This article is more than 5 years old. Information may no longer be current.
Technique allows for hip arthroscopy distraction without perineal post
Click Here to Manage Email Alerts
Hip arthroscopy is a surgical tool that has gained increased popularity with the greater understanding of hip disability in the young athletic population.
In order to access the central hip compartment, traction must be placed on the patient’s operative leg to allow distraction of the joint and introduction of the surgical instruments. Hip arthroscopy is done in either the lateral or supine position. The leg is typically in a boot, and a padded post is positioned in the groin, which serves as counter traction. However, complications related to traction are not uncommon with the procedure and are often related to the pressure that the post puts on the groin.
We present in this Surgical Technique a traction technique that was developed to eliminate skin, deep soft tissue and neurological injury that affects the groin during hip arthroscopy. This technique has been used in thousands of arthroscopies done by several surgeons without reports of groin or perineal complications.
The technique is currently used by the authors of this article at their respective centers. It does not involve any special equipment, and the set-up does not take any longer than for standard supine hip arthroscopy. However, this traction technique allows for safer access to the central hip compartment as it can decrease the likelihood of injury to the delicate tissues of the perineum.
Also, by using this technique, the surgeon can be less concerned with the duration of traction time since no direct compression is applied to the organs, nerves or blood vessels.
Uses a narrow, padded post
Hip arthroscopy with this technique is performed with the patient in the supine position on a traction table. Any type of traction table will work with this surgical technique, including ones with traction arms. The surgeon moves the patient down the table and positions him or her so that the perineum is ultimately situated about 7 cm to 10 cm proximal to the location of the radiolucent traction post. Furthermore, the post should be off-center and toward the operative side. Placing the post about 5 cm off-center should be sufficient.
The radiolucent perineal post is wrapped with soft-roll.
Images: Mei-Dan O
Next, the surgeon places a padded “narrow” post, instead of the commonly used wide-diameter hip arthroscopy post between the patient’s legs. This padded post is placed as such in case the surgeon later needs to move the operated limb into adduction and needs a counter traction device when he or she does that, or if lateral table tilt is needed. Note that the post plays no role, however, in the actual distraction process.
The post is located 10 cm from the perineum (which is represented by the red dotted line) and off-center, such that it rests against the proximal medial thigh. Even after distraction force is applied, the post will still remain far from engaging with the patient’s perineum.
Once the set up is complete, the operative table is placed in approximately 15° to 20° of Trendelenburg position with the upper body tilted down. The limb being operated on is adjusted after Trendelenburg position is established to ensure that the operative limb is positioned in 0° to 5° flexion and abduction relative to the pelvis.
The patient is positioned in 15° of Trendelenburg with the foot in a well-padded boot. The dotted yellow line represents horizontal level, and the dashed yellow line represents bed inclination.
Hip internal rotation applied
The surgeon then applies 15° to 20° hip internal rotation, which he or she measures at the patient’s foot. This should then bring the common femoral neck to 0° version and permit optimal arthroscopic portal placement. The nonoperative limb is placed in 30° to 40° abduction and the foot is allowed to fall into external rotation. This step provides space for the fluoroscopy unit, which is used to obtain lateral images of the hip while putting minimal stress on the nonoperative limb.
By using this technique, with the patient in 15° to 20° of Trendelenburg, enough resistance is created by gravity and friction between the patient’s upper body and the operating table to allow successful hip distraction without the post coming into contact with the perineum.
After prepping, draping and breaking the joint’s suction seal using an air arthrogram, traction is gradually placed on the operative limb.
The post sits at the medial aspect of the patient’s proximal thigh and it should remain between 3 cm and 7 cm away from the groin, depending on the amount of traction applied and the patient’s morphology and ligamentous laxity.
This image shows the position of the post off-center using the Skytron Elite 6500 Surgical Operating Table (Grand Rapids, Mich.) with Smith & Nephew MAXI traction arms (Smith & Nephew; Andover, Mass.).
During the application of traction and throughout surgery, the surgeon can monitor any contact between the post and the patient’s perineum with his or her hand — over the drapes — to unsure that no contact occurs between the two structures.
When the arthroscopic work is completed in the central compartment and traction is no longer required, the surgeon can then release the traction. The table can then be taken out of Trendelenburg position and moved back into a horizontal position. Repositioning the table to flat or horizontal from Trendelenburg functionally lowers the hip relative to the surgeon’s position. Therefore, the table needs to be elevated to its previous working height and the surgeon resumes the work in the peripheral compartment with the table positioned flat.
We have encountered no greater difficulty with access to the hip joint in these kinds of cases, since distraction is no longer an issue. With this technique, properly positioning young patients who are undergoing hip arthroscopy is now quick and easy to do and it requires no special equipment.
In theory, distraction without a post, as we have described in this article, should eliminate most, if not all perineal pressure-related complications to the pudendal and perineal nerves, as well as the delicate tissues of the perineum.
Reference:
For more information:
Omer Mei-Dan, MD, can be reached at University of Colorado, Department of Orthopaedics, 12631 East 17th Ave., Mail Stop B202, Aurora, CO 80045; email: omer.meidan@ucdenver.edu.
David Alexander Young, MBBS, FRACS (Orth), can be reached at Melbourne Orthopaedic Group, 33 The Avenue, Windsor, 3181 Australia; email: davidalexander.young@gmail.com.
Disclosures: McConkey, Mei-Dan and Young have no relevant financial disclosures.