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VID1-01119-EN | A | Overview of Hip Joint Access Featuring the Synergy Extended Length Hip Arthroscope System

Benjamin G. Domb

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Overview of Hip Joint Access Featuring the Synergy Extended Length Hip Arthroscope System

We'll begin today with a demonstration of the landmarks around the hip as we approach access to the hip. Here we've marked the anterior superior iliac spine, or ASIS. We've drawn a line inferiorly from the axis, and we'll avoid going medial to that line with any of our portals in order to protect the femoral neurovascular bundle. Here we've marked the greater trochanter. We'll take care during the procedure not to use the greater trochanter as a landmark, because the greater trochanter can move. So if we have more or less distraction, the greater trochanter may move inferiorly or superiorly. If we have more or less femoral anteversion or more or less internal or external rotation of the hip, the greater trochanter will move anteriorly or posteriorly. So we don't want to use the greater trochanter as a landmark. It's more something to avoid. We want to use the ASIS and the pelvis as our landmark, because ultimately what we're approaching is the acetabulum, and we want to maintain a consistent angle of approach toward the acetabulum. Posteriorly, the sciatic nerve is back in this range, so as long as we're anterior to the. Posterior edge of the greater trochanter, we should be well away from the sciatic nerve. So first we'll begin with an anterolateral portal. And the way that we locate our anterolateral portal. Is by first laying the spinal needle across the expected trajectory. We'll take an x ray here. And that gives us an idea of where we want to be from superior to inferior. Now, as far as anterior to posterior, we want to be somewhere along this line. We will not use the greater trochanter as our landmark. We'll imagine where would be in line with the 12:00 position on the acetabulum. That's where we want to be. We want to be approaching the 12:00 or perhaps 1230 o'clock position on the acetabulum. We're going to get a shot with the spinal needle meeting the most inferior part of the Gram. So that'll be here. We'll turn the bevel so that we pass the labrum. So the flat part of the bevel is toward the labrum. We'll pass through the capsule like this. And then we flip the bevel like this so that now we can use the bevel to pass the femoral head. And here you see it's passed the femoral head without digging into the femoral head. So we want to be as inferiorly as possible in the air ArthroFX gram while not hitting the actual femoral head. Here we insert the guidewire through the spinal needle. We'll take the spinal needle out, and then we'll use over the guidewire technique to insert our cannula. This is a 4 or 5 cannula. And this is generally the first cannula that we'll enter the joint with. So you can you want to avoid plunging with this cannula. And you can do that by using your finger your index finger on the skin. Or you can use a golf grip where you use two hands like so. And use this to avoid plunging, so you stop yourself from plunging. We'll see the cannula coming toward the joint. We'll lever like this away from the femoral head so that we avoid hitting the femoral head. And then we avoid our plunge using our golf grip or using our index finger. Now we're in the joint and we'll place our scope. Through the candle. So there's our scope. Now I generally start my approach dry. And what we want to visualize here is the triangle between the femoral head on the right and the labrum on the left. And this anterior triangle is going to be our insertion site for our second portal. My second portal is going to be an anterior portal. So we want to be a little bit lateral to this line, which we drop down from the ASIS. So we'll come to about here and we'll pick a spot essentially parallel with our anterolateral portal. And I want to pick a spot where my spinal needle and my scope are going to converge at about a 30 degree angle. That's about the the spot that I want to pick. So you shouldn't define a particular distance between these two portals, because the distance may vary depending on the size or shape of the patient. But what can remain consistent is this angle of convergence between the spinal needle and the scope. So we'll then insert the spinal needle into the joint. And we want to come in through this anterior triangle here. And we want to come in at a point where we leave a little bit of a cuff of capsule on the acetabular side, which we can then use later to repair the capsule. So we pass our guidewire again through our spinal needle. And then we'll now pass the blue or 5.0mm scope sheath over the guidewire. This comes into the joint. Again, I'm watching the cannula come in and I can use my index finger to prevent plunges. So my index finger is right up against the patient. I lever away from the femoral head. I make sure I don't scuff the femoral head on the way in. And now my cannula is in. And now we have an outflow. So we can now run the pump and we have an outflow. So we'll be able to flush out the joint. Scope sheaths have been smoothed on the end. So they're less likely to scuff the femoral head. And that's important. But of course we should still take care to avoid bumping them into the femoral head on the way in and out. So now we'll pass a banana blade or any type of blade you choose through this, Us through this scope sheath and into the joint. And I'm going to use this blade for my capsulotomy. Now, I like to do this through the anterior portal, not through a more distal portal, but through the anterior portal, because this gives me an angle where the blade is essentially perpendicular to the fibers of the capsule. And you can see this in the arthroscopic picture. If you come from a more distal portal, the blade will be cutting obliquely across the fibers of the capsule, which makes it harder to repair afterward. So we're going to use this beaver blade to to perform an inter portal capsulotomy. And we want to take care to see the tip of the blade at all times so that we don't cut the femoral head. Take a lot of care to see the tip of the blade so you don't cut the femoral head. Now notice I'm coming. I'm cutting from bottom right to top left because I'm going parallel to the labrum, so I'm not cutting directly toward myself. I'm cutting this way, using the blade as a rudder to cut parallel to the labrum. And that's important as well, because we want to leave a consistent cuff of tissue on the acetabular side. For later capsular repair. Here we go. We can now demonstrate that we'll switch the candles. So I'll turn off the flow. I'll switch portals using the bridging system and put the scope in the anterior portal and look posteriorly. And I'll take that blade. And now we'll pass the blade through. This. And now we can complete our capsulotomy here. And again we've checked that the portal did not go through the labrum and we did not scuff the femoral head, and we keep the beaver blade in view throughout. So we'll complete our capsulotomy now. Cutting anteriorly again parallel to the labrum, not necessarily directly toward us. Rather I'm going parallel to the labrum. That's that's important because that's how we preserve a good cuff. Of a uniform thickness along the acetabular side for the later capsular repair. So now I can switch back using the bridging system. We can use half pipes to pass instruments. One thing I would note is that when you use half pipes, it's important that the half pipe converge toward the switching stick or instrument that it's going along. So you want the half pipe to converge like this. You do not want them running in parallel like this, because if you run them in parallel and it catches a little soft tissue, then it will diverge. So you want it converging. You want the tip running along the switching stick or instrument. So it's converging at all times. So when you go in with the half pipe you come out with the switching stick. When you come in with the switching stick you come out with the half pipe always converging. And same with any other instrument. So we're here converging toward the switching stick as we come in and switching stick out. And then we'll put a probe in sharp part of any instrument, always toward the half pipe converging as we come down and half pipe out. And now we'll go through a diagnostic arthroscopy. So we'll begin with the ligamentum teres. This is obviously a cadaver. So we see the ligamentum teres is quite badly torn. We can evaluate the acetabular fossa. Look at the foveal cartilage here. You see. Femoral head defect in the superomedial. Posterior superior medial femoral head posterior to the fovea. We can look for notch osteophytes like this one around the acetabular fossa and for synovitis in the acetabular fossa. So we begin again at 6:00 at the ligamentum teres below the ligamentum teres you see the transverse acetabular ligament. Then we go anterior inferiorly. So this is 5:00, 4:00. At 3:00 you see the psoas. You. So this is the psoas notch. And this is a good marker directly anteriorly to this is where the iliopsoas runs. So if you do an iliopsoas fractional lengthening at the level of the joint line, it's right on the other side of that capsule. You don't necessarily need to cut through the capsule. You can go up and over the capsule. But this you gives you a good localizer of where it is. A note if you do ISO's lengthening at the level of the joint line, it's often bifid at the level of the joint line. So look for a second or third slip of the tendon. So 3:00 2:00. 1:00. 12:00. And then as you move more posteriorly. 11:00, 10:00, 9:00, 8:00, 7:00. And right back to 6:00. Right back to the ligamentum teres. A couple of interesting views to work with. This is an intra-articular view, of course, of the labrum. And from here you can probe the anterior labrum and the peripheral cartilage of the acetabulum, which are some of the most commonly worked on areas in hip arthroscopy. It's also useful to use a use a bird's eye view where you come from superior from the capsular side, and you can see the capsular side of the labrum from this view. So at this point, I'll point out a distal anterolateral accessory portal, which will be approximately in this region. So I want this to be converging now from distal to proximal at a 30 degree angle to my to my scope. And this will be quite a bit more lateral than the anterior portal was. So through this portal, I'll have a nice trajectory for placement of anchors most of the way around the acetabulum. I can use a I can use a switching stick to enter the joint here. Through the this anterolateral portal, we can see the capsule here. We see the the labrum here. This is the anterior labrum. Lateral labrum. 12:00 here. This is the rectus femoris up above the capsule. The indirect head of the rectus femoris here, traveling above the capsule. I'm now retracting it. These fibers with my probes. So that's indirect. Head of the rectus femoris. And this is capsule. So I'll preserve this cuff of capsule throughout for later repair. And you can see how laterally at 12:00 the capsule almost fuzes with what's left of the indirect head of the rectus femoris. So we'll preserve that as well for later repair. I'll also demonstrate the bird's eye view here, viewing from above the labrum. If you retract the capsule up, you can. You can view the capsular side of the labrum. So nice view of the capsular side. Very useful view. And we'll use this view often to develop the plane between the capsule and the labrum for an acetabular plasty before doing a labral repair. So now we're going to create a posterolateral portal. And this will be parallel with our anterolateral and our anterior portals. And this portal will allow us to access the more posterior parts of the acetabular rim working down here. Okay. So the the posterior portal is parallel to about the 10:00 position on the posterior lateral acetabulum. Usually this coincides with the posterior lateral corner of the trochanter. Approximately. But as before, I do not use the trochanter as my reference point for locating the landmark. I think of where is it going to arrive on the acetabulum. So I'm targeting the acetabulum with this portal, not targeting the greater trochanter.

Overview of Hip Joint Access Featuring the Synergy Extended Length Hip Arthroscope System

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