Review Article

Stepwise Safe Access in Hip

Arthroscopy in the Supine Position:
Tips and Pearls From A to Z

David R. Maldonado, MD
Philip J. Rosinsky, MD
Jacob Shapira, MD
Benjamin G. Domb, MD
From American Hip Institute Research
Foundation (Dr. Maldonado,
Dr. Rosinsky, Dr. Shapira, and
Dr. Domb), and American Hip Institute
(Dr. Domb), Des Plaines, IL.
None of the following authors or any
immediate family member has
received anything of value from or has
stock or stock options held in a
commercial company or institution
related directly or indirectly to the
subject of this article: Dr. Maldonado,
Dr. Rosinsky, Dr. Shapira, and
Dr. Domb.
Abstract
Hip arthroscopy is rapidly growing as a treatment with good outcomes
for pathologic conditions such as femoroacetabular impingement
syndrome and labral tears. At the same time, it is one of the most
technically challenging and demanding procedures in orthopaedics
with a technically demanding skill. The first challenge is to safely
access the joint, which requires accurate anatomical knowledge, a
strong sense of spatial orientation, and repeated practice. Iatrogenic
chondrolabral injury has been reported as the most common
complication in hip arthroscopy and most frequently occurs during hip
joint access. As such, basic foundations cannot be overstated. These
complications can be minimized with adequate patient positioning,
reproducible hip joint access techniques, and proper portals
placement. Nonetheless, these three points are perhaps the greatest
hurdles that orthopaedic surgeons face when entering the hip
arthroscopy field. In this review, we outlined a stepwise approach for a
safe access to hip arthroscopy.

Supplemental digital content is

available for this article. Direct URL
citation appears in the printed text and
is provided in the HTML and PDF
versions of this article on the journal’s
Web site (www.jaaos.org).
This study was performed in
accordance with the ethical standards
in the 1964 Declaration of Helsinki.
This study was carried out in
accordance with the relevant
regulations of the US Health
Insurance Portability and
Accountability Act (HIPAA). Details
that might disclose the identity of the
subjects under study have been
omitted. This study was approved by
IRB (IRB ID: 5276).
J Am Acad Orthop Surg 2020;28:
651-659
DOI: 10.5435/JAAOS-D-19-00856
Copyright 2020 by the American
Academy of Orthopaedic Surgeons.
H ip arthroscopy is rapidly
growing as an efficacious
treatment of pathological conditions
such as femoroacetabular impinge-
ment syndrome and labral tears.1
From 2005 to 2010, the number of
arthroscopic hip procedures per-
formed increased by .600% and the
published articles on this topic
increased by .500%.2 Hip arthros-
copy has a technically demanding
skill and is one of the most techni-
cally challenging and demanding
procedures in the field of joint pres-
ervation. Mehta et al2 reported that
the technically demanding skill for
hip arthroscopy was surprisingly
long, requiring over 500 cases within
five years to be considered a high-
volume hip arthroscopy specialist
and to reduce the rate of revision
surgeries.
Arthroscopic surgery entails the
introduction of sharp instruments
into the joint for visualization and
treatment. In the hip, this may cause
iatrogenic injuries to important intra-
articular structures, including the
labrum, the femoral head, and the
acetabular cartilage.3 A systematic
review by Harris et al4 found that the
most commonly reported complica-
tion during hip arthroscopy was
iatrogenic chondrolabral injury.
Appropriate, accurate, and repro-
ducible portal positioning is crucial
to avoiding potentially nonreversible
lesions.5
The basic foundations of hip
arthroscopy including patient posi-
tioning and portal placement are
critical to perform a safe and effective
surgical procedure. The purpose of
this review is to provide surgeons,

August 15, 2020, Vol 28, No 16 651

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Stepwise Safe Access in Hip Arthroscopy
who are making their early steps in
this demanding discipline, with the
“tips and pearls” for safe and con-
sistent access to the central com-
partment of the hip. The authors
present their expertise that they have
accrued throughout their years of
practice.
Patient Positioning
Positioning is the key for any ortho-
paedic procedure, but this is particu-
larly true for hip arthroscopy. Supine
and lateral decubitus positions have
been promoted as effective positions
from which the hip joint can be ac-
cessed. The supine alternative is cur-
rently the most popular position and
is the authors’ preference6 (Figure 1
and Video, Supplemental Digital
Content 1, http://links.lww.com/
JAAOS/A496). Regardless of the
preferred position, sufficient pad-
ding of the patient’s feet is essential
because of the traction force that is
applied during surgery. This reduces
the risk for skin damage and nerve
injury. General anesthesia, spinal, or
epidural anesthesia can be used in
hip arthroscopy. The combination of
general anesthesia and muscle re-
laxants is the authors’s current
preference choice because of (1)
rapid induction and (2) avoiding
waiting for motor and sensory block
resolution, which is extremely
important in postoperative evalua-
tion, especially for surgeries per-
formed in the outpatient setting.7
Hip Arthroscopy With or
Without Perineal Post?
To gain safe access to the hip joint,
adequate distraction of the joint (ie,
ideally . 10 mm) must be achieved.8
Owing to the thick soft-tissue enve-
lope around the joint, this has
traditionally been accomplished
through the use of a specialized
traction table and perineal post. The
use of a perineal post has been
652
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
described for both the supine and
lateral positions.9,10 The force
required to achieve adequate dis-
traction changes throughout the
procedure. Initial distraction force
ranges from 444 N in women to
517 N in men. This force decreases
by an average of 17% after capsu-
lotomy.11 One of the potential
complications of using a perineal
post is damage to the pudendal and
the perineal nerves.12 A systematic
review by Habib et al13 which
included 3,405 hip arthroscopies
found the risk of pudendal nerve
injury to be 1.8%, although all cases
were transient and resolved within
3 months. Potential risk factors for
the development of pudendal nerve
injury were long traction time and
the use of a perineal post.
To minimize the risk of pudendal
nerve and perineal injuries (eg, scro-
tal and labial necrosis as well as vag-
inal tears), some authors have
proposed eliminating the perineal
post.14 This can be achieved
through a variety of methods. Mei-
Dan et al have popularized the
elimination of the perineal post by
demonstrating favorable results with
the introduction of 5
to 15
Tren-
delenburg to the operating table.15
Other solutions share the common-
ality of increasing friction between
the torso and the operating bed,
thereby enabling adequate joint dis-
traction and avoiding the risk for
soft-tissue damage associated with
the use of a perineal post.16
The Trendelenburg
Technique, Why and How?
Once the patient is secured on the
surgical table, the introduction of the
Trendelenburg position serves two
purposes (Figure 2, A and Video,
Supplemental Digital Content 1,
http://links.lww.com/JAAOS/A496).
First, this position decreases the
amount of traction force required
during surgery, thereby reducing the
Journal of the American Academy of Orthopaedic Surgeons
risk of skin and nerve damage.15
Second, when using a perineal post,
the decreased traction force also re-
lieves the pressure between the post
and the perineum, thereby lowering
the risk of injuries caused by direct
pressure.17 Our results on patient
positioning demonstrated a reduc-
tion in perineal pressure of 15.5%,
28%, and 46% at 5
, 10
, and 15
of
Trendelenburg compared with 0
(ie,
no Trendelenburg), respectively,
without compromising the spatial
anatomic perception of the sur-
geon.18 We propose the use of 8
to
10º of Trendelenburg inclination, a
position in which the anterosuperior
iliac spines (ASISs) are level in the
horizontal plane.
Addressing Pelvic Tilt
It is critical for the surgeon to main-
tain adequate spatial orientation
during the entire procedure.19 To
avoid anatomic disorientation, the
pelvis should not be tilted to either
side. This may be accomplished by
adjusting the operating bed so that
the ASISs will be leveled (Video,
Supplemental Digital Content 1,
http://links.lww.com/JAAOS/A496).
The patients position is verified by
assessing the symmetry of the obtu-
rator foramens and the position of
the coccyx relative to the pubic
symphysis, using fluoroscopy.5
Key Points and Pearls
After the patient is secure on the
traction table and before draping, the
authors recommend the following
steps for the final patient positioning
in a reproducible manner:
(1) The arm in the surgical side can
be padded and placed just above
the level of the umbilicus with
90
flexion of the elbow (Figure
2, A and B).
(2) Provided that a perineal post is
used, simultaneously apply
traction to both legs manually to
achieve an even contact

distribution between the peri-
neum and the post.
(3) Establish neutral rotation, ad-
duction against the post and 5

of hip flexion of the surgical leg
while the nonsurgical leg is in
30
of abduction and neutral
rotation (Figure 2).
(4) Apply at least 8
to 10º Tren-
delenburg inclination. To
address the pelvic tilt, the oper-
ating bed is usually placed in an
“airplane away” from the sur-
geon’s side to level the ASISs, as
described previously (Figure 2)
Fluoroscopy, Is It
Necessary?
Radiation exposure is always a con-
cern in hip arthroscopy. It has been
reported that the mean intraoperative
radiation dose to patients in hip
arthroscopy is 12.6 mGy, a value that
is below the threshold for radiation
associated complications.20 Alterna-
tively, the lifetime risk of death
because of malignancy is 0.025% for
the operating room staff because of a
cumulative exposure to radiation.21
According to Smith et al, exposure to
fluoroscopy decreases with time and
practice.19 Although accessing the hip
joint without the use of fluoroscopy
has been described,22 the authors of
this review think fluoroscopy is crit-
ical for reproducing safe access and
diminishing the risk of iatrogenic
damage to the labrum and the artic-
ular cartilage.23 Alternatively, the use
of ultrasonography has been pro-
posed. Although this concept is
potentially promising, the success of
this method is heavily dependent on
the operator’s experience.24
C-arm Location in the
Operating Room
When supine position is selected, the
C-arm can be placed either between
the patient legs or on the nonsurgical
side of the patient, perpendicularly to
August 15, 2020, Vol 28, No 16
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Figure 1
Photograph showing hip arthroscopy with the patient (right hip) in the supine
position using a perineal post.
the operating bed (Figure 2 and
Video, Supplemental Digital Content
1, http://links.lww.com/JAAOS/
A496). The authors find the second
option more convenient and repro-
ducible not only for the purpose of
joint access but also for other parts
of the procedure such as femo-
roplasty and subspine decompres-
sion. This allows the C-arm to move
freely to obtain several views for
bony correction purposes.25
C-arm and Patient Pelvic
Position
As mentioned previously, the authors
modified the supine position of the
patient by applying Trendelenburg to
the operating bed; however, the
C-arm must be cephalically tilted to
avoid obtaining inlet views because
of the angular displacement. This will
provide a true AP view.5
Do Not Get Lost Before You
Even Start! Correcting Pelvic
Rotation
It is critical to obtain a true AP pelvis
view when assessing the hip joint
during an arthroscopic procedure.
When the surgeon attempts to esti-
mate the spinal needle trajectory, the
smallest degree of pelvic rotation can
lead to unnoticed misdirection. To
David R. Maldonado, MD, et al
avoid this, ensure that the pubic
symphysis is displayed in a vertical
position on the monitor. The authors
recommend using this pearl after
each time traction is applied to the
operated leg because it may alter the
position of the pelvis.5,18
Key Points and Pearls
(1) Place the C-arm on the non-
surgical side at an angle that is
perfectly perpendicular to the
patient’s body (Figure 2).
(2) Compensate for the patient’s
Trendelenburg position by
cephalically tilting the C-arm.
(3) Check the patient’s pelvic rota-
tion by obtaining an AP pelvis
view centered on the pubis.
(4) Once pelvic rotation is checked,
move the C-arm forward to the
surgical side and obtain an AP
hip view.
Venting the Hip Joint
Importance of Hip Joint
Venting
Breaking the seal of the hip joint is
vital to successfully accessing the
joint arthroscopically. Venting the
joint neutralizes the normal negative
pressure of the hip joint, thereby
653
Stepwise Safe Access in Hip Arthroscopy

Figure 2

Phtographs showing A, Trendelenburg is applied to the surgical table using a perineal post in preparation to a right hip (*)
arthroscopy. The C-arm (black arrow) is placed on the nonsurgical side of the patient, perpendicularly to the operating bed.
The arm in the surgical side is padded and placed just above the level of the umbilicus with 90
flexion of the elbow (white
arrow). B, From another perspective, the C-arm (black arrow) and arm in the surgical side (white arrow) are shown view in
preparation to a right hip (*) arthroscopy. C, The surgical table has been “airplane” away from the surgical side, right hip (*) in
this case. C-arm (black arrow).

enabling to increase the intra-
articular space without the necessity
of applying an excessive traction
force to the leg.23
Venting Technique
Using the ASIS as a landmark,
advance the spinal needle with the
bevel facing toward the femoral head
until the capsule is reached. A true
“12-O’clock” position can be con-
firmed when the surgeon has a tactile
feeling of reaching the capsule,
although the needle is not over-
lapping the joint (Figure 3 and
Video, Supplemental Digital Content
1, http://links.lww.com/JAAOS/
A496). After confirming the “12-
O’clock” position of the needle
with fluoroscopy, gently perforate
the capsule. The presence of an air-
arthrogram after removing the stylet
confirms that the suction seal of the
joint has been broken. Traction
should then be applied until at least
10 mm of intra-articular space is
gained. The surgeon must keep
in mind that while the venting entry
point serves as a guide for placing the
anterolateral portal, their exact
position will rarely coincide.5
Key Points and Pearls
(1) Check pelvic rotation before
venting.
(2) For venting purposes, use a
small diameter spinal needle.
The authors find that a 18 G ·
3.5-inch pink spinal needle (BD,
Franklin Lakes, NJ) is reliable
for this step.
(3) Pelvic rotation is usually altered
after venting and the initial
application of traction. Re-
checking pelvic rotation is vital.
Hip Arthroscopy Portals
Anterolateral Portal
The anterolateral portal is classically
the first portal to be established in hip
arthroscopy.8 There are two reasons
which make this portal unique when
compared with the others: (1) it is
not performed under direct visuali-
zation as such because the risk of
iatrogenic injury is relatively high
and (2) the location of this portal will
determine the placement of the other
portals, for example, the midanterior
and distal anterolateral accessory
(DALA) portal.
Anatomic References
Traditionally, the greater trochanter
(GT) is commonly used as an ana-
tomic landmark to establish the
anterolateral portal. The antero-
lateral portal is routinely placed 1 to
2 cm anterior and 1 to 2 cm superior
to the tip of the GT.26 However, the
GT location and its relationship to
the hip joint change depending on leg
rotation and traction; furthermore,
the cervico-diaphyseal angle and
neck length also affect GT spatial
location regarding the hip joint. In
addition, in large patients, the
excessive soft-tissue makes GT pal-
pation difficult, leading to misjudg-
ment. The authors have found that
the ASIS is a more reliable bony
landmark (Figure 4 and Video,
Supplemental Digital Content 1,
http://links.lww.com/JAAOS/A496).

654 Journal of the American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

Unlike the GT, the ASIS is unaffected
by leg rotation and its exact location
is more readily identifiable by pal-
pation, irrespective of the patient
size.5 By palpating the two ASIS, the
surgeon gains a spatial understand-
ing of the pelvic sagittal tilt and can
aim the portal placement trajectory
accordingly.
Identify Anterolateral Portal
Position and Trajectory
The trajectory used for venting the
joint serves as a reference for the
creation of the anterolateral portal;
however, the femoral head displaces
inferiorly after venting and distrac-
tion. Consequently, using the same
placement may not fulfill the funda-
mental requirement for the antero-
lateral portal placement as you must
maintain proximity to the femoral
head to retain adequate capsular tis-
sue for closure at the end of the pro-
cedure.23 The anterolateral portal
skin incision is generally 1 to 2 cm
distal to the venting point. For this
step, the 12-O’clock position is the
authors’ work horse starting point to
access the hip joint5 (Video, Sup-
plemental Digital Content 1, http://
links.lww.com/JAAOS/A496).
Identify the 12-O’clock
Position
This point refers to the 12-O’clock
position at the level of the acetabu-
lum (Figure 3). It is the authors’
choice to access the hip joint by
creating the anterolateral portal at
the 12-O’clock position5 (Figure 5
and Video, Supplemental Digital
Content 1, http://links.lww.com/
JAAOS/A496). By entering at this
equidistant point, a perfect intra-
articular perspective is achieved for
any additional portals that are
needed. Fluoroscopy confirms the
target point in the AP view, staying
as close as possible to the femoral
head (Figure 6). The surgeon must
learn how to identify the most
August 15, 2020, Vol 28, No 16
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
anterior and posterior aspect of the
capsule by palpating the capsule
using the spinal needle and con-
firming the position by fluoroscopy.
When the position is confirmed, the
capsule is penetrated, and the
guidewire is introduced, followed by
the corresponding cannulated dilator
and arthroscope (Figure 6 and
Video, Supplemental Digital Content
1, http://links.lww.com/JAAOS/
A496). If required, an axial view
can be obtained with the C-arm to
determine the AP location of the
needle. A critical step during inser-
tion of the cannulated dilator is
levering of the cannula away and
superior to the femoral head to avoid
cartilage scuffing (Video, Supple-
mental Digital Content 1, http://
links.lww.com/JAAOS/A496). The
70
arthroscope is the authors’ pre-
ferred optical device throughout the
entire procedure.
Key Points and Pearls
(1) Check osseous anatomic land-
marks, especially the ASIS.
(2) Identify the 12-O’clock position.
(3) After entering the capsule, turn
the long spinal needle 180
, al-
lowing the bevel to face the
femoral head. This will prevent
potential iatrogenic damage
caused by the sharp side of the
needle (Video, Supplemental
Digital Content 1, http://links.
lww.com/JAAOS/A496).
(4) Lever the cannulated dilator
away from the femur to avoid
cartilage scuffing.
(5) The guidewire must be re-
trieved 1 to 2 cm to prevent its
bending or breaking while using
the cannulated dilator for access.
(6) The arthroscope has sharp and
beveled sides similarly to the spi-
nal needle. The sharp side of the
arthroscope is on the same side as
the light source. When introduc-
ing the arthroscope, ensure that
David R. Maldonado, MD, et al
Figure 3
Photograph showing the 12-O’clock
position at the level of the right
acetabulum in the supine position.
The 3-O’clock, 6-O’clock, and 9-
O’clock positions are also shown.
this side is always facing away
from the femoral head.
(7) Stay “dry” during this phase.
The use of saline without an
outflow portal will compromise
the intra-articular visibility.
Once the second portal (ie,
modified midanterior) has been
established, water inflow may
start (Video, Supplemental Dig-
ital Content 1, http://links.lww.
com/JAAOS/A496).
The Modified Midanterior
Portal
Byrd described the use of the anterior
portal during hip arthroscopy.27 In
an effort to diminish the risk of lat-
eral cutaneous femoral nerve injury
and to accomplish a better angle for
intra-articular work, the midanterior
portal, which is more lateral and
distal than the anterior portal, was
described.28 Different authors have
introduced their variations to the
midanterior portal (modified mid-
anterior portal), also striving to
easily gain access for osseous
655
Stepwise Safe Access in Hip Arthroscopy

Figure 4 into the joint. It is easier to tri-

angulate this way (Video, Sup-
plemental Digital Content 1,
http://links.lww.com/JAAOS/
A496).
(3) This portal is made under direct
arthroscopic visualization; there-
fore, the surgeon should aim to be
as close as possible to the femoral
head. This is an essential step in
preserving the capsule for further
plication or closure.

Distal Anterolateral
Accessory Portal

Photograph showing RH in the supine position. Anterosuperior iliac spine is After completion of the capsulotomy
drawn and marked with the *. AL—12-O’clock—portal; MA portal; DALA portal; P using the anterolateral and the mod-
portal. AL = anterolateral, DALA = distal anterolateral accessory, MA = ified midanterior portal, the decision
midanterior portal, P = posterolateral, RH = right hip of labral treatment should be con-
cluded. Both labral repair and
reconstruction necessitate the place-
Figure 5
ment of anchors in the acetabular
rim. The DALA portal provides the
required “attack angle” because it is
less steep and therefore safer than the
modified midanterior for capsular
elevation and anchor placement.29
The DALA portal has been shown to
decrease the risk of intra-articular
penetration during anchor drilling or
placement.23 In addition, the spatial
relationship and distance relative to
the anterolateral and the modified
midanterior portal should be con-
Photograph showing the right hip showing the ideal location of the 12-O’clock sidered to avoid “cross-hands” dur-
position in the AP view. A, Plastic model. B, Fluoroscopy. ing anchor placement. The three
portals should form an inverted
correction and anchor placement, medial acetabular rim, beyond the equilateral triangle, with the DALA
placing it 3 cm anterior and 4 to 5 cm 2:30-O’clock position, when needed. portal forming the distal apex and
distal to the anterolateral portal.28 the anterolateral and modified mid-
The authors advocate using the anterior forming the proximal apices
midanterior portal; however, it is Key Points and Pearls (Figure 4). In the authors’ hands,
preferable to establish this portal 3 suture managing becomes more
to 4 cm anterior and in line with the (1) Because this portal is made based reproducible by the use of three
anterolateral portal (Figure 4). This on the location of the antero- portals, especially in avoiding su-
portal is useful to initiate the lateral portal, it is critical that tures tangling. Nevertheless, this is
capsulotomy from the 1- to 2- the anterolateral portal is accu- not a requirement and labral repair
O’clock position (Video, Supple- rately situated in the 12-O’clock and even segmental labral recon-
mental Digital Content 1, http:// position. struction can be performed using just
links.lww.com/JAAOS/A496) and (2) Make the incision first before two portals (anterolateral and
for anchor placement in the most advancing the long spinal needle midanterior).30

656 Journal of the American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 David R. Maldonado, MD, et al

Figure 6

Photograph showing fluoroscopy sequence during the 12-O’clock portal placement in a right hip. Patient in the supine
position. A, Spinal needle is introduced before hip traction. B, Hip is vented, and gentle traction is applied. C, Long spinal
needle is repositioned as close as possible to the femoral head. D, Guidewire is inserted. E, 4.0 mm cannulated dilator is
introduced until the capsule is reached. F, Before advancement of the dilator, the guidewire is partially retrieved.

Key Points and Pearls
(1) Although anatomic reference
points are important, the DALA
portal position is mostly based on
the position of the anterolateral
and modified midanterior portal.
(2) It is easier to triangulate by
incising the skin before using the
long spinal needle.
(3) In the authors’ experience, the
DALA portal is ideal for anchor
placement, especially from the
2:30- to 9-O’clock positions. As
previously mentioned, beyond
the 2:30-O’clock position, the
angle provided by the mid-
anterior portal is usually better
for anchor placement purposes.
(4) Although not mandatory,
introducing a cannula through the
DALA portal is extremely useful
in elegant suture management.
Posterolateral Portal
In the authors’ hands, the postero-
lateral portal is used particularly for
labral reconstruction and for the
treatment of pertrochanteric patholo-
gies, such as gluteus medius tears. This
portal is placed 3 to 4 cm posterior and
in line with the anterolateral portal
(Figure 4). Although the sciatic nerve is
potentially at risk during the use of this
portal, this remains a relatively safe
portal. Thorey et al31 reported a mean
distance of 3.5 cm from the postero-
lateral portal to the sciatic nerve.
Key Points and Pearls
(1) Avoid using the spinal needle in
multiple directions; this may
increase the risk of neuro-
vascular injury. Fluoroscopy is a
valid tool for assessing the tra-
jectory of hardware introducing
through this portal.
Alternative Access
Techniques
These alternatives are (1) inside-
out—going to the peripheral com-
partment first32—and (2) outside-in
(extracapsular) which can also be
used routinely if desired.33 In our
experience, these options are partic-
ularly useful in cases of difficult
access such as acetabular over-
coverage (lateral center-edge angle $
39
) and in cases where adequate
joint distraction is not feasible.34
Inside-out Peripheral
Compartment First
Positioning the patient is accom-
plished similarly to the traditional

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Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Stepwise Safe Access in Hip Arthroscopy
approach. However, as described by
Dienst et al,32 no traction is applied
to the surgical leg which is placed in
20
to 30
of flexion. This maneuver
relieves the tension in the peripheral
compartment, allowing for a more
comfortable approach to this com-
partment. The authors’ preference is
to flex the hip after marking the
anterolateral and midanterior por-
tals, using the same landmarks pre-
viously mentioned. Using
fluoroscopy, the long spinal needle is
introduced perpendicularly to the
femoral neck axis and directed distal
to the femoral head-neck junction.
The guidewire is advanced medially
until resistance of the medial capsule
is felt. At that point, the 70

arthroscope is introduced intra-
articularly and the midanterior por-
tal is established. After performing
the capsulotomy, the leg is brought
to extension and traction can be
applied. Provided that adequate joint
space is achieved, proceed with the
intra-articular diagnosis and treat-
ment. If joint space is still limited,
capsular elevation and acetabulo-
plasty should be followed, based on
preoperative planning until the cen-
tral compartment can be accessed
safely.
Keys Points and Pearls
(1) Mark the anterolateral and
midanterior portal in extension
before placing the hip in flexion
as required for this technique.
(2) After the capsulotomy is com-
pleted, a first attempt of traction
can be made to access the central
compartment. If adequate trac-
tion cannot be accomplished,
proceed with capsular elevation
and planned acetabuloplasty.
This will increase the space for
intra-articular access. Once an
adequate central compartment
accessibility is achieved, proceed
intra-articularly safely.
658
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
(3) T-capsulotomy, inverted
T-capsulotomy, or H-capsu-
lotomy can be used to improved
visualization if needed.
Outside-in (Extracapsular)
Unlike the two “inside-out” methods
previously described, this technique
is initiated from the extracapsular
space. This is particularly useful for
extreme cases of an overcoverage.
The patient is positioned as previ-
ously described; the surgical hip joint
is vented and the anterolateral and
midanterior portals are marked
with a sterile marking pen while the
leg is still in extension. The surgical
hip is brought into 10
to 20
of
flexion and as described by Matsuda
et al, the anterolateral portal is cre-
ated under fluoroscopy aiming for
the anterolateral acetabular rim with
the 70
scope. The midanterior
portal is created, and the capsule has
been identified. Capsulotomy is
made just proximal to the lateral
acetabular rim and extended. How-
ever, protecting the labrum and
acetabuloplasty must be performed
to allow access to the central
compartment.
Tips and Pearls
(1) The hip joint can be vented to
enable capsular distention which
will decrease the risk of labral
damage.
(2) Fluid can be used from the
beginning of the case to improve
visualization.
(3) With the shaver introduced
from the midanterior portal, the
fat pad over the capsule must be
cleared to properly identify the
capsule.
Summary
The inherent inelasticity of the hip
joint makes hip arthroscopy one of
Journal of the American Academy of Orthopaedic Surgeons
the most technically demanding
procedures in the field of joints
preservation. Recently, it has been
shown that the hip arthroscopy
technically demanding skill is
astonishingly steeper than the pre-
viously thought. Access to the hip
joint is the first challenge that sur-
geons must confront in hip arthros-
copy. Nevertheless, it can be
performed in a safe and reproducible
fashion. To achieve this goal, a
thorough understanding of the hip
anatomy is crucial. Navigating
through the technical concepts and
pearls brought in this review will
allow to conquer this challenge.
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