Arthroscopic Portals Research Articles

The Incidence of Propionibacterium acnes in Shoulder Arthroscopy

To document the skin colonization and deep tissue inoculation rates associated with arthroscopic shoulder surgery and how these rates differ with procedural and demographic factors. We prospectively recruited outpatient shoulder arthroscopy patients who agreed to participate and met the inclusion criteria from February 2013 to May 2014. All patients received routine antibiotic prophylaxis intravenously. Initial cultures were obtained before the skin preparation by swabbing the skin at the 3 standard portal sites: posterior, anterosuperior, and anterolateral. The skin preparation used 4% chlorhexidine scrub and 2% chlorhexidine gluconate/70% isopropyl alcohol paint applied to the entire shoulder. After completion of the arthroscopic procedure, a second culture was obtained through a cannula at the surgical site. All cultures were plated for 21 days using Brucella medium. We enrolled 51 patients over a 15-month period. Cultures showed a 72.5% Propionibacterium acnes superficial colonization rate: 46.1% of female and 81.6% of male patients (P = .027). We identified a deep culture-positive inoculation rate of 19.6%, all with positive P acnes skin colonization. No correlation could be made concerning diagnosis, procedure, suture anchor use, age, or sex. The rate of skin colonization with P acnes is high at arthroscopic portals, especially in men. Despite standard skin preparation and prophylactic antibiotics, the rate of deep tissue inoculation with P acnes in shoulder arthroscopy is much higher than the rate of infection reported in the literature. Shoulder arthroscopy introduces a significant amount of P acnes into the deep tissues.

Arthroscopic Treatment of Suprascapular Neuropathy from a Suprascapular Notch Cyst Using a Lateral Subacromial Approach

We describe a safe surgical technique for arthroscopic decompression of a suprascapular notch cyst in the setting of compressive suprascapular neuropathy. Position the patient in the standard beach-chair position. Palpate and mark the subcutaneous landmarks of the shoulder in preparation for later arthroscopy. Create standard anterior and posterior portals for glenohumeral visualization. Establish accessory superior and lateral portals and transition to a lateral viewing portal to perform suprascapular notch decompression. Establish a G Portal and release the transverse scapular ligament using arthroscopic scissors. Perform arthroscopic lavage of the subacromial space and glenohumeral joint and close arthroscopic portals. As suprascapular nerve entrapment is a relatively rare entity, with only a limited number of studies from which to draw conclusions regarding the outcomes of arthroscopic suprascapular nerve release, Shah et al. recently reported on their results in twenty-four patients using this surgical technique.IndicationsContraindicationsPitfalls & Challenges.

Arthroscopic Technique for the Treatment of Pigmented Villonodular Synovitis of the Hip

Open synovectomy remains the treatment of choice for pigmented villonodular synovitis (PVNS) of the hip but has shown modest results compared with the treatment of other joints. Recent advances in hip arthroscopy permit a thorough evaluation of the joint surfaces, improved access, and decreased postoperative morbidity. We describe an arthroscopic synovectomy technique for PVNS of the hip. The use of additional arthroscopic portals and creation of a large capsulotomy enable successful visualization and extensive synovectomy of the entire synovial lining of the hip. The T-capsulotomy enables extensive soft-tissue retraction for complete exposure. The midanterior portal enables use of an arthroscopic grasper and shaver to directly access and excise the synovial lining of the peripheral compartment while avoiding damage to the medial and lateral retinacular vessels. Technical innovations in hip arthroscopy have enhanced visualization in the central and peripheral compartments, as well as instrument management and diagnostic evaluation of the capsule, therefore allowing enhanced management of PVNS of the hip.

Acetabular Retrograde Drilling: A New Arthroscopic Technique for Treatment of Chondral Lesions Grade 1 and 2 in Patients with Femoroacetabular Impingement

Introduction: Acetabular chondral lesions in patients with femoroacetabular impingement are common findings in a surgical procedure. At present arthroscopic management has been proven effective in most cases treated. Poor results of this treatment have been attributed, among other things, to presence of these articular lesions. Several management alternatives have been described, however most of these options were devised for the treatment of grade 3 and 4 cartilage injuries. Actually, there are not good alternatives for the treatment of lesions grade 1 and 2 during hip arthroscopy in patients with femoroacetabular impingement. The aim of our work is present a new surgical technique of arthroscopic retrograde drilling for treatment of grade 1 and 2 acetabular chondral lesions in patients with femoroacetabular impingement. Indications: Grade 1 and 2 acetabular chondral lesions identified during hip arthroscopy in patients with femoroacetabular impingement. Surgical Technique: Through anterior and anterolateral arthroscopic portals, acetabular retrograde drilling is performed from the capsular side of the acetabular rim, to the cartilage detachment zone, without interrupting the indemnity of the articular cartilage surface. Conclusion: Acetabular retrograde drilling is a new arthroscopic treatment alternative for acetabular chondral lesions grade 1 and 2 associated with femoroacetabular impingement. Is technically simple, inexpensive, reproductible and does not interfere with rehabilitation.

Safety of posterior ankle arthroscopy portals in different ankle positions: a cadaveric study.

To investigate anatomic relation of standard and coaxial ankle arthroscopy portals with neurovascular structures during different degrees of ankle motion. Twenty posterior ankles of ten fresh cadavers were assessed. Posteromedial, posterolateral and coaxial (transmalleolar) portals were created using 4-mm Steinmann pins in accordance with the defined technique in neutral position. The ankles were then dissected, and the distance from the portals to the peroneal tendons, short saphenous vein and sural nerve was measured laterally and that from the tibial nerve, flexor hallucis longus tendon and posterior tibial artery was measured medially. Changes in the distance between these structures were noted in neutral positions, 15° of dorsiflexion and 30° plantar flexion. In the neutral position, the mean distance of the conventional posterolateral portal to the sural nerve was 6mm (SD 2.9, range 2.7-14.5). The mean distance of the posterolateral coaxial portal to the peroneal tendon was 1.6mm (SD 0.55, range 1.1-2.9). The mean distance of the posteromedial portal to the FHL was 2.11mm (SD 1.1, range 0-4.7). The mean distance of the posteromedial coaxial portal to the posterior tibial artery was 6mm (SD 1.4, range 3.9-9.5). Although not statistically significant, the distance between the portal and neurovascular structures increased in dorsiflexion for the portals placed posteriorly to the neurovascular structures and increased in plantar flexion for the portals placed anterior to the neurovascular structures. In comparison with the portals made in the neutral position, the distance between neurovascular structures and portals changes with portal placement in plantar flexion and dorsiflexion. In clinical practice, therefore, it might be safer to place the posteromedial-posterolateral portals in dorsiflexion and posterolateral-posteromedial coaxial portals in plantar flexion. The tibial nerve is closer to the posteromedial coaxial in dorsiflexion and could be in danger if making this portal with the foot in this position.

Topographic anatomical study of the sciatic nerve relationship to the posterior portal in hip arthroscopy.

To evaluate the anatomic topographic relation between the sciatic nerve in relation to the piriform muscle and the posterior portal for the establishment of hip arthroscopy. We dissected 40 hips of 20 corpses of adult Brazilians, 17 male and three female, six black, six brown and eight white. We studied the anatomical relationship between the sciatic nerve and the piriform muscle with their variations and the distance between the lateral edge of the sciatic nerve and the posterior portal used in hip arthroscopy. We then classified the anatomical alterations found in the path of the sciatic nerve on the piriform muscle. Seventeen corpses had bilateral relationship between the sciatic nerve and the piriform muscle, i.e., type A. We found the following anatomical variations: 12.5% of variant type B; and an average distance between the sciatic nerve and the portal for arthroscopy of 2.98cm. One body had type B anatomical variation on the left hip and type A on the right. the making of the posterior arthroscopic portal to the hip joint must be done with careful marking of the trochanter massive; should there be difficult to find it, a small surgical access is recommended. The access point to the portal should not exceed two centimeters towards the posterior superior aspect of the greater trochanter, and must be made with the limb in internal rotation of 15 degrees.

Arthroscopic Release of the Deep Medial Collateral Ligament to Assist in Exposure of the Medial Tibiofemoral Compartment

Arthroscopy of the knee is a widely used surgical procedure for addressing intra-articular pathology. In assessing the intra-articular structures, visualization is of paramount importance. The medial tibiofemoral compartment is often difficult to fully visualize in tight knees in which limited access can compromise surgical efficacy. Poor visualization can increase the possibility of a residual meniscal tear after attempted partial meniscectomy, as well as the possibility of iatrogenic chondral injury from arthroscopic instruments. We describe a technique that allows improved medial tibiofemoral visualization with release of the deep medial collateral ligament. We use standard arthroscopic portals, without the need for further incisions or stab holes and with minimal additional patient morbidity. This procedure allows easier exposure of the medial knee chondral surfaces and meniscus and easier use of arthroscopic instrumentation in the medial compartment.

Evaluation of simple, fast endoscopic technique of popliteal cyst resection: About 200 cases of 9 years of experience

Popliteal cyst existence and high recurrence rate after its surgical excision is still matter of concern. The purpose of this study is to evaluate results and introduce simple, fast technique of popliteal cyst excision based on more than 200 cases of arthroscopic/endoscopic and about 9 years experience. From 2003, we prefer endoscopic excision of popliteal cyst as a treatment of choice. In 2006, we developed very simple technique of its treatment with use regular arthroscopic portals. Since this time we have used the procedure as a standard part of our each knee arthroscopy. We performed all in one procedures that included intra-articular pathologies treatment combined with valvular mechanism removal and endoscopic cystectomy. We treated and evaluated 240 patients with popliteal cyst in arthroscopic/endoscopic way but in 136 cases we have used our simple technique. One hundred and eleven of them were evaluated at the final follow-up. In all patients, we made MRI and ultrasound exam as a qualification. Observation time after surgery was between 6–71 months and patients age between 6–57 years. Intra-articular pathologies, valvular mechanism type and frequency of its occurrence were estimated. Rauschning and Lindgren criteria, Lysholm score and VAS were used for evaluation. We measured time of the cyst and valvular mechanism excision. Patients underwent following ultrasonography 6, 12 months after procedure and at the follow-up. All patients had coexisting intra-articular pathologies: medial meniscal tears, patellar chondral lesions, synovitis and synovial hypertrophy, ligament instabilities, plica syndrome, rheumatoid diseases and lateral meniscus tears, chondromatosis and OCD in order of incidence. Valvular mechanism was observed in all patients as transverse capsular fold, overgrowth synovium and coat-like synovial hypertrophy. Preoperatively Rauschning and Lindgren score was about 2.3 and about 0.5 at follow-up. Average VAS was preoperatively about 4.9 and 9 at follow-up. Average Lysholm knee score was 56 preoperatively and about 85 at follow-up. Full range of motion was gained in 2.5 days on average, mean time of pain elimination was 29 h. Ultrasound exam showed persistent cyst in 14 cases at follow-up. The time of “cyst procedure” depended on thickness of its walls and patients weight and was between 6–19 minutes (mean 9 min). There were no persistent complications in our material. We found statistically significant correlation between grades III/IV cartilage lesions and cyst recurrence after cystectomy (P = 0.02 exact Fisher test). We consider our endoscopic treatment of popliteal cyst as a treatment of choice and our technique as a save, fast and reproducible procedure that could be used as a part of standard arthroscopy.

Anatomical relations of anterior and posterior ankle arthroscopy portals: a cadaveric study.

Ankle arthroscopy is an increasingly used technique. Knowledge of the anatomical structures in relation to its portals is paramount to avoid complications. Twenty cadaveric ankles were analysed to assess the distance between relevant neurovascular structures to the anteromedial, anterolateral, posteromedial, and posterolateral arthroscopy portals. The intermediate dorsal branch of the superficial peroneal nerve was the closest structure to any of the portals (4.8mm from the anterolateral portal), followed by the posterior tibial nerve (7.3mm from the posteromedial portal). All structures analysed but one (posterior tibial artery) were, at least in one specimen, <5mm distant from one of the portals. This study provides information on the anatomical relations of ankle arthroscopy portals and relevant neurovascular structures, confirming previous studies identifying the superficial peroneal nerve as the structure at highest risk of injury, but also highlighting some important variations. Techniques to minimise the injury to these structures are discussed.

Arthroscopic decompression at the suprascapular notch: a radiographic and anatomic roadmap

Arthroscopic decompression of the suprascapular nerve (SSN) at the suprascapular notch is a technically demanding procedure. Additional preoperative and intraoperative information may assist surgeons. The purpose of this study was to (1) identify which imaging modality most accurately represents the anatomic distance to the notch and (2) quantify the mean intraoperative distances from routine arthroscopic portals to the notch. Ten matched pairs of fresh cadaveric shoulders were imaged by roentgenogram, computed tomography (CT), magnetic resonance imaging, and 3-dimensional (3D) CT, followed by arthroscopic SSN decompression at the notch and anatomic dissection. Measurements obtained included the distances from the anterolateral, posterior, and SSN portal sites to the notch in addition to the distance from the anterolateral acromion to the notch. Statistical analysis with Spearman correlation coefficients and Bland-Altman plots were used to determine the correlation and agreement between measurements. The preoperative imaging modality with the highest correlation to anatomic distances from the anterolateral acromion to the notch was 3D CT (Rs = 0.90, P < .0001). The mean intraoperative distances to the notch from the anterolateral, posterior, and SSN arthroscopic portals were 89 mm, 88 mm, and 49 mm, respectively. The mean anatomic distance from the anterolateral acromion to the notch was 64 mm. Preoperative imaging with 3D CT may assist surgeons in performing arthroscopic SSN decompression. Understanding of the mean distances from the portal sites to the suprascapular notch and being cautious of arthroscopic instruments placed beyond 9 cm from laterally based portals may result in safer intraoperative medial dissection.

Arthroscopic Treatment for External Snapping Hip

PurposeThe purpose of this study was to evaluate the clinical outcome of arthroscopic treatment for recalcitrant external snapping hip.Materials and MethodsBetween September 2011 and June 2013, we evaluated 7 patients (10 cases) with snapping hip who were refractory to conservative treatments for at least 3 months. Two patients (4 cases) were impossible to adduct both knees in 90°of hip flexion. Surgery was done in lateral decubitus position, under spinal anesthesia. We made 2 arthroscopic portals to operate the patients, and used cross-cutting with flap resection technique to treat the lesion. We performed additional gluteal sling release in those 2 patients (4 cases) with adduction difficulty. Average follow-up length was 19 months (range, 12-33 months). Clinical improvement was evaluated with visual analog scale (VAS), modified Harris hip score (mHHS), and also investigated for presence of limping or other complications as well.ResultsThe VAS decreased from 6.8 (range, 6-9) preoperatively to 0.2 (range, 0-2) postoperatively, and the mHHS improved from 68.2 to 94.8 after surgery. None of the patients complained of post-operative wound problem or surgical complications.ConclusionThe clinical outcome of arthroscopic treatment for recalcitrant external snapping hip was encouraging and all patients were also satisfied with the cosmetic results.

Generalidades, portales y anatomía artroscópica

To perform a safe and effective wrist arthroscopy requires knowledge of the anatomy of the region, as well as the existence and precise location of the arthroscopic portals that must be used. A general configuration, the performing and location of the arthroscopic portals, the anatomical structures that can be visualized through them, as well as the at-risk structures that must be avoided in all wrist arthroscopies, are presented in this chapter.

Hip Arthroscopic Portal Bridge Retraction Technique for Improved Peripheral Compartment Visualization

Hip arthroscopy has been shown to be an effective technique in managing an increasingly widening set of indications for hip pathology. In any arthroscopic procedure, obtaining good visualization is one of the most critical components to performing a successful operation. Whereas other authors have described various techniques for improving visualization, we describe an additional simple but effective technique in this report. We describe the use of a retracting suture bridge between portal sites that allows for improved visualization of the peripheral compartment in hip arthroscopy, as well as other arthroscopic procedures.

The Relation Between Knee Flexion Angle and Anterior Cruciate Ligament Femoral Tunnel Characteristics: A Cadaveric Study Comparing a Standard and a Far Anteromedial Portal

The purpose of this study was to compare the anterior cruciate ligament (ACL) femoral tunnel characteristics between 2 common arthroscopic portals used for ACL reconstruction, a standard anteromedial portal and a far anteromedial portal. Seven cadaveric knees were used. A 1.25-mm Kirschner wire was drilled through the center of the ACL femoral footprint and through the distal femur from the standard anteromedial and far anteromedial portals at knee flexion angles of 100°, 120°, and 140°. No formal tunnels were drilled. Each tunnel exit point was marked with a colored pin. After all tunnels were created, the specimens were digitized with a MicroScribe device (Revware, Raleigh, NC) to measure the tunnel length; distance to the posterior femoral cortical wall (posterior cortical margin); and tunnel orientation in the sagittal, coronal, and axial planes. The standard anteromedial portal resulted in a longer tunnel length, a less horizontal tunnel in the coronal plane, and a greater posterior cortical margin compared with the far anteromedial portal at all knee flexion angles. For both portal locations, the tunnel length and posterior cortical margin increased, and the tunnel position became more horizontal in the coronal plane, more anterior in the sagittal plane, and less horizontal in the transverse plane as knee flexion increased. Portal position affects femoral tunnel characteristics, with results favoring the more laterally positioned standard anteromedial portal at all flexion angles. Increasing the knee flexion angle leads to a longer femoral tunnel length and posterior femoral cortical margin with either portal position. Understanding how portal positioning and knee flexion angle affect femoral tunnel orientation and characteristics may lead to improved surgical outcomes after ACL reconstruction.

Arthroscopic Bankart Repair for Anterior Shoulder Instability Using a Posterolateral Portal

A successful surgical outcome for patients with shoulder instability requires a complete preoperative evaluation, a thorough diagnostic arthroscopy to evaluate for concomitant co-pathology, and an effective postoperative therapy program tailored to the repair strategy. In addition to the Bankart lesion, the surgeon must be aware of other co-pathologies such as the HAGL lesion, the ALPSA lesion and SLAP tears, all of which may occur in concert with capsular pathology and which present as potential barriers to a successful outcome. We have previously described the use of a posterolateral arthroscopic portal, 4 cm lateral to the posterolateral corner of the acromion. This portal simplifies and improves anchor placement, trajectory, and anatomic capsulolabral repair of the inferior glenoid. In this case, we perform a hybrid repair using the posterolateral portal to place the first suture anchor at the 6 o’clock position on the glenoid and the mid-glenoid portal to place two labral tape knotless anchors.

Talonavicular arthroscopy for osteochondral lesions: technique and case series.

Traditional treatment of talonavicular osteochondral lesions (OCLs) requires an open procedure. Arthroscopic microfracture of talonavicular OCLs may provide a viable, minimally invasive approach. The purpose of this study was to describe an arthroscopic approach for treatment of talonavicular OCLs, describe the proximity of arthroscopic portals to important structures in cadaver specimens, and report magnetic resonance imaging (MRI) findings and clinical outcomes of this technique. Five cadaver specimens were dissected so proximity of portals to adjacent tendons and neurovascular structures could be assessed. Subsequently, 3 athletic patients with OCLs of the talonavicular joint were treated with arthroscopic debridement and microfracture. Patient records and imaging studies were retrospectively reviewed. In the cadaver specimens, the mean distance between the neurovascular bundle and the medial border of the extensor hallucis longus (EHL) was 9.0 (range, 8 to 10) mm. The saphenous nerve was located a mean of 6.8 (range, 6 to 7) mm from the medial border of the tibialis anterior tendon. Therefore, portals were placed just medial to the EHL and tibialis anterior tendon to avoid the neurovascular bundle and saphenous nerve, respectively. In all patients, access, identification of the OCL, debridement, and microfracture were successfully performed. All patients demonstrated improvements in Foot and Ankle Outcome Scores and Short Form-12 scores and began gradual return to activity within 12 weeks following the operation. No significant complications occurred. MRI indicated signal consistent with reparative fibrocartilage in all patients. Talonavicular arthroscopy allowed visualization, curettage, synovectomy, loose body removal, and microfracture of OCLs that would have otherwise required an open approach. At early follow-up, all patients had returned to their previous activity levels. Arthroscopy of the talonavicular joint was a viable approach for microfracture of OCLs. Level IV, case series.

Simulation Training Decreases Surgical Errors and Improves Performance during Diagnostic Shoulder Arthroscopy performed by Residents in Training

With its continued evolution, arthroscopic simulation has been increasingly recognized as a means for surgical skill training within graduate medical education. The purpose of this study was to ascertain whether a standardized arthroscopic simulation curriculum improved diagnostic shoulder arthroscopy operative performance, efficiency, and patient safety among orthopaedic trainees. Twenty-two orthopaedic surgery residents with varying levels of shoulder arthroscopy experience were consented and randomized into two groups, simulator (SIM) and standard practice (SP). All subjects were oriented to a virtual reality shoulder simulator, an anatomic checklist, and the Arthroscopic Surgery Skill Evaluation Tool (ASSET), a validated metric for assessing technical ability during arthroscopy. Video recording of expert diagnostic shoulder arthroscopy and relevant errors were also demonstrated, and individual case logs were queried to identify cumulative exposure to shoulder arthroscopy. At baseline testing, the attending surgeon established standard arthroscopic portals and all participants performed supervised, in vivo diagnostic arthroscopy with video recording, as well as the simulator-based diagnostic arthroscopy test. The SIM group subsequently received four 15-minute simulator-training sessions conducted by a single instructor over a 3-month period, while the SP group received routine arthroscopic exposure without further simulator training. After intervention, both groups were re-evaluated with supervised diagnostic shoulder arthroscopy and simulation testing. Two blinded, independent experts evaluated arthroscopic performance utilizing the 14-point checklist, ASSET score, and total time elapsed. Outcome measures were evaluated using the student t-test. Multivariate analysis was conducted to correlate simulator performance with number of arthroscopic cases. Following the intervention, subjects randomized to the SIM group had significantly better safety scores (p=0.005) during the diagnostic arthroscopy and performed better on the ASSET (p=0.061) when compared to the SP group; however, the latter difference only approached statistical significance. The SIM group also completed the simulation testing significantly faster (p=0.001) and was much more efficient in using the probe (p=0.001) during the simulation test following the intervention when compared to the SP group. Subjects in the SIM group were also more efficient in using the camera following the intervention when compared to the SP group; however, the difference between the groups was not statistically significant (p=0.070). Both groups demonstrated significant improvements on the ASSET during the diagnostic arthroscopy following the intervention when compared to their pre-intervention baseline assessments. In addition, the SIM group also performed the diagnostic arthroscopy significantly faster following the intervention (p=0.026). Finally, the SIM group demonstrated significant improvements from pre intervention to post intervention for the time required to complete the simulator assessment (p=0.030) and both probe (p=0.040) and camera (0.049) efficiency during the task, while none of the improvements observed in the SP over time were statistically significant for the simulator task assessment. We demonstrated that our SIM group was able to not only perform the designated tasks faster but also while demonstrating improved patient safety following high fidelity simulation training. To the best of our knowledge, the current study is the first to establish transfer validity, meaning surgical skills learned in a simulated environment can be reflected in the operating room theater.

Arthroscopic Delivery of Cancellous Tibial Autograft for Unstable Osteochondral Lesions in the Adolescent Knee

The appropriate surgical technique for the treatment of unstable osteochondral lesions of the knee remains unclear and had been traditionally described with an open arthrotomy. Administration of bone grafting material in the knee may be performed for a variety of pathologic conditions, including unstable osteochondritis dissecans, traumatic osteochondral defects, or subchondral fracture nonunion, or for preparation of residual tunnels during revision anterior cruciate ligament reconstruction. Although various grafting materials have been described in the literature, cancellous autograft remains the gold standard for treatment safety and efficacy. We describe a successful technique for arthroscopic delivery of autogenous bone graft during fixation of unstable osteochondral lesions of the knee. When the indication for grafting is established, cancellous autograft is harvested from the proximal tibia, undergoes morcellation, and is soaked in bone marrow aspirate obtained through the harvest window. The bone graft is then packed into a modified tuberculin syringe. After arthroscopic preparation of the unstable osteochondral fragment and the respective donor surface, the tuberculin syringe is placed through a standard arthroscopy portal and the bone graft is introduced into the defect under direct visualization, followed by an appropriate osteochondral fixation technique.

How to Avoid Ulnar Nerve Injury When Setting the 6U Wrist Arthroscopy Portal

The dorsal sensory branch of the ulnar nerve (DSBUN) is at risk in setting the 6U wrist arthroscopy portal. Although surgeons know the risk and are careful when they set the 6U portal, DSBUN injuries still occur. The purpose of the present anatomical study was to evaluate the possibility that DSBUN undergoes dynamic anatomical variations in its location during wrist arthroscopy. The goal of the study was to clarify (1) whether the nerve-to-portal (NTP) distance changes with flexion/extension wrist and/or hand/forearm rotation, and (2) whether there is any particular combination of flexion-extension/hand-forearm rotation where the NTP distance is maximal. Six fresh cadaver arms were suspended in a traction tower with forearm rotation locked, the skin and subcutaneous tissue around the ulnar head was removed, and the NTP distance measured in three predetermined loading/positional conditions. Of all options, the one that consistently showed the longest and safest NTP distance involved wrist flexion and radiocarpal supination when forearm rotation is limited. In conclusion, when an arthroscopic traction device restricts the forearm rotation, the 6U portal should not be set under traction with the hand passively pronated. Failure to observe this precaution can result in serious neuropathic pain.

Ultrasound-Assisted Hip Arthroscopy

We describe the use of intraoperative ultrasound for the safe development of arthroscopic portals during hip arthroscopy without the requirement for fluoroscopy. We find this technique consistently accurate, allowing the safe introduction of arthroscopic instruments into the hip with a very low rate of iatrogenic injury. We have further developed the technique for application to both central- and peripheral-compartment procedures. We now have a total experience of more than 700 procedures to date. With the described technique of ultrasound guidance for portal placement, fluoroscopy is required in fewer than 2% of hip arthroscopy procedures at our institution.