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

Fluoroscopy, is it Necessary?

Radiation exposure is always a concern in hip arthroscopy. It has been reported that the mean intraoperative radiation dose to patients in hip arthroscopy is 12.6 mGy, a value that is below the threshold for radiation associated complications.[20] Alternatively, the lifetime risk of death because of malignancy is 0.025% for the operating room staff because of a cumulative exposure to radiation.[21] According to Smith et al, exposure to fluoroscopy decreases with time and practice.[19] Although accessing the hip joint without the use of fluoroscopy has been described,[22] the authors of this review think fluoroscopy is critical for reproducing safe access and diminishing the risk of iatrogenic damage to the labrum and the articular cartilage.[23] Alternatively, the use of ultrasonography has been proposed. Although this concept is potentially promising, the success of this method is heavily dependent on the operator's experience.[24]

C-arm Location in the Operating Room

When supine position is selected, the C-arm can be placed either between the patient legs or on the nonsurgical side of the patient, perpendicularly to the operating bed (Figure 2 and Video, Supplemental Digital Content 1, http://links.lww.com/JAAOS/A496). The authors find the second option more convenient and reproducible not only for the purpose of joint access but also for other parts of the procedure such as femoroplasty and subspine decompression. This allows the C-arm to move freely to obtain several views for bony correction purposes.[25]

C-arm and Patient Pelvic Position

As mentioned previously, the authors modified the supine position of the patient by applying Trendelenburg to the operating bed; however, the C-arm must be cephalically tilted to avoid obtaining inlet views because of the angular displacement. This will provide a true AP view.[5]

Do not get Lost Before you Even Start! Correcting Pelvic Rotation

It is critical to obtain a true AP pelvis view when assessing the hip joint during an arthroscopic procedure. When the surgeon attempts to estimate the spinal needle trajectory, the smallest degree of pelvic rotation can lead to unnoticed misdirection. To avoid this, ensure that the pubic symphysis is displayed in a vertical position on the monitor. The authors recommend using this pearl after each time traction is applied to the operated leg because it may alter the position of the pelvis.[5,18]

Key Points and Pearls

  1. Place the C-arm on the nonsurgical side at an angle that is perfectly perpendicular to the patient's body (Figure 2).

  2. Compensate for the patient's Trendelenburg position by cephalically tilting the C-arm.

  3. Check the patient's pelvic rotation by obtaining an AP pelvis view centered on the pubis.

  4. Once pelvic rotation is checked, move the C-arm forward to the surgical side and obtain an AP hip view.

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