Stepwise Safe Access in Hip Arthroscopy in the Supine Position

Tips and Pearls From A to Z

David R. Maldonado, MD; Philip J. Rosinsky, MD; Jacob Shapira, MD; Benjamin G. Domb, MD

Disclosures

J Am Acad Orthop Surg. 2020;28(16):651-659. 

In This Article

Patient Positioning

Positioning is the key for any orthopaedic procedure, but this is particularly true for hip arthroscopy. Supine and lateral decubitus positions have been promoted as effective positions from which the hip joint can be accessed. The supine alternative is currently the most popular position and is the authors' preference[6] (Figure 1 and Video, Supplemental Digital Content 1, http://links.lww.com/JAAOS/A496). Regardless of the preferred position, sufficient padding of the patient's feet is essential because of the traction force that is applied during surgery. This reduces the risk for skin damage and nerve injury. General anesthesia, spinal, or epidural anesthesia can be used in hip arthroscopy. The combination of general anesthesia and muscle relaxants is the authors's current preference choice because of (1) rapid induction and (2) avoiding waiting for motor and sensory block resolution, which is extremely important in postoperative evaluation, especially for surgeries performed in the outpatient setting.[7]

Figure 1.

Photograph showing hip arthroscopy with the patient (right hip) in the supine position using a perineal post.

Hip Arthroscopy With or Without Perineal Post?

To gain safe access to the hip joint, adequate distraction of the joint (ie, ideally > 10 mm) must be achieved.[8] Owing to the thick soft-tissue envelope around the joint, this has traditionally been accomplished through the use of a specialized traction table and perineal post. The use of a perineal post has been described for both the supine and lateral positions.[9,10] The force required to achieve adequate distraction changes throughout the procedure. Initial distraction force ranges from 444 N in women to 517 N in men. This force decreases by an average of 17% after capsulotomy.[11] One of the potential complications of using a perineal post is damage to the pudendal and the perineal nerves.[12] A systematic review by Habib et al[13] which included 3,405 hip arthroscopies found the risk of pudendal nerve injury to be 1.8%, although all cases were transient and resolved within 3 months. Potential risk factors for the development of pudendal nerve injury were long traction time and the use of a perineal post.

To minimize the risk of pudendal nerve and perineal injuries (eg, scrotal and labial necrosis as well as vaginal tears), some authors have proposed eliminating the perineal post.[14] This can be achieved through a variety of methods. Mei-Dan et al have popularized the elimination of the perineal post by demonstrating favorable results with the introduction of 5° to 15° Trendelenburg to the operating table.[15] Other solutions share the commonality of increasing friction between the torso and the operating bed, thereby enabling adequate joint distraction and avoiding the risk for soft-tissue damage associated with the use of a perineal post.[16]

The Trendelenburg Technique, why and how?

Once the patient is secured on the surgical table, the introduction of the Trendelenburg position serves two purposes (Figure 2, A and Video, Supplemental Digital Content 1, http://links.lww.com/JAAOS/A496). First, this position decreases the amount of traction force required during surgery, thereby reducing the risk of skin and nerve damage.[15] Second, when using a perineal post, the decreased traction force also relieves the pressure between the post and the perineum, thereby lowering the risk of injuries caused by direct pressure.[17] Our results on patient positioning demonstrated a reduction in perineal pressure of 15.5%, 28%, and 46% at 5°, 10°, and 15° of Trendelenburg compared with 0° (ie, no Trendelenburg), respectively, without compromising the spatial anatomic perception of the surgeon.[18] We propose the use of 8° to 10º of Trendelenburg inclination, a position in which the anterosuperior iliac spines (ASISs) are level in the horizontal plane.

Figure 2.

Phtographs showing A, Trendelenburg is applied to the surgical table using a perineal post in preparation to a right hip (*) arthroscopy. The C-arm (black arrow) is placed on the nonsurgical side of the patient, perpendicularly to the operating bed. The arm in the surgical side is padded and placed just above the level of the umbilicus with 90° flexion of the elbow (white arrow). B, From another perspective, the C-arm (black arrow) and arm in the surgical side (white arrow) are shown view in preparation to a right hip (*) arthroscopy. C, The surgical table has been "airplane" away from the surgical side, right hip (*) in this case. C-arm (black arrow).

Addressing Pelvic Tilt

It is critical for the surgeon to maintain adequate spatial orientation during the entire procedure.[19] To avoid anatomic disorientation, the pelvis should not be tilted to either side. This may be accomplished by adjusting the operating bed so that the ASISs will be leveled (Video, Supplemental Digital Content 1, http://links.lww.com/JAAOS/A496). The patients position is verified by assessing the symmetry of the obturator foramens and the position of the coccyx relative to the pubic symphysis, using fluoroscopy.[5]

Key Points and Pearls

After the patient is secure on the traction table and before draping, the authors recommend the following steps for the final patient positioning in a reproducible manner:

  1. The arm in the surgical side can be padded and placed just above the level of the umbilicus with 90° flexion of the elbow (Figure 2, A and B).

  2. Provided that a perineal post is used, simultaneously apply traction to both legs manually to achieve an even contact distribution between the perineum and the post.

  3. Establish neutral rotation, adduction against the post and 5° of hip flexion of the surgical leg while the nonsurgical leg is in 30° of abduction and neutral rotation (Figure 2).

  4. Apply at least 8° to 10º Trendelenburg inclination. To address the pelvic tilt, the operating bed is usually placed in an "airplane away" from the surgeon's side to level the ASISs, as described previously (Figure 2)

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