Dear colleagues, it's a great pleasure and honor to be invited for your meeting in Chicago. And I would like to thank John Christopheretti and Al Stubbs for your invitation. I would have loved to come over to Chicago to this wonderful learning center. But as you know, the pandemic is hindering us from traveling, so I hope that this will be possible again during the next years. It's a great pleasure for me to speak about the preferred compartment first technique. Some of you may know that this is my preferred technique, accessing and operating the hip joint. I have been using this technique for, I would say, almost 20 years. So let me, yes, so my disclosures. I'm consultant and receive royalties for Karl Storz and the doctor, but this is probably not affecting my lecture. As you know, there are mostly, there are three different techniques used worldwide to access the hip joint. First is the central compartment first technique. I think this is the technique which is used by most of the surgeons in the world. The peripheral compartment first technique has been developed, I would probably say, in the mid-90s. This is my preferred technique. And about 10 to 15 years ago, there was the third technique, which was added to this options. And this is the extra articular first technique. This is the central compartment first technique. So you are imaged by fluoroscopy. You enter the central compartment. And then after probably working in the central compartment, you sneak into the peripheral compartment and do your work over there. This is the peripheral compartment technique. You access the hip joint and the periphery. And then probably after working in the periphery, you work your way into the central compartment and do your work in this part of the joint. And this is the extra articular compartment first technique. So you start actually extra articular, so outside of the articular capsule, work your way through the capsule into the peripheral compartment. And from there, you work your way into the central compartment. This technique has been developed, I would say, probably 10, 15 years ago, mostly by French and Spanish surgeons. And let me go back to the peripheral compartment technique. This should be credited by Doffman and Boyev, actually French surgeons in Paris. Those surgeons are mostly interested or were mostly interested in rheumatology aspects. So this is why they entered the peripheral compartment first, because most of the synovium can be found in the periphery. As many of you know, this is one of the basic concerns, especially when you are young and less experienced surgeons, especially when you're using the central compartment first technique. There is a higher risk of scuffing the articular cartilage, mainly of the femoral head, perforating the labrum, because the only way how you can control access to the hip joint is via fluoroscopy. This is, from my experience, another big advantage of the central compartment first technique. When you access the central compartment, you make incisions in the capsule. Some surgeons may prefer larger incisions, such as interportal incisions. The problem is when you do this, you're losing tension of the iliofemoral ligament. And then the iliofemoral ligament is dropping down to the femoral neck. And you have much less space to work. You're losing visibility. And then you start to make bigger incisions. You make T-cuts, et cetera. And this is really impairing the visibility in the peripheral compartment. This is the problem when you don't have a good overview, especially in the peripheral compartment. You may end up with something like that. And this is something that we definitely need to avoid. This is, of course, not related to the central compartment first technique. But it is related to not enough overview when you start to work in the peripheral compartment. There are other cases where you're not able to access the central compartment first. This is, of course, a very severe case of pincer FAI with a ossified labrum. But in this case and, of course, in less severe cases, you're not able to introduce your instruments directly into the central compartment. You have to work in the peripheral compartment first to resect the ossified labrum. And then you are able to enter the central compartment. When you look into the literature, you find, of course, lots of studies about complications. There was one systematic review of 81 studies published by Gupta and Arthroscopy in 2014. And here you see that the risk of cartilage scuffing and labor perforation appears to be very small. But as many of you know, especially when you are not so experienced, I would probably say this is not true. There's a big variety of iatogenic lesions. And when you look closer into the literature, you see that the rate of scuffing and labral scuffing and labral perforation, especially when you're less experienced, is much higher. Who likes to publish own labral scuffing, cartilage scuffing as a complication? I think that's understandable. So extra articular first, I would say Frederick Lord has published and done a lot of work to that. The problem is when you use this technique, you make a relatively big cut in the capsule. And there are, of course, disadvantages for making big incisions into the capsule. You have fluid extravasation. The capsular flaps reduce your visibility. You may have an increased rate of heterotropic bone formation. And of course, which has been coming up over the past 10 years, you are causing hip instability. The risk of heterotropic bone formation has been shown to increase. And when you look back, I would say until 2008, 2009, we have not seen reports of iatrogenic hip instability. Nowadays, there are many publications out there, even indicating frank dislocations after hippofroscopy making big incisions in the capsule. So we know nowadays that if you make big incisions, you should repair those incisions. So please consider the peripheral compartment first technique. I would like in the rest of my talk to go over this technique step by step. So first, of course, you have to apply your portals to the peripheral compartment. We like to make three portals. We apply the proximal anterolateral portal to the peripheral compartment. So it's about one third to the anterior iliac spine, two thirds to the tip of the crater trochanter. And we direct our portal directly here to the anterolateral transition of the head-neck junction. This is our main viewing portal. And the anterior and the classic anterolateral portals are our main working portal. Working portals from the anterior portal, we address the anterior, anteromedial, and anterolateral parts of the head-neck junction and labral. And from the classic anterolateral portal, we address the lateral and postolateral parts of the peripheral compartment. It's very essential that placing the first portal is very precise. So we are coming from the incisions I just told you. And the right direction is usually 90 degrees to the axis of the femoral neck. And it's very important not to place your portal too distal. When you apply your portal too distal, you're distal to the psona orbicularis, which is hindering vision in the peripheral compartment. So the tip of the portal entry should be closer to the head. It should not be too distal. That's very important when you place the first portal. This is the second portal. We place the anterior portal. And the capsular perforation of the anterior portal should be somewhere at 3 o'clock. So it should be really anterior. When you start to use this technique, one mistake is that you enter the joint too medial. And especially when you deal with impingement, that's not good because the chem deformity is more anterolateral and not anteromedial. So it's very important that you place your portal not too far medially. The first thing we do is we release the circular fibers of the capsules. So we perform a release of the zona orbicularis. We always start here, anterior, and work our way lateral. So you should avoid to release the fibers here medially because on top of that, the iliopsoas compartment can be opened. And this is definitely something that you like to avoid at the early phase of the procedure. Usually, at least in normal hips, that's sufficient. But if the hip is a little bit stiffer, you have to do also a partial internal release of the iliopsoas ligament. And we do that here at the insertion of the ligament close to the acetabular rim, right proximal to the acetabular labrum. For placement of the classic anterolateral portal, we perforate the capsule here laterally. And we always use a knife to enlarge the capsular perforation because the capsule, the iliofemal ligament in this part of the joint is very stiff. So you really have to make a little incision here. Otherwise, your portal maneuverability is not sufficient. A short sequence to show you that. So we start with the release of the zona orbicularis here, anterior. We work our way laterally. And that's very often sufficient to have at least a good starting overview. And then we release some of the internal fibers here close to the labrum. We go up into the perile prosulcus. The hip is flexed about 30 to 35 degrees in order to hide the femoral head cartilage. Here you see how we expose the acetabular labrum. And then we receive a very good overview in the peripheral compartment. We usually start with all work that is needed in the peripheral compartment. For example, when we have chondromatosis, we remove all chondromas. We do a synovectomy. Or when we have a CAMFAI, we do our camera section right away. So that's very important that you have a good overview. You see, you need to see the whole deformity here. You see the rest of the zona orbicularis is very important that you need to see the femoral neck area. This is very crucial in order to control an adequate resection of the CAM deformity. And one key point is you need to combine the no traction technique with the traction technique. So when you resect the CAM deformity, we always start without traction. The hip is usually in flexion. We remove the anterior and anterolateral part of the CAM deformity. And then the hip is progressively put into full extension. In full extension, we address the anterolateral and lateral part. And then the hip is distracted. And under distraction, this part, the pistol grip deformity, is being distracted from the labrum. And then you are able to address via this portal the postolateral pistol grip part of the CAM deformity. So this sequence is very important in order to receive a complete resection and adequate resection of the CAM deformity. Here you see how we do that. So we start medially because medially, usually, the head-neck offset is good. So what we do is we advance the anterior medial concavity, convexity of the head-neck junction, and progress that to the lateral part of the neck. As I just said, it's very important that you expose also the distal parts. You almost need to see the intertrochanteric line because in many cases, you need also to thin out the femoral neck in order to achieve a good, concave, convex transition of the head-neck junction. The anterolateral portal is crucial in order the lateral and postolateral part of the CAM deformity. You see how we do that from here. This is the anterolateral portal. The burr is introduced via the anterolateral portal, and we are addressing the lateral part of the head-neck junction. And when you're done with this, you can apply traction and undertraction and progressive distraction of the head from the socket. You can apply your portals to the central compartment under vision. The risk of scuffing the head cartilage or perforating the labrum by using this technique is very, very small. These are the portals that we use to address the central compartment. You see that we are using a multi-portal technique. So for the central compartment, we use the anterior, anterolateral, frequently the postolateral portal, and also distal portals. And depending on where our labrature is, we apply different distal portals. As I said in the beginning, we try to avoid to make big capsular incisions. So what we do is we make little incisions, enlarge the incisions a little bit, and then we always try to keep bridges between our incisions. And that's, I think, the key point in order to avoid iatrogenic instability when you work in the hip joint. So keeping bridges between your incisions, I think, is the key point. Try to avoid big peri, big inter-portal incisions. Do not connect your portals with a big capsulotomy. And that's usually sufficient to have a good overview on the rim, on the labrum, on the tear. And you see here, we, I think, kept most of the capsule here. And then you are able to address the pincer deformity. You can trim your rim. You can detach the labrum. You can recess the labrum. You can relocate the labrum, repair the labrum. And this amount of approach is usually sufficient in order to avoid post-operative instability. Labral repair, of course, this is what you will learn, I think, also during your course. You have to use different distal portals, additional distal portals, in order to avoid re-entry of your drill, of your anchor. If you put in your anchor in this way and then the anchor is sticking out the cartilage, this is destroying your hip joint. Very, very, in a very short time, I have seen a couple of those cases that I had to revise. And I don't want to tell you how the head looked like after four months of this continuous scuffing by the anchor at the head. So consider a multi-portal technique. Avoid, in my opinion, you should not scope the hip joint via two portals. I think in my experience, I need at least three or four portals to do a complete hip arthroscopy. And that's very important. So if you have, at least if you have a pistal crip deformity, the pistol grip extends very posterior. And this is the key technique. So you are only able to address the post-lateral part of the cam deformity by applying traction. And you see here, the hip is being distracted. And this part of the cam deformity can be addressed only using an anterolateral portal. So from this portal, you are able to address the pistol grip deformity. And when you use this technique, you're also able to see the vessels entering the head-neck junction here from the post-lateral fold. So if you have a pistol grip deformity, you need to expose this part of the retinacular fold in order to avoid avascular necrosis of the head. And in the end, we always go back into the peripheral compartment where you release traction. And we check if we have achieved a nice labral seal, if our head-neck reshaping, the camera section was sufficient. So at the end of the procedure, we always go back to the peripheral compartment and make sure that the job that we have done was adequate. If you're interested in that technique, we have just recently published a step-by-step description in the Journal of Hip Preservation Surgery. So this is accessible, open, online. And so if you are interested or if you have any questions, don't hesitate to contact me via email. Or if you're interested to come over to Germany, please do so. And I wish you a wonderful course. And thank you for having me as virtual faculty.

hip joint

compartment first technique

peripheral compartment first technique

labral repair

cam deformity