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Editorial Commentary: Hip Joint Venting Prior to Initiating Traction Reduces Postoperative Complications

      Abstract

      Hip arthroscopy for the treatment of femoroacetabular impingement syndrome requires access to the central compartment of the hip, which is more easily obtained with hip distraction. However, surgeons must balance improved surgical access with the risks of postoperative complications. Hip joint venting describes the disruption of the suction seal by introducing a large-gauge needle into the joint space and injecting air or fluid into the joint. Joint venting performed before initiating axial traction may reduce the force required to obtain central compartment access while mitigating postoperative complications.
      Femoroacetabular impingement syndrome is a common cause of hip pain in the young adult population, with the current gold standard of failed conservative management being hip arthroscopy. Treatment of chondrolabral pathology necessitates access to the central compartment of the hip. Many hip arthroscopists advocate for the use of hip distraction, because it allows for improved visualization of intra-articular structures and ease of instrumentation within the hip. Until recently, distraction of the hip has required countertraction provided by a padded perineal post, placing substantial force at the patient’s groin which has resulted in rare but impairing neurovascular complications, particularly of the pudendal and perineal nerve. In a young, active, and otherwise healthy patient population, care should be taken to avoid iatrogenic nerve injury, with potential for associated sexual dysfunction.
      Prior literature has suggested that the risk of neurovascular complications increases with traction time greater than 2 hours.
      • Papavasiliou A.V.
      • Bardakos N.V.
      Complications of arthroscopic surgery of the hip.
      To minimize these complications, our team is mindful of when traction is first initiated and the duration that it has been applied throughout surgery, particularly during more complicated and time-consuming procedures. Nevertheless, longer operative durations are inevitable for the young hip arthroscopist, academic centers with resident and fellow teaching, and the more technically demanding cases (e.g., labral reconstruction, ligamentum teres reconstruction, revision surgery, and other concomitant procedures) This begs the question: Aside from traction time, how can we reduce neurovascular complications related to hip traction?
      Joint venting describes the disruption of the joint suction seal by introducing a large gauge needle into the joint space and injecting air or fluid into the joint. Until recently, the effect of venting before application of axial traction has not been studied in vivo. We congratulate O’Neill, Mortensen, Tomasevich, Ohlsen, Adeyemi, Maak, and Aoki on their recent contribution titled “Joint Venting Prior to Hip Distraction Minimizes Traction Forces During Hip Arthroscopy.”
      • O'Neill D.C.
      • Mortensen A.J.
      • Tomasevich K.M.
      • et al.
      Joint venting prior to hip distraction minimizes traction forces during hip arthroscopy.
      This study included 78 patients (58 vented, 20 controls) undergoing primary hip arthroscopy requiring access to the central compartment. Patients were positioned in 10° to 15° of Trendelenburg on a post-free traction table. Axial traction was applied at 25 lb increments from 0 to 100 lbs, and fluoroscopic images were collected at each interval. Traction was then released for 15 minutes, joint venting was performed with 20 mL of air, and axial traction was applied for a second time at 25 lb increments from 0 to 100 lbs. The authors reported significant differences in the distraction distance following venting at all traction intervals (P < .001). Importantly, a control group that underwent the same protocol without joint venting showed no differences in distraction distance between the first and second traction application, thereby demonstrating that the differences seen in the vented group were not due to repeated traction application.
      In a recent study of 309 hips, Mei-Dan et al.
      • Mei-Dan O.
      • Kraeutler M.J.
      • Garabekyan T.
      • Goodrich J.A.
      • Young D.A.
      Hip distraction without a perineal post: A prospective study of 1000 hip arthroscopy cases.
      demonstrated that male sex, increased body mass index (BMI), and increased acetabular coverage (quantified by the lateral center edge angle) were associated with greater forces required to achieve joint distraction. Accordingly, O’Neill et al.
      • O'Neill D.C.
      • Mortensen A.J.
      • Tomasevich K.M.
      • et al.
      Joint venting prior to hip distraction minimizes traction forces during hip arthroscopy.
      demonstrated that there were no differences in patient sex or acetabular coverage between vented and control participants, though there was a small difference in BMI (0.7 kg/m2), that is unlikely to explain the magnitude of the study findings. In addition, there were no differences in the preoperative Beighton Score or anesthesia used between groups. In summary, this study demonstrates that a single intervention requiring minimal additional operative time may lower the force required to achieve sufficient joint space and reduce the risk of postoperative complications.
      The benefits of reduced traction forces for young hip arthroscopist, academic teaching centers, and surgeons requiring extended operative time using perineal post traction tables is well defined. In addition to the aforementioned advantages, reduced traction forces may lessen the risk of foot slippage, subsequent loss of traction, and possible iatrogenic chondrolabral damage. With the recent introduction of post-free hip distraction tables and thus reduced risk of neurovascular complications, we anticipate that some readers may fail to recognize the value of incorporating the study findings into clinical practice. One limitation of the post-free hip distraction tables that comes to mind is specific to patients who are difficult to distract (e.g., older males with osteoarthritis, young thin males, “stiff patients”, and patients with large cam deformities)
      • Mei-Dan O.
      • Kraeutler M.J.
      • Garabekyan T.
      • Goodrich J.A.
      • Young D.A.
      Hip distraction without a perineal post: A prospective study of 1000 hip arthroscopy cases.
      and therefore require increased Trendelenburg positioning throughout surgery. Similarly, patients with increased body habitus (BMI > 30) may experience increased abdominal pressure and reduced respiratory compliance with Trendelenburg positioning,
      • Rouby J.J.
      • Monsel A.
      • Lucidarme O.
      • Constantin J.M.
      Trendelenburg position and morbid obesity: A respiratory challenge for the anesthesiologist.
      ,
      • Perilli V.
      • Sollazzi L.
      • Bozza P.
      • et al.
      The effects of the reverse trendelenburg position on respiratory mechanics and blood gases in morbidly obese patients during bariatric surgery.
      resulting in an increase work of breathing and an unhappy anesthesiologist. Reducing the force required to distract the hip through joint venting may allow these patients to return to a more neutral Trendelenburg position, facilitating improved ease of operation for the surgeon and the rest of the team.

      Supplementary Data

      References

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