Table 1.

Modifications in Hip Arthroscopy Procedure Directly Preceding PAO

Central compartment

Perform an interportal capsulotomy that is as small as possible and located laterally (staying lateral to the direct head of the rectus origin if possible).

For labral repair, if 2 portals provide an adequate trajectory for suture anchor placement, 2 portals can be used (especially if the cam does not need to be addressed or will be addressed with an open capsulotomy after the PAO).

For labral repair, if a more distal-to-proximal trajectory is needed, as is often the case with a dysplastic acetabulum, a distal anterolateral accessory (DALA) portal can be created. This is the portal through which the first author prefers instruments when resecting the cam lesion if this is done arthroscopically.

For labral repair, the decision on whether to use simple suture repair or mattress suture repair is often dependent on the morphology and quality of the labral tissue.

Careful evaluation of the articular cartilage, on both the acetabular and femoral side, is performed. If cartilage wear is more significant than was estimated based on preoperative imaging, this may be the decision point on whether proceeding with the PAO is indicated.

Peripheral compartment

Traction is removed and the hip is flexed to 30-45°. Tension on the traction boots is released.

If there is no cam lesion to be addressed, or if the cam will be addressed via an open incision after the PAO, no additional peripheral compartment work is necessary. The interportal capsulotomy can be closed arthroscopically or via open repair after the PAO is completed.

If a cam lesion is present and will be addressed arthroscopically, instruments are inserted through the DALA portal. A T-capsulotomy can be made with a radiofrequency ablation device through this portal, if needed. The cam can then be resected with the burr.

It is the first author’s choice to close the T-capsulotomy and interportal capsulotomies arthroscopically to restore the tension to the hip capsule before performing further dissection in preparation for the PAO.

Dissection of the iliocapsularis off the hip capsule is performed with the radiofrequency ablation device. Care is taken to perform this dissection to minimize damage to the capsule as well as the iliocapsularis (Video 1).

The iliocapsularis dissection is carried medially off the capsule until the psoas bursa is identified. Proximally, the iliocapsularis is dissected off the medial edge of the direct head of the rectus tendon as far as can be safely visualized (Video 1); the remaining fibers of the iliocapsularis attached to the rectus will be dissected from the medial rectus tendon during the open PAO exposure.

PAO, periacetabular osteotomy.