Portal Placement for Hip Arthroscopy
In this short, fundamental case, Dr. Scott D. Martin walks us through how to place anterolateral and anterior portals for a diagnostic hip arthroscopy by first identifying the anatomic landmarks.
Main Text Coming Soon...
This article is the companion to the JoMI article "Diagnostic Hip Arthroscopy" by Scott D. Martin, MD.
- Sagittal Plane
- Anterior Superior Iliac Spine
- Greater Trochanter
- Parallel Approach
- Femoral Head Drop
- Orientation with 70º Scope
- Advancement of Cannula above Femoral Head
- Cutaneous Incision Avoiding Lateral Femoral Cutaneous Nerve
- Capsule Release with Arthroscopic Knife
Check Position of Anterior Portal with Scope
- Labrum Examination
Has a little tattoo right there. I’ll mark a sizeable plane here. You always want to try and keep them over also, so you can see your pubic line, because where that ends - her pubic hair - that's usually where the joint is. So it really gives you a good idea where you are - all these internal and external landmarks.This should be good right there. So it’s a 70° scope, guys. Kind of like operating out of the corner of your eye. Okay, so right here is one prominence. Right here is the anterior superior iliac spine, and we draw a plane down here - a sagittal plane - and everything medial to that is tiger country. So we want to stay lateral to that, so everything over here is out of bounds. Everything over here is where our surgical portals are going to be.
First portal’s going to be our anterolateral portal. So we feel the top of our trochanter, and then there's a soft spot above and below it. A posterolateral portal would go here. Directly in line in this cross-sectional plane is their anterolateral portal. And then the anterior portal, we draw cross-sectional line across our anterolateral portal through her pelvis. We drop down off of that line right here one centimeter and over one centimeter. That's that mark right there for our anterior portal. We’ll use up to seven portals. We use whatever we need depending on the size of the tear and what we need to do.
The biggest problem is the anterolateral portal is a blind stick, so it's done fluoroscopically and then also proprioception - what you can feel. That's the one that we have to be careful on. Every other portal’s established arthroscopically under direct visualization.
The wires are nitinol wires. They're very flexible, but they will break. I've broken them, so they can break pretty easily too - especially if we've been using them for the whole case and we're on our 7th utility portal. We've been banging up and bending them a little bit. They undergo a little bit of plastic deformation, and then they'll get a weak spot - and you can cut right across it and break it. Happens very quickly - there’s just no warning, so it doesn't bend a little bit more. It just goes!
I feel my soft spot here, but you know, her femur’s not going to be too big. So big thing is that you want to be going parallel to the floor or slight posterior in tilt. Never anterior, okay? So I have a head drop technique where I’ll go in first with a needle and we insufflate the joint and the fluid will actually help to push the head out and get rid of the vacuum. So there's a relative vacuum in our joints - makes it very efficient. So you put a little bit of synovial fluid in a vacuum, and joints function very efficiently with a very low coefficient of friction. When you lose that - that seal and with such a labral tear, the coefficient of friction is more like sandpaper on sandpaper. But sometimes even with the labral tear, they’ll have a pretty good seal where it's tough to get them out.
We do the bevel down toward the femoral head, so that gives us a little bit more room. So our puncture is just above the articular cartilage. If it was vice versa with the bevel up, then we would be skiving the head going in. So he's trying to get it about 2 millimeters off the head. You would think you got a lot of room between the head and the labrum, but you don't. So medially in here, you got a lot of room, but laterally out here where the pincer is, you don't. Keep your hand up. Keep your hand up. So make sure every time you change direction, you got to come back out. Just don't get don't any anterior tilt on it.
We're going parallel to the floor or a slight posterior tilt. A common mistake is going anterior and ending up on the ileum. So they’ll look perfect down here, but then he's hitting bone. So we know we're up above it even though it looks perfect there. Remember - it’s three dimensions. Now if it's really tight - if it was really tight, then we’re going to need to do a head drop. What do you think? I thought it went nice and smooth. Okay, you think you’re through the capsule? I do, yeah. Okay fluid. That’s okay. Nitinol wire. Start making your incision. So cut around that. So 11 blade.
There's a lot of ways that you can get burnt on scoping hips, and one is right here. So he's cutting right down the needle, and it's very easy to get a dermal tag. So even though you're through the epidermis and everything looks good - especially if you just leave the nitinol wire in and not the rigid needle when you're cutting down, you can have the wire going through the dermis, but then on the outside, it's coming through the epidermis. And you won't know it until you start pushing your obturator through it, and you can break the wire - the nitinol wire because there's a huge amount of torque and a focal point because of all that wire that’s sticking in the joint and where we are in the skin. We're down this far into her joint. So see, I have good backflow here. So Glenn puts it in. Put a lot in. Good. G - good backflow. Nitinol wire? That’s fine. So you didn't think you were through the labrum, right? I thought it felt nice and smooth going in.
So I’m going to go 4-5 first just to get the tip of the obturator through to dilate it, and then we'll go right to the 5 - 5-0. Sometimes if we're not sure if we're through the labrum or not, we'll start with a smaller obturator and cannulas. This is a 4-5, and if he's feeling a lot of resistance, we’ll go through with this and scope her dry. If it feels good, then we'll switch right over to 5-0, which gives us better inflow. So the bigger the cannula we go with, the better flow we get, and the problem with the smaller cannula is - is this is all made for more of a less constrained joint where there's not much flow.
So when you’re - remember - it's more of a twisting motion than a push, okay? Than a direct linear push - yep. So the first tether is going to be at the skin and sub-Q, where he feels resistance. Then he’ll go down the joint. The next tether’s going to be at the capsule. Those are the two areas where you can break this wire. If you break it at the skin, it's not a big deal because it'll be subcutaneous and we can just fish it out. If he breaks it down at the capsule, it's a big deal because the wire will go medial, so they’re tough to fish out. She's 24, so she'll have a pretty tight capsule. So sometimes though, it's tough to tell if your perforating the labrum or not. You'll see when we get in there.
And you have to remember we’re using a 70 degree scope, and the problem with that is it's like operating out of the corner of your eye. It's a very short focal length, so if you look from here to here, you have to refocus everything - and it's - it’s like operating like this out of the corner of your eyes - always peripheral. So it can distort your image. When he's putting the scope in, cord should be straight down, and that's - think of that as your feet. So if I wanted to look at you, I can do it two ways. So I can turn my whole body, which would be my camera, or I can just turn my head, which would be my lens. So he just wants to use his lens, but because it's 70 degrees, he has to finesse it a little bit also with the camera.
It's very difficult to teach them how to scope hips, so once they get it down - there's a very steep learning curve, but once they get it down, they have it. It's like learning how to drive a stick shift. And everything is upside down and backwards as far as what his mind will see with this - rather than 30 degree scope, which is pretty anatomic. With this your mind wants to tell you - your brain wants to tell you left is right, and right is left, and up is down, and down is up. And so you have to do cerebellar tracking - like learn how to play the piano - to teach your mind that no, no - this is… And we do that by telling them to go in circles first, and then their brain will pick up - oh okay, that is left over there - even though the brain was telling them originally it was the opposite side. Very interesting that to watch someone when they’re first scoping. They're going completely opposite direction, and then they they literally pick it up after a couple scopes. Can you come feel this? How's it feel? So I just - just keep pushing. It’s a pretty tough capsule. It’s about right there. We'll find out.
Okay let’s have the scope. Now you can see the capsule moving. We’ll try to get the center of that. You got to be right on big guy - got to be right on. Okay, you got to be right in the center of that. So you're drifting. Just gonna take it for a second. Right there. Do you think I was just a little too high? Maybe a little bit - this looks like it’s off a little bit. So nitinol wire. And here the lateral femoral cutaneous nerve arborizes out. So anywhere that we cut through the dermis, we’re likely to hit a branch of it. So we just make a teeny little knick right in the epidermis and just hardly to the dermis - like way - maybe 2 mm, and then we dilate with the Mosquito. So right where we are, it's really branched out and arborized, so you really have to be careful. If you just went in with a knife like we make most portals, you'll hit a branch.
5-0, 5-0 blue. So make sure you really dilated that, right? Good. Alright, let's get in there so we get our flow before we get some bleeding. You have our knife? You have the arthroscopic knife - the long one? So we don’t want this whole cannula in here. We keep our obturator back because you could see how tight she is, so we need to loosen her up a little bit. If you could just back up that cannula on here just a little bit. So see, you're up a little bit too much of an angle here. So you've been coming in a little bit high with your portals, so it just makes it so - see the angle line, where I am? It makes it difficult to go straight up and down to like grab the suture and stuff. Good, thanks. Gonna go with the obturator again. So - you want to come - you want to have that straight. You don't want to - once you get down there, you don't want to start cheating with the needle. You got to readjust. So I got to make sure it's locked in. Okay, give me 2 more turns.
Now I'm going to look back on her anterior portal, which is a blind stick. Make sure that was not through the labrum. And we’ll take an obturator down here, and let me just have a switching stick because I’m going to switch it out anyway. So he's right there. Right here.
To maintain access: please let your librarian know you would like a subscription or send us an email at firstname.lastname@example.org and we will forward your feedback to your librarian.