Hello, thank you for letting me present today for the Anna HIP toolkit on patient positioning and traction. My disclosures for this, I'm a consultant for Stryker. Some of the instrumentation and table you see in here are from them. I don't think that's relevant for the content of this talk, however. In terms of operating room setup, it's really important to think about the room size, depending what kind of surgery center, AAC, you might be working in. Make sure you have an adequate size to allow for all the instrumentation that's needed. Table choice as well, I've transitioned a few years ago to a postless system, but overall, again, make sure these are big tables and systems, make sure you have enough space. Just accommodate for the C-arm, the tower, the instrumentation, all the things you need for doing a proper hip arthroscopy. Make sure you understand and your team you're working with what traits you need, maybe specials as well. If you're thinking about a reconstruction, a graft master, all this stuff takes space, so make sure it's available. And then HIP Check, for example, if you have additional imaging software that helps make sure you have the space to accommodate for that, and the setup. Grafts should be available, freezer, or if you do autograft, obviously, it's another source. Talk to the team. If you start doing this in a new center, tell them, kind of walk them through the surgery, what is needed, what's a setup. In most settings, you'd have possibly people operating the fluoroscopy. If not, figure out a way to be able to do that with your own team, PA or the fellows. But typically in most of the centers I work, I have access to radiology tech, and some of them I don't. It's really important to talk to people through about the setup and what you need. So here, I tried to make a nice depiction of the operating room setup before it works for me. Number one is the primary surgeon, number two, the assistant, three, I put a nice little picture next to it, the anesthesiologist. And then, you know, on the left hand side, you see the back table, then the Mayo, close to the patient. The patient is obviously here in red, and the OR table. You want to have the tower and the monitor positioned close by in a way that you can actually see the monitor, and that the cables and everything have enough distance to cover and be connected. You want to have the CRM in a way that you can take the imaging for access but also resection. But it's also not in the way for you during your surgery, or in the way of the tower and monitor. And also should allow for easy, you know, putting it in and out, moving it in and out without obstructing things. So that's, that's really important. Also, depending on what table you use, make sure it's radio lucent in the area you need to have to look at CR monitor also in a way position that you can see it and utilize it. So again, transition from post to postless a few years ago. The way I'm using it now, I don't need to Trendelenburg typically. So we're doing elective surgeries to minimize any potential risk factors. And while I did not have any issues, at least I know of while using a post, I figured out I've limited one potential risk factor. For me, it also helped with improvement in terms of fluid pressure, interoperative bleeding, I think overall, I get better distraction. Also, the system I'm particularly using prefer the boot system, it's easier, more, more reliable. And you know, if you're getting started and you're worried about traction time, that puts a little bit release a little bit of that stress and worry, I still minimize my traction time, I still document even though it's postless thing, you still want to minimize it, however, a little bit stress, less stress potentially. So this is kind of what the setup was for me initially. On the right, you see the post, CR in place. So padded perineal post, and then boots as well and fluoroscopy in place. And this is my OR setup now. So again, postless, making sure that any parts of the table are not really loosened or out of the way. Here you see, thanks to my friend and colleague, Max Salada, see a video of applying boot system some padding in between, I usually don't wrap the ankles anymore, like the padding is sufficient without it. And you see here being applied into the boot system while the patient is there on the table. So that being applied, making sure you put everything in place, and then tighten the boot. This particular system is a BOA system, evenly distributed, and it's great at minimizing any slippage. So seeing this being tightened down and here in this particular setting, patient is awake, it's moved over, transfer onto the pad, it's a high friction pad. This is again, it looks like the pad, the gray pad underneath, you see there's a little indentation there, you make sure that is lined up distally to that not really loosened part of the table. So I take the greater trochanter here again that you see that you want to be distal to that. So I take a fist width distal to the not really loosened part of the table. See that here, and then abduction particularly with this technique, applying the traction. And then here, allows for abduction and adduction, putting traction on and then adducting this in this particular setting. I usually keep it just straight without starting in abduction, but you certainly can do this as well. Just want to show it so people see this technique as well. So first, you see here, there's more of an egg crate, egg crate kind of padding, moved to a different one, it doesn't necessarily require Trendelenburg, so I don't, I'm not Trendelenburg anymore. When I try to get traction up, and it doesn't come out right away, I typically internally or externally rotate quickly, under traction, it helps break the traction, the suction seal. If not, then I would do an Arthrogram. Most cases, I don't need an Arthrogram. This particular table has a force gauge as well. Typically I'm somewhere around 100 or below, but you can go up to 150 pounds if needed. Again, I try to minimize the amount, not only the amount, but also the length of traction. So this is what it looks like typically for me now in the OR, C-arm positioned, again patients distally from any non-radioleucine parts and postless table, again, mitigates for me any potential risks regarding a perineal post. Before I transitioned to this a few years ago, I really didn't have any issues, but again, minimizing risk factors. Good boot system, typically not needed in Trendelenburg. And also this allows for, you know, if you do, we do some combined cases, go PAO, can use the same table, or some of my colleagues use this table also for direct anterior total hips, different extension for that. And C-arm positioning, I pointed out briefly, this is what this typical setup is. This is what it looks like once everything is draped, AP view for access. And then once I start resecting the peripheral compartment, I start with my AP views and also have two views, inflection and neutral and external rotation. C-arm is in a rainbow position, 20 degrees. So it's out of the way, the top of the C-arm, so I can use my instrumentation while still taking images. In summary, using a system, a table system is specifically designed for post-lip, post-lip hip arthroscopy. Some systems have a tensiometer, it can be helpful to roughly gauge the level of traction force. It's not really super accurate, but at least gives you a general sense where you are. Now I typically don't need Trendelenburg anymore. I use it sometimes in patients that are fairly light because they tend to travel a lot when they put the traction on. So I would, that the Trendelenburg can help at least establish the traction and break the suction seal and enter the joint. Some systems have cross functionality scope, PAO or direct anterior total hip. And again, when establishing traction doesn't come out right away, rapid internal and external rotation and traction helps to break the suction seal, otherwise using an air arthrogram. Acknowledgements, my friends and colleagues, Mike Salata and Chad Mather. Some of the videos you've seen, they provided them for me. This would be it from my side. Thank you very much again for giving me the opportunity to be part of the HANA Hip Toolkit. Thank you.

hip arthroscopy

operating room setup

patient positioning

postless systems

BOA boot system