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.

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.

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.