Portal Placement for Hip Arthroscopy

CHAPTER 1

Has a little tattoo right there.I’ll mark our sagittal plane.You always want to try and keep them over also,so you can see ourpubic 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 tothat is tiger country.So we want to stay lateral to that, so everythingover here is out of bounds.Everything over here is where our surgical portalsare 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 it and below it.A posterolateral portal would go here.Directly in line in this cross-sectional plane is theanterolateral portal. And thenthe anterior portal, we draw a cross-sectional lineacross our anterolateral portal throughher pelvis. We drop down off of that lineright here 1 cm and over 1 cm.That's that mark right there for our anterior portal.We’ll use upthe seven portals. We'll use whatever we needdepending on the size of the tear andwhat we need to do.The biggest problem is the anterolateral portal isa blind stick, so it's done fluoroscopicallyand then also proprioception - what you can feel -that's the one that we have to be careful on.Every other portal's established arthroscopicallyunder direct visualization.The wires are Nitinol wires.They're very flexible, but they will break. I'vebroken them, so they can break pretty easily too -especially if we've been using themfor the whole case and we're on our 7th utility portal.We've been banging upand bending them a little bit.They undergo a little bit of plastic deformation, and thenthey'll get a weak spot -and then you can cut right across it and break it.Happens very quickly - there’s just no warning,so it doesn't bend a littlebit more - it just goes Kck!

CHAPTER 2

I feel my soft spot here, but you know, her femur’s notgoing to be too big. So the big thing is that you want to begoing parallel to the floor or slight posterior in-tilt.Never anterior, okay?So I have a head drop techniquewhere I’ll go in first with a needleand we insufflate the joint,and the fluid will actually help to push thehead out and get rid of the vacuum.So there's a relative vacuum inour joints - makes it very efficient.So you put a little bit of synovialfluid in a vacuum, and joints function very efficientlywith a very low coefficient of friction.When you lose that seal - with such as with a labral tear -the coefficient of friction is more likesandpaper on sandpaper. But sometimes evenwith the labral tear, they’ll have a pretty good sealwhere it's tough to get them out.We do the bevel down toward the femoral head, so that givesus a little bit more room.So our puncture is just above the articularcartilage. If it was vice versa with the bevel up,then we would beskiving the head going in.So he's trying to get it about 2 mm off the head.You would think you got a lot of roombetween the head and the labrum,but you don't. So medially in here, you got a lot of room, butlaterally out here where the pincer is, you don't.And keep your hand up. Keep your hand up.So make sure every time you changedirection, you got to come back out.Just don't get an anterior tilt on it.We're going parallel to the floor or a slight posterior tilt.The common mistakeis going anterior and ending up on the ileum.So they’ll look perfect down here,but then he's hitting bone. So we knowwe'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 youcan get burnt on scoping hips,and one is right here. So he's cuttingright down the needle,and it's very easy to get a dermal tag.So even though you're through theepidermis and everything looks good - especially if youjust leave the nitinol wire in and not therigid needle when you're cuttingdown, you can have the wire goingthrough the dermis, but then on theoutside, it's coming through the epidermis.And you won't know it untilyou 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 pointbecause of all that wire that’s sticking in the jointand where we arein 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. Good backflow.You okay with that? I know - wire - that's fine.So you didn't think you were through the labrum, right?I thought it felt nice and smooth going in. All right.So I’m going to go 4-5 first just to get the tipof the obturator through todilate it, and then we'll go right to the 5-0.Sometimes if, you know, we're notsure if we're through the labrum or not,we'll start with a smallerobturator 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, thenwe'll switch right over to 5-0, which gives us better inflow.So the biggerthe cannula that we go with, the better flow we get,and the problem with thesmaller cannula is is this is all made for more of a lessconstrained joint where there's not much flow.So when you’re - remember, it's more of atwisting motion than apush, okay?Than a direct linear push - yep.So the first tether is going to be at the skin and sub-Qwhere he feels resistance. Then he'll go downthe 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 theskin, it's not a big dealbecause it'll be subcutaneous and we canjust fish it out. If he breaks it down at the capsule, it's abig 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 tellif 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 likeoperating out of the corner of your eye. It's a veryshort focallength, so if you look from here to here,you have to refocus everything -and it's like operating like thisout of the corner of your eyes -always peripheral.So it can distort your image.When he's putting the scope in, the cord shouldbe straight down, and that's - think of that as your feet.So if I wanted tolook at you, I can do it two ways. So I can turn my wholebody, which would be my camera,or I can just turn my head, whichwould be my lens.So he just wants to use his lens, but because it's70 degrees,he has to finesse it a little bit also with the camera.It's very difficult to teach them how to scopehips, but once they get it down, it -there's a very steep learning curve, butonce they get it down, they have it.It's like learning how to drive a stick shift.And everything is upside down and backwardsas far as what his mind will see withthis - rather than the 30-degree scope, which is pretty anatomic.With this yourmind wants to tell you - your brain wants to tell youleft is right,and right is left, and up is down, and down is up.And so you have todo cerebellar tracking - like learn how to play the piano - toteach your mind that no, no - this is...And we do that by telling them to go in circles first,and then theirbrain will pick up - oh okay, thatis left over there - even though the brainwas telling them originally it was the opposite side.Very interesting that to watch somebodywhen they first start scoping.They're going the completely opposite direction, and then theyliterally pick it up after a couple scopes.Can you just come feel this and see? How's it feel?So I just - just keep pushing.It’s a pretty tough capsule.Spot right there.We'll find out.All right, let’s have the scope.

CHAPTER 3

So now you can see the capsule moving.We're gonna try to get right through the center of that.You got to be right on big guy - got to be right on.Okay, you got to get right in the center of that.So you're drifting. So I'm just gonna take it for a second.Yeah, right there. Do you think I was just a little too high on that?Maybe a little bit, but this looks like it’s off a little bit.Okay. So Nitinol wire.And here the lateral femoralcutaneous 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 epidermisand 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 outand arborized, so you reallyhave to be careful. If you just went in with a knifelike we make most portals, you'll hit a branch or get a neuroma5-0. 5-0 blue.So make sure you really dilated that, right? Yep, good.Yeah, it's dilated.All right, let's just get in there so we get our flowbefore we get some bleeding, I just want to get this in.Do you have our knife?Do you have the arthroscopic knife - the long one?So we don’t want this whole cannula in here.We keep our obturator backbecause 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 herejust a little bit. So see,you're up at a little bit too much of an angle here.So you've been coming in a little bit highwith your portals, so it just makes it so -see the angle line, where I am? Yeah.It makes it difficult to gostraight up and downto like grab suture and stuff. Good, thanks.I'm 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 we got to make sure it's locked in.Okay, give me 2 more turns.

CHAPTER 4

Now I'm going to look back on her anterior portal, which is a blind stick,And make sure that that was not through the labrum.And we’ll take an obturator down here,and let me just have a switching stickbecause I’m going to switch it out anyway.So he's right there.Right here.