The Hip Arthroscopy Post-less Procedure Impingement (HAPPI) Technique: Achieving Distraction With Standard Hip Tables at Zero Additional Cost

Patient Positioning for Postless Hip Arthroscopy

Hip arthroscopy has been on the rise since its inception. Initial descriptions of the procedure required skeletal traction of the operative extremity with countertraction provided by a perineal post. Perineal posts are associated with complications such as perineal nerve palsy, genital laceration, and hematoma formation. Postless traction has been developed to avoid complications related to use of perineal posts. A patient is positioned supine on a postless traction table (Guardian; Stryker, Greenwood Village, CO) with a disposable traction pad. The anterior superior iliac spine is positioned at the distal aspect of the semicircle cutout in the traction pad. The patient is placed in approximately 3° of Trendelenburg positioning. Both lower extremities are secured into traction boots. The operative extremity is prepared and draped in the standard sterile fashion. Traction is applied to the operative extremity with countertraction being applied manually to the pelvis during hip dislocation. Many pathologies around the hip including femoral acetabular impingement can be effectively managed with hip arthroscopy. Postless hip arthroscopy is an effective method of obtaining sufficient traction for hip dislocation. Significant complications related to the perineal post can be avoided with postless traction. We expect postless traction use to increase in hip arthroscopy.

Association of Postless Distraction in Hip Arthroscopy With Decreased Postoperative Groin Numbness

BACKGROUND

Patients undergoing hip arthroscopy performed with perineal post distraction may experience postoperative nerve and soft tissue complications related to the perineal post.

PURPOSE

To compare rates of postoperative numbness in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) with postless distraction and perineal post distraction methods.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective review of prospectively collected data was performed on patients who underwent hip arthroscopy for FAIS, with postless distraction and perineal post distraction methods. Medical records were reviewed for patient characteristics, radiographic data, and operative data. Traction force data were collected on all patients prospectively using a previously validated method. Data on postoperative numbness (presence/absence and regionality) were collected prospectively at routine postoperative follow-ups (6-week and 3-month postoperative clinic visits).

RESULTS

Overall, 195 patients were included, with 94 patients (mean age, 30.4 years) in the postless distraction cohort and 101 patients (mean age, 31.9 years) in the post distraction cohort. The overall numbness rates were 29 of 94 (30.9%) in the postless distraction group and 45 of 101 (44.6%) in the post distraction group (P = .068). Rates of postoperative groin numbness were 1 of 94 (1.1%) in the postless distraction group and 19 of 101 (18.8%) in the post distraction group (P < .001). Multivariate analysis for postoperative groin numbness demonstrated post distraction (odds ratio [OR], 16.5; P = .022) and traction time (OR, 1.7; P = .020) to be statistically significant variables. In subgroup analysis of the post distraction group, traction time (P = .015), but not holding (P = .508) or maximum traction force (P = .665), reached statistical significance in patients who developed postoperative groin numbness.

CONCLUSION

Postless distraction hip arthroscopy demonstrated a statistically significantly lower rate of groin numbness rates in comparison with a traditional perineal post distraction method. In the post distraction group, traction time was significantly higher in patients who developed postoperative groin numbness than in those who did not.

Team Approach: Hip Preservation Surgery

The evaluation and treatment of adolescents and young adults with hip pain has seen tremendous growth over the past 20 years. Labral tears are well established as a common cause of hip pain but often occur because of underlying bony abnormalities. Femoroacetabular impingement (FAI) and acetabular dysplasia are now well-established causes of hip osteoarthritis and are increasingly treated in the prearthritic stage in hopes of improving symptoms and prolonging the longevity of the native hip. Beyond FAI and acetabular dysplasia, this patient population can present with a complex and variable group of underlying conditions that need to be taken into account. Expertise in the conservative management of this population, including physical therapy, is valuable to maximize the success. Preoperative, surgical, and postoperative decision-making and care in this population is complex and evolving. A comprehensive, multidisciplinary approach to the care of this patient population has been used for over 20 years by our institution with great success. The purpose of this article is to review the "team-based approach" necessary for successful management of the spectrum of adolescent and young adult hip disorders.

Postless Hip Distraction Systems Decrease the Amount of Traction Force Needed to Obtain Adequate Hip Distraction Versus a Conventional Post Hip Distractor

PURPOSE

To directly compare hip distraction distance and traction force data for hip arthroscopy performed using a post-basedsystem versus a postless system.

METHODS

Adult patients undergoing primary hip arthroscopy for femoroacetabular impingement were prospectively enrolled. Before March 26, 2019, arthroscopy was performed using a post-based system. After this date, the senior author converted to using a postless system. Intraoperative traction force and fluoroscopic distraction distance were measured to calculate hip stiffness coefficients at holding traction (k-hold) and maximal traction (k-max). We used multivariable regression analysis to determine whether postless arthroscopy was predictive of lower stiffness coefficients when controlling for other relevant patient-specific factors.

RESULTS

Hip arthroscopy was performed with a post-based system in 105 patients and with a postless system in 51. Mean holding traction force (67.5 ± 14.0 kilograms-force [kgf] vs 55.8 ± 15.3 kgf) and mean maximum traction force (96.0 ± 16.6 kgf vs 69.9 ± 14.1 kgf) were significantly lower in the postless group. On multivariable analysis, postless traction was an independent predictor of decreased k-hold (β = -31.4; 95% confidence interval, -61.2 to -1.6) and decreased k-max (β = -90.4; 95% confidence interval, -127.8 to -53.1). Male sex, Beighton score of 0, and poor hamstring flexibility were also predictors of increased k-hold and k-max in the multivariable model.

CONCLUSIONS

Postless traction systems decrease the amount of traction force required for adequate hip distraction for both maximal and holding traction forces when compared with post-based systems. Postless traction systems may help further reduce distraction-type neurologic injuries and pain after hip arthroscopy by lowering the traction force required to safely distract the hip.

LEVEL OF EVIDENCE

Level III, prospective cohort-historical control comparative study.

A Prospective Comparison of Groin-Related Complications After Hip Arthroscopy With and Without a Perineal Post

BACKGROUND

Previous studies have demonstrated various groin-related nerve and soft tissue complications in patients undergoing hip arthroscopy with a perineal post.

PURPOSE

To prospectively compare groin-related nerve and soft tissue complications between patients undergoing hip arthroscopy with and without the use of a perineal post.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A prospective single-surgeon cohort study was performed on all patients undergoing hip arthroscopy by the senior author between January 2020 and March 2022. A post-free hip distraction system was used at 1 center in which the senior author operates, and a system with a large padded perineal post was used at another surgical location. Patients completed a survey at the first postoperative visit (7-10 days) to determine if they had experienced any groin-related complications after surgery (groin numbness, sexual/urinary dysfunction, skin tears). Patients with a positive survey response repeated the survey at each follow-up visit (6 weeks, 3 months, 6 months) until the symptoms resolved. The rate and duration of groin-related complications were then compared between the groups.

RESULTS

A total of 87 patients were included in the study who underwent hip arthroscopy: 53 with a perineal post and 34 without. No differences were found between the post and postless groups in terms of age at surgery, sex, body mass index, or traction time. We found that 16 patients (30%) in the perineal post group experienced groin numbness versus 0 (0%) in the postless group (P < .0001). On average, groin numbness lasted 5 ± 3 days (mean ± SD) in the perineal post group. Three patients in the perineal post group experienced sexual dysfunction for a mean 7 days, as compared with none in the postless group. Seventeen patients (32%) in the perineal post group experienced foot numbness versus 4 (12%) in the postless group (P = .04). One patient in the perineal post group reported a superficial skin tear.

CONCLUSION

Postless hip arthroscopy resulted in no risk of groin-related complications as compared with traditional hip arthroscopy with a perineal post.

Postless Arthroscopic Hip Preservation Can be Adequately Performed Using Published Techniques

Purpose

To identify and evaluate techniques used for postless hip arthroscopy.

Methods

A narrative review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify surgical technique articles or clinical studies describing techniques for the use of postless hip arthroscopy. Specific items sought for analysis included hip arthroscopy for femoroacetabular impingement including cam or pincer-type lesions, surgical time, traction time, traction force, bed Trendelenburg angle, intraoperative techniques, and postoperative outcomes, including complications. Exclusion criteria included any postless techniques used for open hip surgeries such as periacetabular osteotomy, sports hernia, peritrochanteric work, gluteus medius repair, ischiofemoral impingement, hamstring repair, or need for intraoperative conversion from postless to posted technique.

Results

Ten studies (1 Level III, 3 Level IV, 6 Level V), published from 2007 to 2021, were analyzed (1,341 hips, 51.5% male, mean age ranged from 16.0 to 66.0 years). In 4 studies, Trendelenburg position with a foam pad (The Pink Pad; Xodus Medical, Inc.) was used at 5 to 20°. Six of 10 studies contained no clinical results. The average traction force and time ranged from 65.0 to 88 pounds and 31.0 to 73.5 minutes, respectively. The remaining studies used the yoga mat technique, the Tutankhamun technique, the beanbag technique, and the Hip Arthroscopy Post-less Procedure Impingement technique. There was only one incident of pudendal neurapraxia, which resolved spontaneously at 6 weeks without complication. Sufficient distraction was able to be obtained using postless traction in all cases.

Conclusions

Postless hip arthroscopy may adequately be performed with a variety of techniques. Obtaining adequate traction and countertraction may be achieved through these postless methods.

Clinical Relevance

Given the potential serious complications that may result from use of a perineal post, it is important for surgeons to be aware of postless techniques that may be used effectively for hip arthroscopy.

Current Trends in the Use of Postless Hip Arthroscopy: A Survey of the International Society for Hip Arthroscopy Membership

Background

Previous studies have demonstrated the risks of pudendal nerve and/or soft tissue complications due to the use of a perineal post during hip arthroscopy. Recently, various postless hip arthroscopy techniques have been described in the literature.

Purpose

To assess the current international trends in the use of postless hip arthroscopy among hip preservation specialists.

Study Design

Cross-sectional study.

Methods

An anonymous 11-item survey was sent by email to all members of the International Society for Hip Arthroscopy (ISHA) in January 2022. Surgeons were asked various questions regarding their current use of post-assisted or postless hip arthroscopy, if they had changed their setup technique during their career and the reason for that change, and their perceived rate of pudendal nerve and/or perineal soft tissue injuries using their current technique. Descriptive statistics were used to report the results of each question. The Student t test was used to compare the number of years in practice between post-assisted and postless users. Fisher exact tests were performed to compare categorical rates of pudendal nerve and soft tissue complications between post-assisted and postless users.

Results

A total of 126 surveys were completed from 431 ISHA members (29.2%). Sixty-one percent of the surgeons currently use a perineal post, while 33% use a postless technique. Seventy-five percent of the perineal post users and 98% of the postless users self-reported a rate of pudendal nerve and/or soft tissue injury of <1% (P = .015). Among 41 respondents who indicated changing their technique at some point, 59% reported doing so because of pudendal nerve and/or soft tissue complications. Among surgeons who switched from a perineal post to a postless setup, 71% indicated they have noticed a decrease in the rate of pudendal nerve and/or soft tissue complications.

Conclusion

Although use of a perineal post is still a more common setup technique among hip arthroscopists, approximately one-third of surgeons use a postless technique. Surgeons who have switched to a postless technique often did so because of perineal complications, with the majority noticing a subjective decrease in these complications with the use of postless hip arthroscopy.

The Pink Pad: A Method of Post-Free Distraction During Hip Arthroscopy

Distraction is essential during hip arthroscopy to allow for adequate working space during central and peripheral compartment procedures. Pudendal posts are frequently used with traction boots to achieve distraction, but use of these posts is believed to be associated with the iatrogenic pudendal area and perineal nerve injuries seen with hip arthroscopy. Current post-free distraction tables are costly and cumbersome. The pink pad positioning device allows for post-free distraction through the creation of friction between the patient, the pad, and the bed. This device can be used with a standard hip arthroscopy table, is easy to learn, allows for adequate distraction, and allows for greater access to the femoral neck during osteochondroplasty, as there is less restriction of the patient's range of motion without a post present. The purpose of this Technical Note is to describe a method of post-free distraction using the pink pad positioning device.

The Yoga Mat Technique in Postless Hip Arthroscopy

Hip arthroscopy for the treatment of femoroacetabular impingement syndrome with anti-sliding techniques and without the use of a perineal post to achieve hip distraction has increased greatly in the past 5 to 10 years. To access the hip joint, distraction is mandatory to treat intra-articular disorders such as labral tears, acetabular cartilage defects, loose bodies, ligamentum teres tears, and avascular necrosis of the hip. In hip distraction, counter-distraction is needed, and this is achieved with a bulky and cushioned perineal post. Most of the described techniques in hip arthroscopy worldwide use a perineal post, but iatrogenic pudendal nerve, genital lacerations, hematomas, and groin complications have been reported to occur. In Latin American countries, disposable hip pad devices are expensive, and not all the arthroscopic companies provide them. Our yoga mat technique provides enough countertraction to achieve adequate hip distraction. Labral repair, labral reconstruction, and decompression of femoroacetabular impingement syndrome have been achieved properly, reliably, and reproducibly, and no Trendelenburg position is needed. Postless hip arthroscopy is made simple, and positioning the patient is not difficult. Hip surgeons can adapt this technique to a fracture table, a hip distractor, and a standard operating room table.