Synovial osteochondromatosis

The article "Arthroscopic hip surgery" is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, education program professional, Center for Perioperative Education.

Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is Dec 31, 2008.

Complete the examination answer sheet and learner evaluation found on pages 1021-1022 and mail with appropriate fee to

AORN Customer Service

c/o Home Study Program

2170 S Parker Rd, Suite 300

Denver, CO 80231-5711

or fax the information with a credit card number to (303) 750-3212.

You also may access this Home Study via AORN Online at http://www.aorn.org/journal/homestudy/default.htm.

BEHAVIORAL OBJECTIVES

After reading and studying the article on arthroscopic hip surgery, nurses will be able to

1. explain how hip anatomy affects pathological changes,

2. describe how range of motion examinations are used to make a diagnosis of specific hip diseases,

3. discuss preoperative preparation of the patient undergoing arthroscopic hip surgery, and

4. identify intraoperative care provided to ensure the safety of the patient undergoing hip surgery.

The ability to look into a joint with a small optical instrument through a limited incision to diagnose and possibly treat a joint problem (ie, arthroscopy) has been possible for many decades. The most accessible joint for arthroscopic procedures is the knee, and knee arthroscopy became popular and widely available in the 1970s. (1) The shoulder was next, with many procedures developed and refined in the 1980s. (1) By the late 1980s and early 1990s, other joints such as the elbow, wrist, and ankle routinely were treated arthroscopically. (1)

The hip has been the final frontier for arthroscopic treatment of the major joints in the body. Although the first hip arthroscopic procedure was performed in 1931, only in the last five years has hip arthroscopy been performed routinely, with specific indications and better defined techniques. (1) Hip arthroscopy developed later than arthroscopic treatment of other joints because

* the hip is a deep ball and socket joint, and it is difficult to see around the curve of the femoral head;

* the hip has strong ligaments that resist distraction, making it a difficult joint to enter; and

* the closely surrounding neurovascular structures make access more challenging.

This article explores the advances in instrumentation and techniques that have been decisive in making hip arthroscopy a more routine surgical procedure. The surgical team, however, needs to be well-versed in the nuances of hip arthroscopy to ensure that the procedure is safe and effective.

ANATOMY

The hip is a ball and socket joint (Figure 1). The ball is the femoral head, which forms three-fourths of a sphere. The socket is the acetabulum, which is not a true hemisphere, but rather forms a horseshoe-shaped joint surface with a depression in the middle called the fossa. The transverse acetabular ligament connects the bony portions to complete the rim of the socket. The ligamentum teres arises from the confluence of the acetabular fossa, and the transverse ligament then inserts into a small depression in the femoral head. This structure provides the head with blood flow early in development, but it is not essential for blood flow in adults. The ligamentum teres does appear to provide some stability for the hip, especially in the flexed/abducted/externally rotated position or with hyperabduction. The anterior rim of the acetabulum has a small depression called the psoas notch; the iliopsoas muscle tendon is located extracapsularly in this area. The iliopsoas attaches to the lesser trochanter of the femur and functions as the primary flexor of the hip. A series of ligaments connects the acetabulum to the femoral neck; collectively, this structure is called the hip capsule. (2)

[FIGURE 1 OMITTED]

The labrum is a fibrocartilaginous structure located around the bony acetabular rim, blending with the capsule. It increases the surface area of the socket, thereby increasing hip stability and decreasing stress on the acetabular articular cartilage. Like the meniscus of the knee, there is blood flow only at the peripheral capsular attachment with poor healing potential in the avascular portion. (2)

If the pelvis were viewed from the front with a flat object lying on the acetabular rim, the relationship of the pelvis to the plane of this object would be called the acetabular version. The term anteversion means the plane faces toward the person examining the object; retroversion means the plane faces away. A normal acetabulum is 20-degrees to 30-degrees anteverted; however, wide variation exists. The term acetabular dysplasia means that the acetabulum does not develop into a normal deep socket; the socket is shallower. (2)

Surgical team members must be knowledgeable about the relevant nerves around the hip to prevent nerve injury during surgery and to assess for nerve deficits afterward. The pudendal nerve arises from sacral nerve roots at S2 to S4, exits the pelvis, and then branches to provide sensation to the labia and clitoris in women and the perineal region and penis in men. The genitofemoral nerve arises from lumbar nerve roots at L1/L2, and its genital branch travels through the inguinal canal to supply sensation to the proximal medial thigh and, in men, the scrotum. The obturator nerve arises from the lumbar nerve roots at L2 to L4 and enters the thigh. Its anterior branch supplies sensation to the hip joint and the mid to proximal medial thigh. (2)

The sciatic nerve is the largest nerve in the body. It arises from the lumbosacral plexus and then enters the thigh through the greater sciatic foramen. The sciatic nerve lies under the piriformis muscle, sometimes traversing through that muscle. The sciatic nerve is posteromedial to the hip joint, and internal rotation of the hip increases the distance from the nerve to the joint capsule. (2)

The femoral nerve arises from lumbar nerve roots at L2 to L4, passes into the thigh below the inguinal ligament 1.25 cm lateral to the femoral artery, then extends 2.5 cm below the inguinal ligament before dividing into many branches. Its position can be ascertained during surgery by palpating the femoral artery just below the inguinal ligament. Finally, the lateral femoral cutaneous nerve also arises from the lumbar plexus and passes into the thigh below the inguinal ligament, but does so just medial to the anterior-superior iliac spine of the pelvis. This nerve passes into the subcutaneous tissues several centimeters distal to the anterior-superior iliac spine, and its many branches supply a broad area of sensation along the anterolateral thigh towards the knee. (2)

PATHOPHYSIOLOGY

Table 1 summarizes the most common hip problems that currently can be treated arthroscopically. Many patients have more than one condition. For example, labral tears can be isolated lesions, but labral tears in conjunction with other conditions are much more common. Specifically, there is a higher incidence of labral tears with

* acetabular dysplasia, including coxa valga;

* acetabular retroversion;

* chronically inverted labrum;

* degenerative joint disease;

* hip impingement; and

* hip instability.

Degenerative joint disease usually occurs diffusely over the articular surfaces of a joint, and arthroscopic debridement of generalized wear typically is not of much value. Focal degenerative change is much less common but often does respond to debridement and microfracture, which are described in more detail later.

Femoroacetabular (ie, hip) impingement is related to abnormal morphology at the anterolateral head/neck junction of the femur. Normally, there is a certain amount of offset between the head and neck, but in some patients a so-called "pistol-grip" shape exists that lacks this normal offset (Figure 2). The cause is not clear, but it may relate to either a mild, subclinical slipped capital femoral epiphysis or to a developmental abnormality of the lateral femoral physis. (3) The prominent femoral neck in this region impinges on the acetabulum in flexion and adduction, which can then cause tears of the labrum or damage to the acetabular articular cartilage.

[FIGURE 2 OMITTED]

Chondral or osteochondral loose bodies can result from degenerative cartilage fragmentation, trauma to the joint surface, or synovial osteochondromatosis. Removal of loose bodies usually offers good pain relief for the patient and is one of the more satisfying procedures for surgeons to perform. (4)

Hip trauma generally is caused by either a direct blow to the upper thigh with impaction of the joint surfaces or a force on the extremity resulting in subluxation or dislocation of the hip. Penetrating trauma to the hip (eg, a bullet wound) is much less common. Subluxation or dislocation can occur with trauma, in the setting of total hip replacement, or sometimes secondary to repetitive stress, such as can occur in a ballet dancer or gymnast. Pathologic findings with instability can include capsulolabral avulsion, labral tears, capsular laxity, or partial or complete tears of the ligamentum teres. When a fracture of the acetabular rim occurs in conjunction with a hip dislocation, the incidence of free cartilage fragments in the joint is so high that many surgeons recommend routine hip arthroscopy in these patients to remove any fragments. (4)

Osteonecrosis of the femoral head is characterized by loss of blood flow to the subchondral bone. Alcohol abuse and oral corticosteroid use are the most common etiologies, although many cases are idiopathic. Treatment often includes revascularization procedures for the femur, but the role of hip arthroscopy in these patients is controversial. Although some surgeons feel there is no benefit, others feel arthroscopy helps to stage the disease and allows removal of any loose osteochondral fragments that might accelerate degenerative changes if left in the joint. (5)

The most common athletic injuries are labral tears, chondral injury, and ruptured ligamentum teres. Sports most at risk include ballet dancing, figure skating, golf, football, gymnastics, and hockey. (4)

DIAGNOSTIC TESTING AND SURGICAL INDICATIONS

Patients with hip pathology usually describe pain deep in the hip area, which sometimes radiates into the groin or anteromedial thigh and much less often radiates posterior towards the buttocks. Sometimes the patient feels a clicking, popping, or catching sensation, but often the only symptom is pain that increases with activity. Walking on a level surface and straight flexion may be well-tolerated, but impact activity (eg, walking on stairs or inclines, pivoting) usually increases pain. Prolonged sitting, rising from a chair, putting on socks and shoes, and toenail care may cause soreness. Female patients may complain of dyspareunia.

Physical examination of abnormal gait, tenderness, hip range of motion, muscle flexibility, and baseline neurovascular status should be performed. The provocative test for impingement or labral tears is 90-degree flexion, maximum adduction, and mild internal rotation, which brings the neck of the femur up against the superolateral labrum. The provocative test for anterior instability is 90-degree flexion, full abduction, then pushing forward on the back of the proximal thigh. Finally, the provocative test for snapping iliopsoas tendon is to bring the hip back and forth between flexion and external rotation and extension and internal rotation.

Anteroposterior and frog-leg lateral radiographs of the hip usually are normal; however, the following entities may be seen:

* acetabular dysplasia,

* coxa valga,

* early degenerative changes,

* femoral neck impingement,

* hip joint incongruity,

* osteonecrosis of the femoral head, and

* retroverted acetabulum.

Some surgeons report better visualization of impingement with a crosstable lateral versus a frog-leg lateral radiograph. (6)

Typically, magnetic resonance imaging (MRI) also is performed. This test is highly sensitive for intraosseous pathology (eg, osteonecrosis, regional osteoporosis, intraosseous tumors), and also extraarticular tumors. The presence of a paralabral ganglion cyst invariably is associated with an adjacent torn labrum, although the labral tear often is not visible on the MRI. Joint effusion may be present, which implies significant intraarticular pathology of some type. In general, MRI accurately reveals the pathology in less than one-third of patients with hip pain who do not have a diagnosis based on plain radiographs. (7)

To improve the accuracy of MRI, some surgeons order MRI arthrograms. During this test, iodinated contrast and gadolinium is injected into the joint first, then MRI scans are performed. This procedure significantly improves the sensitivity and diagnostic accuracy of labral tears compared to regular MRIs. Other than for labral tears, overall accuracy of MRI and MRI arthrograms is about the same. Both MRI and MRI arthrograms have poor sensitivity in detecting articular cartilage injury, but when it is detected, specificity is 100%. (7)

Lidocaine can be injected into the joint to determine whether the source of the patient's symptoms are intraarticular or extraarticular. This is done as an office procedure under local anesthetic without the need for imaging. Intraarticular pathology is confirmed if the local anesthetic relieves the patient's symptoms. (7)

Indications for hip arthroscopy include clinical suspicion of a problem that can be corrected arthroscopically based on history and corroborating physical examination, failure to respond to conservative treatment, and functional impairment. Physicians at Hunterdon Medical Center (HMC), Flemington, NJ, routinely order MRIs, but not MRI arthrograms when evaluating these patients. A regular MRI is invaluable at helping diagnose certain conditions and, more importantly, to rule out others. The physicians at HMC feel that the increased accuracy of diagnosing labral tears with MRI arthrogram is not worth the added expense and invasiveness. A patient with a clinically suspected labral tear but a negative MRI arthrogram who meets the other criteria for arthroscopy probably should have the procedure. A positive or negative MRI arthrogram will not affect this decision.

PREOPERATIVE ASSESSMENT

Based on the patient's past medical history, the surgeon decides whether to require medical clearance from the patient's primary care of internal medicine physician. The surgeon reviews the patient's current medications and instructs the patient not to take aspirin or aspirin-containing products for two weeks before surgery to decrease bleeding risks. Similarly, the surgeon instructs the patient not to take nonsteroidal anti-inflammatory drugs (NSAIDs) before surgery based on the half life of the medication (eg, five days for naproxen). Cox-2 inhibitors do not affect bleeding parameters and can be continued until surgery. The surgeon instructs the patient not to take certain over-the-counter supplements (eg, glucosamine sulfate, vitamin E, some herbal remedies) a week before surgery because of their effect on bleeding. The surgeon instructs the patient to take cardiac medications, except diuretics, with a sip of water the morning of surgery.

The office nurse provides the patient with crutches and teaches the patient the three-point crutch gait with weight bearing as tolerated. The nurse also gives the patient a handout that outlines exactly what to expect from the time he or she enters the same day surgery (SDS) center until the first postoperative visit (Table 2). Anecdotally, patients have reported that the handout is extremely useful and reassuring, and there has been a substantial decrease in the number of calls to the office since the handout was developed.

AMBULATORY TESTING CENTER ASSESSMENT. The office nurse instructs the patient to make an appointment at the ambulatory testing center at least seven days, but not more than 30 days, before the procedure. An ambulatory testing center nurse conducts a detailed assessment of the patient's circulatory, respiratory, neurological, genitourinary, and gastrointestinal systems. The assessment allows appropriate plans specific for each patient's needs to be instituted (eg, medical clearance, preparing the OR for latex allergy). It also gives the patient and his or her family an opportunity to discuss any concerns or questions about the surgery and their stay in the SDS center.

The nurse informs the patient about preoperative routines, emphasizes remaining NPO the night before surgery, and explains the sequence of events that will occur on the day of surgery. The nurse also determines appropriate preoperative testing. A complete blood count is performed on all patients. Other testing is based on age or health status guidelines; for example, all patients older than 40 years of age receive an electrocardiogram. The nurse completes the assessment form, which includes

* admitting diagnosis;

* capped, loose, or chipped teeth;

* current medications;

* dentures or dental implants;

* height and weight;

* history of immunizations (eg, tetanus, hepatitis, influenza, pneumonia);

* implanted devices (eg, pacemaker, metal hardware);

* language of communication barriers;

* medication, food, or latex allergies;

* past medical history;

* prior hospitalizations;

* prior surgery;

* special dietary requirements;

* tobacco, drug, or alcohol use; and

* vital signs.

ANESTHESIA REVIEW. The anesthesia care provider reviews the ambulatory testing center assessment form and preoperative test results as soon as they are available. The anesthesia care provider determines whether the patient requires further medical clearance or a formal anesthesia consult before surgery. The anesthesia care provider gives the patient an anesthesia teaching form that includes preoperative and postoperative instructions and information.

DAY OF SURGERY

The patient arrives at the hospital at least one hour before the scheduled surgery time and reports to the admissions area. An admissions clerk checks in the patient and secures an identification bracelet to the patient's wrist.

SDS CENTER. The patient proceeds to the SDS center where a nurse greets the patient and escorts him or her to a room. The SDS nurse identifies the patient verbally and with the patient's identification bracelet. The nurse also verifies the patient's medical record number on the chart and the consent. The patient changes into a hospital gown, and the SDS nurse makes sure that all jewelry, dentures, contact lenses, and hearing aides are removed. The nurse gives the patient's belongings to a family member for safekeeping or locks them in an SDS locker. The nurse initiates a patient care plan and surgical checklist. The nurse measures the patient's vital signs; administers any preoperative medications ordered; and reviews the patient's medical chart to ensure that consents, test results, and a history and physical examination are all present. The SDS nurse also assesses the patient for any changes that have occurred in his or her health status since the ambulatory testing center assessment was performed. Family members are allowed to remain with the patient until the OR calls for the patient to be transported to the holding area.

PREOPERATIVE HOLDING AREA. A transportation aide transports the patient via stretcher from the SDS area to the preoperative holding area. A preoperative holding area nurse greets the patient. He or she identifies the patient verbally using two patient-specific identifiers from the patient's identification bracelet. (8) The patient's name and medical record number can be compared to the chart and consents. The nurse notes any language or hearing barriers and appropriate interventions needed, such as a translator. The nurse reviews and completes the surgical checklist, which was initiated in the SDS admission area, and reviews the patient's medical chart in order to begin the perioperative nursing assessment record.

The nurse reads the patient's medical history and physical examination report and reviews test results. He or she communicates any discrepancies or concerns to the appropriate team member. The nurse and anesthesia care provider each interview the patient for pertinent information that may affect the plan of care, such as

* current pain level using a zero to 10 pain scale,

* existing medical conditions,

* medication or latex allergies,

* medications the patient is currently taking,

* NPO status,

* presence of metal hardware previously implanted,

* previous surgeries, and

* prior blood transfusions.

The nurse confirms that the surgical and anesthesia consents are present and complete and then asks the patient to verify the surgeon's name, procedure, and surgical site and side. The surgeon and patient cooperatively mark the surgical site with a permanent disposable marker.

The nurse places an IV line and ensures that the patient is kept warm and comfortable until the OR is ready. The holding area nurse is available to provide emotional support and answer the patient's questions or address concerns regarding the procedure.

INTRAOPERATIVE PHASE

The circulating nurse and scrub person prepare the OR, obtaining all necessary instruments, supplies, medications, and equipment. Although some surgeons prefer to use either the standard supine or lateral positions, the surgeons at HMC prefer the modified supine technique of Phillippon (ie, oversized perineal post, hip in some flexion and internal rotation)) The surgeon and circulating nurse assemble a standard fracture table in the room using an oversized, well-padded perineal post (Figure 3). The large post keeps pressure off the patient's perineal area, thereby protecting the perineal nerves, and also imparts an appropriate lateral distraction vector to open the hip joint as the surgeon applies axial distraction to the extremity.

[FIGURE 3 OMITTED]

PERIOPERATIVE NURSING ASSESSMENT. After opening the sterile field, the circulating nurse goes to the preoperative holding area while the scrub person prepares the sterile tables. The nurse greets the patient and after reviewing the patient's chart, performs an assessment. The nurse then develops a specific nursing care plan for this patient undergoing a hip arthroscopic procedure (Table 3).

TIME OUT. The circulating nurse draws the shades over all windows to ensure patient privacy and then brings the patient to the room and introduces him or her to the other surgical team members (eg, surgeon, anesthesia care provider, scrub person, RN first assistant [RNFA]). The circulating nurse institutes a time out by asking the patient to tell the surgical team what procedure he or she is having and which is the surgical hip. Just before placing the surgical hip in traction, all members of the surgical team pause, then use the signed consent form and active verbal communication to confirm the following:

* correct patient identity,

* correct procedure to be performed,

* correct site and side,

* correctly signed informed consent form,

* correct patient position, and

* availability of any special equipment. (9) The circulating nurse then documents the verification process on the patient's OR record.

INDUCTION OF ANESTHESIA. The patient remains on the stretcher for induction of general anesthesia. The circulating nurse provides additional warm blankets and assists the anesthesia care provider with placing all monitoring devices (eg, blood pressure cuff, pulse oximeter, electrocardiogram) on the patient. The circulating nurse also assesses and documents the patient's neurovascular condition and tissue perfusion of both lower extremities to establish the patient's baseline status. The circulating nurse remains immediately available to provide assistance to the anesthesia care provider during intubation, after which the anesthesia care provider secures the airway and all IV lines. The circulating nurse then places special foam antirotation foot boots on the patient (Figure 4). The boots will be used when positioning the patient to minimize pressure on the feet and ankles while in traction and postoperatively to prevent hip rotation and stabilize the lower extremities when the patient sleeps during the first three weeks after surgery.

[FIGURE 4 OMITTED]

POSITIONING. The surgeon, anesthesia care provider, circulating nurse, and RNFA carefully transfer the patient to the fracture table. (10) The circulating nurse and RNFA help the surgeon position the patient's feet and foam boots in the table's foot-holding devices. The RNFA wraps an adhesive elastic bandage wrap around the foam boots and the foot holders in a figure-eight pattern, followed by three-inch silk or cloth tape in a similar figure-eight fashion. The feet now are secured to the fracture table, well-padded, and ready for the large amount of traction necessary to accomplish the procedure. The self-adherent wrap material allows the tape to be removed easily from the foam boots after the surgery, preserving the boots for later use by the patient.

The circulating nurse documents the preoperative assessment; position, type, and location of positioning and padding devices; names and titles of persons positioning the patient; and postoperative outcome evaluation on the OR record. (10) The circulating nurse applies a radiofrequency electrosurgical unit (ESU) dispersive pad to the patient's contralateral anterior thigh.

The surgeon places the patient's surgical hip in zero-degree abduction and the opposite side in 30-degrees. Too much abduction would allow the perineal post to press against the patient's perineal area. Instead, as traction is applied, the post contacts the upper medial thighs. The surgical hip also is placed in 15-degree flexion and 45-degree internal rotation to relax the anterosuperior joint capsule to allow easier access for the arthroscopic instruments.

The circulating nurse brings the patient's ipsilateral upper extremity across the patient's body and secures it in place with a wrist restraint tied to the opposite side rail of the table. The radiology technician positions the portable fluoroscopy unit perpendicular to the patient and opposite the surgeon. The radiology technician positions the image collector on top of the patient and close to the skin to minimize magnification. Posteroanterior images are taken during the initial portion of the procedure; lateral images are not needed. The circulating nurse places the fluoroscopy monitor inferior and the arthroscopy tower superior to the fluoroscopy unit. The circulating nurse positions the irrigation tower, suction canisters, and monopolar device as shown in Figure 5.

[FIGURE 5 OMITTED]

TRACTION. A substantial amount of traction is applied to the surgical extremity in order to distract the hip joint sufficiently to enable arthroscopy to proceed. Some surgeons have attached a scale to the fracture table to monitor the exact amount and have reported that up to 50 lbs of force is required. (11) The surgeons at HMC have determined that this is not necessary. Instead, traction is applied that enables the joint gap to open approximately 1 cm. The amount of traction necessary to reach this endpoint varies in different patients, but in general, it is quite a bit more than is customarily used during reduction of femoral shaft or intertrochanteric proximal femur fractures. A lesser amount of traction is used on the contralateral side to keep the patient centered on the perineal post.

MEDICATIONS ON THE STERILE FIELD. The scrub person marks all syringes and containers of medications, including the irrigation solution basin and asepto, with a medication label indicating name and strength of medication after visually and verbally verifying this with the circulating nurse. (12) The circulating nurse hangs premixed arthroscopy irrigant (ie, one 1-mL ampule of epinephrine 1:1,000 in each of four 3-L bags of lactated Ringer's solution [LR]).

The surgeon injects the hip joint with 0.5% bupivacaine with epinephrine. Bupivacaine provides postoperative analgesia and epinephrine decreases intraoperative bleeding. The surgeon also instills fluid into the joint to provide joint capsular distention and achieve the desired 1-cm joint opening.

Under fluoroscopic guidance, the surgeon inserts a six-inch, 17-gauge spinal needle into the lateral portal just above the greater trochanter, aiming at the superolateral aspect of the joint. The surgeon attaches a 20-mL syringe containing the bupivacaine to the spinal needle before insertion. The distraction creates a vacuum pressure in the joint, and as soon as the needle enters the joint, the bupivacaine flows spontaneously into the joint space, which opens the joint to approximately 1 cm. The surgeon decreases the traction temporarily until after skin preparation and draping.

SKIN PREPARATION. The circulating nurse and surgeon place a plastic drape with an adhesive edge to protect the perineal area. The circulating nurse then performs the surgical scrub preparation of the hip area. The RNFA paints an alcohol/iodine solution over the prepped area. If the patient is allergic to iodine, the RNFA uses 4% chlorhexidine gluconate solution diluted with water. After the solution is dry, the RNFA and scrub person place adhesive barrier drapes along the four sides of the surgical field:

* superiorly just above the anteriorsuperior iliac spine,

* inferiorly at mid-thigh,

* medially just lateral to the perineal post, and

* laterally just posterior to the greater trochanter.

The RNFA lays a clear, sticky isolation drape with an incorporated suction pouch over the surgical field, covering the entire patient. This special drape offers visual assessment of the perineal region and lower extremities during the procedure in case problems with the traction develop.

SURGICAL TECHNIQUE

The surgeon, RNFA, and scrub person stand on the surgical side. All monitors and equipment are positioned on the opposite side. The scrub person places a covered Mayo stand at the surgeon's right for the radiofrequency probes, and the scrub person keeps one covered Mayo stand on his of her left for all remaining instrumentation. The scrub person prepares all cords for monitors, surgical devices, and fluid and suction tubes ahead of time and gathers them in a sterile towel. The scrub person brings the towel with the cords to the sterile field in one motion and secures the group to the drapes with a nonpenetrating clip. The circulating nurse spikes the bags of LR irrigating solution first so that the irrigation tubing is primed and ready for the surgeon immediately. The circulating nurse connects the cords for the surgical devices and foot pedal to the arthroscopy tower and ensures that the foot pedals for the arthroscopy shaver and radiofrequency probe are in a comfortable position for the surgeon.

The surgeon uses a special hip arthroscopy cannula with cannulated obturators to establish the portals. He of she first creates the lateral portal in the soft spot, 1 cm proximal and 1 cm anterior to the anterolateral corner of the trochanter. With the fluoroscopy unit in position for a posteroanterior view, the surgeon inserts a six-inch, 17-gauge spinal needle, traveling just superior to the trochanter and aiming for the superior joint space. The surgeon verifies entry into the joint by removing the stylet and observing backflow of the previously injected bupivacaine. The surgeon places a flexible switching wire into the needle and uses fluoroscopic images to confirm advancement of this wire medially well into the joint. Leaving the wire in place, the surgeon removes the needle and uses a #15 blade to make an 8-mm to 10-mm transverse incision. He of she passes the 4.5-mm cannula and cannulated obturator over the wire, and removes the wire. The surgeon toggles the cannula back and forth to be sure the portal is well-established. He or she then attaches the bridge to this cannula and introduces the long, 70-degree arthroscope designed for the hip. An alternative is to use the arthroscopic switching stick to change to the standard knee cannula and 70-degree knee arthroscope. This alternative is preferred especially if the patient is thin.

The same sequence of instruments is used to create the anterior portal again using fluoroscopic guidance. Portal placement is medial to the lateral portal but 1.5 cm lateral to an imaginary line drawn inferior to the anterior-superior iliac spine, and portal direction is approximately parallel to the lateral portal. When the anterior portal is created, the surgeon switches the arthroscope between the two portals to allow diagnostic arthroscopy of the joint. The switching stick serves as a convenient probe; it is stout and unlikely to bend or break in the joint. Some surgeons use three portals, but the surgeons at HMC have not found this to be necessary.

TENDON RELEASE. The iliopsoas muscle and tendon are the primary flexors of the hip joint. The surgeon releases the tendon arthroscopically if the patient has a tight iliopsoas associated with either snapping hip syndrome or degenerative joint disease of the hip. With the arthroscope lateral and a 5-mm cannula anterior, the surgeon passes an arthroscopic knife into the cannula and releases the tendon at the level of the acetabulum. At this level, there are tendon and muscle fibers, but only tendon is released.

SYNOVECTOMY. For synovial diseases, such as pigmented villonodular synovitis, rheumatoid arthritis, and osteochondromatosis, it is desirable to remove as much of the synovium as possible. Although a complete synovectomy of the hip cannot be achieved arthroscopically, the majority of the synovium can be accessed and removed. The posteroinferior joint is the most difficult area to reach, so some surgeons make a third, posterolateral portal to facilitate working in this area. This portal, however, puts the sciatic nerve at greater risk, so the risks have to be weighed carefully against the benefits of this additional portal.

The surgeon accomplishes synovectomy effectively with a flexible radio-frequency probe. He or she can ablate all hypertrophic synovial tissue efficiently, which enhances visualization of the joint. The surgeon also can debride fibrotic tissue associated with ligamentum teres tears with these probes.

OSTEOCHONDRAL LOOSE BODY REMOVAL. The surgeon removes osteochondral loose bodies using a large-bore, 5.6-mm, anterior cannula. The curved shaver blades help the surgeon gain access to the inferior recess below the ligamentum teres and the posterior joint space where the loose bodies may reside and be difficult to reach. The flexible radiofrequency probes also help to get around the curved femoral head to hard-to-reach locations to ensure removal of all fragments.

ARTICULAR CARTILAGE DEBRIDEMENT. The surgeon performs articular cartilage debridement with the curved shaver blades. He or she mobilizes large, unstable flaps with the flexible "ligament chisel" radiofrequency probe. Full thickness cartilage lesions that are focal (ie, localized, not diffuse) with intact surrounding cartilage should undergo microfracture using the chondral picks. Most instrument sets have a variety of picks with different curves and angles, enabling the surgeon to reach most areas of the joint. The chondral picks do not fit through the cannulae; they are passed directly into the portal, which usually is well established and allows easy passage at this point in the procedure. Cartilage lesions that are not quite full thickness often require curettage down to subchondral bone before the surgeon performs microfracture. The surgeon also passes the straight and curved curettes directly into the portal.

LABRAL TEAR DEBRIDEMENT. The surgeon debrides labral tears with the shaver blades but uses the radiofrequency probes for ablating diseased, unstable tissue. Almost all labral tears are located in the anterosuperior quadrant, which is fortunate because this is the area of the acetabulum that is most accessible arthroscopically.

LABRAL REATTACHMENT. Instruments similar to those used in shoulder arthroscopy are used to perform labral reattachment. The surgeon places an 8.25-mm, clear, threaded disposable cannula anteriorly. He or she then freshens the acetabular rim to bare bone with the rasp and shaver. The surgeon predrills and implants a suture anchor. He or she uses a tissue hook to pass an absorbable, monofilament #1 suture through the capsulolabral tissue and then uses it to shuttle one limb of the suture from the suture anchor. Arthroscopic knot tying brings the labrum and capsule down to bone anatomically.

INSTABILITY REPAIR. The surgeon accomplishes instability repair by reattaching the capsule and labrum to the acetabulum as described above, as well as shrinking the capsule using monopolar radiofrequency probes. As a final step of the instability repair procedure, the surgeon closes the anterior portal using absorbable, monofilament #1 suture in a style similar to rotator cuff interval closure during arthroscopic repairs in the shoulder.

IMPINGEMENT. The surgeon corrects impingement secondary to abnormal head/ neck morphology without traction. (13) The circulating nurse adjusts the fracture table under the drapes to remove traction and place the hip in 45-degree flexion, neutral abduction, and 10-degrees internal rotation, which enables relaxation of the anterolateral hip capsule. The clear drape allows the surgeon to confirm proper hip positioning. With the arthroscope placed in the anterior position, the surgeon uses the shaver and the radiofrequency ablation device through the anterolateral portal to peel away the capsule from the neck. He or she then uses the shaver burr to reshape the head/neck junction to restore normal head/neck offset, which eliminates impingement. The radiology technician brings the fluoroscopy unit back into position so the surgeon can confirm adequate bony resection. Real-time fluoroscopic examination of the hip through range of motion is needed to demonstrate complete femoral neck contouring. (6)

CONCLUDING THE PROCEDURE

Typically, no drain is necessary unless the patient has an infection. If the patient has a diagnosed infection, the surgeon uses copious amounts of irrigation. Before cannula removal, he or she passes a medium closed-suction drain through a cannula. The drain will be left in the joint space. The surgeon then closes the portal incisions with monofilament, nonabsorbable suture or staples.

After the surgical procedure is completed, the surgeon and scrub person apply sterile dressings. Team members support both of the patient's legs as positioning devices are removed. At least four staff members work together to carefully transfer the patient from the fracture table onto the stretcher. The circulating nurse assesses postoperative neurovascular status of both the patient's lower extremities and compares this to the patient's baseline assessment. The circulating nurse assesses and documents the patient's skin integrity at all pressure points and under the ESU dispersive pad. After the anesthesia care provider extubates the patient, the circulating nurse telephones the postanesthesia care unit (PACU) to inform staff members of the patient's approximate arrival time.

ANTIROTATION FOOT BOOTS. The circulating nurse places the boots used during the procedure back on the patient's feet after the patient has been transferred to the stretcher. Self-sticking straps run between the boots to hold the lower extremities in neutral abduction and rotation. The boots are mainly for patient comfort, but they also are necessary to protect an instability repair.

POSTOPERATIVE CARE

The circulating nurse and anesthesia care provider transport the patient to the PACU. The assigned PACU nurse monitors the patient for respiratory and cardiac complications, inspects the dressings for excessive bleeding, and manages the patient's pain. He or she assesses the neurovascular status of both the patient's lower extremities and compares it to the baseline assessment documented by the circulating nurse. A PACU staff member transfers the patient back to the SDS room when the patient's postoperative pain is manageable, vital signs are stable, and Aldrete recovery score is a two in each of the categories (ie, activity, respirations, circulation, consciousness, color).

SDS CENTER. The SDS nurses continue to monitor the patient's vital signs and note the patient's peripheral vascular and sensory functions. The patient remains in the SDS area for at least an hour, although this can vary depending on a variety of factors, such as the patient's age, general health status, severity of hip injury/ disease, length of surgical procedure, and pain control. Discharge criteria includes having

* manageable postoperative pain,

* the ability to void,

* dry and intact dressings,

* no complaints of nausea or vomiting,

* a written discharge order from the surgeon, and

* a responsible adult to take the patient home.

The SDS nurse discontinues the patient's IV, explains the postoperative discharge instructions to the patient and his or her family members, and also provides a copy in written form. The nurse removes the antirotation foot boots to allow the patient to get out of bed but gives the patient instructions regarding how and why the boots should be used at bedtime.

REHABILITATION

The goal of rehabilitation is to return the patient to the highest functional status possible. Rehabilitation proceeds in a stepwise fashion over six to 12 months. Patients with a microfracture need touch-down weight bearing for three to six weeks (ie, three for smaller lesions, six for larger). A physical therapist instructs other patients to wean themselves from crutch use as tolerated.

All patients wear the antirotation boots at bedtime for approximately three weeks. The boots limit rotation and help patients sleep more comfortably through the night. A physical therapist also instructs patients with instability repairs not to rotate their hips throughout the day to allow proper capsular healing. Patients who have not had instability repairs are allowed movement of the hip as tolerated. In fact, they are encouraged to gently stretch the hip in all planes of movement (ie, flexion, internal rotation, external rotation, abduction) starting immediately after the surgery. Each movement is performed to the limit of pain, then held for about 30 seconds; the stretches are performed once each hour while awake during the first postoperative week, then two to three times per day subsequently. This program of early range of motion allows good healing of the joint capsule and minimizes postoperative hip stiffness.

Approximately six weeks after surgery, comfortable hip motion usually is regained, and strength training can begin. Low impact exercises, such as walking, swimming, and biking, are well-tolerated and can be performed up to five or six times per week. Optimally, strength training is performed three times per week and includes using a leg press machine and doing hamstring curls and squats and lunges. The therapist instructs the patient to be careful during isolated hip movements with resistance on the ankle because these movements can generate high hip joint loads. Strength training should be varied for maximal gains, alternating between low resistance/high repetition and high resistance/low repetition workouts.

As strength returns, usually after approximately three months, sport-specific functional activities can begin. For example, a soccer player may return to the field and practice ball-handling skills and passing drills. As coordination, endurance, muscle quickness, and skills are regained, the patient prepares for full return to competitive activities. This entire process usually takes between six and 12 months but may vary among patients.

RESULTS

Debridement of isolated labral tears successfully relieves symptoms in 90% of patients. When the labral tear is associated with other pathology, the success rate is lower. Labral repairs are much less common than debridements, but early results have been favorable. (4)

When the patient gives a history of either an isolated traumatic event or an acute onset of symptoms, as opposed to an insidious onset of symptoms, the results of arthroscopy generally are better. The former situation often means a loose body, chondral flap, torn labrum, or torn ligamentum teres that can be corrected arthroscopically. The latter often means degenerative changes that are diffuse in the joint and cannot be effectively corrected. Within the realm of degenerative joint disease, the size of the lesion is critical. Debridement and microfracture of small, well-contained lesions is much more successful than for larger, more diffuse lesions.

Many patients present to the surgeon's office with early degenerative changes in the hip joint. The challenge for the surgeon is to select the patients most likely to benefit from arthroscopy and treat other patients conservatively. A small focal cartilage lesion identified on MRI or an acute onset of symptoms with or without trauma are the best clues that hip arthroscopy can benefit a particular patient.

COMPLICATIONS

The overall complication rate in a large series of arthroscopic hip surgeries was reported to be 5.5%, with 5% of those transient and 0.5% permanent. (14) Most serious complications result from either the traction or the irrigant fluid needed to perform the procedure. The nerves around the hip joint can be injured by

* direct pressure,

* stretching during traction, or

* direct injury from a scalpel or other instrument.

The pudendal nerve is most susceptible to pressure neuropraxia during traction. The sciatic, femoral, and lateral femoral cutaneous nerves also can be injured by stretching or direct trauma. Injury by stretching is more common for the sciatic and femoral nerves. Most neuropraxias from stretching or pressure are transient, but permanent neuropraxia of the pudendal nerve has been reported. (14) Direct laceration, which can result in a painful neuroma, is more common for the lateral femoral cutaneous nerve. (14)

During hip arthroscopy, the irrigating solution can leak into the extraarticular tissues, travel along the iliopsoas muscle, and collect in the abdomen. Increased abdominal pressure from fluid extravasation has caused one reported death during hip arthroscopy. (14) Risk factors for abdominal fluid distention include prolonged surgical time and extraarticular surgery (eg, releasing the iliopsoas, removing an impinging osteophyte).

Rare complications reported include iatrogenic trauma to the joint from the instruments, instrument breakage with retained instrument in the joint, scrotal skin necrosis, heterotropic ossification, and osteonecrosis of the femoral head. (14) Infection has not been reported, and based on very low infection rates for arthroscopic surgery in general (ie, less than 0.1%), it should be an infrequent occurrence. (14)

Risk of complications increases with prolonged surgical time and, in particular, prolonged traction time. As such, it is imperative for the surgical team to take every measure to be organized, have all equipment available, and perform hip arthroscopic procedures as expeditiously as possible.

CASE STUDY

Ms H is a 42-year-old woman who presented with two years of increasing hip pain. During the past 10 years, Ms H suffered several injuries that involved the hip. She experienced pain when she was on her feet for more than a few hours and was notable to walk for exercise. Clinical evaluation was consistent with intraarticular pathology, but imaging studies were negative. The patient was unresponsive to nonsurgical treatment.

Ms H underwent hip arthroscopy. Her body habitus was larger than average (ie, body mass index = 32), so greater than average traction was needed during the procedure. The surgeon noted an articular cartilage defect with associated labral tear in the anterior-superior quadrant. The surgeon performed cartilage debridement and microfracture. As a result of good coordination of the OR team, the entire procedure was accomplished uneventfully with only 75 minutes total traction time.

After surgery, Ms H did touch-down weight bearing on crutches for six weeks because of the need for microfracture. She then received physical therapy. She tolerated this well, in part due to extensive preoperative patient education by the surgeon's office staff members, the RNFA, and the perioperative nurses at the ambulatory testing center and the SDS center. Six months after surgery she was able to stand most of the day without pain and was able to take five-mile walks without difficulty.

TRENDS

The number of arthroscopic surgical procedures of the hip has increased tremendously during the last five years, becoming a much more routine procedure with well-defined indications and expectations for success. It is a good example of the overall trend in surgery towards less invasive procedures. A specific instance of the decreased invasiveness is the treatment of impingement. Traditional surgery to remove the abnormal bone at the head/neck junction involved

* long skin and fascial incisions,

* partial mobilization of the gluteus medius muscle,

* a large anterior capsular incision, and

* extensive retraction of neurovascular structures.

In many patients, this procedure can be per-formed arthroscopically through two small incisions. Patients with impingement are at in-creased risk of developing osteoarthrosis (OA) in the future. Early in the disease process, however, many patients do not have debilitating symptoms and do not want an extensive procedure, even with the promise of OA prevention. With arthroscopy offering this procedure less invasively, more patients may choose to intervene when symptoms are not as severe, and by doing so, perhaps prevent OA.

The advantages of arthroscopy over open surgery go beyond being able to treat pathology less invasively; arthroscopy also has allowed conditions to be diagnosed that previously were unrecognized. For example, a small area of chondral injury may not appear on any imaging study but can be seen and treated effectively during arthroscopy.

Clinical suspicion based on history and physical examination often is the main indication that arthroscopic surgery should be considered for a patient for whom conservative treatment has failed. Imaging studies, such as radiographs and MRIs often are negative, although they are helpful in that they rule out other pathology that would not be amenable to arthroscopic surgery. Although MRI arthrograms are more sensitive for certain pathology, they are not routinely warranted because they usually do not affect the decision to proceed with surgery.

Hip pathology amenable to arthroscopy can develop secondary to a single traumatic event, from repetitive trauma in sports, or as a result of everyday stresses on the joint. When a patient gives a specific history of trauma without previous hip problems, it often means that a well-defined, focal lesion in the hip is causing the patient's symptoms. Arthroscopy has a better chance of correcting this type of problem, as opposed to a condition with a more insidious onset of symptoms.

Serious, permanent complications from this procedure are rare but can be minimized by limiting the amount of time that the patient is in traction. The scrub person and circulating nurse must be well organized, have all needed equipment readily available, and work closely with the surgeon and RNFA to ensure that the procedure moves along efficiently. As with any technically demanding procedure, strict attention to detail with surgical indications, surgical technique, and OR efficiency will enhance the success rate and diminish the chance of problems.

Examination

Arthroscopic hip surgery

1. The labrum

a. is another name for hip ligaments.

b. decreases stress on the articular cartilage by increasing the surface area of the acetabulum.

c. has good blood flow throughout.

d. cannot be repaired after it has been torn from its bony attachment.

2. The primary nerve that supplies sensation to the anterolateral thigh is the

a. pudendal.

b. genitofemoral.

c. femoral.

d. lateral femoral cutaneous.

3. A higher incidence of labral tears is associated with

1. acetabular dysplasia.

2. degenerative joint disease of the hip.

3. hip instability.

4. hip impingement.

a. 1 and 3

b. 2 and 4

c. 1, 2, and 3

d. 1, 2, 3, and 4

4. When performing physical examinations, 90-degree flexion, maximum adduction, and mild internal rotation is the provocative test for

a. anterior instabitity.

b. impingement or labral tears.

c. osteonecrosis of the femoral head.

d. snapping iliopsoas tendon.

5. Before hip arthroscopy, the patient is instructed to stop taking

1. aspirin and aspirin-containing products.

2. cardiac medications.

3. cox-2 inhibitors.

4. diuretics.

5. nonsteroidal anti-inflammatory drugs except cox-2 inhibitors.

6. supplements such as glucosamine sulfate, vitamin E, and some herbal remedies.

a. 1, 3, and 5

b. 2, 4, and 6

c. 1, 4, 5, and 6

d. 1, 2, 3, 4, 5, and 6

6. The oversized perineal post used during hip arthroscopy

1. keeps pressure off the perineal area.

2. protects the perineal nerves.

3. imparts distraction vector to open the hip joint when axial distraction is applied to the extremity.

4. can increase the risk of postoperative blood clots.

a. 1 and 3

b. 2 and 4

c. 1, 2, and 3

d. 1, 2, 3, and 4

7. The circulating nurse places special foam antirotation foot boots on the patient to

1. minimize pressure on the feet and ankles while in traction.

2. prevent hip rotation post-peratively.

3. stabilize the lower extremities in an externally rotated position postoperatively.

4. stabilize the lower extremities when the patient sleeps during the first three weeks after surgery.

a. 1 and 3

b. 2 and 4

c. 1, 2, and 4

d. 1, 2, 3, and 4

8. Local anesthetic with epinephrine is injected into the hip before surgery to

1. decrease intraoperative bleeding.

2. distend the joint more easily before the cannula is placed.

3. provide postoperative analgesia.

4. make sure it is possible to place

a needle in the hip.

a. 1 and 3

b. 2 and 4

c. 1, 2, and 3

d. 1, 2, 3, and 4

9. A complete synovectomy of the hip cannot be achieved arthroscopically.

a. true

b. false

10. Risks of complications increase during hip arthroscopy

a. because an oversized perineal post is used.

b. when epinephrine is not placed in the irrigant bags.

c. with prolonged surgery time and traction time.

d. when curved arthroscopy blades are not used.

AORN Home Study

This program meets criteria for CNOR and CRIVFA recertification, as well as other continuing education requirements.

A minimum score of 70% an the multiple-choice examination is necessary to earn 5.5 contact hours for this independent study.

Purpose/Goal: To educate perioperative nurses about arthroscopic hip surgery.

AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. AORN recognizes these activities as continuing education for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.

NOTES

(1.) R W Jackson, "History of arthroscopy," in Operative Arthroscopy (Philadelphia: Lippincott, Williams and Wilkins, 2003) 3-7.

(2.) R J Last, Anatomy: Regional and Applied," (New York: Churchill Livingston, 1978) 190-196.

(3.) R Ganz et al, "Femoroacetabular impingement: A cause for osteoarthritis of the hip," Clinical Orthopaedics and Related Research 417 (June 2003) 112-120.

(4.) B T Kelly, R J Williams III, M J Phillippon, "Hip arthroscopy: Current indications, treatment options, and management issues," American Journal of Sports Medicine 31 (November/December 2003) 1020-1037.

(5.) M Phillipon, director of hip arthroscopy, Stedman-Hawkins Clinic, personal communication with the author, Chicago, 20 Aug 2005.

(6.) A A Bare, C A Guanche, "Hip impingement: The role of arthroscopy," Orthopedics 28 (March 2005) 266-273.

(7.) J W T Byrd, K S Jones, "Diagnostic accuracy of clinical assessment, magnetic resonance imaging, magnetic resonance arthrography, and intraarticular injection in hip arthroscopy patients, American Journal of Sports Medicine 32 (October/November 2004) 1668-1674.

(8.) K Catalano, "Update on the National Patient Safety Goals--Changes for 2005," AORN Journal 81 (February 2005) 337.

(9.) "Surgical site verification/time out," in Hunterdon Medical Center Administrative Policy and Procedure Manual (April 2004) 2.

(10.) "Recommended practices for positioning the patient in the perioperative practice setting," in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2005) 427-432.

(11.) T Sampson, associate clinical professor at the University of California, San Francisco, personal communication with the author, Chicago, 19 Aug 2005.

(12.) "AORN guidance statement: Safe medication practices in perioperative practice settings, in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2005) 196-198.

(13.) M Dienst et al, "Hip arthroscopy without traction: In vivo anatomy of the peripheral hip joint cavity," Arthroscopy 17 (November/December 2001) 924-931.

(14.) T G Sampson, "Complications of hip arthroscopy," Clinical Sports Medicine 20 (October 2001) 831-835.

Rochelle A. Shugars, RN, BSN, CNOR, is a staff nurse at Hunterdon Medical Center, Flemington, NJ.

Robert C. More, MD, is an orthopedic surgeon and the director of the hip arthroscopy program at Hunterdon Medical Center, Flemington, NJ.

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