Craig S. Mauro, MD (Pittsburgh, PA), performs a live surgical demonstration of a postless hip arthroscopy procedure using the Hip Distraction System (HDS) and disposable postless pad. Postless hip arthroscopy can decrease time in traction and has been shown to have significantly lower nerve injury incidence and numbness than post-assisted techniques.1
Reference
1. Ramadanov N, Voss M, Lettner J, et al. Postless vs. traditional hip arthroscopy: a multilevel meta-analysis of current evidence on efficacy and safety. Knee Surg Sports Traumatol Arthrosc. Published online August 28, 2025. doi:10.1002/ksa.70048

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VID1-005613-en-US | A | Hip Distraction System: Live Case

Craig Mauro

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Hip Distraction System: Live Case

This is the technique for hip arthroscopy positioning. Patient has been anesthetized. And we're now moving the patient down into the appropriate position. And then we'll apply traction. In the next steps. So first step is to have the team all together. And we move the patient in the same position that we would be in if we were doing posted hip arthroscopy. So we use three blankets just for a secure fit and padding of the extremity. Then we move to the feet. Place the feet into the traction boots. Inflection gives a better fit of the heel down into the device. Make sure we're centered and put it down so it gives resistance but doesn't have to be overly tightened. Ideally, we'd like her positioned in the same position based on the pad with the black line. In this case, she seems just a touch proximal, so we're going to gently move her down. All right. So that'll give a better x ray. Okay. So now we'll apply the traction. So the steps here are that we'll place the bed into a bit of Trendelenburg making sure we're locked down here about 15, 20 degrees. Just put a little bit of gentle traction on the contralateral hip to give it some stability. And then the steps here I use a three person technique. One person just giving some gentle compression to the pelvis primarily on the contralateral side. It tends to prevent the pelvis from rotating and then the second person placing the in-line traction. And I like to just control the leg so I can kind of feel the degree of traction. So I grab the leg and we together just gently put the hip into traction. See the attraction that's achieved? In this case, we won't apply any fine traction, but you can apply a fine traction at this point in the procedure if needed. But that hip nicely came out of out of place with just gentle in-line traction. No paralytic on board. Just good relaxation with anesthesia. Now we'll prepare for the surgical part of the case. So in this case, for video purposes the patient is wearing undergarments. They can be used or but you have to you have to deal with them for access in the sterile field. You can also do this procedure as easily without any undergarments. And you may get some more contact between the skin and the pad in that case, but both work. Work just fine. So before we prep and drape, we'll take the patient out of a little bit of Trendelenburg. I like to keep them in some Trendelenburg, maybe ten degrees here just for stability. But it basically keeps the leg parallel with the floor. We'll position the bed at the appropriate height. And sometimes once the traction is applied, you need to tilt the bed. And oftentimes it's away from the operative side to give you better access to the entire soft tissue envelope that we'll be working on. Okay, so we've applied traction and then prepped and draped. Traction is still applied. It you know, has the benefit here where we have a nice working space. There's no compression of the soft tissues from the post. There's no paralytic on board. Our anesthesia team can really manage their pain levels and we think give a more efficient anesthetic. There's no reversal agents that are needed because we don't have any paralytics on board. So overall we think a better patient experience, less pain from no post between the legs and and no risk for perineal palsy, no risk for pudendal nerve palsy from compression in the perineum. So we have a nice working space here. We've applied good traction and we'll start the case now. So I like to make my portals based on topical landmarks that I can feel, as well as using fluoroscopy. I've got access to the joint. One of the nice features here is that we can titrate our traction. So at this point, she has an appropriate space for accessing the joint. But if we needed to at this point, we can vent the joint, which will just pop into the joint there. I'll get an error. Arthrorome. So we know we're in the joint. And then we can apply some fine traction if we need any more traction. In this case, we can apply a couple of turns. Another benefit is we really can get a great assessment of the stability of the person's hip joint based on how easily they come into traction without a post. I think it gives a truer sense of how stable or unstable the hip is when we don't have paralytic on board and we don't have a post in there, and we're able to assess the stability of the joint on our application of traction to work our femoral plasty. We'll do some bed repositioning. We'll abduct a little bit. That's good. All right. So we've leveled the pelvis again. Flex just a little bit more. Good. So we finished our labor repair. We're at the point now where we're managing our capsule. We're going to do our plasty. We don't need don't need to be in traction anymore. So for the femoral plasty here, I'm. I'm viewing from a mid anterior portal, which gives us nice access to the soft tissues anteriorly. The left tips. I like to hold my camera in my left hand, so I'm going to position my body and manage the hip with my own body. The right hip sits the opposite. I'll hold the camera in my left hand, the assistant will manage the body and I'll stand more superiorly. So we'll now access the hip for the femoral plasty. We're working on our capacity. We've started distally way down the neck after we've done a t capsulotomy. You can see the work done distally there. This is very medial, so we externally rotate the hip in flexion. We can get all the way to the medial synovial fold. And that's with the hip in flexion and external rotation. And then as we internally rotate the hip I'm using my body to internally rotate the hip. I can get over the superior part of the neck. And I'm viewing from the mid anterior portal which gives me this view down on the joint. So then I can get over the top if I want to find the retinacular vessels there, Right over the top there. There's the pulse. So we know we're not too superior so we can get our superior and our proximal thermoplasty. We'll have to do in a little more extension. So at this point, we'll finish the part that we can see with the hip flexed. And then we'll slowly come into extension, moving from a from the distal cam to the more proximal cam. Taking special care not to take unnecessary bone proximally. All right. So we've completed our femoral plasty. And we've put in three stitches to close the bottom of the T with the hip out of traction and with the hip flexed. And now we're going to reapply traction to allow better access for capsule closure in the inner portal Capsulotomy. So we'll stabilize the pelvis there generally have to tilt the bed back again away from us. That's good. And then we'll just apply a gentle in-line traction. Good. Okay. Let's see an x ray. We can put some fine traction on now. A little more traction. Okay. X ray there. Okay, so we've reapplied some traction. Help give us access to the capsule for placing our stitches. We can place our superior stitches without hitting into the head or without hitting into the rim. So being able to quickly go back between traction in and out of traction is real helpful at different portions of the case. So we're placing our capsular stitches here in traction. Really you can see some of the technical benefits of BioTalus traction techniques are that you can go in and out of traction certainly much more easily through the case. You have a lot more freedom of movement with your hands when you're working. There's no compression of the tissues. For me, it's also very helpful to be able to to gauge how unstable or stable the hip is with our traction. And I feel like I can get this better whenever we're not using a post. There are many benefits to the patient as well. And it's not just that it's as easy to easy to do. We think this is a technique that's safer for the patients and provides better outcomes for several reasons. Number one, it certainly eliminates the risk of pudendal nerve palsy. There's there's no post. Not just that patients who don't get a palsy still can have significant pain from the compression of a post in their perineum over the course of even 30 to 60 minutes. So eliminating that, we found that we see the patients post-op day one. They're really have minimal pain. We think it's really helped with their post-operative pain by eliminating the post. Number two, the anesthesia team can, by giving an effective traction technique, eliminate the need for paralytics, which gives them a much more functionality and ability to titrate pain medications. They don't have to use reversal agents, so it gives much better anesthesia experience to help these cases be done at a ASC or hospital, but be able to be discharged much more easily. So we think it's a big a big benefit to the patients, our access to the joint, and it's easy to. Do. So. Some of some of the tricks and pitfalls. As with any technique, you really want to work with your team, your anesthesia team, your nursing staff in the room to all have a collaborative approach to this, because it does take a team to safely apply traction. So some of the pitfalls, I would say, really come from either poor communication and and a room that's not used to doing this type of work. I would do some dry runs with your team, know who's going to be pulling and pushing where. It's important to have a radiology technician who knows where to position the fluoro and can change positions with you. So everyone really working on the same team is really helpful. Number two, we do think that giving a little compression to the pelvis whenever we apply the traction is, is very helpful for just maintaining that position on the bed, because what you don't want to do is pull the patient too far off the bed. We want them to stay in that position. So some of the ways that we do that, we maintain that Trendelenburg position. We provide a little gentle compression when we're putting the patient on the bed. The keys are both for the positioning, for the traction, but also to make sure that when you place the traction that you can get, a good fluoroscopy image is to position the patient in the exact position where that little cutout is and where that line is on the pad in the same position. They would be as if there were a post. That ensures that you can get x ray access, and that the patient has enough support to their torso and to their buttock region, and that they don't slide off the bed distally. So real important consideration there. The last piece that we've really changed our traction, we found that even if we only get halfway of your traction with gently pulling it, leave it, go prep and drape, come back in. And then when you vent the capsule and just put some gentle, fine traction on the patient, oftentimes is a little more relaxed and it'll come right out even without venting. If you leave this partial traction on for the couple of minutes that it takes to prep and drape and then come back and just put the fine traction on. Usually that hip is is relaxed enough at that point that it'll it'll come right out. In conclusion, this is a technique we started doing hip arthroscopy probably about five years ago. For the first 6 or 7 years of my practice had done posted arthroscopy, which we had some problems with, but performed well. We made the change and we had the post in the room when we first started and said, okay, if we can't do it, we'll we'll put the post back in. But probably over the course of well over a thousand cases, I would say by now, over five years. I don't even know if we know where the post is in the hospital anymore. We never we've never had to put it back in. That concern is gone. We've been really happy with using post arthroscopy. We think it's very safe for the patient. We think it provides some real benefits for the surgeon, with ease of going in and out of traction, with a better understanding of the stability of the joint. We think it provides some real benefits for rehab and for anesthesia care. And so for a number of reasons, we've been really happy with this technique. And we think it provides a very safe alternative to the standard posted hip arthroscopy that we've all done for years.

Hip Distraction System: Live Case

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