Greetings, everyone. My name is Marcelo Queiroz and I'm a hip surgeon from Sao Paulo, Brazil, and today I'll be presenting a very straightforward talk about hip arthroscopy positioning and traction tips so you can enhance your surgery. Regarding my conflicts of interest, I have educational grants from AKE that may have some products in this presentation. So as a summary, I'm going to talk first of all about the room setup, after that about traction table, and after that some tips about traction technique. So the room setup, you can have the fluoroscopy between the legs of the patients and the video directly straight from the surgeon, or you can have the fluoroscopy 90 degrees from the surgeon and the video below or over it. Regarding the left arm, it depends on your setup. If you have something right in front of the patient, you may have to let it like this, or if you have something, a fluoroscopy, you may want to leave the arm beside the patient. So it depends on your room, the size of your room, and your team. So you have to develop a room setup that is specifically made for you. What I usually like to do, I leave the fluoroscopy between the legs of the patients, and nowadays I have two monitors, so I leave one right here 45 degrees above the patient, and another one just straight, and I leave this myo-arthroscopy stand above the patient. So it looks like a little bit like this, so I have one monitor here 45 degrees, another one in front of the patient, and another one for the assistance at the scrub nurse. So I can have all the team engaged at the surgery, and I can use one of them to show the patient images and x-rays and 3D CT scans, and I like to have a monitor right in front of me so I don't have to twist a lot my neck and I have a better ergonomy during the surgery. I always use fluid collector bags, so you can use a field that already has it, or you can use like a gynecology or urology field that has it, but it helps a lot so you don't flood your surgery room. Always have your patient exams inside the room, especially the x-rays, the MRI, and I always use a 3D CT scan. It's useful also to do a resection map with fluoroscopy images right in the beginning of the surgery, and after when you finish, especially your chem work, you can compare with this fluoroscopy resection map. So this is how it looks like, with monitors around the room and the images, so you can know exactly where you are working and you can have a good view of the video and the exams. So sometimes you have doubts if the patient has a lot of hyperlexia, so you can do this dynamic test with the patient already at the OR table, and in this case you can see there's a lot of hyperlexia and translation of the femoral head and you can adapt your surgical technique for this characteristic. The traction table has to have an effective traction, it must allow heat manipulation, it must fit fluoroscopy around it, and must allow intraoperative positioning and traction adjustments. So you can use a regular traction table or you can have some dedicated hypertroscopy connections. So whatever you use, it has to have those characteristics that I said before. About a postless technique and postless table, I don't have experience, but it's something that is on the market and it's already shown to have good results, so you may use it also. So this is something that I think is very, very, very important. So you must have a boot with a connector that allows rotations and fine traction, and you'll see later why fine traction is so important to reduce the traction that we use during the surgery. The perineal post must be over nine centimeters, this is the one that I have available here in Brazil. So in the beginning we used to use a central pin, so we developed a perineal cleft that was used to avoid overpressure at the pudendal nerve, and it also helps at women that may have big vaginal labia, and that may fold with traction and may result in edema. So sometimes we do that until nowadays. And if you're using a lateral post, you must use a size that is not so big as that that I showed you, so sometimes you have to undersize it, cutting it. The feet padding you can do with cotton, with foam ball boots, but you always have to accommodate the heel so the foot doesn't slip during the surgery, and you can fix it with bands or co-band or tensile plast, something that avoids the foot slipping during the surgery. So nowadays we have strap systems that are safer and much faster, and that's what I'm using, so I can strap the foot in like 30 seconds, it's really really fast and good, so I think this is advanced. The operative side must be 20 degrees of flexion and neutral abduction. I think it's very important to have a full muscle relaxation with general anesthesia and curare, and I always turn the table 10 degrees lateral to the non-operative side so I can have a better position of the instruments and they don't fall when I let them go. So if you're using a lateral post, an eccentric pin, you must support this eccentric pin, you must align it with the ischium, so this is very important. So you must align the pin with the ischium, and frequently you have to move the patient to the operative side, so you must move the patient a little bit to the operative side and get the pin exactly aligned with the ischium. So about the complications related to traction, they can be skin lesions, pudendal, and sciatic neuropraxia. And when do they happen? They happen when you have time above two hours of traction, so this is described, but it also depends on the force. So the more force you do, the more danger you have of complications, either skin lesions or neuropraxia. So you must do a fast surgery and with a low traction force. If you can't do a fast surgery because you're doing a labor reconstruction plus cartilage repair, so it may take more time than you usually take, you can use intermittent traction. So this is what I'm going to show later. So how the usual traction is done, how we learned it in the books. So we do an abduction of the operative side, then we do traction, an abduction, and then we do adduction of this side. But what happens when you do that? You do over traction. So you usually do more traction than you need and you keep operating with a lot of traction and then you have a greater chance of complications. So how can you minimize traction force? First of all, breaking the joint's suction seal at the beginning with an artogram. So I always do that nowadays and also with fine traction. So how do we do that? So some years ago, we did what was called the minimal traction technique and what we did at a time. So here we are seeing the adduction and then we checked the x-ray and we saw over traction. Then we do abduct again, release traction partially. And we kept doing that until there was no articular space at the x-ray and it was the least traction needed to start having space at the x-ray. So that's what we called minimal traction. But it took some time because you had to do traction and abduct and check the x-ray. And then we developed a second generation traction technique that is called the minimal traction. So what's the difference? The difference is that we release the gross traction when doing adduction. So the traction barrier is totally loose when you do adduction. And then you gain space so you have no over traction when doing adduction. And then you gain space only with the fine traction. So it's an optimized technique, it takes less time and you do less traction than you would do with the other technique. So what we see sometimes is that when you do over traction, you sometimes have a bleeding you sometimes have a bleeding also from the pulmonary artery. So it's something that may happen and may impair your surgery. So nowadays we do like that, we release gross traction when doing adduction, let the traction bar loose and that's it. And it works really, really fine. So the take-home message, you have to do a personalized room setup that fits your OR team and your rooms. I think you should always have images available at the room. And you have to do an optimized traction technique either with a postless technique or with this minimal traction post technique to avoid complications. So thank you very much for your attention and you can reach me at this email if you have any doubts. Goodbye.

hip surgeon

hip arthroscopy surgery

operating room setup

traction techniques

minimize complications