The indications for HA without traction do not differ from those described for the traction technique. The traction and nontraction techniques should be combined to allow a complete diagnostic inspection of the hip joint. Performing HA solely as a nondistraction method should be limited to children and situations in adults in which distraction is not sufficient to introduce instruments into the central compartment of the hip.
The author does not have experience with HA of children and adolescents. Personal communications with other hip arthroscopists,55,56 who have performed HA in children with septic arthritis and Perthes disease, reveal that a traction table is not necessary in patients younger than 12 to 14 years. Soft tissues, including the hip joint capsule and pericapsular ligaments, are so lax at this age that HA can be performed solely as a combination of nontraction and manual traction.
A minimum distraction of the central compartment of the hip of about 8 to 10 mm should be confirmed under fluoroscopy before placement of the first portal. In patients with osteoarthritis of the hip joint, shortening and fibrosis of the joint capsule and peri-capsular tendons may lead to less distraction of the hip. Under those circumstances, introducing cannulas between head and socket must not be tried. Otherwise, labral and cartilage damage are likely. However, proceeding with the nontraction technique for an exclusive scope of the hip joint periphery may be considered. Certain pathology, as indicated below, can be found and addressed here.
With respect to the limited sensitivity and specificity of preoperative radiologic methods for intraarticular hip joint lesions, indicating hip arthroscopy for patients with unclear hip pain is not uncom-mon.17'23'25'36'48'57-59 However, preoperative evaluation should exclude spinal, abdominal-inguinal, neurologic, and rheumatologic diagnoses before the patient is considered for a hip scope. In addition, radiologic imaging of intraarticular loose bodies and labral and cartilage lesions has improved since the advent of computed tomography (CT) and magnetic resonance (MR) arthro-grams (MRA) (personal communication, J.W. Thomas Byrd, Nashville, TN).52,60,61 Intraarticular application of radiopaque material and air (double-contrast CT) or gadolinium (MRA) enhances the contrast between in-traarticular structures.
Relief of pain with a local anesthetic is another strong indicator that the hip is the source of pain. If the etiology remains unclear, a complete diagnostic inspection of the hip joint is mandatory. Especially in this situation, it is important to combine the traction with the nontraction technique. As described in case example 1, loose bodies can be easily missed if only the central compartment is scanned. Synovial diseases such as a chondromatosis or an inflammatory syn-ovitis typically manifest first in the hip joint periphery. Here, access to the synovium for biopsy and syn-ovectomy is easy and is less harmful.
Radiologic evidence of loose bodies may be the classical indication for hip arthroscopy.2'22'23'34'38'50'59'62-64 Loose bodies prefer to accumulate in the peripheral recesses. This realization is important in assessing pre-
operative radiographs or CT or MR imaging and also for operative planning.13'43 The medial neck area, the perilabral recesses, and the recess underneath the transverse ligament especially need to be scanned. The technique of removal depends on the size and consistency of the loose bodies. Small loose bodies may be easily washed or sucked out via an additional portal cannula. In contrast to the limitation of the cannula diameter to 5 or 6 mm during arthroscopy with traction of the central compartment (narrow gap between labrum and femoral head), the nontraction technique allows the use of larger cannulas. This is helpful especially for synovial chondromatosis, where chopping up of the chon-dromas can be time consuming. Larger loose bodies must be chopped up with a shaver or more aggressive instruments if they have a bony core (see case 2). Inspection and removal of loose bodies in the posterior area of the peripheral compartment of the hip is more demanding. As indicated earlier, it may be difficult to pass the lateral femoral neck and bring the 70-degree scope into the posterior area, particularly if visibility is decreased by synovitis or the joint is tight. Sometimes, rotation of the hip, manual ballotement, or intraartic-ular suction can bring loose bodies from the posterior area into the visible anterior or medial areas.35 To confirm a complete loose body removal, especially in synovial chondromatosis, an intraoperative arthrogram can be helpful before joint evacuation.
If the hip joint is under distraction, the synovium (pul-vinar) of the acetabular fossa can be seen. However, only small parts of the synovial lining of the medial, anterior, and lateral capsule are visible. From our and other authors' experience, this part of the synovium can best be seen without traction.13,43 As indicated, chondromas tend to accumulate in the medial neck area, the perilabral recesses, and the recess underneath the transverse ligament. Here, cannulas can be easily placed via another anterolateral or anterior portal for synovial biopsies (reactive or specific synovitis, PVNS), synovectomies, and removal of chondromas. In addition, other pathologic conditions such as cysts of the labrum, anterior capsule, and communications with the iliopectineal bursa have to be ruled out. Particularly in patients with rheumatoid arthritis, an il-iopectineal cyst has to be considered as a source of a painful hip. Depending on the size of the cyst, ar-throscopic decompression may be performed. However, in case of larger cysts with fibrotic walls and related compression syndromes or recurrence, open excision may be the treatment of choice.
Arthroscopic treatment of a septic arthritis of the hip joint should include a debridement of detritus and necrotic tissue, a lavage with at least 3 to 4 L irrigation fluid, placement of a drain into the femoral neck area, and antibiotic treatment for at least 7 days.65-68 The author does not have experience with this disease or complication, but recommends combining the traction with the nontraction technique. During traction, the labrum and the zona orbicularis hinder flow of the irrigation fluid to and back from the peripheral recesses. Direct access to the peripheral areas without traction ease direct inspection, washing, and debridement of necrotic tissues and detritus. In addition, placement of a drain can easily be performed.
Klapper and Silver35 and Dorfmann and Boyer13 used the nontraction technique for arthroscopic treatment of labral lesions. From the author's experience, a good indication for the nontraction technique is a labral cyst, which is better accessed from the peripheral side. A typical location of a labral cyst is the anterior labrum close to the iliopsoas tendon. Here, the differential diagnosis should include an iliopectineal, capsular cyst. From the author's experience, tears of the labrum are more difficult to address with the non-traction technique. An instrument can be passed underneath the labrum for partial resection or trimming only if the labrum can be elevated from the femoral head by flexion. However, traction is usually preferred because labral lesions are commonly found at the articular side of the labrum. In addition, under traction the labrum does not adhere to the femoral head and allows better access for mechanical or electrothermal instruments.
A review of the literature reveals that considerable numbers of HA are performed for traumatic and non-traumatic (osteoarthritis, osteochondritis dissecans) chondral lesions. In osteoarthritis-associated lesions such as loose bodies, labral lesions and synovitis can be frequently found preoperatively and intraoperatively.51
Was this article helpful?