Hello, my name is Dr. Winston Gwathmey from the University of Virginia. Today I'll be speaking about OR setup, positioning, portals, and access. I have no disclosure relevant to this talk. I do want to say thank you to Anna and Dr. Shane Ngo for inviting me to speak at this course. Let's start with the OR table. So for safe, effective, and efficient access for hip arthroscopy, the table must be able to administer adequate traction, allow manipulation of the hip, accommodate fluoroscopy, and be safe during long cases. As an added bonus, the size of the table is easy to set up and take down and storable, as many of these cases to be done at an outpatient surgery center. So many different tables have been utilized, the fracture table, HANA table, as well as different traction attachments. It's also possible to use a lateral hip positioner for some of these hip scopes. Here's a standard traction attachment on a regular table with a post. So I use an oversized perineal post to disperse force across the perineum. Also important to pad the feet well, as these feet will be in these boots for a couple hours during some of these cases. Postless tables have received more attention lately, and some proprietary tables have been designed to use postless traction. Josh Harris and his group describe using a standard table of post for distraction as well. It's a nice strategy to be utilized. Here's my standard table with the post for distraction set up. I use this blue pad, which is basically a memory foam that secures a body in place, and then put the feet in a standard apparatus, and then use some deliberate position in order to get access to the joint. Here's my normal setup with the post. Again, I bring fluoroscopy between the legs, and looking at it from straight up and down, you can see that the surgeon, the assistant will be in the operative side, with a scrub nurse there as well. Again, I bring CR from between the legs. You can also bring CR from across the other side of the table. I did go and observe several different experts, how they set up their operating rooms. I think we're getting started. It's really nice to be able to go out and see how the experts set up their operating rooms and do their cases. So as far as fluoroscopy, this paper by Jim Ross and Chris Larson ends up being really important to you, because it helps to describe the proximal hormonal anatomy, and how to get the x-rays during the operating, during surgery. So I try to match my pre-operative x-rays to my intraoperative x-ray. So I'm going to AP x-ray and a 45-degree done. I also get a 90-degree done intraoperatively to make sure that I have a pretty good idea of the proximal hormonal anatomy. As far as distraction, you're going to apply longitudinal distraction across the perineal post. It's important to apply counter traction to the contralateral foot to make sure you don't pull the pelvis around the post. Some tricks for improving distraction, Ben Dome described as the intrandelibular positioning, and it is nice to put four or five degrees of intrandelibular to your table, to reduce the pressure on the perineum. You can also vent the capsule and do an air orthogram in order to alleviate the vacuum seal inside the joint. And for post-cystic arthroscopy, I do this in all of my cases. So it's important to talk to your anesthesiologist about muscle relaxation and paralysis. I tend to use general anesthesia. I can also use a spinal epidural. As far as postoperative anesthesia, I use a pair of capsular infiltration plus or minus peripheral nerve block. I don't love peripheral nerve blocks. The risk of falling into their complications that might be associated with them. So portal placement ends up being key. A quick shout out to Dr. Ben Dome. He's an amazing doctor. He's an amazing person. He's a great person to work with. So portal placement ends up being key. A quick shout out to my mentor, Dr. Thomas Bird, who described a lot of different portals and the safety of them during his early days as hip arthroscopist. So key to portal placement, you want to be safe, allow good visualization, efficient instrumentation. You want your portals far enough apart to avoid convergence of your instrument and your scope. And also to be able to place your anchor safely. So external landmarks are important. The neurovascular bundles obviously immediately. The line between the ASIS and the patella ends up being a good line to differentiate between the dangerous zone immediately and the safe zone laterally. The tip of the trochanter and the transverse lines run across this will basically give you your total safe zone where you can put portals in pretty safely. Bill Robertson and Brian Kelly wrote this nice paper here describing the different portals that can be used as well as the safety of each one. I tend to use an anterior lateral portal for all my cases. I think most surgeons will use this for their primary first portal. A mid-anterior portal, slowly more distal and more lateral than the standard anterior portal just to make sure you've got good access for anchor placement as well as safety of the LFCN. I use a dollop portal in about I'd say two-thirds of my cases mainly for anchor placement as well as sometimes access for the peripheral partner, a peripheral compartment. And I rarely use a post-lateral portal mainly for trying to get to a posterior rim problem. Again Bill Robertson's paper is nice to look at as far as trying to identify where the danger zone is. The LFCN ends up being the big problem here anteriorly. Make sure when you do your anterior portal use a make and spread technique in order not to get into the LFCN. So you want to get your first portal perfectly. It's like lining up a putt. So I'll initially rotate the foot so the patella is straight up and down. This gives me a nice profile of the femoral neck so I can see the femoral neck in profile as well as the greater trochanter. I find this is more reproducible to get my first portal in. I'll mark my portals and just kind of get a sense of where I want to put my portals. But I'm always going to use x-ray in order to mark out the greater trochanter to make sure I know exactly where it is because I want to make sure my first portals can be above the greater trochanter. So I'll take a spinal needle down the capsule initially and as soon as I hit capsule I'll mark it and kind of see where I am under fluoroscopy. When you're putting the spinal needle in you want to aim at cephalad slightly toward the head but also slightly toward the floor. If you're flatter toward the floor you're going to enter the joint in a better place. If you end up aiming to anteriorly you can get yourself into the anterior labrum. So some considerations under fluoroscopy. Again this is x-ray so you don't see your soft tissue. You try to imagine where the labrum and the articular surface is as well as the capsule. And the sore sealants are being a good landmark as well. I also try to imagine where you are anterior to posterior. You really want to enter the joint kind of centrally the 12 o'clock position so that first portal is nice and central so you can get a good position for your second portal okay. So the spinal needle should kind of hit the capsule just basically at the very lateral edge of the femoral head. That way you know you're in a good position okay. You want to be about between between two-thirds and one-third. So one-third above the femoral head two-thirds down from the sore seal or stay out of the labrum. You want to make sure when you're you're past your 9-0 wire passes all the way in the cotyloid fossa. This makes sure that you're central in the joint. If you're too anterior what you'll find is you pass the spinal needle and you hit capsule you'll actually overlap the femoral head by 30-40 percent or so. That usually means you're slightly too anterior and you got to be careful when you place your spinal needle because you might put it into the anterior rim or into the labrum here okay. So this is the big no-no. You do not want to violate the anterior labrum on your first portal okay. So when you pass your 9-0 wire if it only goes halfway across that means you're probably hitting the anterior wall and you want to redirect yourself so you're more central in the joint. As far as labral safety again the bevel ends up being pretty important here. So I usually go bevel up as I pass the labrum. Here's my thought behind that. If my bevel is up as I pass the labrum I think I'm a lower risk of actually penetrating the labrum than if my bevel is facing down. I might sky a little bit more toward the head and get a labral injury. If I pass a 9-0 wire through the labrum and put my pearls in the labrum that's going to be a problem down the road. After I pass the labrum and I'm passing the cartilage I do shift my bevel and have my bevel facing down to the cartilage. The last thing I'm going to do is hit the cartilage of the femoral head and create this cartilage damage okay. So I usually go bevel down as I pass the cartilage. Again you make sure your 9-0 wire passes all the way in the convoid fossa. So here's a quick little picture of a couple of different access pearls. So again bevel up as I pass the labrum. The capsule is now vented. My bevel is down and you can actually see the 9-0 wire passing all the way in the middle part of the joint. Here's another just an example of it. Bevel up I pass the labrum and you actually can see the labrum here and you can see that if you can kind of get a sense in the orthogram where that labrum is you can see that we're safe beneath the labrum here. So sometimes it's a tight squeeze. I'll sometimes use a plastic tip cannula if the joint's pretty tight. That way I have a little bit less pressure in the joint. Be careful with your guide wire. As you push your guide wire in it can bend. It can actually bend pretty dramatically sometimes. It can also break and if you have a broken guide wire that can really ruin your day. Guide wires can also misguide you. You have to make sure the guide wire is actually in the joint before you start placing your cannulas. Look for this anterior triangle. Again you're trying to find this anterior triangle between the femoral head and the anterior labrum and you want to penetrate the capsule about a centimeter off the labrum so you can actually have a good capsule closed there at the end. This is a picture of what it looks like when you're outside. Your light source is facing straight anterior. You'll see this anterior triangle. With normal version the triangle can be quite big and easy to find but be aware with retroversion or a big pinching deformity sometimes it can be a pretty tight squeeze and so just be aware that you might have a smaller anterior triangle to work with here. So just a quick access video. You can see as we place the scope into the joint here we're going to find the anterior triangle where we place our spondyl and we place our nylon wire. Again we want to be off the labrum. As you're passing your cannula into the joint you want to make sure that you keep it off the femoral head. It's okay to press it against the labrum but the more you press against the femoral head your higher risk of cartilage damage. Okay and the first thing I always do after I get my anterior portals I always look back in the post at the anterior lateral portal to make sure that I'm safe and free from the labrum. The last thing you want to see here is your cannula through the labrum here and the last thing you want to do is actually manipulate the cannula loss in the labrum. So again safe entry into the joint ends up being pretty important. You can see it can be a tight squeeze. If you get yourself into the labrum it can be a big problem. I always get my access dry mainly because if you put fluid in the joint and you start getting some bleeding you get this red out. Nobody wants to see this. So now it's time to fix the hip. You got your access, you got your portals in, you're ready to go. So hopefully the rest of the talks here today will help you figure out how to fix your impingement in your labrum. I just want to say thank you again and if you have any questions I'm available and enjoy your course.

hip arthroscopy

OR table

fluoroscopy

portal placement

labral injury