Portal Setup: the Key Point in the Learning Curve for Hip Arthroscopy Technique

ObjectiveTo analyze the learning curve experience of hip arthroscopy based on patient demographics, surgical time, portal setup time, and postoperative complications and to find the key point in the learning curve.MethodsFrom May 2016 to February 2019, a prospective study on the learning curve experience of hip arthroscopy was performed in our hospital. We evaluated the first 50 consecutive hip arthroscopy procedures performed by a single surgeon. There were nine females and 41 males with a mean age of 30.8 years. We divide the patients into early group and late group according to the date of their operation, with each group including 25 patients. Data on patient demographics, types of procedure, surgical time, portal setup time, and postoperative complications were collected. Functional scores were assessed with the modified Harris Hip Score (mHHS).ResultsPatients were followed up for 16.4 months on average (range, 13–27 months). The early group of patients had a mean age of 35.2 years and the late group a mean age of 26.5 years. The most common procedures performed for the early group were debridement (17 patients, 68%), and in the late group, most patients underwent labral repair (18 patients, 72%). Mean total surgical time was 168 min for the early group and 143 min for the late group, and there was no statistically significant difference between two groups. The portal setup time in the early group and late group was 40.2 ± 12.4 min and 18.5 ± 6.2 min, respectively (P < 0.001), and the portal setup time was significantly longer in the early group. Further analysis of the learning curve of portal setup showed that the average portal setup time was not statistically significant changed after 30 cases. There were six complications including iatrogenic cartilage injury and iatrogenic labrum injury in the early group and five complications including perineal crush injury and nerve stretch injury in the late group. The functional score of patients in the late group was significantly higher than that in the early group during follow‐up.ConclusionThe steep learning curve of hip arthroscopy is mainly caused by the challenge of portal setup and portalrelated complications were more common in the early group than in the late group. Surgical time is not an effective indicator for evaluating progress on the learning curve of hip arthroscopy.     

Usefulness of the Medial Portal during Hip Arthroscopy

The current conventional portals for hip arthroscopic surgery are the anterior, anterolateral, and posterolateral portals. For lesions in the medial anteroinferior or posteroinferior portion of the hip, these portals provide insufficient access to the lesion and consequently lead to incomplete treatment. Thus, in such a situation, a medial portal approach might be helpful. However, operators have avoided this procedure because of the risk of injury to the obturator, femoral neurovascular structures, and the medial femoral circumflex artery. Thus, to overcome the disadvantages of the conventional method for medial lesions of the hip, we performed a cadaveric study to evaluate the technique, usefulness, and risk of the medial portal technique.     

髋关节镜术的入路选择

目的探讨髋关节镜手术不同入路的可见视野和操作安全性.方法使用三点入路,2个入路分别位于大粗隆的外侧上方,1个入路位于前方.使用30/70镜头并更换镜头入路,记录关节镜下视野.通过18例髋关节镜检查和手术操作过程及并发症分析,评价不同髋关节镜入路的有效性和安全性.结果本研究显示,以30°/70°标准关节镜经髋关节前方及侧方入路,可确切观察到的髋关节结构包括髋臼上部的负重区,陷窝及圆韧带,上、前、外侧的髋臼盂唇;通过手术中台下外旋和内旋髋关节,可以观察到大部分股骨头关节面.本组未出现神经血管并发症.结论经由3个入路相配合交替使用镜头和手术器械,可以完成关节镜的系统检查与手术操作.该入路的操作具有安全、有效和可重复性.     

The Role of Arthroscopy in Resurfacing Arthroplasty of the Hip

Arthroscopy of the hip joint has become a well-established procedure in treating many intra- and extra-articular disorders around the hip. As surgeons improve their expertise, indications for hip arthroscopy also expand. Persistent pain after joint replacement can be a diagnostic and therapeutic challenge, especially if the results of investigations performed to rule out loosening and infection are negative. Arthroscopy has previously proved to be a useful diagnostic and therapeutic tool in such cases in the knee and the shoulder. We report on the use of hip arthroscopy in a patient with persistent pain after resurfacing arthroplasty, identifying loosening of the acetabular component. It was perhaps the only way to identify component micromovement in the background of all other investigations’ results being normal or indeterminate. Arthroscopy of the hip in a patient with resurfacing arthroplasty is technically safe to perform and allows good visualization of the component surfaces and synovium, and the dynamic component of arthroscopy enables the surgeon to assess component loosening. In conclusion, we have found arthroscopy to be an extremely valuable technique for the evaluation of our patient with a persistently painful resurfacing arthroplasty.     

Hip Arthroscopy Without a Perineal Post: A Safer Technique for Hip Distraction

Pudendal nerve palsy is a reported complication of hip arthroscopy. We report a technique using a deflated taped beanbag rather than a perineal post. The patient is placed in the supine or lateral position on a fracture table. The beanbag is contoured around the patient’s flank and thorax. The distal aspect of the beanbag is placed no further than the iliac crest, and care is taken to avoid compression of the posterior aspect of the axillary region or the posterior humerus. The molded beanbag is deflated, a blanket is positioned over the abdomen and lower thorax, and with the use of 3-in-wide cloth tape, the patient and beanbag are secured to the operative table circumferentially. The superior margin of the deflated beanbag remains firm, preventing compression of the thorax and avoiding compromised ventilation. The arm on the operative side is placed across the chest and secured to avoid obstruction of the operative field. This patient positioning provides sufficient stability for adequate traction and good visualization while minimizing the risk of a pudendal nerve palsy.     

Utility of Ultrasound‐Guided Anesthetic Intra‐articular Injection to Estimate the Outcome of Hip Arthroscopy in Patients with Femoroacetabular Impingement Syndrome

ObjectiveTo investigate the effectiveness of ultrasound (US) guided intra‐hip joint injection to estimate the outcome of hip arthroscopy in patients with femoroacetabular impingement (FAI) syndrome.MethodsPatients with FAI syndrome (n = 60) were prospectively enrolled in our study. Before hip arthroscopy, a mix of 4 mL 2% lidocaine and 4 mL 1% ropivacaine were injected into the hip joint under the guidance of US. The clinical efficacy of the intra‐articular injection was evaluated by comparing the visual analog scale (VAS) and international hip outcome tool 12 (iHOT‐12) results before and after the injection. The outcome of hip arthroscopy was evaluated by iHOT‐12, the modified Harris hip score (MHHS), and the patient''s satisfaction 12 months after the operation. The outcome of intra‐articular injection and hip arthroscopy were compared. Factors related to the outcomes of hip arthroscopy were evaluated. The correlation between the efficacy of intra‐hip joint injection and arthroscopy was evaluated.ResultsThe VAS of patients decreased from 11.3 ± 7.7 to 3.3 ± 4.5, and the iHOT‐12 increased from 52.1 ± 23.2 to 84.1 ± 18.1 after intra‐articular injection (all P < 0.001). The iHOT‐12 score increased from 52.1 ± 23.2 to 78.9 ± 19.2, and the MHHS increased from 66.5 ± 6.8 to 81.6 ± 8.1 after hip arthroscopy (all P < 0.001). The satisfaction rate of arthroscopy, including very satisfied and effective patients, was 93.3%. Multi‐variable logistic regression showed that only iHOT‐12 improved value after injection was included in the regression formula of satisfaction, with the β of −0.154, standard error of 0.071, Wald value of 4.720, and OR of 0.857 (95%CI 0.746–0.985) (P = 0.03). Significant correlation was detected between iHOT‐12 scores after intra‐articular anesthesia and at 12 months after arthroscopy (r = 0.784, P < 0.001). So was the iHOT‐12 improved value (r = 0.781, P < 0.001) and the iHOT‐12 improved ratio (r = 0.848, P < 0.001). If we had performed arthroscopy only on patients with post‐injection iHOT‐12 score improvement ≥10, the satisfaction rate of arthroscopy would have increased to 96.6%.ConclusionsUS‐guided intra‐hip joint injection may provide a feasible way to estimate the outcome of hip arthroscopy in patients with FAI syndrome, and could be used as a method for indication selection of hip arthroscopy.     

Beginning Hip Arthroscopy: Indications, Positioning, Portals, Basic Techniques, and Complications

Hip arthroscopy is becoming increasingly popular for the diagnosis and treatment of hip pathology, and the indications continue to evolve. The two most common approaches are the supine and lateral decubitus position. Both approaches can be performed effectively; however, each approach has its own benefits and drawbacks. In this review we will describe the indications for hip arthroscopy, the pros and cons of each approach, and the necessary equipment, portals, portal placement, commercially available distraction devices, and complications.     

Arthroscopy Confers Favorable Clinical Outcomes in Asian Patients with Borderline Developmental Dysplasia of the Hip

Objective

Hip arthroscopy has recently appeared as a successful therapy in treating borderline developmental dysplasia of the hip (BDDH). This study aimed to describe the minimal 2-year follow-up after hip arthroscopy for patients with BDDH in the Asian population and use the combination of lateral center edge angle (LCEA) and alpha angles to detect the appearance of impingement in the BDDH population.

Methods

This retrospective investigation was conducted utilizing information from arthroscopically treated BDDH patients in 2018 and 2019. The following patient-reported outcomes were reported: modified Harris Hip Score, Hip Outcome Score-Activities of Daily Living, International Hip Outcome Tool 12-component form, and Visual Analog Scale. We also considered the clinical data regarding radiological measurements, intraoperative findings, interventions, complications, and subsequent surgical revisions, in the analysis of combination angles in detecting the occurrence of impingement. Patients with asymptomatic contralateral hips from traumatic hip injury (pelvic fracture) served as the control group. A 2:1 propensity score matching was based on age, sex, and BMI. A receiver operating characteristic curve (ROC) was used to identify the thresholds of combination angles and their accuracies.

Results

A total of 77 hips met the inclusion and exclusion requirements. After the follow-up period, most patients showed a considerable improvement in patient-reported outcomes compared to their preoperative values (P < 0.001 for all). The overall rate of complications was 5.2%, whereas the rate of revisions was 3.9%. Increasing preoperative alpha angle age was significantly positively correlated with improving patient-reported outcomes. The combined angle cut-off was determined to be 80.5° (AUC, 0.858; 95% CI: 0.757–0.938; sensitivity (SE), 98.1%; specificity (SP), 74.1%; P < 0.001) for the occurrence of impingement in BDDH population.

Conclusion

Good patient-reported outcomes and low revision rates can be expected in the BDDH population with careful selection of patients in Asian populations. A combination angle >80.5° could be a reliable predictive factor of impingement in BDDH populations.     

The 23-Point Arthroscopic Examination of the Hip: Basic Setup,Portal Placement,and Surgical Technique

The 23-point arthroscopic examination of the hip has been used for more than 400 arthroscopic hip procedures. It ensures that all components of the hip are carefully inspected and allows for proper documentation. It is vital that a precise knowledge of hip anatomy and common portal placement is coupled with proper patient selection, sound preoperative planning, and a consistent arthroscopic technique in order to maximize clinical outcomes. The 23-point arthroscopic examination of the hip uses 3 standard portals (anterior, anterolateral, and posterolateral) that provide a systematic method of examination of the key structures of the central and peripheral hip joint. The points are divided up into groups based on the portal through which they are viewed. The 23-point arthroscopic examination of the hip is reproducible, and offers some standardization within the evolving field of hip arthroscopy. It provides a consistent routine for hip arthroscopy that has yet to be published. Using this standardized examination can assist with the diagnostic accuracy of hip arthroscopy.     

Techniques of Wrist Arthroscopy

Wrist arthroscopy is a promising new technique for the evaluation of wrist pain or dysfunction. Cadaveric wrist specimens were used to devise safe and advantageous entry portals for arthroscopy and to establish respective advantages for each portal. Thirty-five clinical cases were used to correlate the laboratory experience and to refine a reproducible surgical technique. Seven portals are useful: five in the radiocarpal interval, one in the midcarpal area, and one in the distal radioulnar joint space. Detailed wrist anatomy is reviewed in this paper and must be thoroughly understood to interpret arthroscopic views. Blunt subcutaneous dissection protects cutaneous nerve branches at the various portals. Intraoperative photographs illustrate the excellent perspectives achieved using these techniques.     

Hip Arthroscopy for Femoracetabular Impingement in China: A Review and Meta‐Analysis

ObjectiveTo explore the development of hip arthroscopy in China through reviewing the change of the application of hip arthroscopy operation on treating femoracetabular impingement (FAI).MethodPapers were retrieved from January 1, 2005 to November 1, 2019, from databases CNKI, Wanfang Data, VIP, PubMed, and Embase. The keywords are Hip Impingement, Femoroacetabular impingement, Hip arthroscopy, Arthroscopic operation, Hip Arthroscopy operation, and Arthroscope, etc. The quality of papers was assessed through MINORS , and statistics and meta‐analysis were performed by Word, Excel, and Revman 5.3 Zurich, Switzerland.ResultsFrom a total of 8,953 papers, 46 review articles without data and 48 articles with data were involved, and 25 papers were included in the Meta‐analysis. The twenty‐five papers were selected from 48 papers with data, of which 41 were reported in Chinese, 11 were missing complete Harris scores, five did not mention the number of patients who had lost follow‐up, three had minors quality scores below 7, one did not have enough FAI cases, and three did not have standard deviations in Harris scores. Overall, in China, the application of hip arthroscopy regarding FAI has flourished while maintaining a high level of treatment and has reached its peak in the past 2 years.ConclusionWith the rapid development of hip arthroscopy in China, hip operation is widely recognized, many reports on its application on FAI have emerged successively, and the scope of application and technical level have been improved.     

Hip Arthroscopy: Surgical Indications

Successful outcomes of hip arthroscopy are most clearly dependent on selecting appropriate patients. The indications are numerous and continue to evolve. These indications are summarized in this report. The anatomic architecture of the hip region imposes unique challenges to performing this procedure. As a surgeon’s experience evolves, so will his or her indications for this operation. It is imperative to be knowledgeable about the technique, to exercise care with the procedure, and to be certain that it is being performed for proper reasons.