Portal Placement for Hip Arthroscopy
Hip arthroscopy is a well-established technique that has become a mainstay in the repair of bony and ligamentous injuries when conservative methods fail to return adequate joint mobility and function. The technique has both diagnostic and therapeutic utility and its use as a minimally invasive orthopedic surgery continues to advance. Several studies have suggested that arthroscopic surgical management has more favorable outcomes in certain circumstances when compared to hip-specific conservative measures. The approach to establishing adequate sites for portal placement is dependent upon recognizing the pertinent anatomy of the surgical site. At the same time, the operator must be mindful of the desired views once access to the joint space has been obtained. Proper visualization of the desired joint region is critical to reducing the conversion into inherently riskier total hip arthroplasties (THAs). Additionally, the neurovascular landscape of the groin presents technical challenges with the procedural approach that requires significant skill to avoid injuring vital structures in the area. Acetabular labral tears are frequently repaired with this type of operative management as techniques and approaches become more refined. Here, we present the case of a 24-year-old female who is undergoing an arthroscopic anterior labral repair, highlighting both the anatomical landmarks and the access points for portal placement used in the procedure.
The evolution of hip arthroscopy and its utility have coincided with the rapid advancements in technology and user competency. Specialized equipment and a more thorough comprehension of hip pathology assisted the transition from a diagnostic procedure to a viable therapeutic modality.1 Injury to the hip can cause a variety of intra-articular pathology; however, labral tears and degeneration in the context of femoroacetabular impingement (FAI), dysplasia, or trauma have become the mainstay of hip arthroscopy procedures.2 Labral tears are prevalent in patients with FAI, occurring commonly in active adults of all age groups with the anterosuperior labrum being frequently involved.1,3
This patient is a 24-year-old female who is undergoing reconstruction of an anterior labral tear. As techniques have improved, hip arthroscopy has become one of the preferred modalities to repair labral injury as it is minimally invasive and effectively relieves pain symptoms compared with non-operative management.4 Understanding proper portal placement is paramount in successfully establishing both safe and adequate access to the central and peripheral compartments required for surgery. In this case, three portals were used to establish adequate repair; however, upwards of 11 portal locations can safely be established without damaging vital structures.5 Most notably in this case, the structure at greatest risk for damage with portal placement is the lateral femoral cutaneous nerve (LFCN), which passes under the inguinal ligament and then bifurcates into two branches as it crosses over the sartorius muscle, leaving it in a vulnerable position for iatrogenic complications.6 The surgeon must also exercise caution with the incisions used for portal placement, not proceeding deeper than the subcutaneous fat given that the LFCN runs rather superficially.7 Therefore, identifying the anterior superior iliac spine (ASIS), marking directly inferior and proceeding lateral to this newly created plane will minimize risk of injury to the major nervous structures in the area.5
In the sequence of portal placement for this case, the anterolateral portal is established first. To identify this access point, the surgeon palpates the top of the greater trochanter, then proceeds slightly superior to the trochanter in the cross-sectional plane where an area devoid of bone can be appreciated. The posterolateral portal placement follows a similar path but is located inferior to the trochanter. A guidewire inserted into the joint space at the anterolateral portal is visualized under fluoroscopy and confirmed with the arthroscope once the portal is established. The anterior portal access is marked 1 cm lateral and below the intersection of the ASIS sagittal plane and the cross-sectional plane of the greater trochanter. In contrast to the anterolateral portal, the anterior portal enters the inner capsule of the joint via a blind stick from the outside while being directly visualized from the joint space with the established anterolateral arthroscope. Following these anatomical boundaries creates a systematic approach to portal placement while ensuring that vital neurovascular structures remain unharmed.
Focused History of the Patient
Patients with labral tears will generally present complaining of impingement-like symptoms including pain, clicking, catching, or decreased range of motion, particularly in flexion and abduction. Two primary lesions contribute to the pain syndrome of FAI. Cam, pincer, and mixed types of impingements are caused by irregularities of the interface between the femoral head and acetabulum. Cam type lesions are bony protrusions at the anterolateral head-neck junction, leading to an erosive disruption of the chondrolabral junction. Pincer lesions are caused by an over-coverage of the femoral head within the acetabulum with a resulting breakdown of the labrum and cartilage involved in the shear forces between the proximal femur; mixed type deformities are a combination of cam and pincer deformities.2,5,8,9 These symptoms can be the result of chronic, repeated compressive forces, athletics, old age, or can be of an acute nature as found in traumatic events such as motor vehicle accidents or falls.1 A particularly interesting finding in the history and physical exam is that some patients—particularly women—may find that their labral dysfunction has negatively impacted various aspects of their lives, including sexual intercourse.3 In many cases, there may not be a specific etiology of a patient’s hip pain, but the history correlated with physical exam findings are generally adequate enough to establish a clinical diagnosis prior to confirmatory imaging.10
The pain associated with labral tears and impingement syndromes usually develops in a gradual manner, occurring at night and being provoked by prolonged sitting, running, or pivoting.8 Patients with FAI and labral tears do not usually have significant deficits with simple movements such as walking, but it does significantly reduce range of motion of the hip, especially flexion. This can be provoked from maneuvers such as deep squatting or performing the FABER test during physical exam.1 Various evaluation techniques, including anterior impingement, subspine impingement, lateral impingement, and posterior impingement maneuvers may be used to reproduce the pain and symptoms responsible for the patient’s chief complaint.10 Positive physical exam findings from these provocative tests are frequently sufficient to diagnose an impingement syndrome with confirmatory imaging to follow.
Imaging studies in the context of hip pathology are especially useful in assessing the structural abnormalities leading to positive physical exam findings. The two most used modalities are an anteroposterior (AP) pelvis X-ray and magnetic resonance imaging (MRI). AP pelvis radiographs allow visualization of any dysplasia and evaluation of the pathognomonic “crossover sign” seen in FAI.8,10 This finding is then corroborated with a soft-tissue focused imaging modality such as MRI, which focuses on the chondral lesions created by the bony pathology assessed in the preliminary pelvis radiograph.
MRI has a relatively high efficacy in diagnosing labral pathology, having a sensitivity of 66–87% and specificity of 64–79% when a direct MRI or conventional MRI is used.11 Once a diagnosis has been established from the clinical picture created by the patient’s history, physical exam, and imaging, the decision must be made of whether conservative, non-operative management or surgical intervention should take place.
Options for Treatment
Hip arthroscopy is considered a second-line treatment in the initial management of labral pathology. Currently, the standard of practice is aimed at first using non-invasive measures, including rest, stretches, strengthening, and targeted physiotherapy at the abnormal movement patterns that tend to be present in patients with FAI.4 When symptoms or continued loss of function persist after an extended, multiple-month course of non-operative measures, surgical intervention is indicated.10
Rationale for Treatment
Arthroscopic management revolves around two main objectives: labral debridement or repair. Debridement is amenable to those patients who have failed to improve with nonoperative modalities and are also not candidates for repair.10 This technique is accomplished through removal of loose bodies or other obstructions within the capsule of the hip joint, thereby eliminating the impingement and improving range of motion. However, outcomes using only debridement have been shown to be inferior to repair and reconstruction.10 One proposed mechanism highlights that debridement alone has a tendency to compromise the negative pressure interaction between the labrum and acetabulum, thereby reducing the inherent stability of the ball and socket joint.8 Recent literature supports a superior treatment response in patients receiving labral repair and reconstruction over simple debridement.10,12 Indications for labral repair also include symptoms that have failed with non-operative measures but contain a full-thickness tear at the labral-chondral junction. Labral repair and reconstruction maintain the integrity of the labral-acetabular junction while eliminating the impeding agent. Thus, debridement is less recommended for many conditions as repair proves to be better in the long term.
The literature supports the escalation of care to arthroscopy after conservative measures fail to improve symptoms. 1,2,4,8 In comparison to non-operative management, surgical treatment has shown statistically significant improvement in outcomes over a 10-year period.4 There is currently a lack of longitudinal follow-up studies examining if these trends continue in the long term, but as technique and technology improve, research into their efficacy for longer time periods will likely follow.
As previously mentioned, those who experience chronic pain from various hip pathology leading to impingement or pain syndromes involving the hip joint are favorable candidates for hip arthroscopy. These indications must be weighed with other pre-existing conditions that may make operative management more complicated and less likely to succeed. Such contraindications include advanced osteoarthritis, congenital dysplasia due to slipped capital femoral epiphysis or Perthes deformities, and other dysplastic features that indicate a larger structural instability that are not amenable to arthroscopy.2 Through careful selection and open discussion with patients about their clinical prognosis, the clinician is able to mitigate complications that may arise during the procedure. Modifying risk factors in the preoperative setting reduces the chance of needing to intraoperatively convert to open hip arthroplasty, which tends to carry worse results.13 Most of the complications arising from hip arthroscopy are related to the traction used to create space in the joint, and patients with conditions or ill-suited body habitus who are not amenable to hip traction for long durations would have to undergo special consideration of whether the procedure may cause more harm than benefit.14 Proper patient selection continues to be an important predictor for operative success, and the criteria for suitable arthroscopy candidates evolve in parallel with surgical advancements.
Hip arthroscopy presents several technical challenges that require great familiarity with relevant anatomy and the equipment for the procedure. Inherent to a rapidly evolving field is the technical acumen that can only be acquired through direct experience and not merely gleaned from observation. As noted in this case, the instruments in hip arthroscopy are generally longer and more flexible than traditional arthroscopic equipment, which can better accommodate the curvature of the ball and socket joint of the hip. The specialized nature of the equipment and joint geometry of this procedure presents a steep learning curve for budding surgeons. To compound the pressure, the poor outcomes associated with surgeon inexperience adds to the emphasis of obtaining numerous training opportunities. Alluded to in this case, a surgeon’s initial attempts at portal placement and operating through arthroscopy are not entirely intuitive, where the angles of visualization do not perfectly correspond to a two-dimensional plane. The instruments used in a common arthroscopic surgical kit are vastly different than that used in a standard orthopedic surgical kit, and the proper maneuvering of the devices requires extensive repetition to become competent with their use in surgery.
It is evident that to ensure the highest number of positive outcomes, the surgeon must go through numerous procedural repetitions under the guidance of other physicians well-versed in the procedure. It is difficult to quantify the point at which a physician should become proficient with a surgical technique, but there are studies that have investigated the topic. A literature review found that once a surgeon had reached 30 cases of performing hip arthroscopy, there was a significant reduction in operative time and postoperative complications.15 This number should be considered cautiously as multiple, uncontrollable factors play a role in skill acquisition, but it reiterates the importance of repetition in one’s training. With fewer opportunities to operate on live patients without formal training, it can be difficult to find an entry point for a newly-licensed surgeon to learn the necessary skills and nuances of hip arthroscopy and portal placement. In order to allow a greater exposure to the procedure without the incumbent risks of surgery, simulators and cadaveric models may be utilized in future training endeavors. Several studies have found that these simulations can increase performance and familiarity with arthroscopy while improving the user’s skills without the need for live patients in the initial phase of the learning curve.16 However, once these obstacles have been overcome and the operator gains a relative acquaintance with the procedure, the benefits of hip arthroscopy outlined in this article can be readily achieved in a safe manner that can afford patients an improved quality of life.
A standard Arthrex hip arthroscopic repair and reconstruction kit with nitinol guidewire provides the necessary basics to perform hip arthroscopy, but additional supplies may be necessary depending on the patient’s needs and the surgeon’s preferences.
Nothing to disclose.
Statement of Consent
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
The article is written by Steven D. Sartore and under review by Scott D. Martin, MD.
This article is the companion to the JoMI article "Diagnostic Hip Arthroscopy" by Scott D. Martin, MD.
- Griffiths EJ, Khanduja V. Hip arthroscopy: evolution, current practice and future developments. Int Orthop. 2012;36(6):1115-1121. https://doi.org/10.1007/s00264-011-1459-4
- Ross JR, Larson CM, Bedi A. Indications for Hip Arthroscopy. Sports Health. 2017;9(5):402-413. https://doi.org/10.1177/1941738117712675
- Raut S, Daivajna S, Nakano N, Khanduja V. ISHA-Richard Villar Best Clinical Paper Award: Acetabular labral tears in sexually active women: an evaluation of patient satisfaction following hip arthroscopy. J Hip Preserv Surg. 2018;5(4):357-361. https://doi.org/10.1093/jhps/hny046
- Griffin DR, Dickenson EJ, Wall PDH, et al. Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): a multicentre randomised controlled trial. Lancet. 2018;391(10136):2225-2235. https://doi.org/10.1016/S0140-6736(18)31202-9
- Robertson WJ, Kelly BT. The safe zone for hip arthroscopy: a cadaveric assessment of central, peripheral, and lateral compartment portal placement. Arthroscopy. 2008;24(9):1019-1026. https://doi.org/10.1016/j.arthro.2008.05.008
- Grothaus MC, Holt M, Mekhail AO, Ebraheim NA, Yeasting RA. Lateral femoral cutaneous nerve: an anatomic study. Clin Orthop Relat Res. 2005;(437):164-168. https://doi.org/10.1097/01.blo.0000164526.08610.97
- Nakano N, Khanduja V. Complications in Hip Arthroscopy. Muscles Ligaments Tendons J. 2016;6(3):402-409. https://doi.org/10.11138/mltj/2016.6.3.402
- Su T, Chen GX, Yang L. Diagnosis and treatment of labral tear. Chin Med J (Engl). 2019;132(2):211-219. https://doi.org/10.1097/CM9.0000000000000020
- Robertson WJ, Kelly BT. The safe zone for hip arthroscopy: a cadaveric assessment of central, peripheral, and lateral compartment portal placement. Arthroscopy. 2008;24(9):1019-1026. https://doi.org/10.1016/j.arthro.2008.05.008
- Harris JD. Hip labral repair: options and outcomes. Curr Rev Musculoskelet Med. 2016;9(4):361-367. https://doi.org/10.1007/s12178-016-9360-9
- Saied AM, Redant C, El-Batouty M, et al. Accuracy of magnetic resonance studies in the detection of chondral and labral lesions in femoroacetabular impingement: systematic review and meta-analysis. BMC Musculoskelet Disord. 2017;18(1):83. https://doi.org/10.1186/s12891-017-1443-2
- Krych AJ, Thompson M, Knutson Z, Scoon J, Coleman SH. Arthroscopic labral repair versus selective labral debridement in female patients with femoroacetabular impingement: a prospective randomized study. Arthroscopy. 2013;29(1):46-53. https://doi.org/10.1016/j.arthro.2012.07.011
- Byrd JW, Jones KS. Prospective analysis of hip arthroscopy with 10-year followup. Clin Orthop Relat Res. 2010;468(3):741-746. https://doi.org/10.1007/s11999-009-0841-7
- Jamil M, Dandachli W, Noordin S, Witt J. Hip arthroscopy: Indications, outcomes and complications. Int J Surg. 2018;54(Pt B):341-344. https://doi.org/10.1016/j.ijsu.2017.08.557
- Hoppe DJ, de Sa D, Simunovic N, et al. The learning curve for hip arthroscopy: a systematic review. Arthroscopy. 2014;30(3):389-397. https://doi.org/10.1016/j.arthro.2013.11.012
- Bartlett JD, Lawrence JE, Yan M, et al. The learning curves of a validated virtual reality hip arthroscopy simulator. Arch Orthop Trauma Surg. 2020;140(6):761-767. https://doi.org/10.1007/s00402-020-03352-3
Table of Contents
- Sagittal Plane
- Anterior Superior Iliac Spine
- Greater Trochanter
- Parallel Approach
- Femoral Head Drop
- Orientation with 70º Scope
- Advancement of Cannula above Femoral Head
- Cutaneous Incision Avoiding Lateral Femoral Cutaneous Nerve
- Capsule Release with Arthroscopic Knife
- Labrum Examination
Has a little tattoo right there. I’ll mark a sizeable plane here. You always want to try and keep them over also, so you can see your pubic line, because where that ends - her pubic hair - that's usually where the joint is. So it really gives you a good idea where you are - all these internal and external landmarks.This should be good right there. So it’s a 70° scope, guys. Kind of like operating out of the corner of your eye. Okay, so right here is one prominence. Right here is the anterior superior iliac spine, and we draw a plane down here - a sagittal plane - and everything medial to that is tiger country. So we want to stay lateral to that, so everything over here is out of bounds. Everything over here is where our surgical portals are going to be.
First portal’s going to be our anterolateral portal. So we feel the top of our trochanter, and then there's a soft spot above and below it. A posterolateral portal would go here. Directly in line in this cross-sectional plane is their anterolateral portal. And then the anterior portal, we draw cross-sectional line across our anterolateral portal through her pelvis. We drop down off of that line right here one centimeter and over one centimeter. That's that mark right there for our anterior portal. We’ll use up to seven portals. We use whatever we need depending on the size of the tear and what we need to do.
The biggest problem is the anterolateral portal is a blind stick, so it's done fluoroscopically and then also proprioception - what you can feel. That's the one that we have to be careful on. Every other portal’s established arthroscopically under direct visualization.
The wires are nitinol wires. They're very flexible, but they will break. I've broken them, so they can break pretty easily too - especially if we've been using them for the whole case and we're on our 7th utility portal. We've been banging up and bending them a little bit. They undergo a little bit of plastic deformation, and then they'll get a weak spot - and you can cut right across it and break it. Happens very quickly - there’s just no warning, so it doesn't bend a little bit more. It just goes!
I feel my soft spot here, but you know, her femur’s not going to be too big. So big thing is that you want to be going parallel to the floor or slight posterior in tilt. Never anterior, okay? So I have a head drop technique where I’ll go in first with a needle and we insufflate the joint and the fluid will actually help to push the head out and get rid of the vacuum. So there's a relative vacuum in our joints - makes it very efficient. So you put a little bit of synovial fluid in a vacuum, and joints function very efficiently with a very low coefficient of friction. When you lose that - that seal and with such a labral tear, the coefficient of friction is more like sandpaper on sandpaper. But sometimes even with the labral tear, they’ll have a pretty good seal where it's tough to get them out.
We do the bevel down toward the femoral head, so that gives us a little bit more room. So our puncture is just above the articular cartilage. If it was vice versa with the bevel up, then we would be skiving the head going in. So he's trying to get it about 2 millimeters off the head. You would think you got a lot of room between the head and the labrum, but you don't. So medially in here, you got a lot of room, but laterally out here where the pincer is, you don't. Keep your hand up. Keep your hand up. So make sure every time you change direction, you got to come back out. Just don't get don't any anterior tilt on it.
We're going parallel to the floor or a slight posterior tilt. A common mistake is going anterior and ending up on the ileum. So they’ll look perfect down here, but then he's hitting bone. So we know we're up above it even though it looks perfect there. Remember - it’s three dimensions. Now if it's really tight - if it was really tight, then we’re going to need to do a head drop. What do you think? I thought it went nice and smooth. Okay, you think you’re through the capsule? I do, yeah. Okay fluid. That’s okay. Nitinol wire. Start making your incision. So cut around that. So 11 blade.
There's a lot of ways that you can get burnt on scoping hips, and one is right here. So he's cutting right down the needle, and it's very easy to get a dermal tag. So even though you're through the epidermis and everything looks good - especially if you just leave the nitinol wire in and not the rigid needle when you're cutting down, you can have the wire going through the dermis, but then on the outside, it's coming through the epidermis. And you won't know it until you start pushing your obturator through it, and you can break the wire - the nitinol wire because there's a huge amount of torque and a focal point because of all that wire that’s sticking in the joint and where we are in the skin. We're down this far into her joint. So see, I have good backflow here. So Glenn puts it in. Put a lot in. Good. G - good backflow. Nitinol wire? That’s fine. So you didn't think you were through the labrum, right? I thought it felt nice and smooth going in.
So I’m going to go 4-5 first just to get the tip of the obturator through to dilate it, and then we'll go right to the 5 - 5-0. Sometimes if we're not sure if we're through the labrum or not, we'll start with a smaller obturator and cannulas. This is a 4-5, and if he's feeling a lot of resistance, we’ll go through with this and scope her dry. If it feels good, then we'll switch right over to 5-0, which gives us better inflow. So the bigger the cannula we go with, the better flow we get, and the problem with the smaller cannula is - is this is all made for more of a less constrained joint where there's not much flow.
So when you’re - remember - it's more of a twisting motion than a push, okay? Than a direct linear push - yep. So the first tether is going to be at the skin and sub-Q, where he feels resistance. Then he’ll go down the joint. The next tether’s going to be at the capsule. Those are the two areas where you can break this wire. If you break it at the skin, it's not a big deal because it'll be subcutaneous and we can just fish it out. If he breaks it down at the capsule, it's a big deal because the wire will go medial, so they’re tough to fish out. She's 24, so she'll have a pretty tight capsule. So sometimes though, it's tough to tell if your perforating the labrum or not. You'll see when we get in there.
And you have to remember we’re using a 70 degree scope, and the problem with that is it's like operating out of the corner of your eye. It's a very short focal length, so if you look from here to here, you have to refocus everything - and it's - it’s like operating like this out of the corner of your eyes - always peripheral. So it can distort your image. When he's putting the scope in, cord should be straight down, and that's - think of that as your feet. So if I wanted to look at you, I can do it two ways. So I can turn my whole body, which would be my camera, or I can just turn my head, which would be my lens. So he just wants to use his lens, but because it's 70 degrees, he has to finesse it a little bit also with the camera.
It's very difficult to teach them how to scope hips, so once they get it down - there's a very steep learning curve, but once they get it down, they have it. It's like learning how to drive a stick shift. And everything is upside down and backwards as far as what his mind will see with this - rather than 30 degree scope, which is pretty anatomic. With this your mind wants to tell you - your brain wants to tell you left is right, and right is left, and up is down, and down is up. And so you have to do cerebellar tracking - like learn how to play the piano - to teach your mind that no, no - this is… And we do that by telling them to go in circles first, and then their brain will pick up - oh okay, that is left over there - even though the brain was telling them originally it was the opposite side. Very interesting that to watch someone when they’re first scoping. They're going completely opposite direction, and then they they literally pick it up after a couple scopes. Can you come feel this? How's it feel? So I just - just keep pushing. It’s a pretty tough capsule. It’s about right there. We'll find out.
Okay let’s have the scope. Now you can see the capsule moving. We’ll try to get the center of that. You got to be right on big guy - got to be right on. Okay, you got to be right in the center of that. So you're drifting. Just gonna take it for a second. Right there. Do you think I was just a little too high? Maybe a little bit - this looks like it’s off a little bit. So nitinol wire. And here the lateral femoral cutaneous nerve arborizes out. So anywhere that we cut through the dermis, we’re likely to hit a branch of it. So we just make a teeny little knick right in the epidermis and just hardly to the dermis - like way - maybe 2 mm, and then we dilate with the Mosquito. So right where we are, it's really branched out and arborized, so you really have to be careful. If you just went in with a knife like we make most portals, you'll hit a branch.
5-0, 5-0 blue. So make sure you really dilated that, right? Good. Alright, let's get in there so we get our flow before we get some bleeding. You have our knife? You have the arthroscopic knife - the long one? So we don’t want this whole cannula in here. We keep our obturator back because you could see how tight she is, so we need to loosen her up a little bit. If you could just back up that cannula on here just a little bit. So see, you're up a little bit too much of an angle here. So you've been coming in a little bit high with your portals, so it just makes it so - see the angle line, where I am? It makes it difficult to go straight up and down to like grab the suture and stuff. Good, thanks. Gonna go with the obturator again. So - you want to come - you want to have that straight. You don't want to - once you get down there, you don't want to start cheating with the needle. You got to readjust. So I got to make sure it's locked in. Okay, give me 2 more turns.
Now I'm going to look back on her anterior portal, which is a blind stick. Make sure that was not through the labrum. And we’ll take an obturator down here, and let me just have a switching stick because I’m going to switch it out anyway. So he's right there. Right here.