This is Dustin Richter, Nicholas Newcomb from University of New Mexico discussing hip arthroscopic portal anatomy. Our disclosures can be found on the Academy website. Good hip access and hip portal placement begins with appropriate patient positioning. I utilize a perineal post about 10 to 12 centimeters in diameter. This is a large padded post that allows controlled traction for venting the joint and monitoring traction applied. The bed is in a slight Trendelenburg position and the leg is typically in a neutral or slightly internally rotated position with adduction. I bring in my fluoroscopy machine from between the legs and then initially I'll do an exam under anesthesia and I'll pull some traction on the leg to see if the patient's hip distracts which allows for some evaluation of instability. I'll also take the patient out of the boot and flex them up to evaluate for any CAM lesion morphology in addition to looking at internal or external rotation of the hip. Shower curtain drape is used and then I mark out our bony landmarks with the ASIS and the patella. A line is drawn between the two of these so that no portals are placed medial to it to protect the femoroneurovascular bundle. I'll then palpate and assess the location of the greater trochanter. With initial portal placement, we're going just off the anterior and superior tip of the greater trochanter so I'll mark out the anterior border of our greater trochanter as well as the tip of the greater trochanter. A switching stick is brought in and I bring in fluoroscopy so that I can mark the level of our greater trochanter. We'll then begin looking at portal location. Once again, palpate for our proximal anterolateral portal. This will be approximately a centimeter anterior and a centimeter proximal to the anterior superior border of the greater trochanter. When I begin, I'll mark the proximal anterolateral portal. You can also see here where the direct anterior portal used to be. This is more historical as it's now the mid-anterior portal that we utilized given the prior structures that were at risk with the direct anterior portal from lateral femoral cutaneous nerve and ascending branches of the femoral circumflex artery. The mid-anterior portal functions as our main working portal. It's about two to three centimeters lateral to the ASIS line and two fingerbreadths distal to the proximal anterolateral portal. The DALA or distal anterolateral accessory portal is about five to seven centimeters distal to the anterolateral portal and one to two centimeters medial to the proximal anterolateral portal. A posterolateral portal can be utilized as well for hip joint access posteriorly and this is located about a centimeter posterior and proximal to the tip of the greater trochanter when the leg is in neutral rotation. Structures at risk with that portal include the sciatic nerve. So once the portals are understood and the patient is placed in gentle traction, we need to vent the hip joint. I initially start with an air arthrogram and if you watch carefully here as the air is injected, you'll actually see the hip pop as the joint is vented and the suction seal is released. This allows appropriate controlled traction for no nerve injury. I then go through our proximal anterolateral portal and the angle for this is approximately 15 degrees trajectory posterior encephalad, paralleling the trajectory of the acetabular sore seal. I start with a bevel pointed away from the joint and then as I go in through the capsule, the bevel point towards the joint to protect both labrum as well as cartilage respectively. Once in, this is another way that you can also do a air arthrogram, but then I will inject approximately 30 to 40 cc's of sterile saline. This helps expand the joint, but at the same time it pushes the labral tissue away from the femoral head. I remove our spinal needle and then I put the spinal needle back in so that there's less chance of actually penetrating the labrum. Once again, I'm aiming in the same trajectory. You can see the outline of our hip capsule on the fluoroscopic images. Once I bring the spinal needle in in a similar fashion, you can see it going into the hip joint. We remove the stylus and you'll see the water coming out from the femorostabular joint. We then put in a nitinol and then I utilize an 11 blade and put in our cannula at that time. You can either use a metal cannula or there's soft cannulas as well to protect the cartilage in better fashion. Once we establish our proximal anterolateral portal, this is the primary viewing portal for the hip and it's the main portal that's established under fluoroscopic guidance. The primary risk with this is superior gluteal nerve. I'll then establish the mid-anterior portal. As you can see here, you're fairly parallel with your trajectory. I insert the spinal needle followed by our guide wire and then establish this portal in similar fashion with another cannula. The mid-anterior portal, once again, helps with visualization, but it's also a portal for instrumentation such as putting in anchors and also suture passage. I then switch my arthroscope to the mid-anterior portal and I'm looking back on my proximal anterolateral portal to ensure that I did not go through the labrum, which you can clearly see capsule as well as labrum and no penetration of the labrum. At this point, I insert a capsulotomy knife and I begin my interportal capsulotomy extending from the proximal anterolateral portal. It's important to spin back your metal cannula to allow full access and excursion of your blade. Here I'm beginning the capsulotomy and then I'm going to switch my arthroscope back to the proximal anterolateral portal and we will complete the capsulotomy from our mid-anterior portal, once again, visualizing the femoral head on the left of the screen and the labrum on the right. You want to ensure that your capsulotomy is in line for later capsular closure. For the distal anterolateral accessory portal, this portal, again, is a good trajectory for anchor insertion and also can be used for shuttling grafts or reconstruction. I typically only use two portals, but I will use a dollop portal for reconstruction or access to the joint. Thank you for your attention.

hip arthroscopy

portal placement

patient positioning

fluoroscopy

anatomical precision