Video: Hip Arthroscopy ICL 301: Femoroacetabular Impingement Thursday, February 17th, 2011 Bryan T. Kelly, MD Co-Director Center for Hip Pain and Preservation

Hospital for Special Surgery Bryan T. Kelly, MD Hospital for Special Surgery Disclosure: I DO NOT have a financial interest in any commercial products or service presented in this lecture AND DO NOT INTEND to discuss off label or investigational use of products or services.

Pivot Medical, Inc.: Consultant Smith & Nephew: Educational Consultant Types of financial relationships and the companies with whom I have relationships are as follows: Pivot Medical, Inc.: Consultant Smith & Nephew: Educational Consultant A2 Surgical: Consultant

Arthroscopic FAI Set up Access Capsule Cut Rim Prep / Resection Labral Refixation Cam Decompression Capsular Repair

1. Patient Set Up

1. Patient Set Up Adequate traction requires approximately 10mm of distraction across the joint. Careful attention to padding is critical.

Greatest Risk →→ Anterior Portal 2. Access – Portals Anterior Anterolateral Posterolateral Greatest Risk →→ Anterior Portal Avg. 3 mm from a branch of the lateral femoral cutaneous nerve In 1995, Dr. Byrd assess the safety of 3 standard portals as they entered the central compartment of the hip and found that the greatest risk came from the Anterior Portal as it coursed just medial to the lateral femoral cutaneous nerve. Primal Pictures Limited

2. Access: Expanded Portal Placement Palpate and Outline: Greater Trochanter Anterior Superior Iliac Spine (ASIS) Portal Placement Anterolateral Portal (AL) 1cm superior and anterior to GT Posterolateral (PL) 1cm superior and posterior to GT Anterior Portal (AP) In line with AL portal 1 cm lateral to ASIS Mid-Anterior Portal (MAP) Proximal Mid-Anterior Portal (PMAP) This is an illustration of a left hip with ASIS and greater trochanter outlined. Using the previously described anterior, anterolateral, and posterolateral portals as a foundation, we systematically marked 8 skin incisions for the placement of 11 possible arthroscopic portals. We place the 1 cm lateral to the ASIS in an effort to avoid the lateral femoral cutaneous nerve. The distance between the Anterior and Anterolateral portal was then measured and represented here as “X”. An equilateral triangle was then constructed distally with all sides equaling “X”. The apex of this triangle marks the location of the Mid-Anterior Portal. This was then repeated proximally to determine the location of the Proximal Mid-Anterior Portal.

Portal Safety The Mid-Anterior and Anterior portals pass in close proximity to a small terminal branch of the ascending LCFA Greatest risk still comes from the proximity of the anterior portal to the LFCN A slightly more lateral location may provide some protective benefit

Safe Zone Robertson et al, Arthroscopy 2008. The findings from this study seem to support the concept of a relative neurovascular safe zone for arthroscopic access to the hip joint within the outlined parameters.

2. Access / Visualization

2. Access / Visualization

2. Access / Visualization Transition zone injury Contra-Coup injury

3. Capsule Cut

3. Capsule Cut – IA Evaluation Cam Injury Rim Injury Cam delamination Loss of normal attachment of labrum to transition zone. Capsular sided injury to the labrum / capsule against the rim lesion

4. Rim Preparation Rim Exposure Rim Decompression Severe rim inflammation around the rim lesion Outline the rim lesion prior to decompression

4. Rim Preparation

3. Rim Resection

Pre Post

4. Labral Refixation

4. Labral Refixation

Entry into peripheral compartment

Reposition patient and fluoro for peripheral compartment work.

5. T-Cut and Visualization

6. Cam Decompression

7. Capsule Closure and Assessment

Pre and post fluoro shots of a patient with primary cam impingement

Pre and post fluoro shots of a patient with combined subspine / rim / and cam impingement

Thank You