Overview
Hip arthroscopy permits examination and treatment of the central and peripheral compartments of the hip. Access is technically demanding because the femoral head is spherical, the capsule is thick and the surrounding soft tissues are substantial. Safe distraction and accurate portal placement are essential to avoid labral, chondral and neurovascular injury (Campbell, Chapter 56).
The central compartment contains the femoral head and acetabular articular surfaces, labrum and ligamentum teres. The peripheral compartment includes the femoral neck, surrounding capsule and synovium. Peritrochanteric endoscopy is a separate extension of the approach. This guide focuses on setup, access and examination, principally the supine method in Technique 56.32.
Indications and Selection
Applications include symptomatic labral disease, loose bodies, femoroacetabular impingement, selected chondral or synovial lesions and ligamentum teres pathology.
Selected extraarticular procedures address snapping hip, abductor pathology and other defined conditions; their access and rehabilitation differ from central-compartment arthroscopy.
Assess radiographic arthritis before choosing arthroscopy. Campbell reports poorer results and more conversion to arthroplasty with Tönnis grade 2 disease.
Hip dysplasia requires a stability-focused assessment. Arthroscopy does not correct acetabular undercoverage, and an unstable dysplastic hip is not equivalent to an impingement hip.
Inability to distract the joint, body habitus that prevents instrument access and preexisting arthritis are relative contraindications listed in Box 56.15.
Acute trauma with disruption of the soft-tissue envelope increases the risk of fluid escape into the retroperitoneal or abdominal spaces.
(Campbell, Chapter 56, Box 56.15.)
Positioning and Equipment
Supine Position
Use a fracture table or a table with a suitable hip-distraction device. Ensure unobstructed fluoroscopic views and access for both central and peripheral work.
When a post is used, pad it extensively and lateralize it against the medial thigh of the operative leg to improve the distraction vector and reduce perineal pressure.
Begin with the operative hip in neutral rotation and slight abduction. Adapt position to achieve safe distraction; added flexion can relax the capsule but may increase sciatic nerve tension.
Use traction only as needed for access and monitor its duration. Campbell recommends keeping traction below 2 hours to limit neurapraxia risk; this is an upper limitation, not a target exposure time.
Prepare 30- and 70-degree arthroscopes, long hip instruments, guidewires, dilators and protective cannulas. A 70-degree scope is commonly used for central-compartment work.
(Campbell, Chapter 56, Technique 56.32.)
Lateral and Postless Options
Lateral positioning is an alternative and may improve access in patients whose soft tissues fall away from the operative hip. It requires a suitable distraction system and its own portal orientation. Postless methods avoid direct perineal post compression by using a system that provides secure countertraction, often with a high-friction support surface and controlled table tilt. Campbell describes several methods, including Technique 56.34; one setup should not be improvised from selected steps of another (Campbell, Chapter 56, Techniques 56.33–56.34).
Traction and Joint Access
Confirm adequate distraction fluoroscopically before introducing a cannula. The space must accommodate the chosen instruments without trapping the labrum or contacting the head.
Use a spinal needle under fluoroscopy for the initial access. If unexpected resistance is encountered, reassess and redirect rather than forcing passage.
Distend the joint, pass the guidewire and advance the cannula assembly over it under control. Protect the wire from kinking and the articular surface from the advancing instruments.
After access releases the vacuum effect of the joint, reassess the traction requirement; less force may suffice.
(Campbell, Chapter 56.)
Portal Planning
Mark the anterior superior iliac spine and the anterior, superior and posterior margins of the greater trochanter. Establish the initial anterolateral portal fluoroscopically; subsequent portals are needle-localized under direct arthroscopic observation. Landmarks are starting references, not substitutes for imaging and visualization (Campbell, Chapter 56).
Portal | Reference landmarks in the supine technique | Important structures and checks |
|---|---|---|
Anterolateral | Approximately 1 cm anterior and superior to the anterior edge of the greater trochanter | Usually the first portal. Initial passage is not directly visualized; inspect afterward for unintended labral penetration. |
Anterior | Intersection of a sagittal line from the ASIS and a transverse line from the superior greater trochanter | Branches of the lateral femoral cutaneous nerve are close. Incise skin only, then use controlled blunt passage. |
Posterolateral | Near the posterior and superior border of the greater trochanter | Protect the sciatic nerve; keep neutral rotation and establish under arthroscopic and fluoroscopic guidance. |
Accessory portals | Chosen for the planned treatment and instrument trajectory | Place under direct visualization. Peripheral access may be redirected onto the femoral neck after traction release. |
(Campbell, Chapter 56, pp. 2399–2403.)
Surgical Technique
Establish the Initial Viewing Portal
With distraction confirmed, advance the needle for the anterolateral portal under fluoroscopy, avoiding the acetabular edge and labrum.
If resistance suggests labral contact, adjust the trajectory more parallel to the femoral head as described in Technique 56.32.
Distend the joint and pass the wire, dilator and cannula without scraping the femoral head or penetrating the labrum.
Introduce the arthroscope and orient the view before establishing a working portal.
(Campbell, Chapter 56, Technique 56.32.)
Establish Additional Portals
Place a spinal needle at the planned anterior portal and observe its intraarticular entry with the arthroscope. Confirm the path with fluoroscopy.
Make a skin-only incision and advance the cannula through the soft tissues under control, protecting superficial nerve branches.
If posterolateral access is required, establish it under combined guidance with neutral hip rotation and a trajectory that avoids the sciatic nerve.
Move the scope to another portal and inspect the original anterolateral entry site for labral injury.
Use only the accessory portals necessary for the planned procedure; make each one under direct observation.
(Campbell, Chapter 56, Technique 56.32.)
Central Compartment Examination
Inspect the labrum and chondrolabral junction, femoral head and acetabular cartilage.
Examine the acetabular fossa and ligamentum teres and look for synovial disease or loose bodies.
Alternate the camera between viewing portals and use controlled lens rotation to assess structures hidden from a single approach.
Use the 70-degree scope for peripheral acetabular and labral views and the 30-degree scope where it improves the central field. Controlled internal and external rotation can supplement the survey.
Document the pattern and extent of labral and cartilage pathology before proceeding to the indicated treatment.
(Campbell, Chapter 56, Technique 56.32.)
Peripheral Compartment Examination
Release traction after completing central-compartment work.
Flex the hip, typically about 45 degrees in the described technique, to relax the capsule and improve access to the femoral neck.
Redirect the anterior and anterolateral portals or establish an appropriate additional portal under guidance.
Inspect the femoral head–neck region, peripheral capsule and synovium, then correlate the findings with the preoperative plan.
(Campbell, Chapter 56.)
Capsular Management
The standard portals cross the iliofemoral ligament. An interportal capsulotomy improves central access; a T-extension can improve exposure of the femoral neck when necessary. These releases also affect stability. Campbell recommends complete repair when instability is a concern and supports considering repair more broadly because of reported outcome benefits. Avoid unnecessary capsular damage and incorporate closure into the operative plan (Campbell, Chapter 56, hip capsule section).
Pearls and Pitfalls
Recheck the first portal: a portal placed under fluoroscopy can still penetrate the labrum.
Limit traction exposure: perineal padding and lateral post placement reduce pressure, but do not eliminate traction-related nerve injury.
Protect superficial nerves: the anterior portal lies near branches of the lateral femoral cutaneous nerve.
Separate the compartments: central access requires distraction; peripheral work follows traction release and altered hip position.
Preserve stability: dysplasia, capsular insufficiency, excessive rim resection and other destabilizing interventions require particular caution.
Monitor fluid escape: trauma and capsular or psoas-related pathways can permit serious extravasation.
(Campbell, Chapter 56.)
Postoperative Considerations
Rehabilitation follows the definitive operation, including whether labral repair, cartilage treatment, osteoplasty, tendon surgery or capsular repair was performed. The diagnostic survey itself does not define a universal weight-bearing or motion schedule. Postoperative assessment should also consider traction-related sensory symptoms and the stability implications of the capsular work (Campbell, Chapter 56).
Complications
Traction-related neurapraxia and perineal soft-tissue injury, particularly with excessive duration or post pressure.
Lateral femoral cutaneous nerve injury during anterior access and sciatic nerve risk with posterior access.
Iatrogenic labral penetration or articular surface scuffing during portal and instrument placement.
Fluid extravasation, including rare abdominal compartment syndrome.
Microinstability or dislocation, especially in a predisposed hip after destabilizing bone or soft-tissue procedures.
Venous thromboembolism, heterotopic ossification and persistent symptoms requiring revision.
Complication estimates vary with their definitions and the procedures included. Campbell identifies residual or undertreated impingement as a leading reason for revision hip arthroscopy; an adequate diagnostic survey must therefore support a complete, appropriately selected treatment plan (Campbell, Chapter 56).
References
Bernholt DL, Mihalko MJ. Arthroscopy of the lower extremity. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier; 2026. Chapter 56, hip setup, portals and capsule, pp. 2398–2405; Techniques 56.32–56.34; complications and revision, p. 2415.