Anatomy of the Hip: Open and

Arthroscopic Structure and Function

Anil S. Ranawat, MD, and Bryan T. Kelly, MD

Hip arthroscopy offers a less invasive alternative for hip procedures that would otherwise
require surgical dislocation of the hip. In addition, this procedure allows surgeons to
address intra-articular derangements that were previously undiagnosed and untreated.
Current indications for hip arthroscopy include management of labral tears, osteoplasty for
decreased femoral head-neck junction offset, rim trimming for pincer lesions, rotational
instability and capsular laxity, ligamentum teres injuries, lateral impact and chondral
injuries, osteochondritis dissecans, internal and external snapping hip, removal of loose
bodies, synovial biopsy, subtotal synovectomy, synovial chondromatosis, infection, and
certain cases of mild-to-moderate osteoarthritis with associated mechanical symptoms.
This article discusses the relevant open and arthroscopic anatomy of the hip and related
pathologic and anatomic variations that are commonly encountered during this procedure.
Oper Tech Orthop 15:160-174 © 2005 Elsevier Inc. All rights reserved.

KEYWORDS hip anatomy, central compartment hip anatomy, peripheral compartment hip
anatomy

T he twentieth century marked a revolution in open-hip

surgical procedures. At the beginning of the century, the
primary indication for a hip procedure was related to the
management of tuberculosis. By the end of the century, hip
operations, specifically total hip arthroplasty and fracture
management, were 2 of the most common orthopedic proce-
dures performed annually.1-3 The founding fathers of hip
surgery read like an atlas for surgical procedures and ap-
proaches to the hip. They are, but not limited to, Gathorne
Robert Girdlestone, Russell A. Hibbs, Bernard Langenbeck,
Theodor Kocher, Marius Nygaard Smith-Peterson, and Sir
John Charnley.1
Presently, there are many “safe” windows to access the hip
joint. These include the 5 primary approaches: straight ante-
rior, anterolateral, lateral, posterior/posterolateral, and me-
dial. Surgical preference is based on surgical experience,
technique, purpose of procedure, and implant design. These
exposures have been well studied and have a wide range of
applications. They are all safe and reproducible by not vio-
lating basic surgical anatomic principles. They are all de-
signed to protect neurovascular structures, specifically the
tenuous blood supply to the femoral head. They all lack,
Hospital for Special Surgery, New York, NY.
Address reprint requests to Bryan T. Kelly, MD, Hospital for Special Surgery,
535 East 70th Street, New York, NY 10021. E-mail: kellyb@hss.edu
however, a true exposure of the femoral head. Hence, they
have limited utility to address intra-articular pathology.
During the last 10 years, recent advances in understanding
the anatomical blood supply to the femoral head led Rein-
hold Ganz to champion a safe surgical dislocation of the hip
(Fig. 1). This procedure affords the “open” hip surgeon a tool
to address directly intra-articular pathologies such as acetab-
ular or Pipken fractures, chondral injuries, loose bodies, se-
verely slipped capital femoral ephysies, femoroacetabular im-
pingement, and labral injuries. Multiple series have been
published validating its safety, with avascular necrosis (AVN)
rates from 0% to 1%.4,5 This procedure, however, has a steep
learning curve. It also has numerous potentially disastrous
complications, including AVN, heterotopic ossification, and
trochanteric nonunion.4 In addition, it is an invasive proce-
dure with high health care costs attributable to long hospi-
talizations and recovery time.
In contrast, hip arthroscopy, like arthroscopy in general,
provides the surgeon a tool to diagnose and treat intra-artic-
ular pathology in a less-invasive fashion. Hip arthroscopy
offers a less invasive alternative for hip procedures that would
otherwise require surgical dislocation of the hip. In addition,
this procedure allows surgeons to address intra-articular de-
rangements that were previously undiagnosed and untreated.
Current indications for hip arthroscopy include management
of labral tears, osteoplasty for decreased femoral head neck
junction offset (femoroacetabular impingment), subtle rota-

160 1048-6666/05/$-see front matter © 2005 Elsevier Inc. All rights reserved.
doi:10.1053/j.oto.2005.06.010
Anatomy of the hip 161

Open Structure
and Function of the Hip
The basic anatomy around the hip consists of the superficial
surface anatomy and deep bony, muscular, and neurovascu-
lar anatomy. The clinically relevant surface anatomy of the
hip consists of several superficial palpable bony promi-
nences. The anterior landmarks consists of the prominent

Figure 1 Surgical dislocation of the hip.

tional instability and capsular laxity, ligamentum teres inju-

ries, lateral impact and chondral injuries, osteochondritis
dissecans, internal and external snapping hip, removal of
loose bodies, synovial biopsy, subtotal synovectomy, syno-
vial chondromatosis, infection, and certain cases of mild-to-
moderate osteoarthritis with associated mechanical symp-
toms. In addition, patients with long-standing, unresolved
hip joint pain and positive physical findings may benefit from
arthroscopic evaluation.6-18
Although arthroscopic surgery of the hip was first intro-
duced by Burman in 1931, it did not begin to gain any pop-
ularity in North America until 1977, when Gross reported his
experience with arthroscopy of congenitally dislocated
hips.19,20 Anatomical constraints have made arthroscopy of
the hip significantly more challenging than similar surgery
around the shoulder and knee (Fig. 2). The femoral head is
deeply recessed in the bony acetabulum and is convex in
shape. The thick fibrocapsular and muscular envelope
around the hip joint limits the amount of distention possible
during hip arthroscopy; the relative proximity of the sciatic
nerve, lateral femoral cutaneous nerve, and remaining femo-
ral neurovascular structures make portal placement more
challenging.21,22 Nonetheless, over the past several years, hip
arthroscopy has begun to gain considerably more interest.
The advent of better diagnostic tools, especially magnetic
resonance imaging, has helped in the detection of intra-artic-
ular hip pathology in a more predictable fashion. New tech-
niques and instrumentation have facilitated the visualization
and treatment of these intra-articular lesions by hip arthros-
copy. Most notably, the recent adaptation of arthroscopy
equipment to create flexible scopes and instruments specifi-
cally designed for the hip has led to improved safety, visual-
ization and accessibility of this joint (Fig. 3).18 With these
improvements in technology a more detailed understanding
of the arthroscopic anatomy of the hip has developed. This
chapter discusses the relevant open and arthroscopic anat-
omy of the hip and related anatomic variations that are com- Figure 2 Osseous constraints around the hip depicted in a 3-dimen-
monly encountered during open and arthroscopic hip pro- sional computed tomography scan reconstruction of the hip from an
cedures. anterior (A) and posterior (B) view.
162 A.S. Ranawat and B.T. Kelly

the hip (Fig. 4). They are important landmarks for incision
planning. Understanding the relationship of these structures
to the deeper anatomy is a critical surgical anatomic princi-
ple. Accurate identification and palpation of these structures
are vital to all surgical hip planning.
The hip is a diarthrodial joint and is defined by the con-
strained bony articulation of the proximal femur and acetab-
ulum. The acetabulum, which consists of the 3 bones of the
pelvis, the illium, ischium, and pubis, form the Y-shaped
triradiate cartilage, which usually fuses by 15 to 16 years of

Figure 3 Flexible instruments allow for significantly improved ac-

cess to most structures within the hip joint during routine arthros-
copy. (Reprinted with permission from Kelly et al.13)

anterior superior iliac spine (ASIS) and anterior inferior iliac

spine (AIIS), which serves as insertion points for the sartorius
and direct head of the rectus femoris, respectively. The
greater trochanter and posterior superior iliac spine (PSIS)
also are easily identifiable on the posterior-lateral aspect of

Figure 4 Superficial anatomy of the hip seen with patient in traction

before hip arthroscopy. Palpation of the hip allows for easy identi- Figure 5 Muscular attachments around the hip depicted in an artists
fication of the greater trochanter (lateral) and anterior superior iliac rendition of the superficial (A) and deep (B) muscles. A total of 27
spine (anterior) in most patients. muscles cross the hip joint.
Anatomy of the hip
Figure 6 Vascular anatomy of the deep branch of the middle femoral circumflex artery. (Reprinted with permission from
Gautier et al.27)
age.1 It is orientated approximately 45° caudally (abduction)
and 15° anteriorly (anteversion).23 Its hemispherical shape
covers 170° of the femoral head. On the other hand, the
proximal femur, has only 2 primary growth centers, the fem-
oral epiphysis and the trochanteric apophysis, which both
ossify by age 16 to 18 depending on the sex of the individu-
al.24 The proximal femur has a neck-shaft angle of approxi-
mately 125° with 135° of anteversion of the proximal me-
taphysis compared with the posterior condyles of the
knee.23,25,26
The muscular attachments surrounding the hip are exten-
sive with a total of 27 muscles crossing the hip joint. They can
be broadly broken down by their function. The primary flex-
ors are the iliacus, psoas, iliocapsularis, pectineus, rectus
femoris (direct and indirect heads), and sartorius. The exten-
sors are the gluteus maximus, semimembranosus, semiten-
doninous, biceps femoris (long and short heads), and adduc-
tor magnus (ischiocondyle part). The abductors are the
gluteus medius, gluteus minimus, tensor fascia lata, and ili-
otibial band. The adductors are the adductor brevis, adduc-
tor longus, gracilis, and the anterior part of the adductor
magnus. Finally, the external rotators are the piriformis,
quadratus femoris, inferior gemellus, superior gemellus,
oburator externus, and internus (Fig. 5).1,3 A detailed under-
standing of the muscular attachments and innervations are
critical for safe open surgical procedures.
The vascular anatomy to acetabulum and proximal femur
has been extensively studied. The primary vascular pathways
are extensions from the internal and external iliac vessels.
163
From the internal iliac system, the superior and inferior glu-
teal arteries and obturator artery supply most of the sur-
rounding hip musculature laterally and medially respec-
tively. From the external iliac system, the medial and lateral
femoral circumflex anastomoses around the proximal femur.
The medial femoral circumflex artery (MFCA) has 3 main
branches: the ascending, deep, and trochanteric. The deep
branch of the MFCA is the primary blood supply to femoral
head.27 The lateral femoral circumflex artery, metaphyseal
artery and the medial epiphyseal artery all contribute little to
the vascularity of the head, with the medial epiphyseal artery
providing the most perfusion to the perifoveolar area.
Provided by Ganz’s work, the course of the deep branch of
the MFCA is quite predictable.27 It starts medial between the
pectineus and iliopsoas tendon along the inferior border of
the obturator externus. Here, a trochanteric branch sprouts
off at the proximal border of the quadratus femoris to the
lateral trochanter. Posteriorly, the deep MFCA enters be-
tween the proximal border of the quadratus femoris and in-
ferior gemellus. It then travels anteriorly along the conjoint
tendon of the inferior gemellus, obturator internus and su-
perior gemellus. It then perforates the capsule at the level of
the superior gemellus. It then gives rise to two to four supe-
rior retinacular vessels intracapsularly (Fig. 6).27
The deep branch of MFCA has multiple anastomoses. The
descending branch of the lateral femoral circumflex artery
joins the deep MCFA at the base of the neck of the femur. The
deep branch of the superior gluteal artery joins it at the in-
sertion of gluteus medius. The inferior gluteal artery anasto-
164
Figure 7 The anterior approach to the hip utilizes the interval be-
tween the sartorius and tensor fascia lata (depicted by the pointer in
the photo).
moses with the deep MFCA along the inferior border of the
piriformis, posterior to the conjoined tendon. Finally, the
internal pudenal artery joins it near the retroacetabular space.
Besides the superficial lateral femoral cutaneous nerve, the
important nervous structures around the hip are usually
linked with their arterial counterpart. The superior and infe-
rior gluteal nerves exit with their arterial pedicle thru the
greater sciatic foramen. The superior gluteal nerve and artery
exits above the piriformis, whereas the inferior nerve and
artery travels below it. Likewise, the femoral and obturator
nerves travel with their named arteries anteriorly and medi-
ally respectively. Finally, the sciatic nerve, in the adult pa-
tient, travels without any significant arterial counterpart out
of the greater sciatic foramen with the posterior femoral cu-
taneous and other small nerves innervating the short external
rotators.
Open Hip
Approaches and Procedures
There are 5 main surgical approaches to the hip. They rely on
different surgical internervous planes to enter the hip joint.
Each has unique advantages and disadvantages with different
indications for different procedures. The anterior or Smith-
Peterson28,29 approach uses the plane between the sartorius
and tensor fascia latae superficially and then the rectus fem-
oris and gluteus medius. It has multiple applications, includ-
ing open treatment for acetabular dysplasia, open reduction
and internal fixation for hip fractures, and tumor procedures.
Unlike the anterior approach, the anterolateral requires ei-
ther a trochanteric osteotomy or partial detachment of the
abductors. This approach, also called the Watson-Jones,30,31
A.S. Ranawat and B.T. Kelly
is best used for total hip or hemi-arthroplasty (Fig. 7; Hirsch
D, personal communication re: antero-lateral exposure of
hip, Watson-Jones (ed), 1981). The direct lateral or transglu-
teal Hardinge32 approach has similar indications as the an-
terolateral approach (Fig. 8). Classically, the lateral approach
does not require a trochanteric osteotomy. The posterior or
“Southern approach” popularized by Moore,3,33,34 is quite
similar to the posterolateral or Kocher-Langenbeck approach
(Fig. 9).35-37 They are primarily used for arthroplasty and
acetabular fixation. There are multiple modifications of the
antero-lateral, lateral, and posterior approaches depending
on the extent and type of release of the gluteus medius versus
a trochanteric osteotomy or slide. An example of this is the
Gibson approach.38 Finally, the medial or Ludloff approach39
is primarily an exposure used for pediatric management of
hip dysplasia. The plane lies between the gracilis and adduc-
tor longus superficially and then the adductor magnus and
brevis.
The principle around a surgical dislocation of the hip is
predicated on the understanding and preservation of blood
supply to the femoral head.4 The patient is placed in the
lateral decubitus position and an incision is made over the
greater trochanter. The interval between gluteus maximus
and medius is identified. A trochanteric osteotomy is per-
formed, which leaves the piriformis tendon remaining on the
proximal femur as a landmark of depth. At all times, the deep
branch of the MFCA is avoided and protected. Once, the
osteotomy is carefully mobilized, a “Z”-shaped capsulotomy
is performed. The hip can then be safely exposed, subluxed
and dislocated. Care is taken to preserve all of the short
external rotators, with the obturator externus being the most
important. With proper positioning of the leg and correct
retractor placement, a 360° view of both the femoral head
and acetabulum is possible. In Ganz’s original series of 213
patients, he had a zero incidence of AVN. They did, however,
have complications: 2 sciatic nerve neuropraxias, 79 patients
with heterotopic ossification, and 3 trochanteric nonunions.4
Figure 8 The direct lateral approach lies over the greater trochanter.
The gluteus medius can be seen inserting on the proximal portion of
the greater trochanter, and the vastus lateralis is coming from the
distal extent of the specimen.
Anatomy of the hip
Figure 9 The posterior approach requires the detachment of the
piriformis and short external rotators seen overlying the capsule in
this specimen.
Arthroscopic Structure
and Function of the Hip
The soft tissue in and around the hip joint consists of the
capsulo-ligamentous structures, labrum, ligamentum teres,
transverse acetabular ligament, and pulvinar. In addition, the
intra-articular anatomy consists of the chondral surfaces of
the femoral head and acetabulum as well as the fovea capitus.
Finally, the peripheral compartment defines the region of the
anterior femoral neck. All of these areas are easily visualized
with hip arthroscopy.
The thick, fibrous hip capsule has 3 discrete thickenings
that form the main capsular ligaments: the iliofemoral (Y-
Ligament of Bigelow), the pubofemoral, and the ischiofemo-
ral. These ligaments originate from the 3 named bones of the
Figure 10 Anatomical constraints of the hip. The anterior ligamentous constraints of the hip our seen in the anterior view
and include the iliofemoral and pubofemoral ligaments. The ischiofemoral ligament is the primary posterior restraint.
(Reprinted with permission from Kelly et al.13)
165
pelvis and insert on the intertrochanteric line, resulting in
more than 95% of the femoral neck being intracapsular (Fig.
10). The posterior portion of the neck, specifically the ba-
sicervical portion and intertrochanteric crest, are extracapsu-
lar.1 The iliofemoral ligament covers the anteriosuperior por-
tion of the joint. It is the thickest and strongest of the 3
ligaments and prevents anterior translation of the hip in the
positions of extension and external rotation. When con-
tracted, it causes the hip to fall into flexion and internal
rotation. It along with the pubofemoral ligament provides
anterior support. The ischiofemoral ligament is a posterior
structure. Gaps in the capsule exist anteriorly between the
iliofemoral and pubofemoral ligaments.
The anterior triangle represents the intra-articular portion
of the lateral and medial limbs of the iliofemoral ligament.
The zona orbicularis is the named terminal fibers of the il-
iofemoral ligament that form a deep circular orientation sur-
rounding the femoral neck in a leash-like fashion (Fig. 11).
These spiral fibers tighten during extension but unwind or
loosen during hip flexion.1
The spiral orientation of the capsular ligaments provides a
“screw home” effect in full extension. With maximal exten-
sion, the ligaments tighten or coil making this position of
maximal soft tissue stability. Interestingly, the position of
maximal articular congruency is not with the hip in an ex-
tended position but in a flexed position.40 The position of
optimal articular contact, (FABER- flexion, abduction, exter-
nal rotation) is actually a position of soft tissue laxity with the
ligaments uncoiled. Thus, the position of maximal instability,
from both a soft tissue and osseous perspective, is flexion and
adduction.1
166
Figure 11 Arthroscopic view of the zona orbicularis. These circular
fibers are an extension of the iliofemoral ligament and form a circu-
lar leash surrounding three quarters of the femoral neck. Its func-
tional role is not well understood.
Unlike capsular tissue, labral tissue is made predominantly
of fibrocartilage. The labrum runs circumferentially around
the acetabular perimeter to the base of the fovea and becomes
attached to the transverse acetabular ligament posteriorly and
anteriorly (Fig. 12).18 Arthroscopic visualization of injured
labral tissue has demonstrated more extensive penetration of
the vascular tissue throughout the entire substance of the
labrum, suggesting an improved healing potential than has
been previously believed (Fig. 13). The labrum has vessels
that penetrate it at the outermost layer of the capsular surface
leaving the central articular margins less vascular (Fig. 14).
Like the meniscus, the labrum may have the greatest healing
potential at the peripheral capsulo-labral junction.41 In addi-
Figure 12 The labrum surrounds the rim of the acetabulum nearly circumferentially and is contiguous with the
transverse acetabular ligament across the acetabular notch. The ligamentum teres arises from the margins of the
acetabular notch and the transverse acetabular ligament. (Reprinted with permission from Kelly et al.13)
A.S. Ranawat and B.T. Kelly
tion, the labrum has free nerve endings with both proprio-
ceptors and nociceptors, which may explain the decreased
proprioception and pain in an athlete with a torn acetabular
labrum.42,43
The labrum helps to contain the femoral head in extremes
of range of motion, especially flexion. The labrum and cap-
sule also act as load-bearing structures during flexion causing
a hip with a deficient labrum to be subject to instability if
capsular laxity is present.18,44 The labrum may enhance sta-
bility by maintaining negative intra-articular pressure in the
hip joint.45 It also may act as a tension band to limit expan-
sion during motion between the anterior and posterior col-
umns during loading in the gait cycle.18
The intact labrum appears to have an important sealing
function in the hip joint by limiting fluid expression from the
joint space and thus protect the cartilage layers of the hip.46-48
Ferguson and coworkers have found that the absence of the
labrum significantly increased cartilage surface consolidation
as well as contact pressure of the femoral head against the
acetabulum.46-48 Ferguson and coworkers have further iden-
tified a stabilizing role of the labrum using a poroelastic finite
element model to demonstrate that the labrum provides
some structural resistance to lateral and vertical motion of the
femoral head within the acetabulum.46-48 Because the labrum
appears to enhance joint stability and preserve joint congru-
ity, there is a significant concern about the potential for ro-
tational instability or hypermobility of a labral deficient hip.
This instability may result in redundant capsular tissue, and
create a potential abnormal load distribution due to a tran-
sient incongruous joint resulting from subtle subluxation.18
The ligamentum teres runs from the fovea capitus to the ac-
etabular fossa. It may have a secondary stabilizing effect on the
hip joint especially in the presence of a deficient labrum or a
dysplastic hip.49 Arthroscopic examination of the ligamentum
Anatomy of the hip 167

Figure 13 Arthroscopic view of the anterior superior labrum dem-

onstrating vascular penetration through the substance of the labrum
out to the central articular margin.

Figure 15 Dynamic hip arthroscopy demonstrates significant tight-

Figure 14 The hip labrum is relatively avascular; however, there is ening of the ligamentum teres during external rotation (B) com-
increased vascularity seen arising from the capsular attachments. pared with internal rotation of the hip (A). These findings support
This may have implication for arthroscopic repair of the labrum. the biomechanical role of the ligamentum teres in the stabilization of
(Reprinted with permission from Kelly et al.41) the hip. (Reprinted with permission from Kelly et al.13)
168 A.S. Ranawat and B.T. Kelly

brum known as the “Psoas U” (Fig. 17). The psoas tendon helps
to protect the anterior intermediate portion of the capsule, and
by virtue of its anatomic location can be subjected to increased
load in athletic activities; such loads may be increased in athletes
with further intra-articular pathology.
The anatomy of the hip joint itself is intrinsically stable
except in situations where there is variation in the acetabular
depth and femoral head geometry, which results in more
reliance on the surrounding soft tissue. Version and inclina-
tion of the weight-bearing surface affect the joint capsule and
ligaments of the hip, the labrum, the ligamentum teres, as
well as the suction effect of the hip.13,51 The femoral head
normally forms two-thirds of a sphere and it is flattened in
the area where the acetabulum applies its greatest load. In the
neutral, anatomic position, the anterior part of the femoral
head is not engaged in the acetabulum and the labrum aug-
ments the femoral head coverage by its extension from the
bony acetabulum.
The peripheral compartment is a term to describe the ar-

Figure 16 Arthroscopic view of the pulvinar or fat pad in the central

aspect of the acetabular fossa. The fat pad likely plays a role in joint
lubrication and should be treated cautiously during arthroscopic
procedures. It is also highly vascular and has a propensity to bleed if
it is debrided aggressively (A). The transverse acetabular ligament
can be seen at the inferior most aspect of the acetabulum and fat pad
(B).

teres demonstrates that is composed of an anterior and posterior

bundle (Fig. 15A). The anterior bundle tightens in external ro-
tation of the hip (Fig. 15B). The ligament originates from the
fovea capitus, which is a small depressed bare spot located at the
medial aspect of the femoral head, and inserts adjacent to the
transverse acetabular ligament in the acetabular fossa. The pulv-
inar or fat pad fills the remainder of the acetabular fossa, which
lies in the inferomedial portion of the acetabulum and probably
plays a role in joint lubrication (Fig. 16A). The transverse ace-
tabular ligament runs from the base of anterior and posterior
labrum and act as a conduit to the obturator foramen (Fig. 16B).
The inferior portion of capsule inserts on both its anterior and
posterior aspect.
Figure 17 A normal indentation in the labrum at the anterior medial
The psoas tendon and bursa cross the front of the anterior- aspect of the joint is a consistent landmark for identifying the loca-
medial aspect of the hip joint. It is intra-articular in approxi- tion of the psoas tendon (A). In approximately 20% of patients the
mately 20% of people and other times only the bursa commu- psoas tendon or bursae will lie intra-articularly at this level; in the
nicates with the hip joint.50 The location of the tendon can be remaining patients it can be found behind a thin veil of capsular
predictably located medial to an indentation in the anterior la- tissue (B).
Anatomy of the hip
Figure 18 The peripheral compartment is best visualized from the
anterior portal with the traction released, and the hip flexed to 45°
and externally rotated. Decreased offset at the head neck junction
can be clearly seen in this compartment (A), as well as complete
views of the entire anterior femoral neck (B).
Figure 19 View of the anterior femoral neck and associated vincula.
169
Figure 20 The hypoplastic labrum variant may be associated with
loss of the normal suction seal and result in increased load across the
capsular ligaments.
throscopic anatomic location along the anterior femoral
neck. After completing the inspection of the interior hip joint
(central compartment), the hip is flexed to relax the anterior
capsule and the camera, which is placed in a medial position
in the anterior portal, is gradually repositioned and slipped
distally into the peripheral compartment (Fig. 18). Here the
zona orbicularis is easily identified as well as a medial syno-
vial fold or vincula, which is a capsular reflection roughly at
the six-o’clock position of the head (Fig. 19). The peripheral
compartment is a common place for loose bodies, and with
an accessory portal, a bony impingement lesion can be
débrided under direct visualization.
Normal Anatomic Variants
The acetabular labrum has numerous anatomic variants, pri-
marily in anterior and lateral portions. At times, it may ap-
pear thin, poorly developed, and hypoplastic (Fig. 20).52 In
our experience, a hypoplastic labrum lacks an adequate suc-
tion seal from their incompetent labrum, resulting in exces-
sive loading on the capsular ligaments and the development
of hip pain. At other times the labrum may be enlarged,
especially in the setting of acetabular dysplasia, where the
lateral labrum is hypertrophied to act as weight-bearing and
supportive structure to compensate for deficiency in the
bony acetabulum. Occasionally, there is a labral cleft separat-
ing the margin of the acetabular articular surface from the
labrum.52 This is a normal variant without evidence of
trauma or healing tissue.
Occasionally, misinterpreted as a fracture line, a physeal
scar maybe present just anterior or posterior to the acetabular
fossa. This is a remnant of the triradiate cartilage. It is an area
devoid of cartilage extending in a linear fashion along the
medial wall of acetabulum. More commonly, a stellate crease
or star-like appearing articular lesion may be found just su-
perior to the acetabular fossa. It appears that this is a normal
variant and not a pathological process. It is unlikely it is a
170 A.S. Ranawat and B.T. Kelly

Figure 21 Two portals are traditionally used (anterior and lateral). The anterior portal coincides with the intersection of
a sagittal line drawn distally from the anterior superior iliac spine and a transverse line across the superior margin of the
greater trochanter. The lateral portal can lie just anterior or posterior to the superior tip of the greater trochanter (A).
Careful attention to proper portal placement is essential for avoidance of nearby neurovascular structures (B). (Re-
printed with permission from Kelly et al.13)

cause of pain but its long-term prognostic significance is still
unclear. It must be differentiated from traumatic articular
defects which may occur near this area from a direct lateral
blow to the hip impacting the femoral head on superior-
medial wall of the acetabulum.
Portal Consideration
for Identification of Anatomy
Accurate portal placement is essential for optimal visualiza-
tion of all intra-articular structures as well as the peripheral
Anatomy of the hip
Figure 22 Visualization of the anterior triangle is achieved on entry
into the joint through the anterolateral portal.
compartment. Typically, 2 basic portals are used: lateral, and
anterior (Fig. 21). The vast majority of procedures performed
within the central compartment can be accomplished with
just these 2 portals. The lateral portal allows for optimal
visualization of the iliofemoral ligament, femoral head, ante-
rior superior labrum, ligamentum teres, transverse ligament,
and most of the acetabulum. The anterior portal, typically the
second portal to be established, allows for visualization of the
posterior-superior capsule, posterior superior labrum, the
posterior recess, the femoral head, and the ligamentum teres.
This portal is also the optimal location for viewing structures
in the peripheral compartment such as the head-neck junc-
tion, the anterior femoral neck, the zona orbicularis, and the
distal insertion of the capsular ligaments on the intertrochan-
teric line. In addition, the posterolateral portal, also de-
scribed as the posterior paratrochanteric portal, can be made
from a separate incision or from redirection of the lateral
portal. It allows for visualization of the posterior aspect of the
femoral head, the posterior labrum, posterior capsule, and
Figure 23 The recess between the labrum and the capsule can be
clearly visualized as well.
171
Figure 24 The anterior aspect of the femoral head should be in-
spected in its entirety to identify and chondral defects.
the inferior edge of the ischiofemoral ligament.21 Finally, 2
accessory portals (proximal lateral and distal lateral) are use-
ful for releases of the iliotibial band and osseous debridement
for decreased head-neck junction offset or femoroacetabular
impingement.
Systematic
Arthroscopic Evaluation
We perform hip arthroscopy in the modified supine position
in which the hip is placed in a position of 10° flexion, 15°
internal rotation, 10° lateral tilt, and neutral abduction. How-
ever, the lateral position may also be used depending on
surgeon preference. In either case, distraction of the femoral
head from the acetabulum must be performed to fully visu-
alize the articular surfaces. A minimum of 8 to 10 mm of
distraction is recommended to avoid any iatrogenic injury to
the chondral surfaces or labrum. Adequate traction typically
requires between 25 and 50 pounds of force.53 Gentle
Figure 25 The ligamentum teres can be visualized by driving the
arthroscope into the medial aspect of the joint.
172
Figure 26 Complete view of the posterior labrum from the anterior
portal.
counter-traction also is applied to the contralateral limb. A
thorough understanding of the anatomic relationships
around the hip joint with special attention to neurovascular
structures and tissue planes is of paramount importance. All
of the intra-articular structures in the hip joint can be seen
through the combined use of 70° and 30° arthroscopes as
well as the interchange of portals.13
Once the traction is applied, the lateral portal is established
under fluoroscopic guidance using the landmarks of the tro-
chanter and ASIS. Immediate visualization of the anterior trian-
gle is established through this portal (Fig. 22). The anterior
triangle represents the intra-articular portion of the lateral limb
of the iliofemoral ligament. The anterior portal is established
under direct visualization, as the spinal needle is directed be-
tween the lateral and medial limbs of the Y-Ligament.
A systematic evaluation of the anterior structures of the
joint can be performed with the arthroscope in the lateral
portal. Starting anteromedially at the level of the “Psoas U,”
Figure 27 The posterior superior capsule is inspected. The location
of the entry point for the lateral portal is evaluated from this view to
confirm that the portal has not violated the labrum.
A.S. Ranawat and B.T. Kelly
Figure 28 The posterior recess is a common location for loose bodies
and intra-articular debris to hide. Removal of these items is best
achieved with the arthroscope in the anterior portal and the working
instruments in the lateral portal.
the entire circumference of the labrum can be visualized. The
recess between the labrum and capsule can also be visualized
in its entirety (Fig. 23). The anterior portion of the femoral
head is completely inspected (Fig. 24), and should include a
complete evaluation of the fovea capitus. From this central
position in the joint, the transverse acetabular ligament can
be clearly seen as well as the ligamentum teres (Fig. 25), the
fat pad, and the central aspect of the acetabulum. Finally, the
psoas tendon and/or bursae should be inspected and may be
intra-articular or extra-articular. If extra-articular, it usually
is lying just medial to a thin veil of capsular tissue and can be
easily palpated with probe.
Once the inspection is complete from the lateral portal, the
arthroscope is switched to the anterior portal for a more
complete view of the posterior aspect of the joint. From this
portal a more complete evaluation of the posterior labrum
can be achieved (Fig. 26). The normal posterior sulcus of the
Figure 29 The posterior aspect of the femoral head should be com-
pletely evaluated to identify the presence of chondral lesions.
Anatomy of the hip
labrum can be clearly seen from this vantage point. The pos-
terior superior capsule can be inspected and check if the
lateral portal is in the correct position relative to the labrum
(Fig. 27). The posterior recess can be inspected for loose
bodies which is a common resting ground for any intra-
articular debris (Fig. 28). The posterior aspect of the femoral
head can be more clearly evaluated with the arthroscope in
this position and should be evaluated thoroughly for loose
bodies (Fig. 29).
Once the intra-articular examination is complete, the
scope is left in the anterior portal, and the traction is slowly
released so that the head neck junction can be evaluated. The
anterior aspect of the hip may be adequately visualized with
minimal to no traction. With hip flexion to 45° and external
rotation to 30°, the anterior capsule becomes relatively patu-
lous and can be distended with saline, making visualization
of the head and neck relatively easy. As the traction is slowly
released, an upward pressure must be maintained on the
arthroscope to avoid articular cartilage injury. Once the trac-
tion is completely released, the arthroscope can be slid into
the head neck junction recess (Fig. 30). From this position, a
clear view of the anterior femoral neck and the associated
vincula, and the normal labrum suction seal can be estab-
lished (Fig. 31). If any work needs to be performed in the
head neck junction recess, it is best accomplished through
the distal lateral accessory portal. If there is concern regard-
ing pathology associated with the iliotibail band (ITB), glu-
teus medius, or piriformis, a proximal lateral portal is estab-
lished approximately 2 cm distal and in-line with the lateral
portal. A 30° arthroscope is placed in the lateral portal, which
allows for adequate visualization of the ITB. If the ITB is
released, the arthroscope can be driven into the trochanteric
bursae for evaluation and inspection of the gluteus medius,
and piriformis.
Conclusion
Open surgical exposures have been the “gold standard” for
hip procedures for over a century. Although safe and effec-
Figure 30 Arthroscopic view of the head neck junction from the
anterior portal.
173
Figure 31 View of the normal suction seal of the labrum on the
femoral head with the traction released.
tive, they have limited utility regarding intra-articular and
peripheral compartment pathology. Recently, advances in a
safe technique for surgical dislocation of the hip have created
a new tool to address these problems. This procedure,
though safe and reproducible, is invasive and costly. On the
other hand, hip arthroscopy affords the orthopedic surgeon a
tool for minimally invasive management of intra-articular
and peripheral compartment pathologies. The recent ad-
vances in surgical techniques, advanced imaging modalities,
and more versatile instrumentation, have significantly im-
proved the accessibility of the hip joint despite the numerous
anatomic and technical constraints. Hip arthroscopy can now
be performed safely and effectively as an outpatient proce-
dure. A more thorough understanding of the normal and
variant structure and function of this joint will further im-
prove our ability to appropriately diagnose and treat chal-
lenging hip pathologies.
References
1. Callaghan JJ, Rosenberg AG, Rubash HE (eds): The Adult Hip. Phila-
delphia, Lippincott-Raven, 1998
2. Hoaglund FT, Steinbach LS: Primary osteoarthritis of the hip: Etiology
and epidemiology. J Am Assoc Ortho Surg 9:320-327, 2001
3. Hoppenfeld S, DeBoer P: Surgical Exposures in Orthopaedics: The
Anatomic Approach. Philadelphia, Lippincott Williams & Wilkins,
2003
4. Ganz R, Gill TJ, Gautier E, et al: Surgical dislocation of the adult hip a
technique with full access to the femoral head and acetabulum without
the risk of avascular necrosis. J Bone Joint Surg 83B:1119-1124, 2001
5. Murphy S, Tannast M, Kim Y, et al: Debridement of the adult hip for
femoracetabular impingement. Clin Orthop 429:178-181, 2004
6. Edwards DJ, Lomas D, Villar RN: Diagnosis of the painful hip by mag-
netic resonance imaging and arthroscopy. J Bone Joint Surg, 77B:374-
376, 1995
7. Fitzgerald RH Jr: Acetabular labrum tears. Diagnosis and treatment.
Clin Orthop, 311:60-68, 1995
8. Frich LH, Lauritzen J, Juhl M: Arthroscopy in diagnosis and treatment
of hip disorders. Orthopedics 12:389-392, 1989
9. Gondolph-Zink B: [Current status of diagnostic and surgical hip arthro-
scopy]. Orthopade 21:249-256, 1992
10. Hawkins RB: Arthroscopy of the hip. Clin Orthop 249:44-47, 1989
11. Ikeda T, Awaya G, Suzuki S, et al: Torn acetabular labrum in young
174
patients. Arthroscopic diagnosis and management. J Bone Joint Surg
70B:13-16, 1988.
12. Janssens X, Van Meirhaeghe J, Verdonk R, et al: Diagnostic arthroscopy
of the hip joint in pigmented villonodular synovitis. Arthroscopy
3:283-287, 1987
13. Kelly BT, Williams RJ 3rd, Philippon MJ: Hip arthroscopy: Current
indications, treatment options, and management issues. Am J Sports
Med 31:1020-1037, 2003
14. McCarthy JC, Busconi B: The role of hip arthroscopy in the diagnosis
and treatment of hip disease. Orthopedics 18:753-756, 1995
15. McCarthy JC, Lee JA: The role of hip arthroscopy: Useful adjunct or
devil’s tool? Orthopedics 25:947-948, 2002
16. Okada Y, Awaya G, Ikeda T, et al: Arthroscopic surgery for synovial
chondromatosis of the hip. J Bone Joint Surg 71B:198-199, 1989
17. O’Leary JA, Berend K, Vail TP: The relationship between diagnosis and
outcome in arthroscopy of the hip. Arthroscopy 17:181-188, 2001
18. Philippon MJ: The role of arthroscopic thermal capsulorrhaphy in the
hip. Clin Sports Med 20:817-829, 2001
19. Burman M: Arthroscopy or the direct visualization of joints. J Bone
Joint Surg, 4:669-695, 1931
20. Gross R: Arthroscopy in hip disorders in children. Orthop Rev, 6:43-
49, 1977
21. Dvorak M, Duncan CP, Day B: Arthroscopic anatomy of the hip. Ar-
throscopy, 6:264-273, 1990
22. Keene GS, Villar RN: Arthroscopic anatomy of the hip: An in vivo
study. Arthroscopy, 10:392-399, 1994
23. Reikeras O, Bjerkreim I, Kolbenstvedt A: Anteversion of the acetabu-
lum and femoral neck in normals and in patients with osteoarthritis of
the hip. Acta Orthop Scand, 54:18-23, 1983
24. Siffert RS: Patterns of deformity of the developing hip. Clin Orthop
160:14, 1981
25. Fabry G, Mac Ewen G, Shands A: Torsion of the femus: A follow-up
study in normal and abnormal conditions. J Bone Joint Surg, 55A:1726,
1973
26. Kingsley P, Olmstead K: A study to determine the angle of anteversion
of the neck of the femur. J Bone Joint Surg, 30A:745, 1948
27. Gautier E, Ganz K, Krugel N, et al: Anatomy of the medial femoral
circumflex artery and its surgical implications. J Bone Joint Surg Br
82:679-683, 2000
28. Smith-Peterson M: A new supra-articular subperiosteal approach to the
hip joint. Am J Orthop Surg 15:592, 1917
29. Smith-Peterson M: Approach to and exposure of the hip joint for mold
arthroplasty. J Bone Joint Surg, 31A:40, 1949
30. Charnley J: Low Friction Arthroplasty of the Hip: Theory and Practice.
New York, Springer-Verlang, 1979
31. Harris W: A new lateral approach to the hip. J Bone Joint Surg 49A:891,
1967
32. Hardinge K: The direct lateral approach to the hip. J Bone Joint Surg
64B:17-19, 1982
A.S. Ranawat and B.T. Kelly
33. Moore AT: The self-locking metal hip prosthesis. J Bone Joint Surg
39A:811, 1957
34. Moore AT: The Moore self-locking vitallium prosthesis in fresh femoral
neck fractures: A new low posterior approach (the southern exposure).
Instructional Course Lecture of the American Academy of Orthopedic
Surgeons, 16, 1959
35. Kocher T, in Siles HH, Paul CB (eds): Operative Surgery. London,
Black, 1911
36. Langenbeck B: Ueber die Schussfracturen der Gelenke und ihre Behan-
dlung. 1868
37. Mehlman CT, Meiss L, DiPasquale TG: Hyphenated-History: The
Kocher-Langenneck surgical approach. J Orthopedic Trauma 14:60-
64, 2000
38. Gibson A: Posterior exposure of the hip joint. J Bone Joint Surg, 32B:
183-186, 1950
39. Ludloff K: Zur Blutigen Einrenkung Derangeborenen Huftluxation. Z
Orthop Chir 22:272, 1908
40. Kapandji IA: The Physiology of Joints. Baltimore, Williams & Wilkins,
1970
41. Kelly BT, Shapiro GS, Digiovanni CW, et al: Vascularity of the hip
labrum: A cadaveric investigation. Arthroscopy 21:3-11, 2005
42. Kim YT, Azusa H: The nerve endings of the acetabular labrum. Clin
Orthop 310:60-68, 1995
43. Lephart S, Philippon MJ, Draovitch P: Golf injury prevention research
models, in World Scientific Congress of Golf. St. Andrews, Scotland,
2002
44. Philippon MJ: Arthroscopic capsulorrhaphy of the hip: a review of 12
cases, in 19th Annual Meeting of Arthroscopy Association of North
America. Miami, Florida, 2000
45. Takechi H, Nagashima H, Ito S: Intra-articular pressure of the hip joint
outside and inside the limbus. J Jpn Orthop Assoc 56:529-536, 1982
46. Ferguson SJ, Bryant JT, Ganz R, et al: The acetabular labrum seal: A
poroelastic finite element model. Clin Biomech 15:463-468, 2000
47. Ferguson SJ, Bryant JT, Ganz R, et al: The influence of the acetabular
labrum on hip joint cartilage consolidation: A poroelastic finite element
model. J Biomech, 33:953-960, 2000
48. Ferguson SJ, Bryant JT, Ganz R, et al: An in vitro investigation of the
acetabular labral seal in hip joint mechanics. J Biomech 36:171-178,
2003
49. Rao J, Zhou YX, Villar RN: Injury to the ligamentum teres. Mechanism,
findings, and results of treatment. Clin Sports Med 20:791-799, 2001
50. Philippon MJ: Arthroscopy of the hip in the management of the athlete,
in Operative Arthroscopy. Philadelphia, Lippincott, Williams &
Wilkins, 2003, pp 879-883
51. Bombelli R: Structure and function in normal and abnormal hips. New
York, Springer-Verlag, 1993
52. Byrd JW: Hip arthroscopy, the supine approach: Technique and anat-
omy of the intraarticular and peripheral compartments. Tech Orthope-
dics 20:17-31, 2005
53. Byrd JW: Hip arthroscopy. The supine position. Clin Sports Med 20:
703-731, 2001