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

Distal Anterolateral Accessory Portal

After completion of the capsulotomy using the anterolateral and the modified midanterior portal, the decision of labral treatment should be concluded. Both labral repair and reconstruction necessitate the placement of anchors in the acetabular rim. The DALA portal provides the required "attack angle" because it is less steep and therefore safer than the modified midanterior for capsular elevation and anchor placement.[29] The DALA portal has been shown to decrease the risk of intra-articular penetration during anchor drilling or placement.[23] In addition, the spatial relationship and distance relative to the anterolateral and the modified midanterior portal should be considered to avoid "cross-hands" during anchor placement. The three portals should form an inverted equilateral triangle, with the DALA portal forming the distal apex and the anterolateral and modified midanterior forming the proximal apices (Figure 4). In the authors' hands, suture managing becomes more reproducible by the use of three portals, especially in avoiding sutures tangling. Nevertheless, this is not a requirement and labral repair and even segmental labral reconstruction can be performed using just two portals (anterolateral and midanterior).[30]

Key Points and Pearls

  1. Although anatomic reference points are important, the DALA portal position is mostly based on the position of the anterolateral and modified midanterior portal.

  2. It is easier to triangulate by incising the skin before using the long spinal needle.

  3. In the authors' experience, the DALA portal is ideal for anchor placement, especially from the 2:30- to 9-O'clock positions. As previously mentioned, beyond the 2:30-O'clock position, the angle provided by the midanterior portal is usually better for anchor placement purposes.

  4. Although not mandatory, introducing a cannula through the DALA portal is extremely useful in elegant suture management.

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