Expert Consensus on Trendelenburg Position Postless Hip Distraction Technique in Hip Arthroscopy

Abstract

Postless hip distraction technique is a novel traction method for hip arthroscopy developed in recent years. Studies have shown that, compared with the traditional post hip distraction technique, it can effectively solve perineal complications, lower the technical threshold of hip arthroscopy, and improve patients' postoperative satisfaction. The standardization of this technique is expected to promote the advancement and popularization of hip arthroscopy. To this end, this Consensus identified 17 questions of the greatest clinical concern that were selected through systematic literature retrieval and evidence quality evaluation, and in combination with clinical practice, using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system and the Reporting Items for Practice Guidelines in Healthcare (RIGHT), and 20 evidence-based medical recommendations were finally formulated, aiming to improve the standardization and scientific nature of the postless hip distraction technique and provide a basis for improving the quality of patient-centered medical services.

Keywords

complications / expert consensus / hip arthroscopy / post hip distraction / postless hip distraction

References

[1] F. Y. Zhao, H. M. Dong, H. J. Huang, et al., “The Application of Arthroscopic Techniques in the Diagnosis and Treatment of Hip-Related Conditions in China,” Orthopaedic Surgery 13, no. 6 (2021): 1697–1706, https://doi.org/10.1111/os.13043.

[2] C. Kyin, D. R. Maldonado, C. C. Go, J. Shapira, A. C. Lall, and B. G. Domb, “Mid- to Long-Term Outcomes of Hip Arthroscopy: A Systematic Review,” Arthroscopy 37, no. 3 (2021): 1011–1025, https://doi.org/10.1016/j.arthro.2020.10.001.

[3] A. Habib, C. E. Haldane, S. Ekhtiari, et al., “Pudendal Nerve Injury Is a Relatively Common but Transient Complication of Hip Arthroscopy,” Knee Surgery, Sports Traumatology, Arthroscopy 26, no. 3 (2018): 969–975, https://doi.org/10.1007/s00167-017-4783-4.

[4] L. Haipeng, L. Ji, Z. Juanli, et al., “Portal Setup: The Key Point in the Learning Curve for Hip Arthroscopy Technique,” Orthopaedic Surgery 13, no. 6 (2021): 1781–1786.

[5] J. C. Brand, M. J. Rossi, and J. H. Lubowitz, “Hip Arthroscopy Complications Are Rare, but There Is Room for Improvement,” Arthroscopy 35, no. 5 (2019): 1297–1299.

[6] B. U. Nwachukwu, E. D. McFeely, A. Y. Nasreddine, J. A. Krcik, J. Frank, and M. S. Kocher, “Complications of Hip Arthroscopy in Children and Adolescents,” Journal of Pediatric Orthopedics 31, no. 3 (2011): 227–231, https://doi.org/10.1097/BPO.0b013e31820cadc5.

[7] A. E. Wininger, O. Mei-Dan, T. J. Ellis, et al., “Post-Related Complications in Hip Arthroscopy Are Reported Significantly Greater in Prospective Versus Retrospective Literature: A Systematic Review,” Arthroscopy 38, no. 5 (2022): 1658–1663, https://doi.org/10.1016/j.arthro.2021.11.045.

[8] C. Dippmann, K. Thorborg, O. Kraemer, S. Winge, and P. Hölmich, “Symptoms of Nerve Dysfunction After Hip Arthroscopy: An Under-Reported Complication?,” Arthroscopy 30, no. 2 (2014): 202–207.

[9] G. Merrell, M. Medvecky, J. Daigneault, and P. Jokl, “Hip Arthroscopy Without a Perineal Post: A Safer Technique for Hip Distraction,” Arthroscopy 23, no. 1 (2007): 1–3, https://doi.org/10.1016/j.arthro.2006.07.012.

[10] A. L. Schaver, N. Mattingly, N. A. Glass, M. C. Willey, and R. W. Westermann, “Hip Arthroscopy With and Without A Perineal Post: A Comparison of Early Postoperative Pain,” Arthroscopy 37, no. 9 (2021): 2840–2845, https://doi.org/10.1016/j.arthro.2021.03.045.

[11] K. L. Welton, T. Garabekyan, M. J. Kraeutler, et al., “Effects of Hip Arthroscopy Without a Perineal Post on Venous Blood Flow, Muscle Damage, Peripheral Nerve Conduction, and Perineal Injury: A Prospective Study,” American Journal of Sports Medicine 47, no. 8 (2019): 1931–1938, https://doi.org/10.1177/0363546519849663.

[12] A. P. Salas, J. Mazek, D. Araujo-Reyes, M. Gonzalez-Campos, A. Castillo-Trevizo, and J. Misael Garcia, “The Tutankhamun Technique in Hip Arthroscopy,” Arthroscopy Techniques 7, no. 11 (2018): e1167–e1171, https://doi.org/10.1016/j.eats.2018.07.014.

[13] R. C. Kollmorgen, T. Ellis, B. D. Lewis, and J. D. Harris, “ Achieving Post-Free Distraction in Hip Arthroscopy With a Pink Pad Patient Positioning Device Using Standard Hip Distraction Tables,” 8, no. 4 (2019): e363–e368, https://doi.org/10.1016/j.eats.2018.11.013.

[14] A. K. Perry, S. Gursoy, H. Singh, A. S. Vadhera, N. Mehta, and J. Chahla, “The Pink Pad: A Method of Post-Free Distraction During Hip Arthroscopy,” Arthroscopy Techniques 10, no. 8 (2021): e1897–e1902.

[15] A. P. Salas, E. Mendez-Perez, J. Mazek, H. Velasco-Vazquez, and A. Castillo-Trevizo, “The Yoga Mat Technique in Postless Hip Arthroscopy,” Arthroscopy Techniques 10, no. 6 (2021): e1525–e1530, https://doi.org/10.1016/j.eats.2021.02.020.

[16] A. Aprato, D. C. Secco, A. D'Amelio, E. Grosso, and A. Massè, “Nailing Femoral Shaft Fracture With Postless Distraction Technique: A New Technique Enabled by Shape-Conforming Pad,” Journal of Orthopaedics and Traumatology 22, no. 1 (2021): 14, https://doi.org/10.1186/s10195-021-00573-z.

[17] A. Aprato, G. Parisi, A. D'Amelio, et al., “ Postless Hip Traction Table for Combined Femoral and Pelvic Fractures,” 36, no. 2 (2021): 205–208.

[18] X. Flecher, J. Dumas, and J. N. Argenson, “Is a Hip Distractor Useful in the Arthroscopic Treatment of Femoroacetabular Impingement?,” Orthopaedics & Traumatology, Surgery & Research 97, no. 4 (2011): 381–388.

[19] O. Mei-Dan, M. J. Kraeutler, T. Garabekyan, et al., “Hip Distraction Without a Perineal Post: A Prospective Study of 1000 Hip Arthroscopy Cases,” American Journal of Sports Medicine 46, no. 3 (2018): 632–641.

[20] Y. Wang, H. Yu, L. Wang, J. Zhang, M. Wang, and C. Li, “Postless Distraction Technique With no Additional Equipment in Hip Arthroscopy,” Arthroscopy Techniques 13, no. 6 (2024): 102963, https://doi.org/10.1016/j.eats.2024.102963.

[21] C. M. Larson, “Editorial Commentary: Minimizing Traction Force and Time as Well as Application of Specific Technical Pearls Might Trump the Importance of Choosing Between Post or Postless Hip Arthroscopy With Regards to Complications,” Arthroscopy 39, no. 3 (2023): 748–750.

[22] M. L. Jimenez, M. Haneda, and C. Pascual-Garrido, “The Hip Arthroscopy Post-Less Procedure Impingement (HAPPI) Technique: Achieving Distraction With Standard Hip Tables at Zero Additional Cost,” Arthroscopy Techniques 9, no. 11 (2020): e1697–e1701.

[23] Y. Zhang, Y. Li, J. Chen, et al., “Changes in Cerebral Hemodynamics During Gynecological Laparoscopic Surgery in the Trendelenburg Position,” Journal of Clinical Anesthesiology 31, no. 5 (2015): 436–438.

[24] A. E. Wininger, M. J. Kraeutler, H. Goble, J. Cho, O. Mei-Dan, and J. D. Harris, “The Physics of Postless Hip Arthroscopy,” Arthroscopy Techniques 13, no. 10 (2024): 103077, https://doi.org/10.1016/j.eats.2024.103077.

[25] C. W. Parkes, J. Featherall, M. G. CT, et al., “Association of Postless Distraction in Hip Arthroscopy With Decreased Postoperative Groin Numbness,” American Journal of Sports Medicine 51, no. 13 (2023): 3447–3453, https://doi.org/10.1177/03635465231201607.

[26] D. C. O'Neill, J. Featherall, S. B. Dowdle, et al., “Postless Hip Distraction Systems Decrease the Amount of Traction Force Needed to Obtain Adequate Hip Distraction Versus a Conventional Post Hip Distractor,” Arthroscopy 39, no. 3 (2023): 740–747, https://doi.org/10.1016/j.arthro.2022.10.009.

[27] Y.-d. Wu, K.-k. Yu, C.-b. Li, et al., “Choice of Indications and Contraindications for Hip Arthroscopy,” Orthopedic Journal of China 30, no. 5 (2022): 431–435.

[28] S. Chawla, M. F. Githens, and M. S. Hagen, “Safe Distraction Technique for Hip Arthroscopy in a Polytraumatized Patient With Pelvic, Acetabular, and Ankle Fractures: A Case Report,” JBJS Case Connector 10, no. 3 (2020): e20.00111.

[29] W. M. Meek, P. F. Abraham, M. P. Kucharik, et al., “Limitations of Postless Hip Arthroscopy for a Patient With Coxa Profunda: A Case Report,” JBJS Case Connector 11, no. 1 (2021): e20.00347.

[30] R. Kollmorgen, “Editorial Commentary: Post-Free Arthroscopy Reduces Complications and Pain: To Post or Not to Post? Is That Still a Question?,” Arthroscopy 37, no. 9 (2021): 2846–2847.

[31] M. J. Kraeutler, S. M. Fasulo, I. M. Dávila Castrodad, et al., “A Prospective Comparison of Groin-Related Complications After Hip Arthroscopy With and Without a Perineal Post,” American Journal of Sports Medicine 51, no. 1 (2023): 155–159.

[32] J. J. Telleria, M. R. Safran, A. H. Harris, et al., “Risk of Sciatic Nerve Traction Injury During Hip Arthroscopy—Is It the Amount or Duration? An Intraoperative Nerve Monitoring Study,” Journal of Bone and Joint Surgery. American Volume 94, no. 22 (2012): 2025–2032.

[33] Y. Wang, M. Wang, L. Wang, et al., “Clinical Outcomes of Hip Arthroscopy Without a Perineal Post,” Academic Journal of Chinese PLA Medical School 43, no. 11 (2022): 1118–1122.

[34] Y. Yin, S. Xue, X. Zhang, et al., “The Traction Force of the Pulled Limb in Hip Arthroscopic Surgery Is Determined by Stiffness Coefficient Which Is Significantly Related to Muscle Volume,” Knee Surg Sports Traumatol Arthroscopy 31, no. 7 (2023): 1433–7347.

[35] N. G. Girardi, M. J. Kraeutler, C. Keeter, et al., “During Postless Hip Arthroscopy, Male Patients, High Body Mass Index, Low Beighton Scores, and Limited Range of Motion Require High Traction Force,” Arthroscopy 40, no. 4 (2024): 1136–1142.

[36] J. Zhu, Y. Wei, C.-b. Li, et al., “Nursing Key Points of Hip Arthroscopy With Traction in Supine Position,” Orthopedic Journal of China 30, no. 5 (2022): 478–480.

[37] A. P. Decilveo, M. J. Kraeutler, J. Dhillon, et al., “Postless Arthroscopic Hip Preservation Can Be Adequately Performed Using Published Techniques,” Arthroscopy, Sports Medicine, and Rehabilitation 5, no. 1 (2023): e273–e280.

[38] D. R. Woodard, J. A. Richards, K. Knake, et al., “Patient Positioning for Postless Hip Arthroscopy,” Arthroscopy Techniques 13, no. 6 (2024): 102969.

[39] W. Z. Wysham, K. H. Kim, J. M. Roberts, et al., “Obesity and Perioperative Pulmonary Complications in Robotic Gynecologic Surgery,” American Journal of Obstetrics and Gynecology 213, no. 1 (2015): e1–e7.

[40] C. Arvizo, S. T. Mehta, and A. Yunker, “Adverse Events Related to Trendelenburg Position During Laparoscopic Surgery: Recommendations and Review of the Literature,” Current Opinion in Obstetrics & Gynecology 30, no. 4 (2018): 272–278.

[41] B. Juul-Kristensen, K. Schmedling, L. Rombaut, et al., “Measurement Properties of Clinical Assessment Methods for Classifying Generalized Joint Hypermobility-Asystematic Review,” American Journal of Medical Genetics. Part C, Seminars in Medical Genetics 175, no. 1 (2017): 116–147.

[42] M. Ellenrieder, T. Tischer, R. Bader, et al., “Patient-Specific Factors Influencing the Traction Forces in Hip Arthroscopy,” Archives of Orthopaedic and Trauma Surgery 137, no. 1 (2017): 81–87.

[43] X. Ding, “Effects of General Anesthesia and Peripheral Nerve Block on Elderly Patients With Hip Fractures,” China Modern Doctor 54, no. 29 (2016): 124–126.

[44] D. Chu, Y. Cai, C. Sun, et al., “A Discussion on the Correlation Between the X-Ray Sign Analysis and Clinical Application of Femoroacetabular Impingement Syndrome,” Journal of Binzhou Medical University 38, no. 5 (2015): 356–359.

[45] J. Xue, D. Chu, J.-l. Zhu, et al., “An Analysis on Common Complications of Hip Arthroscopy,” Orthopedic Journal of China 30, no. 5 (2022): 456–459.

[46] J. Moran and A. E. Jimenez, “Editorial Commentary: Postless Hip Arthroscopy May Help Optimize Outcomes, but Use of a Post Is Acceptable and Is Indicated in Select Cases,” Arthroscopy 41, no. 3 (2025): 657–659, https://doi.org/10.1016/j.arthro.2024.05.004.

[47] Q. Zhang and H. Pan, “A Retrospective Study on Traction-Related Complications in 105 Cases of Hip Arthroscopic Surgery,” Chinese Journal of Bone and Joint Surgery 12, no. 2 (2019): 131–134.

[48] J. Zhu, X. Chen, C. Shen, et al., “Short-Term Efficacy Observation of Dislocation Surgery in the Treatment of Hip Impingement Syndrome,” Chinese Journal of Surgery 52, no. 12 (2014): 912–914.

[49] Y.-f. Jiang, C. Sun, W. Sang, et al., “Hip Arthroscopic Treatment of Femoroacetabular Impingement Syndrome,” Orthopedic Journal of China 24, no. 18 (2016): 1679–1682.

[50] V. Khanna, A. Harris, F. Farrokhyar, et al., “Hip Arthroscopy:Prevalence of Intra-Articular Pathologic Findings After Traumatic Injury of the Hip,” Arthroscopy 30, no. 3 (2014): 299–304.

RIGHTS & PERMISSIONS

2026 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.