Overview
Hip arthroscopy is used for intraarticular and extraarticular hip pathology, most commonly labral tears and femoroacetabular impingement (FAI). This guide covers indications, patient positioning, standard portals (supine technique), capsulotomy, labral repair and arthroscopic treatment of pincer impingement. (Campbell)
Indications
Indications (Campbell Box 56.15)
Labral tears, FAI, chondral lesions, loose bodies, synovial disorders, ligamentum teres pathology, septic arthritis, psoas tendon disorders.
Extraarticular impingement (subspine and ischiofemoral), external snapping hip, greater trochanteric pain syndrome, proximal hamstring injuries, sciatic nerve disorders.
Trauma: foreign or loose body removal, femoral head fixation, acetabular fracture fixation, labral and ligamentum teres injury. In acute trauma, a disrupted soft-tissue envelope can allow excessive fluid extravasation into the abdomen and compartment syndrome.
Relative contraindications
Obesity (instruments may be too short), hip dysplasia (risk of chronic instability), inability to distract the joint, and preexisting osteoarthritis (Tönnis grade 2).
Hips with Tönnis grade 2 arthritis have poorer outcomes and higher conversion to THA. Borderline dysplasia (lateral center-edge angle 20–25 degrees) has shown significant improvement in outcomes in some reviews. (Campbell)
FAI (Campbell)
Cam: a nonspherical femoral head with reduced head–neck offset abuts the acetabulum in flexion. Most common in young males. It shears the articular surface and avulses the labrum.
Pincer: acetabular overcoverage (global, as in coxa profunda, or focal, as in retroversion). Most common in middle-aged women. It causes intrasubstance labral tears and, with levering, contrecoup chondral damage posteroinferiorly. Cam and pincer often coexist.
Presentation: insidious groin pain worsened by exercise and sitting, driving or putting on shoes. Reduced internal rotation. A positive impingement test (hip flexed to 90 degrees, adducted and internally rotated). Labral tears may show Byrd's C-sign.
Imaging: AP pelvis (well centered), false profile, cross-table lateral, frog-leg lateral and Dunn views. Crossover sign suggests retroversion. Center-edge angle below 20–25 degrees suggests undercoverage. An alpha angle above 50 degrees indicates loss of sphericity. MRI shows labral and chondral injury.
Treatment: FAI exists in 37% or more of asymptomatic athletes, so there is no indication for surgery without symptoms. Begin with activity modification, NSAIDs and physical therapy. Arthroscopy treats labral and chondral damage and removes bony impingement to restore head–neck offset. Ten-year survivorship was about 85% in one report. At 5 years, osteoarthritis progression was 26.5% after arthroscopy vs 35% with conservative care, and THA conversion 6.8% vs 10.5%.
Technique 56.32: Supine Hip Arthroscopy (Byrd) (Campbell)
Setup
Place the patient supine on a fracture table or a regular table with a distraction device. Supine positioning is easy and familiar and allows a fracture table. The lateral position is often easier in obese patients and needs a distraction device (Technique 56.33, Glick).
Use a heavily padded perineal post lateralized against the medial thigh of the operative leg. Lateral placement improves the traction vector and lowers the risk of neurapraxia.
Position the hip in neutral to slight abduction and neutral rotation. Slight flexion relaxes the capsule but draws the sciatic nerve closer to the joint.
Apply traction and confirm distraction fluoroscopically. About 10–12 mm of distraction is needed for 4.5- or 5.5-mm cannulas, roughly 50 lb of force on devices with tensiometers. Limit traction time to less than 2 hours to reduce traction neurapraxias. Less traction is often needed once the joint is entered and negative pressure is relieved.
Use both 30- and 70-degree scopes. The 70-degree is used for most central compartment work.
Portals
Three standard portals are used (anterior, anterolateral, posterolateral). Draw the landmarks first: femoral artery, vein and nerve; greater trochanter; anterior superior iliac spine.
Anterolateral portal first, with a 6-inch, 17-gauge needle under fluoroscopy. It lies about 1 cm superior and anterior to the anterior edge of the greater trochanter, in the safe zone. It pierces the gluteus medius and then the capsule, with the superior gluteal nerve (about 6 cm) and sciatic nerve (about 4 cm) as the nearest structures.
Avoid penetrating the labrum. If resistance is met, redirect under fluoroscopy, aiming more parallel to the femoral head and away from the acetabular edge. Distend the joint with saline, pass a guidewire, withdraw the needle and pass the cannula over the wire without injuring the femoral head cartilage or labrum.
Anterior portal and posterolateral portal are placed under arthroscopic and fluoroscopic control with a spinal needle seen through the 70-degree scope.
Anterior portal: at the intersection of a line down from the anterior superior iliac spine and a transverse line from the superior margin of the greater trochanter. It passes through sartorius and rectus femoris, about 1.5 cm from the lateral femoral cutaneous nerve, so incise only skin.
Posterolateral portal: just superior to and behind the greater trochanter, directed slightly cephalad and anterior, converging toward the anterolateral portal. Keep the hip in neutral rotation. It lies about 2.2 cm from the sciatic nerve.
After the portals are made, place the outflow in the posterolateral portal. Inspect the anterolateral portal from the anterior portal to confirm the labrum was not pierced.
View the acetabulum, labrum and femoral head from all three portals, alternating scopes and rotating the hip. The 70-degree scope is best for the labrum and periphery, the 30-degree for the central acetabulum, femoral head and fossa.
Incise the capsule transversely with an arthroscopic knife for instrument mobility. Use flexible cannulas with curved shavers and extra-length instruments. Remove large loose bodies piecemeal.
After the central compartment, release traction and flex the hip to about 45 degrees to relax the capsule and enter the peripheral compartment. Redirect the portals onto the femoral neck or add an ancillary portal 4–5 cm distal to the anterolateral portal, guided by fluoroscopy.
Capsulotomy and capsular repair
The portals traverse the iliofemoral ligament. A standard intraportal capsulotomy joins the anterolateral and anterior (or midanterior) portals, parallel to the acetabulum. For FAI a T-shaped extension allows full femoral neck visualization.
Capsular repair improves outcomes. Some surgeons repair the whole capsulotomy and others only the T-limb. Repair of the entire capsulotomy is recommended if instability is a concern and should be considered even if it is not. (Campbell)
Technique 56.35: Labral Repair (Campbell)
Peripheral labral tears with a well-fixed outer rim can be repaired. The periphery is more vascular than the articular region. A labral tear removes the fluid seal and increases contact pressure. Articular damage was noted in 73% of patients with labral tearing or fraying. Labral–chondral separation is more common with cam impingement, intrasubstance tears with pincer.
Debride the torn, frayed tissue. A flexible ligament chisel detaches the torn part from intact labrum, leaving a small portion attached. Remove the torn part with a shaver.
If the labrum is detached from bone, refix it to the acetabular rim with a bioabsorbable suture anchor. Place the anchor on the rim, more on the capsular than the articular side, at an angle that will not penetrate the joint. Confirm with fluoroscopy. Anchors can pass through any portal.
Place the sleeve, then tap the anchor in while watching the acetabular cartilage to avoid iatrogenic chondral injury.
Pass a suture limb through the labral substance with a suture passer, retrieve it, and pass it a second time to create a vertical mattress suture. Pull the cannula back to an extraarticular position and tie with standard arthroscopic knots.
An intrasubstance split that is well fixed to the acetabulum with a stable outer rim can be repaired. Debride the cleavage plane, pass a looped monofilament suture between the cartilage–labrum junction, retrieve it with a bird beak through the outer labrum peripheral to the tear, and pass an absorbable suture around the split with the loop as a suture lasso. Tie the knot extraarticularly.
After repair, examine the capsule and head–neck junction dynamically to see whether capsular plication or femoral osteoplasty is needed.
Labral reconstruction
For labra too damaged, absent, segmentally deficient or ossified. Graft options are allograft (semitendinosus, tibialis, peroneus brevis, capsule, tensor fascia lata) or autograft (ligamentum teres, capsule, indirect head of rectus femoris, iliotibial band, quadriceps tendon, gracilis). No graft has been shown superior, and segmental and circumferential reconstruction gave no difference in outcomes. Technique 56.36 (Matsuda) uses a gracilis autograft fixed with suture anchors. (Campbell)
Technique 56.37: Arthroscopic Treatment of Pincer Impingement (Larson) (Campbell)
Establish standard portals and confirm pincer impingement. A midanterior portal can help with anchor placement.
If the lesion is visible, leave the labral–chondral junction intact and resect the prominence with a burr.
If the rim must be exposed, detach the labrum at the labral–chondral junction over the lesion with a banana blade through the anterior portal.
Put a burr in the midanterior portal on the anterior wall at the level of overcoverage. Confirm with fluoroscopy that the burr is just distal to the crossover sign, resect to the planned level and confirm the crossover is removed. Switch the camera to the anterior portal and burr to the anterolateral portal to finish the more superior rim.
Refix the labrum with suture anchors. Place the first anchor superiorly through the anterolateral portal using fluoroscopy and direct visualization so the joint is not penetrated. Pass one suture limb into the joint between labrum and rim.
Pass a bird beak or other penetrating grasper through the labrum, retrieve the suture and tie it. Alternatively loop the suture around the labrum instead of piercing it.
Place the remaining anchors through the midanterior portal with the camera in the anterolateral portal.
Release traction and move the hip through a range of motion to confirm there is no residual impingement.
Postoperative Care
Rehabilitation protocols depend on whether a labral repair, reconstruction, osteoplasty or capsular repair was performed. The source chapter text available for this guide does not include a specific hip arthroscopy protocol.
Complications
Traction-related. Neurapraxia, particularly pudendal and sciatic. Limit traction to under 2 hours, use a well-padded post placed laterally, and keep the hip in neutral rotation when establishing the posterolateral portal. (Campbell)
Portal-related. Injury to the lateral femoral cutaneous nerve (anterior portal), sciatic nerve (posterolateral portal), superior gluteal nerve and ascending branch of the lateral femoral circumflex artery. Labral or cartilage damage on entry. (Campbell)
Fluid extravasation. Of particular concern after acute trauma. (Campbell)
Outcomes. Worse outcomes and more conversion to THA with Tönnis grade 2 or greater arthritis. (Campbell)
References
Bernholt DL, Mihalko MJ. Arthroscopy of the lower extremity. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 56, Hip: Techniques 56.32–56.37.