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

2. 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.

3. 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

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

5. 1. Patient Set Up

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

7. 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

8. 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.

9. 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

10. 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.

11. 2. Access / Visualization

12. 2. Access / Visualization

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

14. 3. Capsule Cut

15. 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

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

17. 4. Rim Preparation

18. 3. Rim Resection

19. Pre Post

20. 4. Labral Refixation

21. 4. Labral Refixation

22. Entry into peripheral compartment

23. Reposition patient and fluoro for peripheral compartment work.

24. 5. T-Cut and Visualization

25. 6. Cam Decompression

26. 7. Capsule Closure and Assessment

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

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

29. Thank You