Author Archives: Tigran Garabekyan, M.D.

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Hip arthroscopy has become a popular procedure over the last few years, registering a growth of over 250 percent from 2007 to 2011.

The hip is a highly constrained joint, having thick soft tissue envelope, it becomes necessary to create distraction of the joint in order to visualize the central compartment for surgery.

To access the hip joint during arthroscopy, a traction table is typically used with a perineal post to allow for counter-traction and achieve hip distraction. A traction force of 89 to 127 lb may be required to adequately distract the joint in anesthetized patients.

The perineal post causes high force vectors against the patient’s groin, leading to two different traction complications (associated directly with the perineal post). These include:

• Pressure-related soft tissue damage to the perineum
• Compression-related neurapraxias and permanent injury to the pudendal and other surrounding nerves

Assessing the Safety of a Postless technique

A scientific study was performed to prospectively assess the safety of a postless technique for hip distraction during hip arthroscopy. During the course of the study, a total of 1000 hip arthroscopies were performed, and no groin related soft tissue or nerve complications took place.

The study also found no complications (friction burns, skin contusions) as a result of the necessary friction created between the patient’s body and the operating table.

630 subjects were evaluated for a follow-up at two years after surgery, and another 270 were evaluated after at least one year post-operatively as part of the study.

Challenges of Using a Perineal Post

Most patients undergoing hip arthroscopy are young, athletic, and sexually active. Furthermore, hip arthroscopy is an elective procedure. Therefore, perineal nerve- and soft tissue-related complications should be considered unacceptable in this population undergoing this procedure.

With the use of a perineal post, the largest barrier for new hip arthroscopists as well as the most significant concern for experienced surgeons is not the procedure itself but rather the potential complications that may arise based on patient positioning.

Benefits of a Postless Technique

In addition to eliminating nerve and soft tissue related complications, the use of the postless technique for hip arthroscopy offers several other benefits.

In particular, for new hip surgeons who need more time to enter the joint and work in the central compartment, the post-free technique minimizes concerns of complications that may become evident postoperatively. Therefore, this technique allows surgeons to focus on the procedure itself rather than the complications that may occur with the use of a traction post.

Another benefit, which allows the surgeon to enter the joint safely and reproducibly, is the ability to use anteroposterior and true lateral fluoroscopy views when positioning the first needle while establishing the first portal.

An additional advantage possibly affects the anesthetic and surgical fronts, and this is improved blood return to the heart and brain perfusion attributed to the inclined position, which may make it easier to control and maintain a lower blood pressure, thereby enabling the use of lower pump pressure.

Finally, the ability to perform bilateral hip arthroscopy under the same anesthetic without accumulated groin-related stress and increased groin-related complications enables faster recovery for patients with bilateral disease.

Source: NIH

Intraoperative photograph demonstrating (A) supine and (B) lateral positioning for hip distraction utilizing a 10-inch perineal post. Both techniques achieve hip distraction by applying countertraction to the perineum.

(A) Intraoperative photograph demonstrating technique for obtaining an anteroposterior fluoroscopic view by arcing the fluoroscope to maintain an orthogonal beam trajectory to the patient in Trendelenburg. (B) A cross-table lateral hip fluoroscopic view can be obtained by positioning the fluoroscope between the patient’s legs, with good visualization attributed to the absence of the perineal post. The fluoroscopic image demonstrates central placement of the 17-gauge, 6-inch needle utilized to percutaneously establish the midtrochanteric portal. (C, D) Intraoperative photographs of the postless technique showing no pressure on the perineum during application of traction

(A) Anteroposterior fluoroscopic image of a left hip before the application of traction with a 17-gauge, 6-inch needle placed intracapsularly at the level of the femoral head-neck junction to perform an air arthrogram. Air can be seen outlining the labrum laterally and demarcating the level of the zona orbicularis. (B) Gentle application of traction is performed after venting the joint with an air arthrogram, achieving the desired degree of distraction within the hip joint (arrows), as demonstrated in this posttraction anteroposterior fluoroscopic view of the left hip. (C) Arthroscopic view of a right hip with a 30 arthroscope placed in the midtrochanteric portal (the senior author’s version of the anterolateral portal) visualizing the femoral head (FH) to the right, the acetabulum and labrum (L) to the left, and adequate space for instrumentation in between (arrows). (D) Arthroscopic view of a left hip with a 70 arthroscope inserted through the midanterior portal deep into the central compartment to visualize the cotyloid fossa, ligamentum teres (LT), and inferomedial femoral head. (E) Arthroscopic view of a right hip with a 30 arthroscope inserted through the midtrochanteric portal visualizing the anterosuperior labrum, anterior capsule (C), and femoral head, or the so-called anterior triangle, before establishing the midanterior portal under direct visualization. (F) Arthroscopic view of a left hip with the 30 arthroscope placed through the midtrochanteric portal after a labral reconstruction showing the acetabular rim and wellpositioned reconstructed labral (RL) graft. All intraoperative visualization was achievable with postless distraction.

Intraoperative photographs showing (A) the use of a smartphone application to measure the degrees of Trendelenburg tilt on the operative bed before the application of traction; (B) the pressure transducer reading for measuring traction force throughout the procedure; and (C) the locking mechanism for the traction boot and the spider device as well as (D) the positioning of the limb in the traction boot.

Dr. Tigran Garabekyan is a board certified orthopedic surgeon specializing in hip preservation. To learn more about Southern California Hip Institute or to schedule a consultation, click here to contact us or call:

North Hollywood: 818.755.6500
Century City / Los Angeles: 310.574.0375

Serving patients in Encino, Sherman Oaks, Van Nuys, North Hollywood, Burbank, Glendale, West Hollywood, Century City, Beverly Hills, Santa Monica, Los Angeles, and other neighboring cities in the greater Los Angeles area.

Also visit http://www.drgorthopedics.com/

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Acetabular dysplasia is a painful hip disorder that, when left untreated, can lead to cartilage degeneration and end-stage arthritis.The radiographic detection of dysplasia in adults can have poor reliability without the use of valid parameters. In this study, Dr. Garabekyan of the Southern California Hip Institute along with notable colleagues from Colorado University, showed that the Iliofemoral line (IFL) parameter is a reliable and accurate marker of frank and borderline acetabular dysplasia. The use of this parameter is an additional tool for earlier detection of dysplasia in young adults with hip pain.

Figure 1

The IFL is a radiographic measurement defined as the smooth line extending from the apex of the concavity of the lateral femoral neck through the inner cortical lip of the ilium on an AP pelvis radiograph (Figure 1).  Percent medialization of the IFL is calculated by measuring the horizontal distance from the IFL to the lateral femoral head (B) and dividing by the femoral head diameter (A, B) (right image).

This parameter was validated for both supine and weight-bearing standardized radiographs, with results no statistical difference seen between the measurements. The largest difference obtained was  5% of the measured distance with an average difference 2% of the measured distance.

Figure 2

Three-dimensional reconstruction of the pelvis and bilateral hip joints from a computed tomography (CT) scan also illustrates the concept of the iliofemoral line (IFL) (solid white lines). In hips with acetabular overcoverage, the IFL is tangential to the femoral head or may even lie completely lateral to the head (Figure 2). As lateral coverage is reduced or the hip center is shifted superolaterally (as in varying degrees of dysplasia), the IFL increasingly intersects the femoral head, leaving a progressively greater percentage of the head lying lateral to the IFL.

In these cases, medialization of the IFL is quantitatively measured as the horizontal distance between the femoral head line  segment lying lateral to the IFL as a percentage of the entire horizontal femoral head width measured, at the center of the femoral head. Although the IFL is a quantifiable measure, a high value of percent medialization of the IFL may be easily detected visually without necessitating an exact measurement.

Figure 3: Anteroposterior pelvis radiograph of a patient with bilateral frank acetabular dysplasia

Figure 3 displays the Shenton line, which is continuous on the right and broken on the left (dashed white lines), indicating a superolateral left hip center. The IFL line is drawn on both sides (solid white lines) and enables rapid, qualitative visual identification of dysplastic undercoverage of the right femoral head, despite having a continuous Shenton line.

This study depicts a significantly higher sensitivity of the IFL in detecting borderline hip dysplasia compared with the Shenton line (62% vs 3.7%,respectively). Thus, the use of the IFL may detect mild cases of hip instability associated with acetabular dysplasia that otherwise may go undiagnosed and untreated.

Dr. Tigran Garabekyan is a board certified orthopedic surgeon specializing in hip preservation. To learn more about Southern California Hip Institute or to schedule a consultation, click here to contact us. Serving patients in Encino, Sherman Oaks, Van Nuys, North Hollywood, Burbank, Glendale, West Hollywood, Century City, Beverly Hills, Santa Monica, Los Angeles, and other neighboring cities in the greater Los Angeles area.

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Hip dysplasia is a disorder in which the hip socket is too shallow to adequately house the ball. The shallow socket creates hip instability, or excessive translational motion. Several factors can contribute to hip instability, including acetabular bony coverage, femoral torsion, femoroacetabular impingement, and soft tissue laxity. Left untreated, dysplasia can cause progressively worsening pain until the hip deteriorates to end-stage arthritis.

Activity modification and physical therapy may be used as a first-line treatment, but individuals who continue to experience symptoms of pain or instability should seek surgical treatment. Dr. Garabekyan of Southern California Hip Institute recently published a review article summarizing the various treatment options available to patients with hip dysplasia.  If you are suffering from dysplasia, please contact our office for a consultation and we will review all the treatment options to find the best fit for you.

Dr. Tigran Garabekyan is a board certified orthopedic surgeon specializing in hip preservation. To learn more about Southern California Hip Institute or to schedule a consultation, click here to contact us. Serving patients in Encino, Sherman Oaks, Van Nuys, North Hollywood, Burbank, Glendale, West Hollywood, Century City, Beverly Hills, Santa Monica, Los Angeles, and other neighboring cities in the greater Los Angeles area.