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

Alternative Access Techniques

These alternatives are (1) inside-out—going to the peripheral compartment first[32]—and (2) outside-in (extracapsular) which can also be used routinely if desired.[33] In our experience, these options are particularly useful in cases of difficult access such as acetabular overcoverage (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 accomplished similarly to the traditional 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 compartment. The authors' preference is to flex the hip after marking the anterolateral and midanterior portals, using the same landmarks previously 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 portal 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 treatment. If joint space is still limited, capsular elevation and acetabuloplasty should be followed, based on preoperative planning until the central 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 completed, a first attempt of traction can be made to access the central compartment. If adequate traction 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.

  3. T-capsulotomy, inverted T-capsulotomy, or H-capsulotomy 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 previously 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 created 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. However, 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.