So my name is Dr. Winston Guafi from the University of Virginia, and I'm going to talk about hip access, pearls, and pitfalls. So these are my disclosures. So the first thing you have to think about is your operating room table. So for safe, effective, and efficient access to hip arthroscopy, the OR table has to be able to administer adequate traction, allow the hip to be manipulated, accommodate fluoroscopy, and also be safe for long cases. And as an added feature, it's nice to be able to put it up and take it down easily and also storable, because a lot of times we're doing this in outpatient surgery center. You want to make sure you have it in a place where you can store it. So there's different options you could possibly use. A lot of of the hip arthroscopies. You know what, Matt? I'm going to start over from scratch. I just I forgot what my first slide was. So just my apologies. All right. Three, two, one, go. So my name is Dr. Winston Guafi from the University of Virginia, and I'll be speaking about hip access, pearls and pitfalls. So these are my disclosures. So let's talk about the operating room table. So for a safe, effective and efficient hip arthroscopy, your table has to be able to administer adequate traction, allow the hip to be manipulated, accommodate fluoroscopy, be able to shoot X-ray with it and be safe for long cases. And as bonus features, it's nice to be able to take it up and set it up easily and take it down easily and also storable for the outpatient surgery centers you might be working in. So there's different tables who've been used over time. The fracture table is kind of historically we started on that perineal post, the same type of table you might be using in your in your operating room to put together hip fractures. A HANA table, which has basically been converted from a hip arthroplasty type table to a hip arthroscopy table, but also traction attachments. Each company's got a specific attachment that can use with a nephew arthroxies, different attachments. There's also what I like to use is a postless table. So there's the post the table attachment that you can use for post-op hip arthroscopy. So here's my setup that I used prior to 2019. I used a perineal post, an oversized post with philosophy coming between the legs. I also was able to use a postless traction. Josh Harris actually wrote a nice article on how to use a conventional table with postless traction or a postless table. These are the proprietary tables that are being made now for postless traction. This is the striker version of it, where you basically have got a pad that allows for friction against the skin and you can pull traction without a post. So, again, this is my postless table looks like. You can apply some Trendelenburg as needed. A lot of times these new technologies allow for less and less Trendelenburg to be applied, but it also helps prevent the hip from sliding on the table. So a couple of nice things about this table. One, it's got a a basically you can see how much Trendelenburg you're in and also you can see how much traction you're applying is basically a traction, a force measure on the end of the table. You can see how much traction you're applying. So when I was getting started, I think it's important for all the fellows in the room. I went around to lots of different ORs to kind of see how other people were doing it. So, you know, and so Dr. Martin, Dr. Burr, Dr. Wolfe, Noe, Mather, White and Larson. I just basically made my own sort of hip arthroscopy visiting fellowship type thing to see how all the other experts were doing it in their operating rooms. So fluoroscopy, you got to be able to figure out some way to get good pictures during the case. So I really like this article by Dr. Dr. Ross. He wrote this, Chris Larson, some others as far as how to match your intraoperative fluoroscopy to what you're trying to be able to see. And so the important thing about when you're doing hip scopes is you have to be able to see all the different areas of the deformity in order to correct them. So I like to try to match my intraoperative fluoroscopy to my preoperative film. So an APX right here, a 45 degree done X-ray and then a 90 degree done X-ray. So those are the three main views I try to get. So I know exactly what I'm trying to correct. So again, you can see intraoperative fluoroscopy, just kind of how you move the hip around. You can also see in this scenario, we're actually able to lever that hip out of socket and really see how the FAI is affecting this hip. So in order to see into the joint, you have to be able to distract the joint. Not every hip distracts the same. You can see sometimes adding an arthrogram can be helpful. Ensure adequate muscle paralysis. So you want to talk to your anesthesiologist as far as making sure that you're completely paralyzed for this part of the case. If you're fighting against the muscles, then it also makes it a lot harder to get into that hip. Again, venting the air can be very helpful to achieve distraction. Here's an example of just placing some air into the joint so you can actually distract the joint. Have a plan for nonconventional access. Sometimes it doesn't always distract the way that you want to. And so to be able to get into the hip from an outside in type capsulotomy can be what you might have to do. And again, there's a couple of nice videos about this if you want to look at that as far as how to get into the hip from an extra capsular approach. So as far as placing portals, shout out to my mentor, Dr. Thomas Bird, who described these portals for us. There are some keys here I want you guys to be aware of. You want to make sure that your portals are safe to the neurovascular structures, muscles, and tendons. You want to make sure you've got good visualization. You want to have efficient instrumentation and far enough apart to avoid conversions. And lastly, you want your portals to be able to apply for safe anchor placement. So you want to make sure that your portals are going to give you good access to the rim so you can place your anchor safely. So these are the landmarks that I like to use as far as my external landmarks. The ASIS, no question, that's the lighthouse of the hip, a line drawn down to the patella, everything to the lateral aspect of that so-called safe zone if you want to call it that. Look for the trochanter, the tip of the trochanter. And again, we're going to be using most of our portals within this sort of rectangular space, the so-called safe zone. So a couple of things, the anterior lateral portal, the mid-anterior portal, and the dollar portal for the workhorses for most hip arthroscopies, at least in my hand. Some folks will just do a two portal arthroscopy. I do like the dollar portal. It does give you a nice angle for anchor placement as well as for access to the peripheral compartment. Some people, or sometimes I'll make a poster lateral portal if I need to get to the back of the joint. So again, you want to make sure you have an adequate spread between your portals to optimize inter-articular instrumentation. So for instance, if your portals are too close together, you end up scissoring inside the joint and it's really hard to really get good instrumentation inside the joint. I also like to put my AL portal, there's a little soft spot just anterior to the gluteus medius tendon. It's nice to be anterior to that. If you're going through the gluteus medius tendon, it will make it harder to manipulate the scope inside the joint. So I usually try to get just anterior to that gluteus medius tendon. So again, the most important thing I think is getting the perfect first portal. So as far as how to position the leg, I'll internally rotate the leg until the actual femoral neck is elongated and you've got a perfect view of the trochanter. The reason why I like to do that because it basically makes a femoral neck parallel to the floor. And it gives you one less sort of, if you're talking about angles and whatnot, it takes away one angle that you can perfect your portals a lot more effectively if you kind of know where the femoral neck is in space. So I'll mark my portals first. And then again, I'll use fluoroscopy just to verify my landmarks. It's really important to know exactly where the tip of the trochanter is when you're making that first portal. So take the spinal needle down the capsule. As we talked about, what we're gonna see is we're gonna see the bevel sitting just on the actual lateral edge of the capsule. And this is a pretty important part, at least in my hands. I like to know exactly where that bevel is, where it sits on the capsular edge. If you find that you're too anterior, too posterior, what you'll see is that bevel, the tip of that needle will be too far across the joint and you might actually have a problem with sort of penetrating the labrum in that scenario. I like for the spinal needle to be parallel to the lateral edge of the sore seal. It gives you good access to the entire joint that way. And then I'll take a guide wire all over the central fossa. And again, this is one extra place where you can make sure that you're perfect as far as your first portal, because as long as that guide wire is going all the way to the caudaloid fossa, you know you're pretty much centralized within that joint. So you remove the spinal needle at this point. A couple of different fluoroscopic considerations I want you to be aware of is, one, that the X-ray will not show you the soft tissue. So in your mind, make sure you understand where the labrum is and where the cartilage of the femoral head is, okay? So, and then imagine the capsule. And again, when you pull the hip into traction, a lot of times it'll be a vacuum effect on that capsule. So it will actually be kind of flush against that femoral head. And that's why I like to make sure that when I go to a joint, I get that capsule off the femoral head. Remember where the sore seal is? And what I try to do is I try to be about one third above the head and two thirds below the sore seal. If you're trying to imagine, just basically the space between there, that way I know I'm above the cartilage of the femoral head, but also below the labrum, okay? And again, I like to be centered inside the joint in order to go in. So as that nitinol wire goes across the joint, I'm centered within the joint. If I'm too anterior, what you'll see is you'll see the bevel of that needle is overlying the capsule. And I mean by that is instead of floating just against the very edge of the capsule, you'll actually be able to see the bevel of the tip of the needle kind of in the joint itself. And what that usually means, is you're hitting the capsule a bit too anteriorly. And as you place your nitinol wire in, you might actually penetrate the labrum. And that can be a big disaster because if you put a cannula through that anterior labrum, you'll be in big trouble. So again, when I'm telling my fellows to make their portals, I want every single step to be as perfect as possible. And this is probably the most important one because if you have a labral penetration with your needle, that means you'll probably be placing your cannula through it as well. And then suddenly your simple labral tear will turn into a very complex labral tear. So again, reproducible first portal. Again, these are the two different scenarios I was trying to describe. On that top picture, you see how the bevel is flush against that capsule, almost lateral to the very apex of the femoral head. In the bottom picture, it's a little bit overlying the capsule. And that usually means you're slightly anterior on that bottom picture. And as you place your spinal needle in, in your nitinol wire, you're not centered within the joint. That's gonna risk labral penetration. So as far as labral safety, what I like to do is I go past labral with my bevel up in order to prevent it from skiving. So I believe that if you have the bevel down at this point, what can sometimes happen as you penetrate the capsule, it can cause damage to that labrum. However, the moment you pass the cartilage, you wanna make sure your bevel is down. So I'll flip it around after passing the labrum and pass across the bevel so that the bevel's facing the cartilage so I don't get a gouge. There's something worse when you get into the joint and you look and you see a gouged articular head, articular surface of the hip because you haven't had good bevel control on your way in. Then again, I'll place that nitinol wire all the way across the middle of the joint. So here's just a picture of safe access, bevel up, pass the labrum, capsule vented, bevel down, spinal needle or the nitinol wire all the way to the center of the joint. And this is very reproducible. And in fact, sometimes if you do it well and you get that air arthrogram, you actually can see the outline of the labrum that you're beneath that on the way into the joint. It can be a very tight squeeze. So be aware of that. So a lot of times I use plastic tip cannulas. I think it actually helps to avoid injury to the articular surface. Be careful with the guide wire. Even once the guide wire's in, if you push it too hard, you can definitely bend that guide wire. And if you bend it too much, you could break it off inside the joint. Not that you ever wanna see that. This is actually one of my fellows and he shot this x-ray. I'm like, oh my God, what have you done? You just wanna make sure that nitinol wire, although it's very sturdy, it can definitely break if you do the wrong thing. And again, you don't wanna break that guide wire, but also remember the guide wire can misguide you. You wanna make sure the guide wire is in the right place. You have a scenario here where the guide wire is not actually in the joint. And if you follow that cannula, you might find yourself in a space you don't wanna be in. When you're placing that cannula over the wire, a couple of things, you wanna find this anterior triangle. And what you're seeing there is you're seeing the triangle made between the anterior labrum, the femoral head, and the capsule there. And you wanna be pretty centered within that capsule. In fact, you wanna be about eight to 10 millimeters off that anterior labrum so you can close a capsule there at the end. The anterior triangle on a normal hip looks, can be quite big and pretty easy to access. Be aware that you have a retroverted hip. A lot of times that triangle will kind of close itself down. So just be prepared as you go into a hip, you might get yourself a little bit of trouble here. So you can see how tiny that area can be. So just a quick access video. This is actually a little older access video. I'm using metal cannulas here. I don't usually use metal cannulas anymore. But as you can see, you create that mid-anterior portal. You're gonna place the spinal needle in then the nitinol wire through the spinal needle. And you place your second cannula through the mid-anterior portal. And the first thing I always do is I always wanna look back into the back of the joint. So I'll always flip it around to make sure I'm not in the labrum in the back. Because at this point, you don't know what that back cannula looks like. The last thing you wanna do is do a lot of manipulation inside the joint with your cannula through the labrum. So I always wanna make sure I look back in the back and make sure I'm safe as I go into the joint. Because the last thing you wanna see is this. You wanna see the cannula through the actual labrum. I also would encourage you to get your access dry. What can sometimes happen is if you put water on at this point, your view might go from here to just a red out. The last thing you wanna do is you're getting access to the joint and suddenly you can't see anything because the entire joint's turned red. So your first view might be your best view. So I always get my access dry. So as far as troubleshooting, if you have inadequate distraction, make sure you have adequate counter traction. You wanna check your foot in the boot. Verify with anesthesia that you have adequate muscle relaxation. You can always Schoendelberg the bed or vent the capsule. Be careful with the patient's sliding the table in a postless scenario. Sometimes, especially the ones that are probably the most problematic are the underweight women. You're pulling traction against 105 pounds. And what you'll find is there's not enough friction against that table in order to be able to pull the hip out of the socket. So there's underweight women I tend to have to put in more Schoendelberg. As far as poor visualization, make sure your pump is working right, your flow is working right, the blood pressure is not too high. I do use TXA pretty routinely to make sure that I don't have enough bleeding. And you can use Epi in the bag if you need to. Make sure you have the correct scope and cannula assembly. Sometimes you can't see right because you're using a three degree scope and you can't understand why that is. Verify you're in the joint. Sometimes you can't see around because you're actually extra capsular. So make sure you're actually in the joint. Heavy synovitis, if you have a patient who's got a lot of synovitis, they actually can be in front of your scope and it's hard to see. And also make sure your capsulotomy is correct. So now you've gotten to the hip, it's time to fix the hip. So hopefully that was helpful. If you have any questions, I'll be around all weekend to talk to you about access. These are my fellows, Dr. Bird and me. There's my email address here. You can email me any questions.

hip access

arthroscopy procedures

operating room table

fluoroscopy

intraoperative fluoroscopy

hip arthroscopy

fluoroscopy alignment

portal placement

labral safety