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

Abstract and Introduction


Hip arthroscopy is rapidly growing as a treatment with good outcomes for pathologic conditions such as femoroacetabular impingement syndrome and labral tears. At the same time, it is one of the most technically challenging and demanding procedures in orthopaedics with a technically demanding skill. The first challenge is to safely access the joint, which requires accurate anatomical knowledge, a strong sense of spatial orientation, and repeated practice. Iatrogenic chondrolabral injury has been reported as the most common complication in hip arthroscopy and most frequently occurs during hip joint access. As such, basic foundations cannot be overstated. These complications can be minimized with adequate patient positioning, reproducible hip joint access techniques, and proper portals placement. Nonetheless, these three points are perhaps the greatest hurdles that orthopaedic surgeons face when entering the hip arthroscopy field. In this review, we outlined a stepwise approach for a safe access to hip arthroscopy.


Hip arthroscopy is rapidly growing as an efficacious treatment of pathological conditions such as femoroacetabular impingement syndrome and labral tears.[1] From 2005 to 2010, the number of arthroscopic hip procedures performed increased by >600% and the published articles on this topic increased by >500%.[2] Hip arthroscopy has a technically demanding skill and is one of the most technically challenging and demanding procedures in the field of joint preservation. Mehta et al[2] reported that the technically demanding skill for hip arthroscopy was surprisingly long, requiring over 500 cases within five years to be considered a high-volume hip arthroscopy specialist and to reduce the rate of revision surgeries.

Arthroscopic surgery entails the introduction of sharp instruments into the joint for visualization and treatment. In the hip, this may cause iatrogenic injuries to important intra-articular structures, including the labrum, the femoral head, and the acetabular cartilage.[3] A systematic review by Harris et al[4] found that the most commonly reported complication during hip arthroscopy was iatrogenic chondrolabral injury. Appropriate, accurate, and reproducible portal positioning is crucial to avoiding potentially nonreversible lesions.[5]

The basic foundations of hip arthroscopy including patient positioning and portal placement are critical to perform a safe and effective surgical procedure. The purpose of this review is to provide surgeons, who are making their early steps in this demanding discipline, with the "tips and pearls" for safe and consistent access to the central compartment of the hip. The authors present their expertise that they have accrued throughout their years of practice.