Post-Less Hip Distraction

Over the past two decades, surgeons are increasingly using hip arthroscopy, a minimally-invasive surgical procedure, to diagnose and treat a wide array of hip problems. This rapid increase in hip arthroscopy is explained in part by advanced imaging procedures, enhanced understanding and evaluation of the causes and effects of joint conditions and the improved ability to treat hip conditions with minimally invasive procedures.

Surgeons understand how crucial it is to take every precaution to decrease the potential of complications during and after surgeries. But, in some cases, the tools they use for creating the right surgical environment have their own potential of leading to problems. This is the case with traction associated with the perineal post used in hip distraction surgery.

Today, hip arthroscopy is an effective surgical procedure offering the potential to improve function, relieve symptoms and enable a quick return to everyday and sporting activities. And, when performed through a post-less hip distraction technique versus using a perineal post, patients are less likely to experience hip arthroscopy complications.

What Is Hip Distraction?

Using an arthroscope, which is an instrument with a light and a camera about the size of a pencil, hip arthroscopy allows a surgeon to examine or treat your hip joint without having to make a large incision through your skin and soft tissues.

To perform arthroscopic surgery, hip traction needs to be placed on the leg to access the hip joint arthroscopically. Hip distraction is a necessary and vital component in maneuvering you for arthroscopic entry into your hip joint. It's used in correcting and repairing your hip components while keeping the neighboring muscles in place.

Some conditions treated with hip distraction surgery are:

• Labrum tears of the acetabulum

• Femoroacetabular impingement (or FAI, a disorder where hip bones are abnormally shaped)

• Avascular necrosis of the hip (occurs when there is a disruption in the blood supply to the head of the thighbone)

• Torn cartilage or ligaments in the hip

• Chondrolysis (gradual hyaline cartilage degradation in the hip joint)

• Infection of the hip joint whereby infected fluid needs draining

• Bone spurs or bone growths

Traditionally, a padded post in the groin is provided for counter traction. Traction complications often are caused by the post, and they include pudendal or perineal neuropraxia and skin tears, and groin numbness.

Surgeons now more commonly use post-less hip arthroscopy to reduce your chances of complications following hip arthroscopy and to improve their ability to access your injured hip.

What Is a Perineal Post?

When surgeons perform hip arthroscopy, they need to open your joint up so they can pass their instruments into your joint safely. The traditional way of doing it is to pull traction on your leg, placing a big paddled post in your perineal area to provide counter traction.

To get to your hip joint during the procedure, the surgeon would typically use a traction table with a perineal post to allow for counter traction and achieve hip distraction. However, with traditional arthroscopy, individuals often have to deal with long post-surgical pain and rehabilitation, along with the possibility of experiencing one or more complications.

These complications associated with using a perineal post have led surgeons to use the post-less hip distraction technique in hip arthroscopy.

What Are the Challenges and Potential Complications of Using a Perineal Post?

Both from the patient's and surgeon's point of view, there are challenges with the use of a perineal post. The biggest concern for experienced surgeons and largest barrier for new hip arthroscopists is not the surgery itself. Instead, it's the possible complications that could occur based on the positioning of the patient when using a perineal post. Some complications include:

1. Pudendal nerve neuropraxia: Pudendal nerve neuropraxia after hip arthroscopy isn't uncommon and has a reported rate of 1.8 percent in one review. Possible risk factors could include long traction times and the use of a perineal post. the pudendal nerve can be stretched or compressed, leading to permanent or temporary neuropathy. Reports show up to a 4.3 percent iatrogenic pudendal nerve and groin complication rate.

2. Pudendal nerve palsy: The incidence of pudendal nerve palsy after elective orthopedic surgery and routine trauma ranges from 1.9 percent to 27.6 percent. Traction misuse and inappropriate perineal post-placement can lead to stretching and crushing of the pudendal nerve. These are two primary contributing factors leading to post-operative palsy.

3. Vaginal and labial tears: The post's exerted lateral force shouldn't be excessive. In women, there's the risk of vaginal tears, and it could also tear the labia (vaginal lips). Labial skin damage and pudendal nerve palsy are devastating iatrogenic complications from the use of a perineal post.

4. Scrotal tears: Injury to the scrotum is another soft tissue injury that could occur secondary to compression.

5. Impotence: Hip distraction surgery using a perineal post has led to the inability of men to have an orgasm or erection.

6. Scrotal necrosis: Scrotal necrosis also referred to as Fournier's gangrene is an infection in the scrotum and testicles, perineum or penis. The perineum is the spot between a man's scrotum and anus.

7. Groin numbness: A study with 40 male and 60 female patients who filled out a questionnaire found 22 patients experienced groin numbness. And, after two months, three of those patients still experienced groin numbness.

8. Reduced field of vision: Surgeons have a reduced field of vision for accessing the hip precisely.

9. Urinary retention: The perineal post has also been reported to cause things like urinary retention, where you can't partially or completely empty your bladder. You might have trouble urinating altogether, or if you can urinate, you can't completely empty your bladder.

10. Increased postoperative pain: In the acute postoperative period, abdominal pain develops. The adhesions can lead to pain after hip arthroscopy. Individuals demonstrate restricted rotation and flexion, with a positive impingement sign and complain of groin pain.

11. Retrograde ejaculation: This occurs when the semen gets into the bladder rather than emerging during orgasm through the penis. While you can still climax, you may ejaculate with little to no semen.

12. Erectile dysfunction: You can't get or keep a firm enough erection for sex.

Companies have developed tables and techniques to carry out post-less distraction to prevent complications such as the above.

What Is Post-Less Hip Distraction?

Hip joint post-less distraction reduces or eliminates the risk of pudendal nerve palsy. It results in reduced risk of urinary retention, post-operative pain and any of the other comorbidities linked with the post as well.

Dr. Gombera uses a traction pad on the table to employ this new approach keeping the individual in the Trendelenburg (feet-higher-than-the-head) position.

This pad allows for more torso and trunk friction. While you're on the pad, it provides you with enough friction to keep you on the table. Dr. Gombera can then use your body weight as a counter-traction for opening your joint up, which eliminates the need for the post and is a safer hip distraction for the patient.

What Is the Safety of the Post-Less Hip Arthroscopy?

Researchers conducted a study to assess how safe a post-less hip distraction technique was during hip arthroscopy. In the study, 1,000 hip arthroscopies were performed with no groin-related nerve or soft tissue complications having taken place. The study also showed no complications, such as skin contusions or friction burns, due to the necessary friction created between the operating table and the patient's body.

What Are the Benefits of a Post-Less Technique for Hip Arthroscopy?

What makes all the difference is what the table is missing. Most hip surgery tables have the post positioned in the patient's groin area between their legs. The post can lead to complications that could, in some cases, last for a few weeks or longer. The new table uses the stabilizing boots and the patient's weight to position the patient properly. Benefits of the post-less technique include:

1. Fewer, if any, complications: By providing post-less hip joint distraction, surgeons can basically reduce or eliminate the risk of urinary retention, skin tears, pudendal nerve palsy, total groin numbness, nerve damage and postoperative pain.

2. Better boot design: The advanced boot design helps stabilize your leg and provides better hip positioning. It's made to secure your ankle during distraction. It provides exact adjustment and fit to distraction system boots, enhancing your comfort and safety.

3. Improved surgical vision: The surgeon's improved field of vision helps them access your hip more precisely. They can access your joint reproducibly and safely. They can also use true lateral fluoroscopy and anteroposterior when they position the first needle and establish the first portal.

4. Traction force gauge: There's a traction force gauge helping the surgeon estimate the amount of force to put on you.

5. Better traction control: This technique provides better control and range-of-motion. The surgeon can make adduction, abduction and flexion and extension hip adjustments easier now. Additionally, post-less hip arthroscopy allows for internal and external hip rotation. The surgeon can now work with or without traction (peripheral and central compartments) during surgery without having to move the post out of their way and then put it back. This is extremely helpful when they perform cam resection while the assistant is preparing the graft for labral reconstruction.

6. Less concern about complications: For new hip arthroscopists, in particular, who require more time for entering the joint and working in the central compartment, this post-free method reduces concerns of complications that could become evident post-operatively. So, this method allows surgeons to strictly focus on the surgery instead of the complications possibly occuring with traction post use.

7. Improved blood return: Another benefit potentially affecting the surgical and anesthetic fronts is improved blood return to the brain and heart perfusion due to the inclined position. This makes it simpler to maintain and control a lower blood pressure, allowing for lower pump pressure use.

8. Better leg positioning: The surgeon can place your leg in a neutral position or slight traction abduction, relieving sciatic nerve pressure — adduction adds more stress on your nerve. The perineal post means femoral adduction.

9. Quicker recovery: The surgeon can perform bilateral hip arthroscopy using the same anesthetic with no built-up groin-related stress and greater groin-related complications. This means quicker recovery for individuals with bilateral disease. Post-less hip distraction, unlike traditional open hip surgery, requires much less recovery time, allowing you to start walking shortly after your procedure and remain mobile. You will go through hip distraction physical therapy and occupational therapy after your procedure. These sessions will help you heal properly.

Advancements in hip surgery are allowing surgeons to preserve an individual's native hip longer. And as technology improves further, you can expect even more solutions to get you back on your feet quickly. The post-less table helps surgeons reduce the risk of complications and obtain a better view of your hip to make the necessary repairs.

Importance of Choosing an Experienced Orthopedic Surgeon

Hip arthroscopy is one of the most successful and common orthopedic procedures available. Unfortunately, it's not a routine procedure for all orthopedic surgeons — and, of course, you'd want to avoid revision surgery to obtain the results you're looking for.

That's why it's essential to find an experienced orthopedic surgeon like Mufaddal Gombera, MD who specializes in hip arthroscopy. Specifically, arthroscopy with the post-less hip distraction technique can provide you with the best care possible and smoothest recovery. And, along with being specialized, Dr. Gombera's skill and experience performing hip arthroscopic surgery leads to better results and outcomes because he is familiar with it and frequently performs it.

Often, when individuals need a revision, it's not because of complications with the hip surgery, but rather they chose the wrong surgeon.

If you've received a diagnosis requiring hip arthroscopy or you're experiencing hip pain, choosing the right orthopedic surgeon is the most important factor for your full recovery.

Contact Mufaddal M. Gombera, MD to Set up Your Hip Arthroscopy Consultation

The decision to undergo post-less hip arthroscopy is a big step toward being able to have an active lifestyle again. You should feel confident in your choice.

Mufaddal M. Gombera, MD is a fellowship-trained, board-certified orthopedic surgeon specializing in arthroscopy, sports medicine and the treatment of hip, shoulder and knee injuries. He provides professional and expert patient care by using minimally invasive techniques and the latest innovative treatments to expedite recovery, and oftentimes, avoid surgery.

His multidisciplinary team treats patients with hip pain. Dr. Gombera regularly contributes to medical literature on the hip, knee and shoulder injury treatments. He's presently a member of the American Academy of Orthopedic Surgeons, the American Orthopedic Society for Sports Medicine, the Arthroscopy Association of North America, the International Society for Hip Arthroscopy, and American Shoulder and Elbow Surgeons.

He welcomes patients with hip, knee or shoulder pain to his office and provides specialized, personalized, expert healthcare to patients and athletes so they can get back to a fulfilling, active lifestyle. Dr. Gombera and his team pride themselves on being able to deliver outstanding care based on the most recent evidence-based treatments for each patient. Contact our office today to schedule your appointment.

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