Page 24 - ISAKOS 2019 Newsletter Vol II

CURRENT CONCEPTS
Postless Hip Arthroscopy
Table I Complications Secondary to Use of Perineal Post
Introduction
Postless Hip Arthroscopy Techniques and Outcomes
Postless hip arthroscopy can be performed with or without the use of Trendelenburg positioning2. The use of modest Trendelenburg inclination (10° to 15°) utilizes gravity and the friction of the bed to apply distraction. Friction can be generated with use of any type of durable padded material with a high coefficient of static friction (Fig. 1). The procedure can be performed on any radiolucent bed with hip arthroscopy limb-positioning attachments. If the choice is made to perform the procedure with Trendelenburg positioning, even low degrees of inclination can be disorienting and may require a learning curve until the surgeon becomes accustomed to portal and anchor placement. However, there is a major misconception about the need to use Trendelenburg position during postless arthroscopy; in actuality, such positioning is not a requirement.
01 Left: Photograph illustrating the postless pad setup (A) and the appearance of the pad, which is approximately 2.5 cm thick and is composed of soft, compressible,
high-friction material (B).
Right: Photograph showing the postless setup with use of a pad on a hip arthroscopy table (C).
Two methods can be used at the commencement of postless surgery to circumvent the use of Trendelenburg positioning. With the first method, the addition of an air (or fluid) arthrogram can break the suction seal of the hip joint, thereby reducing the amount of force necessary for sufficient distraction3. This reduction in force has been shown to significantly reduce postoperative pain and opioid medication use. Surgery can then be performed with the bed flat (Fig. 2), without any significant differences in comparison with surgical techniques involving a post. With the second method, Trendelenburg positioning can be temporarily used to achieve distraction and then, once traction is achieved, the bed can be brought back to the flat position and surgery can then commence in a familiar manner. Both methods can easily achieve adequate distraction (>10 to 12 mm).
Joshua D. Harris, MD
Houston Methodist Hospital Houston, Texas UNITED STATES
Soft-tissue
• Scrotum,penis • Labia,vagina
Nerve
• Pudendal
• Anteriorbranchobturator • Genitofemoral
• Iliohypogastric
• Cluneal
Arthroscopic hip-preservation surgery continues to rapidly evolve across the globe. Together, sound clinical decision- making and skillful execution of the surgical technique have demonstrated successful outcomes in non-arthritic, non- dysplastic individuals undergoing modern hip arthroscopy. Emphasis is placed on labral preservation, correction of the pathomorphology underlying femoroacetabular impingement syndrome, and patient-specific capsular management. Recent high-quality prospective investigations have demonstrated excellent short and intermediate-term subjective patient-reported and objective clinician-measured outcomes after arthroscopic hip-preservation surgery. Advances in technology have led to significant reductions in postoperative pain, complications, and reoperations. Postless hip arthroscopy is a meaningful innovation that may reduce or eliminate perineal complications (and associated pain) following post-assisted surgery.
Complications Associated with Perineal Post
The rate of complications during and following hip arthroscopy is low (<10%), and the majority of these complications are minor and temporary (Table I)1. However, the published rate of complications is an underestimation of the true rate secondary to low levels of evidence as well as publication and recall biases. In part, this underestimation applies to the use of the perineal post, with the rate of perioperative post-related complications being as high as 30% to 35%. The rate of urologic or sexual dysfunction is approximately 25%. Post-related complications involving the perineal and groin regions can be categorized as soft-tissue complications and neural complications (Table I). Technical advancements related to the use of a post include increasing the diameter of the post (up to 9 inches), the use of soft and smooth padding, and lateralization of the post to lessen compression of the perineum. Despite these improvements, post-related complications still occur and, despite the largely temporary nature and “low rate” of these complications, they are still quite significant. Any measure that can reduce or eliminate the occurrence of these sensitive iatrogenic complications is certainly a welcome solution to a troublesome problem in arthroscopic hip surgery.
22 ISAKOS NEWSLETTER 2019: VOLUME II