Hip arthroscopy without traction: In vivo anatomy of the peripheral hip joint cavity

doi:10.1053/jars.2001.25342

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 17, Issue 9, November–December 2001, Pages 924-931

Presented in part at the Annual Meetings of the Arthroscopy Association of North America, Miami, Florida, April 2000; the Orthopaedic Surgeons of South Germany, Baden-Baden, Germany, April 2000; and the German Society for Orthopaedics and Traumatology, Wiesbaden, Germany, October 2000.

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Abstract

Purpose: To describe the in vivo anatomy of the peripheral compartment of the hip joint using a systematic sequence of examination without traction. Type of Study: Case series. Methods: We performed 35 hip arthroscopies without traction from an anterolateral portal in the supine position. Free draping and a good range of movement of the hip joint were used to relax parts of the capsule and increase the intra-articular volume of the area that was inspected. Each procedure was documented on a standard protocol including detailed information on technical features and normal and pathologic intra-articular findings. Results: A comprehensive inspection of the peripheral compartment was obtained from the anterolateral portal. A systematic sequence of examination was developed separating the periphery of the hip joint into 7 areas: anterior neck area, medial neck area, medial head area, anterior head area, lateral head area, lateral neck area, and posterior area. The arthroscopic in vivo anatomy of each area is described. In 3 patients, 1 to 3 loose bodies were removed. In 1 patient with a synovial chondromatosis, 40 chondromas were retrieved. In osteoarthritis, impinging osteophytes were trimmed in 3 cases and partial synovectomy was performed in 10 patients. The following complications were observed: a temporary sensory deficit of the lateral femoral cutaneus nerve in 1 patient, scuffing of the anterior surface of the femoral head in 3 patients, detaching of an osteophyte in 1 patient, and partial tears of the anterior synovial fold in 10 patients. Conclusions: Arthroscopy without traction allows for a complete evaluation of hip anatomy without the loaded articular surfaces, the acetabular fossa, and the ligamentum teres. For a complete overview of both the central and peripheral part of the hip, traction is necessary for the central part.

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 9 (November-December), 2001: pp 924–931

Section snippets

Methods

We performed 35 hip arthroscopies without traction between 1997 and 1999. Each procedure was documented using a standard protocol that included detailed information on normal and pathologic intra-articular findings. Hip arthroscopy of the peripheral compartment of the hip was performed in the supine position from an anterolateral portal (Fig 1).

. Anterolateral portal to the non–weight bearing part of the hip joint: According to Dorfmann and Boyer,² 3 portal site areas can be differentiated: The

Arthroscopic anatomy

Similar to the knee joint, the key to an accurate and complete diagnosis of lesions within the hip joint is a systematic approach to viewing. A methodical sequence of examination should be developed, progressing from one part of the joint cavity to another and systematically carrying out this sequence in every hip.

For arthroscopic examination, the peripheral compartment of the hip can be divided routinely into the following areas: anterior neck area, medial neck area, medial head area, anterior

Arthroscopic procedures and complications

In our series of 35 hip arthroscopies without traction, 1 to 3 loose bodies were removed in 3 patients with early osteoarthritis and 40 loose bodies were retrieved in a patient with synovial chondromatosis of the hip. In osteoarthritis, impinging osteophytes were trimmed in 3 patients and partial synovectomy was performed in 10 patients. The following complications were observed: A temporary sensory deficit of the lateral femoral cutaneus nerve was present in 1 patient for 2 days. The cartilage

Discussion

Hip arthroscopy without traction was first introduced by Klapper and Silver in 1989.⁵ Apparently, only Klapper himself⁸ and Dorfmann and Boyer2, 4, 9 have continued using this technique. Dorfmann and Boyer² reported that most of their diagnostic hip arthroscopies were performed without traction. In addition to the role of hip arthroscopy without traction as a diagnostic procedure, therapies such as retrieval of loose bodies, trimming of labral tears, and diagnosis of chondromalacia of the

Acknowledgements

Acknowledgment: The authors thank J. W. Thomas Byrd, M.D., for his advice during the preparation of this report.

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Limitations of arthroscopy for managing coxa profunda
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Citation Excerpt :
The most lateral paratrochanteric portal, or a postero-lateral paratrochanteric portal (between the antero-lateral and postero-lateral portals), [28] should be established, if needed with 1 cm of proximal translation. This portal resembles that described by M. Dienst for accessing the peripheral part of the joint [27]. The antero-lateral portal is preferable over the anterior portal for the other approach.
Coxa profunda is a complex entity that can result in femoro-acetabular impingement (FAI). A meticulous evaluation of the type of acetabular overcoverage is essential to determine which treatment is best suited to each individual patient. Focal overcoverage with no posterior impingement can be treated by arthroscopic recontouring of the disproportionate acetabular wall. Any femoral deformities should be managed during the same procedure. General overcoverage, with predominant postero-inferior impingement, requires open surgery to obtain access to the entire acetabular rim. Rim resection should be sparing, to avoid removing an excessive proportion of the joint surface, yet sufficient to eliminate the impingement. In the event of protrusio acetabuli, which is the extreme form of coxa profunda, reverse peri-acetabular osteotomy should be considered, particularly if the acetabular roof angle is reversed. In some patients, chiefly those with coxa vara, valgus femoral osteotomy should be considered as a means of redirecting the loads towards the acetabular roof, thereby diminishing the forces that tend to drive the femoral head deeper into the socket.
Compression and Flip Test for Diagnosis of Unstable Acetabular Labral Tears Using a Peripheral Compartment Approach
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Assessment of integrity of the acetabular labrum is generally done via the central compartment under distraction of the femoral head from the acetabulum. With the technique of raising the extra-articular and peripheral compartment first, there is a need for testing the stability and function of the labrum from the peripheral side in a nondistracted position of the joint. The authors report on the compression and flip test (i.e., the flip test) for the detection of unstable, intrasubstance tears of the labrum or unstable chondrolabral separations. The test can be performed by compressing the labrum with blunt instruments. We grade the labral conditions as follows: grade 0 for firm resistance and elasticity to palpation, grade 1+ as easily compressed by the probe, grade 2+ for eversion of the body of the labrum under compression), and grade 1 for ossified, hard resistance without any elasticity and compressibility. This test can be performed directly after accessing the peripheral compartment through a 2-portal technique without extensive capsular work.
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^*: Address correspondence and reprint requests to Michael Dienst, M.D., Department for Orthopaedic Surgery, University Hospital, 66 421 Homburg/Saar, Germany. E-mail: [email protected] Home Page: www.orthopaedie-homburg.de

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Original ArticlesHip arthroscopy without traction: In vivo anatomy of the peripheral hip joint cavity*

Abstract

Section snippets

Methods

Arthroscopic anatomy

Arthroscopic procedures and complications

Discussion

Acknowledgements

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Hip arthroscopy utilizing the supine position

Arthroscopy

Einsatzmöglichkeiten der operativen Hüftarthroskopie

Arthroskopie

A simple approach to hip arthroscopy

Arthroscopy

Original Articles
Hip arthroscopy without traction: In vivo anatomy of the peripheral hip joint cavity*