition from the anterior horn of the labrum to the transverse ligament, the medial wall of the capsule with the zona orbicularis, and the medial recess can be inspected. Rotating the lens downward, the zona orbicularis vanishes posterior to the femoral neck. Instrument access to the medial area is possible via the anterior portal to search for loose bodies and chondromas underneath the transverse ligament. In addition, changes in hip position, a short period of high-flow irrigation, and the use of a suction forceps or manual ballottement from a posterior position may be necessary to bring loose bodies from the posterior area into the medial or anterior recess.

The Anterior Head, Lateral Head, and Lateral Neck Areas

Further rotation and gentle sliding over the cartilage of the femoral head allow for the viewing of the mostly unloaded cartilage of the femoral head and the labrum from the medial to the anterior and lateral areas. This movement can be hindered by a tight zona orbicularis and extensive synovitis but facilitated by flexion of the hip up to 90 degrees and variations of abduction and rotation. Here, anterior portal placement to the CC can be achieved under direct arthroscopic control. The anterior and anterolateral labrum–head junction needs to be assessed for femoroacetabular impingement with flexion and internal rotation. With regard to other joints, arthroscopy offers the advantage of direct inspection under functional testing. With positive cam or pincer impingement, the depression of the labrum or the early contact of the labrum with the femoral neck with flexion and internal rotation can be observed. In these cases, the labrum frequently shows a significant synovial injection with prominent vessels on its peripheral side as well as a dull, round, free edge. The head–neck transition presents with a loss of offset (i.e., a bump). Frequently, a more extensive lateral synovectomy and the release of the zona orbicularis are necessary to improve the viewing of this region. When sliding laterally over the femoral neck and turning the scope backward, the lateral part of the femoral neck with the zona orbicularis running posteriorly and the posterolateral synovial fold containing the end branches of the medial femoral circumflex artery may be seen. The posterolateral synovial fold is sometimes adherent to the posterolateral neck, and it is not as prominent as the medial fold. In opposition with the medial synovial fold, which can be resected when the fold is inflamed and thickened, any lesion to the lateral fold must be avoided to not compromise the vascular supply of the femoral head.

Posterior Area

Access to the posterior region may be hindered in cases with capsular thickening and capsular fibrosis. It can be achieved by moving the arthroscope posteriorly between the zona orbicularis and the posterolateral synovial fold. With the 70-degree lens, the posterolateral part of the head, neck, and labrum can be inspected. Parts of the posterior area can be viewed and accessed from the medial neck and head area, as indicated previously. In addition, during arthroscopy of the CC with traction, parts of the posterior area can be inspected with the 70-degree arthroscope introduced via the anterolateral portal rotated posteriorly.

Slow withdrawal of the arthroscope to the anterior neck surface finishes the diagnostic round trip of the PC.

The Peripheral Compartment as an Intermediate Space for Safe Access to the Central Compartment

Direct arthroscopic access to the CC is technically demanding. In addition, particularly for the arthroscopic surgeon who is less experienced with this procedure, the acetabular labrum and cartilage of the femoral head are at risk for iatrogenic injury. Thus, we prefer to access the PC first and to then control the first portal placement to the CC via arthroscopic means from the PC (Figure 11-7).

image

Figure 11–7 Anterior portal placement to the central compartment via arthroscopic control from the peripheral compartment. The left upper insert shows the arthroscopic view; the right upper insert shows the fluoroscopic view.

With permission from Michael Dienst, MD.

The hip is placed in 10 degrees of flexion, neutral rotation, and 0 degrees to 10 degrees of abduction, with the knee straight. Without traction, the PC is accessed via the proximal anterolateral portal. The anterior head area is inspected. Under arthroscopic control, the anterior portal to the CC is placed. As soon as the guidewire is passed underneath the labrum (see Figure 11-7), traction is applied, and the wire is advanced into the acetabular fossa. The arthroscope is exchanged with an irrigation cannula via the proximal anterolateral portal, and the arthroscope is introduced via the anterior portal into the CC. At this point, additional portal placement to the CC (anterolateral and posterolateral) can be controlled arthroscopically.

Complications

A review of the literature reveals that most complications associated with hip arthroscopies are caused by traction. The nontraction technique for arthroscopy of the PC avoids complications such as soft-tissue damage of the perineum and foot or neurologic deficits from the compression of the pudendal nerve and the superficial nerves at the ankle or from the tension of the femoral and sciatic nerve palsies around the hip joint. In addition, if arthroscopy is limited to the PC, there is no risk of damage to the acetabular labrum and the hyaline cartilage of the weight-bearing area of the femoral head as long as the arthroscope and the other instruments are not too close to the articulating joint space. However, in cases of femoroacetabular impingement and synovial disease, the arthroscopist has to work directly at the acetabular rim, within the perilabral sulcus, and at the head–neck junction. Here, the labrum and the cartilage need to be avoided during the maneuvering of mechanical and radiofrequency probes. Frequently, it is beneficial to flex and externally or internally rotate the hip joint to “hide” the femoral head cartilage underneath the labrum and socket and to thus increase a certain area of the PC for better inspection and maneuverability.

Technical Pearls

Hip Arthroscopy Without Traction of the Peripheral Compartment

Positioning

• Supine position
• No traction
• Table or device should allow for traction, no traction, and motion

Access and Portals

• Main viewing portal should be proximal to the anterolateral portal
• Main working portal should be the anterior portal
• Ability to switch between portals, if necessary

Diagnostic Round

• Always include the peripheral compartment
• Establish a systematic sequence of viewing
• Consider variations from the normal anatomy

Therapeutic Arthroscopy

• Release of the zona orbicularis and eventually of the iliofemoral ligament
• Play with flexion and rotation to increase visibility and access

Depending on the skin incision sites and the direction of the portals, similar risks apply as those associated with arthroscopy of the CC. The standard anterolateral and proximal anterolateral portal are within the safest zone during hip arthroscopy; neurovascular structures are far away. By contrast, the anterior portal is always very close to a branch of the lateral cutaneous femoral nerve. It is recommended to avoid a deep skin incision, because the nerve or one of its branches runs close to the skin level. We prefer to choose a portal site that is 2 cm to 3 cm lateral to the vertical line from the anterior superior iliac spine and not too distal. On its way to the PC, the direction of the anterior portal should not be too far medial to avoid contact with the femoral nerve. However, the tendency is usually the opposite. The medial direction of the anterior portal should be about 30 degrees, depending on the skin entry site, and the soft-tissue mantle should be a bit more or less. Because the femoral nerve runs farther medially on its course to the distal thigh, the distance to the capsular entry site of the anterior portal at the level of the PC is even bigger as for access to the CC. We prefer to control the direction and capsular perforation of the anterior portal by arthroscopic means via the proximal anterolateral portals. The needle should enter the joint lateral to the psoas tendon (i.e., lateral to the medial synovial fold with the hip in neutral rotation).

Working within the PC requires specific attention to fluid management. In contrast with arthroscopy in the CC, the space in the PC can significantly decrease with the extravasation of fluid into the periarticular space. Thus, big incisions or resections of the capsule should be avoided during the early phase of the operation. We prefer to limit the capsular release of the zona orbicularis. Operations in the lateral and posterolateral peripheral spaces are performed at the end of the procedure. Here, a release of the iliofemoral ligament may be necessary.

Annotated references

Byrd J.W.T., Pappas J.N., Pedley M.J. Hip arthroscopy: an anatomic study of portal placement and relationship to the extra-articular structures. Arthroscopy. 1995;11:418-423.

This is an important anatomic study of the relationship of the standard portals to the hip joint and neurovascular structures. If the recommendations for portal placement are followed, the three standard portals are a safe distance away from the femoral and sciatic neurovascular bundles..

Dienst M., Gödde S., Seil R., et al. Hip arthroscopy without traction: in vivo anatomy of the peripheral hip joint cavity. Arthroscopy. 2001;17:924-931.

This article describes the arthroscopic anatomy of the PC. The technique of arthroscopy without traction for the PC with a sequence of systemic viewing is suggested..

Dienst M., Seil R., Kohn D. Safe arthroscopic access to the central compartment of the hip joint. Arthroscopy. 2005;21:1510-1514.

This is author’s preferred operative technique for accessing the PC first to control portal placement to the central compartment..

Dorfmann H., Boyer T. Arthroscopy of the hip: 12 years of experience. Arthroscopy. 1999;15:67-72.

This article describes the experience Parisian rheumatologists with arthroscopy of the CC and PC. Information about 413 arthroscopies over the course of 12 years is reported. The main indication for these hip arthroscopies was the removal of loose bodies..

Dorfmann H., Boyer T., Henry P., DeBie B. A simple approach to hip arthroscopy. Arthroscopy. 1988;4:141-142.

On the basis of experience with 60 hip arthroscopies, French rheumatologist Henri Dorfmann first publishes a description of the arthroscopic separation of the hip joint into the CC and the PC..

Gautier E., Ganz K., Krügel N., et al. Anatomy of the medial femoral circumflex artery and its surgical implications. J Bone Joint Surg Br. 2000;82-B:679-683.

This is an important anatomic study of the vascular supply of the femoral head. The end vessels of the medial circumflex femoral artery run along the posterolateral surface of the femoral head–neck junction and must not be injured during arthroscopy to avoid the avascular necrosis of the femoral head..

Klapper R.C., Silver D.M. Hip arthroscopy without traction. Contemp Orthop. 1989;18:687-693.

These authors report about their experience with hip arthroscopy without traction for the treatment of eight patients. The authors recommend draping the leg free for flexion and rotating the lower extremity to increase exposure and maximize the visualization of the joint..

Wettstein M., Jung J., Dienst M. Arthroscopic psoas tenotomy. Arthroscopy. 2006;22:907.e1-907.e4.

This article describes an operative technique that makes use of the PC to access the psoas tendon sheath..

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