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

The Modified Midanterior Portal

Byrd described the use of the anterior portal during hip arthroscopy.[27] In an effort to diminish the risk of lateral 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 midanterior portal), also striving to easily gain access for osseous correction and anchor placement, placing it 3 cm anterior and 4 to 5 cm distal to the anterolateral portal.[28] The authors advocate using the midanterior portal; however, it is preferable to establish this portal 3 to 4 cm anterior and in line with the anterolateral portal (Figure 4). This portal is useful to initiate the capsulotomy from the 1- to 2-O'clock position (Video, Supplemental Digital Content 1, and for anchor placement in the most medial acetabular rim, beyond the 2:30-O'clock position, when needed.

Key Points and Pearls

  1. Because this portal is made based on the location of the anterolateral portal, it is critical that the anterolateral portal is accurately situated in the 12-O'clock position.

  2. Make the incision first before advancing the long spinal needle into the joint. It is easier to triangulate this way (Video, Supplemental Digital Content 1,

  3. This portal is made under direct arthroscopic visualization; therefore, 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.