Patient Positioning

In hip arthroscopy the patient must be positioned so the hip can be distracted safely for central-compartment work, moved freely for peripheral-compartment work, and imaged reliably with fluoroscopy. Poor positioning makes portal placement, visualization, and instrument passage harder and increases the risk of traction-related nerve injury or iatrogenic injury to the labrum and cartilage.

The two accepted body positions are supine and lateral decubitus. Either can be combined with a perineal post or a postless distraction system. Both positions can be safely used in hip arthroscopy.

Principles common to every setup

The central compartment requires distraction. A practical target is approximately 8-10 mm of joint space widening before introducing instruments across the capsule. The peripheral compartment usually does not require traction.

Use the minimum traction force and traction time needed. Extended traction time can increase the risk of perineal and pudendal pressure-related injuries. Traction can be released as soon as central-compartment work is complete.

Confirm that the leg can be taken through the range of motion needed for the planned procedure before prepping.

The main setups are summarized below:

1. Supine positioning with a perineal post

This is the classic hip arthroscopy setup and remains widely used. The patient lies supine on a fracture table or dedicated hip-arthroscopy traction table. A large, well-padded perineal post provides countertraction while longitudinal traction is applied through the operative leg.

Sequence:

Place the patient supine with the pelvis square and the operative hip positioned so fluoroscopy can obtain reproducible AP views.

Pad the perineal post generously.

Secure both feet in padded traction boots. A small amount of countertraction can be applied to the non-operative limb to stabilize the pelvis.

For central-compartment distraction, the operative leg is commonly abducted first, longitudinal traction is applied, and the hip is then brought toward neutral or slight adduction across the post. Slight internal rotation helps bring the femoral neck into a more horizontal working orientation.

Important considerations:

The main disadvantage is pressure from the post. Pudendal neurapraxia, genital soft-tissue injury, and groin pain are recognized complications. The risk is reduced by a broad, well-padded, lateralized post and by minimizing traction force and duration.

The post can restrict hip motion once traction is released, particularly during peripheral-compartment work.

2. Supine postless positioning

Instead of pushing the patient against a perineal post, countertraction is generated by friction between the patient and a high-friction pad, often assisted by Trendelenburg positioning.

Important considerations:

The patient must have direct contact with the traction/friction pad; sheets or gowns between the skin and pad reduce friction and increase the risk of sliding.

Trendelenburg is usually modest and system dependent. Published techniques range from approximately 3 degrees to 20 degrees. Use only the amount necessary for secure countertraction.

Some systems allow a wider arc of flexion, abduction/adduction, and rotation after traction is released.

3. Lateral decubitus positioning with a perineal post

There is good data to support both supine and lateral positioning in hip arthroscopy and the decision to use one over the other often has to do with surgeon preference and operating room equipment.

Sequence:

The operative hip is placed uppermost.

The torso and pelvis are securely supported.

The operative leg is placed in traction, and a broad padded post provides countertraction.

Dedicated lateral traction systems simplify the setup, although traditional traction tables can be adapted.

Important considerations:

In a lateral position the greater trochanter becomes more prominent, which can make portal placement and instrument maneuvering easier in patients with a large soft-tissue envelope.

The position can improve access to posterior and inferior portions of the hip.

4. Lateral decubitus postless positioning

A postless lateral technique is also possible, although it is less widely used than supine postless arthroscopy. Dedicated distraction systems exist for this position.