ARTHROSCOPY OF THE HIP: Anatomy and Portals
Section snippets
Sequence of Portal Establishment
Portals for hip arthroscopy should be established in the following sequence:
- 1
Anterolateral portal
- 2
Anterior portal
- 3
Posterolateral portal
Use cannulas for all portals that will allow you to switch from one portal to the other with your scope and operating instruments.
Anterolateral Portal
The anterolateral portal starts at the anterior superior tip of the greater trochanter Figure 1, Figure 2, Figure 3Palpation alone can place you 1 to 2 inches superior to the trochanter, depending on the patient's weight. Using the image intensifier to locate the superior surface of the greater trochanter is a good idea. Both anterolateral and posterolateral portals pass through the gluteus medius and minimus muscles. Once again, it is best to use the image intensifier to establish these
Anterior Portal
The anterior portal is established by drawing a vertical line from the anterior superior iliac spine distally. A second line is drawn anteriorly from the superior surface of the femoral greater trochanter. The anterior portal is established at the point where these lines intersect. The needle is angled 45° cephalad and 30° medially for insertion into the joint. The angles may need to be changed 10° to establish the correct entry. The needle will pass through the rectus femoris and iliofemoral
Posterolateral Portal
The posterolateral portal is established by placing a spinal needle close to the superolateral corner of the greater trochanter and passing along the neck of the femur up into the joint. The two lateral portal needles should be passed fairly parallel to each other. This portal is at least 2.9 cm away from the sciatic nerve, according to published reports.3 Establishing this portal is safe if done carefully. The superior gluteal nerve is 4.4 cm superior to the lateral portals.
ARTHROSCOPIC ANATOMY OF THE HIP JOINT5
The hip joint is basically a large ball-and-socket joint located about 0.5 inch below the middle third of the inguinal ligament (Figs. 4 and 5). The socket is deepened by a labrum, which extends the acetabular cup. The capsule of the joint is attached to the margin of the acetabulum and transverse ligament of the socket, and extends almost to the base of the neck of the femur. The transverse acetabular ligament extends across the acetabular notch and is located antero-inferiorly. The acetabulum
SUMMARY
Establishing the three portals for hip arthroscopy in the correct sequence is crucial, as is use of the image intensifier for location and passage of needles. Patient position for hip arthroscopy can be either lateral decubitus or supine. Gentle techniques are essential to avoid scuffing of the articular surface. The 70° scope is the “workhorse” in this procedure. Location of portals is essential to successful hip arthroscopy.
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Cited by (15)
Hip Arthroscopy: A Brief History
2016, Clinics in Sports MedicineCitation Excerpt :Lanny Johnson15 described the anatomic landmarks and proposed portal locations for hip arthroscopy. Byrd and Sweeney8,16 also published on the anatomic landmarks for hip arthroscopy as well as relative relationships of the portals to the muscles they penetrated and neighboring neurovascular structures. If bony landmarks are accurately marked, portal placement is relatively safe in hip arthroscopy.
Hip Arthroscopy Portals
2011, Operative Techniques in Sports MedicineCitation Excerpt :From this point, the portal is aimed approximately 45° cephalad and 30° toward the midline. On average, the anterior portal is 6.3 cm distal to the ASIS, and it pierces the muscle belly of the Sartorius and the rectus femoris before entering the hip through the anterior capsule.10,15 This portal is established under direct visualization using a 70° arthroscope in the anterolateral portal (Fig 4).
An anatomic arthroscopic description of the hip capsular ligaments for the hip arthroscopist
2011, Arthroscopy - Journal of Arthroscopic and Related SurgeryMR imaging of sports-related hip disorders
2003, Magnetic Resonance Imaging Clinics of North AmericaAn aiming guide for anterior portal placement in hip arthroscopy
2003, ArthroscopyA quantitative analysis of hip capsular thickness
2015, Knee Surgery, Sports Traumatology, Arthroscopy
Address reprint requests to Howard J. Sweeney, MD, Northwestern University Medical School, 1144 Wilmette Avenue, Wilmette, Illinois 60091