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


J Am Acad Orthop Surg. 2020;28(16):651-659. 

In This Article

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 visualization 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 anatomic landmark to establish the anterolateral portal. The anterolateral 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 palpation difficult, leading to misjudgment. The authors have found that the ASIS is a more reliable bony landmark (Figure 4 and Video, Supplemental Digital Content 1, Unlike the GT, the ASIS is unaffected by leg rotation and its exact location is more readily identifiable by palpation, irrespective of the patient size.[5] By palpating the two ASIS, the surgeon gains a spatial understanding of the pelvic sagittal tilt and can aim the portal placement trajectory accordingly.

Figure 4.

Photograph showing RH in the supine position. Anterosuperior iliac spine is drawn and marked with the *. AL—12-O'clock—portal; MA portal; DALA portal; P portal. AL = anterolateral, DALA = distal anterolateral accessory, MA = midanterior portal, P = posterolateral, RH = right hip

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 distraction. Consequently, using the same placement may not fulfill the fundamental requirement for the anterolateral portal placement as you must maintain proximity to the femoral head to retain adequate capsular tissue for closure at the end of the procedure.[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 joint[5] (Video, Supplemental Digital Content 1,

Identify the 12-O'clock Position

This point refers to the 12-O'clock position at the level of the acetabulum (Figure 3). It is the authors' choice to access the hip joint by creating the anterolateral portal at the 12-O'clock position[5] (Figure 5 and Video, Supplemental Digital Content 1, 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 anterior and posterior aspect of the capsule by palpating the capsule using the spinal needle and confirming 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, If required, an axial view can be obtained with the C-arm to determine the AP location of the needle. A critical step during insertion of the cannulated dilator is levering of the cannula away and superior to the femoral head to avoid cartilage scuffing (Video, Supplemental Digital Content 1, The 70° arthroscope is the authors' preferred optical device throughout the entire procedure.

Figure 5.

Photograph showing the right hip showing the ideal location of the 12-O'clock position in the AP view. A, Plastic model. B, Fluoroscopy.

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. Check osseous anatomic landmarks, especially the ASIS.

  2. Identify the 12-O'clock position.

  3. After entering the capsule, turn the long spinal needle 180°, allowing 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,

  4. Lever the cannulated dilator away from the femur to avoid cartilage scuffing.

  5. The guidewire must be retrieved 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 spinal needle. The sharp side of the arthroscope is on the same side as the light source. When introducing the arthroscope, ensure that 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 Digital Content 1,