An Anatomic Arthroscopic Description of the Hip Capsular

Ligaments for the Hip Arthroscopist

Jessica J. M. Telleria, B.S., Derek P. Lindsey, M.S., Nicholas J. Giori, M.D., Ph.D.,
and Marc R. Safran, M.D.

Purpose: To examine and describe the normal anatomic intra-articular locations of the hip capsular
ligaments in the central and peripheral compartments of the hip joint. Methods: Eight paired
fresh-frozen human cadaveric hips (mean age, 73.3 years) were carefully dissected free of soft tissue
to expose the hip capsule. Needles were placed through the capsule along the macroscopic borders
of the hip capsular ligaments. Arthroscopy was performed on each hip, and the relations of the
needles, and thus the ligaments, to the arthroscopic portals and other soft-tissue and osseous
landmarks in the hip were recorded by use of a clock-face reference system. Results: The iliofemoral
ligament (ILFL) ran from 12:45 to 3 o’clock. The ILFL was pierced by the anterolateral and anterior
portals just within its lateral and medial borders, respectively. The pubofemoral ligament was located
from the 3:30 to the 5:30 clock position; the lateral border was at the psoas-U perimeter, and the
medial border was at the junction of the anteroinferior acetabulum and the cotyloid fossa. The
ischiofemoral ligament (ISFL) ran from the 7:45 to the 10:30 clock position. The posterolateral portal
pierced the ISFL just inside its superior/lateral border, and the inferior/lateral border was located at
the posteroinferior acetabulum. In the peripheral compartment the lateral ILFL and superior/lateral
ISFL borders were in proximity to the lateral synovial fold. The medial ILFL and lateral pubofemoral
ligament borders were closely approximated to the medial synovial fold. Conclusions: The hip
capsular ligaments have distinct and consistent arthroscopic locations within the hip joint and are
associated with clearly identifiable landmarks in the central and peripheral compartments. The
standard hip arthroscopy portals are closely related to the borders of the hip capsular ligaments.
Clinical Relevance: These findings will help orthopaedic surgeons know which structures are being
addressed during arthroscopic surgery and may help in the development of future hip procedures.

A lthough the first report of direct arthroscopic vi-

sualization of the hip joint appeared in 1931,1
clinical use of hip arthroscopy did not gain momentum
until the 1980s. Procedures performed arthroscopi-
cally about the hip include bony recontouring proce-
dures, debridement and repair of labral tears and chon-
dral lesions, and hip-stabilizing operations.
Early hip arthroscopists reported difficulties explor-
ing the whole joint, visualizing less than one-third of
the femoral head and acetabulum.2,3 Subsequently, in

From the Stanford University School of Medicine (J.J.M.T.), Stanford; Veterans Affairs Palo Alto Health Care System (D.P.L., N.J.G.),
Palo Alto; and Department of Orthopaedic Surgery, Stanford University School of Medicine (N.J.G., M.R.S.), Redwood City, California,
U.S.A.
Supported by the Office of Research and Development (Rehabilitation R&D Service), Department of Veterans Affairs, and Stanford
University Department of Orthopaedic Surgery Internal Research Grant and Stanford University School of Medicine Medical Scholars
Research Grants. Stanford Sports Medicine receives support from Smith & Nephew Endoscopy, ConMed Linvatec, and Ossur. M.R.S. is a
consultant for Ross Creek Medical, Ferring Pharmaceuticals, Cool Systems, Biomimetica, and Arthrocare.
Received February 3, 2010; accepted January 6, 2011.
Address correspondence to Marc R. Safran, M.D., Department of Orthopaedic Surgery, Stanford University, 450 Broadway St, M/C 6342,
Redwood City, CA 94063, U.S.A. E-mail: msafran@stanford.edu
© 2011 by the Arthroscopy Association of North America
0749-8063/1092/$36.00
doi:10.1016/j.arthro.2011.01.007

628 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 27, No 5 (May), 2011: pp 628-636
 ARTHROSCOPIC HIP CAPSULOLIGAMENTOUS ANATOMY
1986 Eriksson et al.4 determined that good visualiza-
tion of the hip joint could be achieved with 300 to 500
N of distraction force in an anesthetized patient;
shortly thereafter, several surgeons presented their
experiences with hip arthroscopy.5-7 Since then a
number of studies have reviewed the arthroscopic
anatomy of the hip in detail.8-13 These authors identi-
fied and described the soft-tissue and osseous features
of the central and peripheral compartments and the
peritrochanteric space. Dvorak et al.9 and, later,
Dienst et al.8 noted that the iliofemoral ligament
(ILFL) and ischiofemoral ligament (ISFL) could be
identified as thickenings in the capsule; however, the
individual fibers and exact location of the ligaments
were difficult to specifically delineate arthroscopi-
cally. Several authors described the anatomic location,
trajectory, and safety of the standard and accessory
hip arthroscopy portals.14,15 Although these studies
provided excellent reviews of the relation between the
portals and relevant neurovascular and muscular struc-
tures, the hip capsular ligaments were discussed only
in generalized terms.
At present, hip arthroscopy routinely incorporates
capsulotomies and capsulectomies as part of the ar-
throscopic procedure.16-20 These capsuloligamentous
incisions are often left unrepaired and may potentially
compromise the integrity of the hip capsular liga-
ments. To highlight this point, recently, several re-
ports have recognized instability after hip arthroscopy
and recurrent instability as potential sequela of these
procedures.21-23 Furthermore, the hip ligaments can be
damaged during traumatic and atraumatic hip sublux-
ation and dislocation.24-29 There could potentially be
long-term degenerative consequences if the ligaments
are ignored, attenuated, or overzealously resected.
Moreover, some surgeons close or repair their capsu-
lotomies, which may over-tighten the ligaments of the
hip, the consequences of which are unclear.
With the increase in hip-related arthroscopic proce-
dures and the growing interest in the function and
pathology of the nonarthritic hip, there is a need for a
more precise understanding of arthroscopic hip anat-
omy for the surgeon. Therefore the purpose of this
study was to describe the normal arthroscopic anat-
omy of the hip capsular ligaments in the central and
peripheral compartments that the orthopaedic surgeon
may expect to encounter at the time of surgery. We
hypothesize that from an arthroscopic standpoint, the
hip capsular ligaments, as well as other significant
structures, will have distinct and consistent relations
to the standard hip arthroscopy portals and ar-
throscopic landmarks about the hip.
629
METHODS
Experimental Setup
This study used 8 paired fresh-frozen human ca-
daveric hips from 4 cadavers that included the en-
tire pelvis and both complete femurs (mean age at
time of death, 73.3 ⫾ 10.7 years; range, 61 to 88
years; 2 male and 2 female specimens). The exclu-
sion criterion was a known history of previous
trauma, disease, or surgical procedure affecting the
hip. Each specimen was harvested with the muscu-
lature, ligaments, and joint capsule intact as a hemi-
corpse and stored at –20°C until testing. The spec-
imens were thawed for approximately 12 to 24
hours at room temperature (18°C). After thawing,
all periarticular skin and musculature were meticu-
lously dissected to expose the intact underlying hip
capsular ligaments. Each ligament was carefully
cleaned of non-ligamentous soft tissue and left in
situ. Careful examination was performed to identify
the exact origin, insertion, course, and borders of
the ILFL, pubofemoral ligament (PFL), and ISFL,
and the perimeters were outlined with a surgical
marking pen. Throughout preparation and testing,
the specimens were irrigated and wrapped with
moist towels to prevent tissue desiccation.
The pelvis was stabilized in the supine position in a
custom-made metal fixture with threaded Steinmann
pins. A transepicondylar traction pin was placed
through the distal femur, and the pin was hooked into
a custom-made traction system. The pelvic fixture and
traction device were secured to a sturdy table by use of
heavy-duty C-clamps.
Eighteen-gauge syringe needles were inserted through
the capsule along the outlined borders of the hip
ligaments at the following locations: the medial and
lateral borders of the ILFL, the medial and lateral
borders of the PFL, and the superior/lateral and infe-
rior/medial borders of the ISFL entering the central
and peripheral compartments (Fig 1). An additional
needle was placed at the lateral-most point of the
acetabulum to serve as a reference point.
The acetabulum was mapped into 12 sectors like a
clock face by use of previously described methodol-
ogy18,30-33; III o’clock was anterior, VI o’clock was
inferior at the middle of the transverse acetabular
ligament, IX o’clock was posterior, and XII o’clock
was lateral. In the peripheral compartment, the medial
synovial fold (MSF) and lateral synovial fold (LSF)
were used as reference points.
630 J. J. M. TELLERIA ET AL.
FIGURE 1. Annotated photograph showing a right acetabulum in
situ from 1 cadaveric specimen. The needles demarcate the borders
of the hip capsular ligaments. The roman numerals represent hours
on a clock face: III o’clock is anterior, VI o’clock is inferior, IX
o’clock is posterior, and XII o’clock is lateral. (a, ILFL lateral
border; b, ILFL medial border; c, PFL lateral border; d, PFL medial
border; e, ISFL inferior/medial border; f, ISFL superior/lateral bor-
der.) (Courtesy of Marc R. Safran, M.D.)
Arthroscopy
Hip arthroscopy on all specimens was performed by
the supine approach by the senior author, an experi-
enced hip arthroscopist. Traction was applied to dis-
tract the hip joint approximately 1 cm, as confirmed
by fluoroscopic imaging. An 18-gauge spinal needle
was used to penetrate the capsule, and the hip joint
was distended with saline solution by use of a gravity
flow system. The anterolateral portal (ALP) was used
as the introductory portal as is customary during hip
arthroscopy procedures. Under fluoroscopic guidance,
the spinal needle, a guidewire, and finally, a 5-mm
cannulated trocar and sheath were introduced into the
joint to establish the portal; fluoroscopy was used to
confirm that the portal was in the same position as is
observed during routine hip arthroscopy. Under direct
arthroscopic visualization from the ALP, the anterior
portal (AP) and posterolateral portal (PLP) were es-
tablished in a similar fashion. Standard 4.0-mm video-
articulated arthroscopes with 30° and 70° lenses were
used to visualize the entire joint.
Arthroscopy of the central compartment was per-
formed first with traction applied with the hip posi-
tioned at 0° of flexion, at 0° of abduction, and in
neutral rotation. The locations of the needles, and
therefore the borders of the hip capsular ligaments,
were qualitatively and quantitatively recorded relative
to each other and to common arthroscopic landmarks.
When 2 structures were within a few millimeters of
each other, precise measurements could be docu-
mented with a laser-etched probe of known dimen-
sions. However, because acetabular size varies be-
tween hips, and long curved measuring devices are not
generally available or technically applicable, the ace-
tabular clock-face system was used because it allowed
for standardization of ligament position regardless of
distance between structures. Bony landmarks were
used, such as the inferior margin of the articular sur-
face at the cotyloid fossa and the psoas-U, the recess
of the anterior acetabulum corresponding to the more
superficial psoas tendon.34-36 Digital photography and
video recording were also performed to maintain a
permanent record.
Once all measurements in the central compartment
were recorded, traction was released and the hip was
stabilized in 30° of flexion. Arthroscopy was per-
formed in the peripheral compartment, and measure-
ments were recorded.
RESULTS
An insufficiency fracture occurred in 1 hip speci-
men halfway through the experiment; data collected
before the fracture are reported in this study. All
reported distances to the arthroscopic portals were
measured to the perimeter of the 5-mm cannulas;
therefore, the additional 2.5 mm to the center of the
cannula is not included.
Portals
The clock-face locations and relations of the ALP,
PLP, and AP to the hip capsular ligaments are re-
ported in Table 1 and depicted in Fig 2.
Iliofemoral Ligament
The divergence of the ILFL medial and lateral arms
occurred distal to the joint line, and the individual
arms could not be visualized arthroscopically. In the
central compartment the ILFL lateral border was lat-
eral to the ALP and the medial border was medial to
the AP; both portals pierced the ligament (Figs 2 and
3, Table 2). In the peripheral compartment the ILFL
lateral border was anterior to the LSF at the level of
the head and neck junction and the medial border was
 ARTHROSCOPIC HIP CAPSULOLIGAMENTOUS ANATOMY
TABLE 1. Arthroscopic Location of Standard Portals in Central Compartment
Portal Relation
Anterolateral Pierces ILFL just inside lateral border
Posterolateral Pierces ISFL just inside superior/lateral border
Anterior Pierces ILFL just inside medial border
NOTE. Distances were measured from the perimeter of the 5.0-mm cannulas.
lateral to the MSF at the level of the zona orbicularis
(Table 3).
Pubofemoral Ligament
In the central compartment the PFL lateral border
was adjacent to the edge of the psoas-U and the medial
border was near the junction of the anteroinferior
acetabulum and the cotyloid fossa (Figs 2 and 4, Table
2). In the peripheral compartment the PFL lateral
border was lateral to the MSF at the level of the zona
orbicularis and the medial border was not associated
with a consistent arthroscopic landmark (Table 3).
FIGURE 2. The average locations of the hip capsular ligaments
and standard hip arthroscopy portals on the acetabular clock face in
a right hip. The roman numerals represent hours on a clock face: III
o’clock is anterior, VI o’clock is inferior, IX o’clock is posterior,
and XII o’clock is lateral. The larger dots represent the hours of a
clock face and the small dots, the half hour. The thick red lines
represent the average capsular entry site of the respective ar-
throscopic portals into the central compartment; the PLP, ALP, and
AP all pierce their respective hip capsular ligament just inside the
border of the ligament. Variations in the ligament attachments are
not shown in this figure to simplify understanding. (Courtesy of
Marc R. Safran, M.D.)
631
Distance to Ligament Border Clock Face Position
[Mean ⫾ SD (Range)] (mm) [Mean (Range)]
1.1 ⫾ 1.6 (0-3) 1:00 (12:30-1:30)
5.3 ⫾ 5.8 (0-15) 10:30 (9:30-11:15)
1.5 ⫾ 1.8 (0-5) 3:00 (2:30-3:00)
Ischiofemoral Ligament
In the central compartment the ISFL inferior/medial
border was near the most posteroinferior aspect of the
acetabulum and the superior/lateral border was pos-
teromedial to the PLP; the PLP pierced the ISFL (Figs
2 and 5, Table 2). In the peripheral compartment the
ISFL inferior/medial border was not associated with a
consistent arthroscopic landmark and the superior/
lateral border was posterior to the LSF at the level of
the head and neck junction (Table 3).
The individual fibers of the ILFL, PFL, and ISFL
could not be discerned arthroscopically in any speci-
men; however, through localization of the needles, the
exact locations of the ligaments could be determined.
FIGURE 3. Arthroscopic image of the central compartment as seen
from the PLP with a 70° arthroscope. The ALP trocar is a few
millimeters away from the lateral border of the ILFL. (12, 12-
o’clock needle at straight lateral position; L, ILFL lateral border;
FH, femoral head.) (Courtesy of Marc R. Safran, M.D.)
632 J. J. M. TELLERIA ET AL.

TABLE 2. Arthroscopic Location of Hip Capsular Ligaments in Central Compartment

Distance to Landmark Clock Face Position
Ligament Landmark [Mean ⫾ SD (Range)] (mm) [Mean (Range)]

Lateral ILFL Just lateral to ALP (landmark), pierced by portal 1.1 ⫾ 1.6 (0-3) 12:45 (12:30-1:30)
Medial ILFL Just medial to AP (landmark), pierced by portal 1.5 ⫾ 1.8 (0-5) 3:00 (2:30-3:00)
Lateral PFL Adjacent to psoas-U (landmark) 0.4 ⫾ 1.1 (0-3) 3:30 (2:30-4:45)
Medial PFL At junction (landmark) of anteroinferior 1.0 ⫾ 1.9 (0-5) 5:30 (5:00-6:00)
acetabulum and cotyloid fossa
Inferior/medial ISFL Near most posteroinferior aspect of acetabulum 5.5 ⫾ 4.2 (0-10) 7:45 (7:00-9:30)
(landmark)
Superior/lateral ISFL Border is just posteromedial to PLP (landmark), 5.3 ⫾ 5.8 (0-15) 10:30 (9:30-11:15)
pierced by portal

NOTE. Distances were measured from the perimeter of the 5.0-mm cannulas.

DISCUSSION With the marked increase in interest in the nonar-

thritic hip, the need for a concrete understanding of
This past decade has seen growing interest in less arthroscopic hip anatomy is clear. Yet, in our review
invasive joint-preservation surgery of the hip and a of the English-language literature, no study to date has
significant increase in the arthroscopic diagnosis and described the precise arthroscopic anatomy of the hip
treatment of nonarthritic hip disorders. This interest capsular ligaments or their relations to instrumentation
and rapid growth has been fueled by advances in or other pertinent soft-tissue and osseous landmarks in
arthroscopic and minimally invasive techniques, the the hip. Because the hip capsular ligaments are known
development of hip-specific instrumentation, and im- to contribute to hip stability38 and can potentially be
proved imaging and diagnostic modalities. Notably, in compromised during athletic activity,25-29,37,39 in hy-
addition to capsular injury associated with traumatic
dislocation and subluxation,25,26,29 atraumatic hip in-
stability and capsular laxity are being increasingly
recognized as significant sources of disability, espe-
cially in certain athletic populations.24,27,28,37 As a
result, indications for hip arthroscopy are growing,
and procedures such as debridement and repair of
labral tears and chondral lesions, bony recontouring
procedures, and even hip capsular plication are now
commonly performed by experienced hip arthrosco-
pists.

TABLE 3. Arthroscopic Location of Hip Capsular

Ligaments in Peripheral Compartment
Distance to Landmark
[Mean ⫾ SD (Range)]
Ligament Landmark (mm)

Lateral ILFL Anterior to LSF (landmark) at 3.1 ⫾ 3.8 (0-10)

level of head and neck
junction
Medial ILFL Lateral to MSF (landmark) at
level of zona orbicularis
Lateral PFL Lateral to MSF (landmark) at
level of zona orbicularis
Medial PFL No associated landmark
Inferior/medial No associated landmark
ISFL
Superior/lateral Posterior to LSF (landmark) at
ISFL level of head and neck
junction
6.0 ⫾ 5.0 (0-14)
FIGURE 4. The central compartment as viewed from the ALP with
6.0 ⫾ 4.9 (0-14) a 70° arthroscope. The PFL lateral border is closely approximated
to the psoas-U, and the PFL medial border is at the junction of the
— anteroinferior acetabulum and the cotyloid fossa. The long dashed
— line represents the anterior and then distal margin of the anterior
acetabulum, and the dotted line represents the anterior border of the
11.7 ⫾ 5.8 (0-17)
acetabulum at the indentation, often called the psoas-U. (CF,
cotyloid fossa; FH, femoral head; L, PFL lateral border; M, PFL
medial border.) (Courtesy of Marc R. Safran, M.D.)
 ARTHROSCOPIC HIP CAPSULOLIGAMENTOUS ANATOMY
FIGURE 5. Arthroscopic image of the PLP and the needles de-
marcating both borders of the ISFL, as seen from the ALP with a
70° arthroscope. The ISFL superior/lateral border is adjacent to the
PLP. (S/L, ISFL superior/lateral border; I/M, ISFL inferior/medial
border; FH, femoral head.) (Courtesy of Marc R. Safran, M.D.)
perlaxity conditions,40,41 or during arthroscopic pro-
cedures,21,23 a better understanding of the locations
and relations of the ligaments is of clinical impor-
tance.
The ILFL and ISFL were best visualized with the
70° arthroscope from the PLP. Several studies noted
that the ILFL and ISFL could be identified as thick-
enings in the capsule8,9; our findings are in agreement
with these authors and further specify the location of
these ligaments. The PFL was best visualized with the
70° arthroscope from the AP and ALP. In the periph-
eral compartment, the PFL lateral border is located
slightly lateral to the MSF; the ILFL medial border is
also just lateral to the MSF, although the ILFL travels
laterally from the fold whereas the PFL courses me-
dially. Interestingly, because the ILFL and PFL are
known to blend together on the anterior capsule,38 in
the peripheral compartment the MSF appears to ap-
proximately demarcate the arthroscopic transition
point between these 2 ligaments.
From an arthroscopic standpoint, on the basis of
these findings, just over one-half (approximately 60%)
of the hip capsule that can be addressed arthroscopi-
cally is reinforced by the hip capsular ligaments.
There are 2 major areas of the capsule that are not
covered by these ligaments: the inferior/posteroinfe-
rior aspect in the region of the transverse acetabular
633
ligament, from approximately the 5:30 to 7:45 clock
position, and the lateral aspect, from approximately
the 10:30 to 12:45 clock position. Given their large
size, these areas could potentially have implications
for procedures affecting the capsule, such as capsu-
lotomies, capsular plication, or thermal capsulor-
rhaphy. A smaller area in the anterior acetabulum, at
about the 3-o’clock to 3:30 clock position, also lacked
reinforcement by the hip capsular ligaments. How-
ever, the iliopsoas muscle overlies the hip capsule at
this point, as evidenced by the psoas-U being in the
general vicinity of the 3:30 clock position, and may
provide additional support to the capsule in this area.
Instability after hip arthroscopy is a rare but note-
worthy problem and can be attributed to a number of
factors including excessive acetabular rim trimming,
capsulotomy or capsulectomy, and overzealous labral
resection or lack of adequate labral repair.21 In many
arthroscopic procedures, capsulotomies and capsulec-
tomies are routinely performed.16-20 During hip ar-
throscopy for femoroacetabular impingement, for ex-
ample, capsulotomies and capsular windows are
sometimes made by connecting the AP and ALP to aid
in acetabular rim trimming and labral surgery, as well
as to allow cam lesions to be addressed from the
peripheral compartment.20 On the basis of our find-
ings, an incision between these points would almost
completely transect the ILFL near its acetabular ori-
gin. Because the ILFL is reported to be a primary
stabilizer in external rotation38,42 and contributes to
stability in internal rotation,38 iatrogenic damage, at-
tenuation, or intentional transection may lead to post-
operative complications such as hip instability or dis-
location.21 Highlighting this point are several recent
case reports in which instability after hip arthroscopy
was attributed to violation of the anterior capsule and
ILFL21,23; the instability in both cases resolved with
repair of the anterior capsule, suggesting an important
stabilizing function for this ligament. In addition,
given the proximity of the PFL to the psoas-U, ap-
proaching the psoas tendon from the central compart-
ment during transcapsular release43,44 may render the
PFL nonfunctional if the capsulotomy is extended too
far anteroinferiorly.
Occasionally, smaller capsulotomies and capsulec-
tomies are performed around the arthroscopy cannulas
to allow for greater instrumentation maneuverabil-
ity.18 Our results indicate that ALP capsulotomies
extended anteriorly will likely incise into the body of
the ILFL; AP capsulotomies extended laterally or
inferiorly could violate the ILFL and PFL, respec-
634 J. J. M. TELLERIA ET AL.
tively; and PLP capsulotomies extended posteriorly
may violate the ISFL. These capsuloligamentous in-
cisions are often left unrepaired, and because the hip
capsular ligaments are known to play an important
role in hip stability,38 these procedures may have a
detrimental effect on hip stability. Incision or resec-
tion sites may also serve as a nidus for future capsular
injury; as an example, traumatic full-thickness tear of
the ILFL has been reported in the region of a previous
AP capsulectomy.23
On the basis of these findings, it may be preferable
to avoid capsulotomies and capsulectomies when pos-
sible or to create the smallest possible incision when
capsulotomy is deemed necessary for the completion
of the arthroscopic procedure. When required, inci-
sions extended obliquely in line with the ligamentous
fibers are recommended because they will minimize
the impact on ligamentous macrostructure and, there-
fore, stability. Consideration should be given to cap-
sular repair after significant capsulotomies, particu-
larly in individuals with ligamentous laxity. Further
studies evaluating the effect of capsular and ligamen-
tous compromise on hip stability, including partial
sectioning of the individual hip ligaments, are war-
ranted.
Ligamentous disruption after low-velocity trauma
in athletes has been reported if there is a failure in
normal capsular healing after hip trauma-laxity and,
subsequently, instability may occur.25,26,29 Further-
more, capsular redundancy has been found in patients
with recurrent post-traumatic dislocation37,45,46; in
these cases capsular repair, alone or in combination
with other procedures, was shown to resolve the re-
current instability.45-47 Capsular repair has also been
shown to resolve recurrent instability in patients after
hip arthroscopy21,23,26 and even total hip arthroplasty
through the posterior approach,48,49 further highlight-
ing the importance of the hip capsule. Thus knowing
the exact arthroscopic locations of the hip capsular
ligaments may help identify situations in which cap-
sular repair or plication is prudent, could aid surgeons
in localizing which structures may be deficient or in
need of arthroscopic repair, and may potentially help
minimize complications such as hip subluxation or
dislocation after hip arthroscopy.
Of note, this study focused on the normal ar-
throscopic anatomy of the hip ligaments in neutral
rotation with respect to the AP, ALP, and PLP. As
hip arthroscopy continues to gain popularity, and
surgeons gain more experience with the procedure,
some arthroscopists are adopting a 2-portal ap-
proach or are using alternative portals, such as the
midanterior and modified midanterior portals, to
better address specific hip pathology. Furthermore,
whereas some surgeons, including the senior au-
thor, prefer 30° of flexion to evaluate the peripheral
compartment,43 which was investigated in this
study, others favor 40° to 45° of flexion during their
procedures. The relations of the hip ligaments can
reasonably be expected to change in a consistent
manner with different hip positions, such as in-
creasing flexion or internal rotation, and thus should
be considered by the hip arthroscopist.
Therefore, given that many hip procedures are cur-
rently being performed arthroscopically worldwide,
anatomic and functional descriptions using arthros-
copic methods may aid in the diagnosis and treatment
of hip soft-tissue pathology.
Limitations
Although we believe that this study provides a
comprehensive and detailed evaluation of the ar-
throscopic anatomy of the hip capsular ligaments,
there are a few potential factors that may limit the
generalizability of our data. First, this study only
used 4 cadavers, for a total of 8 hips. As a result,
uncommon ligament variations in anatomy may be
missed in our study or may be inadvertently present.
However, the results are relatively consistent
among the 4 cadaveric specimens. Another limita-
tion is the difficulty in accurately measuring ar-
throscopic distances of more than a few millimeters.
These measurements are partially limited by the hip
arthroscopy equipment that is currently commer-
cially available, because the equipment needs to be
calibrated, flexible, and curved to account for the
3-dimensional relations. In addition, this study only
evaluated the hip in neutral rotation and 0° and 30°
of flexion. Although we achieved our goal of de-
scribing normal arthroscopic anatomy, additional
studies exploring ligamentous anatomy through the
full hip range of motion are advisable to further
describe these ligaments. However, the description
of ligamentous anatomy in the central compartment
is close to the fixed bony attachment of these liga-
ments, and it would not be expected to change as
much as the peripheral definition of the ligaments
with changes in hip position. In addition, the liga-
mentous relations to alternative arthroscopic portals
and in specimens with intact soft-tissue envelopes
would provide additional valuable information.
 ARTHROSCOPIC HIP CAPSULOLIGAMENTOUS ANATOMY
CONCLUSIONS
The hip capsular ligaments have distinct and con-
sistent arthroscopic locations within the hip joint and
are associated with clearly identifiable landmarks in
the central and peripheral compartments. The standard
hip arthroscopy portals are closely related to the bor-
ders of the hip capsular ligaments.
Acknowledgment: The authors thank Alexander H.
Sox-Harris, Ph.D., for assistance in statistical analysis;
Mark Bracken and Smith & Nephew Endoscopy for use of
arthroscopy equipment.
REFERENCES
1. Burman MS. Arthroscopy or the direct visualization of joints:
An experimental cadaver study. Clin Orthop Relat Res 1931;
2001:5-9.
2. Parisien JS. Arthroscopy of the hip. Present status. Bull Hosp
Jt Dis Orthop Inst 1985;45:127-132.
3. Holgersson S, Brattstrom H, Mogensen B, Lidgren L. Arthros-
copy of the hip in juvenile chronic arthritis. J Pediatr Orthop
1981;1:273-278.
4. Eriksson E, Arvidsson I, Arvidsson H. Diagnostic and opera-
tive arthroscopy of the hip. Orthopedics 1986;9:169-176.
5. Dorfmann H. Arthroscopy of the hip. Presse Med 1988;17:
611-612.
6. Glick JM, Sampson TG, Gordon RB, Behr JT, Schmidt E. Hip
arthroscopy by the lateral approach. Arthroscopy 1987;3:4-12.
7. Hawkins RB. Arthroscopy of the hip. Clin Orthop Relat Res
1989:44-47.
8. Dienst M, Godde S, Seil R, Hammer D, Kohn D. Hip arthros-
copy without traction: In vivo anatomy of the peripheral hip
joint cavity. Arthroscopy 2001;17:924-931.
9. Dvorak M, Duncan CP, Day B. Arthroscopic anatomy of the
hip. Arthroscopy 1990;6:264-273.
10. Keene GS, Villar RN. Arthroscopic anatomy of the hip: An in
vivo study. Arthroscopy 1994;10:392-399.
11. Ranawat AS, Kelly BT. Anatomy of the hip: Open and ar-
throscopic structure and function. Oper Tech Orthop 2005;15:
160-174.
12. Sweeney HJ. Arthroscopy of the hip. Anatomy and portals.
Clin Sports Med 2001;20:697-702.
13. Voos JE, Rudzki JR, Shindle MK, Martin H, Kelly BT. Ar-
throscopic anatomy and surgical techniques for peritrochan-
teric space disorders in the hip. Arthroscopy 2007;23:1246.e1-
1246.e6.
14. Byrd JW, Pappas JN, Pedley MJ. Hip arthroscopy: An ana-
tomic study of portal placement and relationship to the extra-
articular structures. Arthroscopy 1995;11:418-423.
15. Robertson WJ, Kelly BT. The safe zone for hip arthroscopy: A
cadaveric assessment of central, peripheral, and lateral com-
partment portal placement. Arthroscopy 2008;24:1019-1026.
16. Sampson TG. Arthroscopic treatment of femoroacetabular im-
pingement. Tech Orthop 2005;20:56-62.
17. Horisberger M, Brunner A, Herzog RF. Arthroscopic treat-
ment of femoroacetabular impingement of the hip: A new
technique to access the joint. Clin Orthop Relat Res 2010;468:
182-190.
18. Philippon MJ, Stubbs AJ, Schenker ML, Maxwell RB, Ganz
R, Leunig M. Arthroscopic management of femoroacetabular
impingement: Osteoplasty technique and literature review.
Am J Sports Med 2007;35:1571-1580.
635
19. Sampson TG. Arthroscopic treatment of femoroacetabular im-
pingement: A proposed technique with clinical experience.
Instr Course Lect 2006;55:337-346.
20. Byrd JW, Jones KS. Arthroscopic femoroplasty in the man-
agement of cam-type femoroacetabular impingement. Clin Or-
thop Relat Res 2009;467:739-746.
21. Matsuda DK. Acute iatrogenic dislocation following hip im-
pingement arthroscopic surgery. Arthroscopy 2009;25:400-
404.
22. Jones CW, Biant LC, Field RE. Dislocation of a total hip
arthroplasty following hip arthroscopy. Hip Int 2009;19:396-
398.
23. Ranawat AS, McClincy M, Sekiya JK. Anterior dislocation
of the hip after arthroscopy in a patient with capsular laxity
of the hip. A case report. J Bone Joint Surg Am 2009;91:
192-197.
24. Epstein DM, Rose DJ, Philippon MJ. Arthroscopic manage-
ment of recurrent low-energy anterior hip dislocation in a
dancer: A case report and review of literature. Am J Sports
Med 2010;38:1250-1254.
25. Moorman CT III, Warren RF, Hershman EB, et al. Traumatic
posterior hip subluxation in American football. J Bone Joint
Surg Am 2003;85:1190-1196.
26. Philippon MJ, Kuppersmith DA, Wolff AB, Briggs KK. Ar-
throscopic findings following traumatic hip dislocation in 14
professional athletes. Arthroscopy 2009;25:169-174.
27. Guanche CA, Sikka RS. Acetabular labral tears with underly-
ing chondromalacia: A possible association with high-level
running. Arthroscopy 2005;21:580-585.
28. Stein DA, Polatsch DB, Gidumal R, Rose DJ. Low-energy
anterior hip dislocation in a dancer. Am J Orthop 2002;31:591-
594.
29. Stiris MG. MR imaging after sports-induced hip dislocations.
Report of three cases. Acta Radiol 2000;41:300-302.
30. Beck M, Kalhor M, Leunig M, Ganz R. Hip morphology
influences the pattern of damage to the acetabular cartilage:
Femoroacetabular impingement as a cause of early osteo-
arthritis of the hip. J Bone Joint Surg Br 2005;87:1012-
1018.
31. Blankenbaker DG, De Smet AA, Keene JS, Fine JP. Classifi-
cation and localization of acetabular labral tears. Skeletal Ra-
diol 2007;36:391-397.
32. Leunig M, Podeszwa D, Beck M, Werlen S, Ganz R. Mag-
netic resonance arthrography of labral disorders in hips with
dysplasia and impingement. Clin Orthop Relat Res 2004:
74-80.
33. Leunig M, Beck M, Woo A, Dora C, Kerboull M, Ganz R.
Acetabular rim degeneration: A constant finding in the aged
hip. Clin Orthop Relat Res 2003:201-207.
34. Maruyama M, Feinberg JR, Capello WN, D’Antonio JA. The
Frank Stinchfield Award: Morphologic features of the acetab-
ulum and femur: Anteversion angle and implant positioning.
Clin Orthop Relat Res 2001:52-65.
35. Vandenbussche E, Saffarini M, Taillieu F, Mutschler C. The
asymmetric profile of the acetabulum. Clin Orthop Relat Res
2008;466:417-423.
36. Vandenbussche E, Saffarini M, Deloge N, Moctezuma JL,
Nogler M. Hemispheric cups do not reproduce acetabular rim
morphology. Acta Orthop 2007;78:327-332.
37. Graham B, Lapp RA. Recurrent posttraumatic dislocation of
the hip. A report of two cases and review of the literature. Clin
Orthop Relat Res 1990:115-119.
38. Martin HD, Savage A, Braly BA, Palmer IJ, Beall DP, Kelly
B. The function of the hip capsular ligaments: A quantitative
report. Arthroscopy 2008;24:188-195.
39. Torry MR, Schenker ML, Martin HD, Hogoboom D, Philip-
pon MJ. Neuromuscular hip biomechanics and pathology in
the athlete. Clin Sports Med 2006;25:179-197.
636 J. J. M. TELLERIA ET AL.
40. Philippon MJ. The role of arthroscopic thermal capsulorrhaphy
in the hip. Clin Sports Med 2001;20:817-829.
41. Bellabarba C, Sheinkop MB, Kuo KN. Idiopathic hip instabil-
ity. An unrecognized cause of coxa saltans in the adult. Clin
Orthop Relat Res 1998:261-271.
42. Fuss FK, Bacher A. New aspects of the morphology and
function of the human hip joint ligaments. Am J Anat 1991;
192:1-13.
43. Ilizaliturri VM Jr., Camacho-Galindo J. Endoscopic treatment
of snapping hips, iliotibial band, and iliopsoas tendon. Sports
Med Arthrosc 2010;18:120-127.
44. Wettstein M, Jung J, Dienst M. Arthroscopic psoas tenotomy.
Arthroscopy 2006;22:901.e1-901.e4.
45. Liebenberg F, Dommisse GF. Recurrent post-traumatic dislo-
cation of the hip. J Bone Joint Surg Br 1969;51:632-637.
46. Schweitzer D, Breyer JM, Cordova M, Fica G. Recurrent
anterior dislocation of the hip. A case report. J Bone Joint Surg
Am 2004;86:581-583.
47. Dall D, Macnab I, Gross A. Recurrent anterior dislocation
of the hip. J Bone Joint Surg Am 1970;52:574-576.
48. Pellicci PM, Bostrom M, Poss R. Posterior approach to total
hip replacement using enhanced posterior soft tissue repair.
Clin Orthop Relat Res 1998:224-228.
49. Clough TM, Hodgkinson JP. Two-stage revision with
pseudocapsular resection for recurrent dislocation of total
hip prostheses. J Arthroplasty 2000;15:1017-1019.