---

Hip Arthroscopy

---

Indications

• Femoroacetabular impingement (FAI) - by far the most common current use
• Acetabular labral tears
• Loose bodies (e.g., synovial chondromatosis)
• Ligamentum teres disorders
• Snapping hip syndrome
• Synovial conditions

• Gluteal tendon tears
• Hamstring tears
• Ischiofemoral impingement
• Deep gluteal space disorders
• Septic arthritis (joint washout)

• Morgan and Mikhail's Clinical Anesthesiology 7e

---

Contraindications

• Hip dysplasia (relative - see borderline dysplasia below)
• Avascular necrosis of the femoral head
• Advanced osteoarthritis
• Global acetabular or femoral deformities
• Rotational deformities of the hip

• Cam deformity extending into the posterior-superior head-neck junction (behind retinacular vessels)
• Pincer deformity involving the posterior-superior wall
• Significant proximal femoral deformity (e.g., femoral retrotorsion, residual SCFE, Legg-Calve-Perthes, or post-DDR open reduction deformity)

---

Patient Setup

• A well-padded perineal post is used to provide a counterforce for traction
• Reported complication rate ~7.1% in prospective studies (mainly perineal/pudendal injury)

• Eliminates risk of pudendal nerve palsy and perineal soft-tissue injury
• Methods include:
  • Yoga mat technique: cut yoga mat placed under posterior trunk; arms folded in figure-eight position
  • Tutankhamun technique: patient secured to table with a long sheet + duct tape in figure-eight fashion; arms crossed over chest
  • Jimenez technique: post used only for initial positioning, then removed; table placed in 10-15 degrees Trendelenburg

---

Portals

---

Compartments

1. Central compartment - Intra-articular space between cartilaginous portions of the femoral head and acetabulum. Requires traction for access. Structures visualized: articular cartilage, labrum, ligamentum teres, synovium.
2. Peripheral compartment - Intra-articular but lateral to the labrum along the femoral neck/acetabular rim. Does not require traction. Structures: head-neck junction (key for cam resection), capsule.
3. Lateral (peritrochanteric) compartment - Extra-articular; trochanteric bursa and peritrochanteric space. Used for gluteal tendon and snapping hip pathology.

---

FAI-Specific Surgery

• Cam lesion: osteochondroplasty of the femoral head-neck junction
• Pincer lesion: acetabular rim trimming
• Labrum: debridement or refixation

• Male sex
• Age >40 years
• Microfracture treatment
• Preoperative joint space <2 mm
• Tonnis grade 2 or 3 preoperative arthritis

---

Complications

---

Key Points - Bailey & Love Summary

---

HIP ARTHROSCOPY

10-Mark Postgraduate Exam Answer

---

DEFINITION

---

INDICATIONS

• Femoroacetabular impingement (FAI) - cam, pincer, or mixed type
• Acetabular labral tears
• Loose bodies (e.g., synovial chondromatosis)
• Ligamentum teres disorders / rupture
• Snapping hip syndrome (coxa saltans)
• Synovial disorders (synovitis, chondromatosis)
• Septic arthritis - washout and debridement

• Gluteal tendon tears
• Hamstring tears (proximal)
• Ischiofemoral impingement
• Deep gluteal space disorders

---

CONTRAINDICATIONS

---

PREOPERATIVE WORKUP

• X-ray: AP pelvis + lateral (alpha angle, LCE angle, Tonnis grade, crossover sign)
• MRI arthrogram: Labral tears, chondral damage, ligamentum teres
• CT scan (3D): Cam deformity quantification, acetabular version
• Diagnostic injection: Image-guided intra-articular local anesthetic - confirms intra-articular source of pain

---

PATIENT POSITIONING & SETUP

• Patient supine on hip distraction table
• ~50 lb (22.7 kg) traction applied
• Well-padded perineal post as counterforce
• Complication rate ~7.1% (pudendal nerve, perineal injury)

• No perineal post
• Table in 10-15° Trendelenburg
• Foam pad / yoga mat under patient's torso
• Methods: Yoga mat technique, Tutankhamun technique, Jimenez technique
• Eliminates pudendal nerve and perineal injuries

---

PORTALS

PORTAL POSITIONS (surface anatomy)
─────────────────────────────────────────────
            ASIS
             |
   AP ●──────┼
             |
        MAP ●│
             |
   DALA ●────● AL
             |
             ● PL
         Greater
        Trochanter

• Standard setup uses 2-3 portals: AL + MAP ± DALA
• AL portal established first under fluoroscopic guidance with spinal needle

---

COMPARTMENTS ACCESSED

┌─────────────────────────────────────────────────┐
│           HIP ARTHROSCOPY COMPARTMENTS          │
├──────────────────┬──────────────────┬────────────┤
│   CENTRAL        │   PERIPHERAL     │   LATERAL  │
│  COMPARTMENT     │   COMPARTMENT    │ COMPARTMENT│
├──────────────────┼──────────────────┼────────────┤
│ Intra-articular  │ Intra-articular  │ Extra-     │
│ cartilage zone   │ lateral to labrum│ articular  │
│                  │ along femoral    │ peritroch- │
│                  │ neck             │ anteric    │
├──────────────────┼──────────────────┼────────────┤
│ REQUIRES TRACTION│ NO TRACTION NEEDED│ NO TRACTION│
├──────────────────┼──────────────────┼────────────┤
│ • Articular      │ • Head-neck jxn  │ • Trochant-│
│   cartilage      │   (cam resection)│   eric     │
│ • Labrum         │ • Capsule        │   bursa    │
│ • Lig. teres     │ • Peripheral rim │ • Gluteal  │
│ • Synovium       │                  │   tendons  │
└──────────────────┴──────────────────┴────────────┘

---

MANAGEMENT FLOWCHART FOR FAI (Most Common Indication)

PATIENT: Groin pain, worsened by flexion/sitting
                    │
                    ▼
        CLINICAL ASSESSMENT
   Positive anterior impingement test
   Limited passive internal rotation
                    │
                    ▼
              IMAGING
   X-ray: Alpha angle >50°, pistol grip,
          crossover sign, Tonnis 0-1
   MRI: Labral tear, chondral damage
                    │
                    ▼
      CONSERVATIVE TREATMENT (≥3 months)
   Activity modification + NSAIDs + Physio
   + Intra-articular steroid injection
                    │
           ─────────┴─────────
          │                   │
       RESPONDS            FAILS
          │                   │
     Continue Rx              ▼
                   ASSESS JOINT SPACE
                  ┌──────────────────┐
                  │                  │
              >2 mm              <2 mm
          Tonnis 0-1           Tonnis 2-3
              │                  │
              ▼                  ▼
       HIP ARTHROSCOPY      TOTAL HIP
        CANDIDATE          ARTHROPLASTY
              │
    ┌─────────┴──────────┐
    │                    │
  CAM TYPE           PINCER TYPE
    │                    │
Femoral head-neck    Acetabular rim
osteochondroplasty   trimming ±
                     labral refixation
              │
              ▼
   POST-OP REHABILITATION
   Protected WB × 2-4 weeks
   Physio: ROM, strengthening
   Return to sport: 4-6 months

---

STEPS OF THE PROCEDURE (Summary)

1. GA or spinal anesthesia; supine on fracture table
2. C-arm fluoroscopy in position
3. Traction applied; joint distracted 8-10 mm
4. AL portal established first with spinal needle under fluoroscopy
5. Arthroscope inserted; MAP established under direct vision
6. Central compartment work (with traction): labral assessment/repair, chondral work, loose body removal
7. Peripheral compartment work (traction released): cam resection, capsular management
8. Capsular closure if significant capsulotomy performed
9. Traction released; wound closure

---

COMPLICATIONS

• Iatrogenic labral damage (most common)
• Iatrogenic chondral injury
• Neurovascular injury (portal-related)
• Instrument breakage

• Traction neuropraxia - sciatic and pudendal nerves
  • Maximum traction weight (not duration) is the key risk factor
• Heterotopic ossification - prevented by NSAIDs prophylaxis
• Perineal soft tissue injury (post-related)
• Avascular necrosis (rare)
• Conversion to THA

• Neuropraxia: 0.92%
• Iatrogenic chondral/labral injury: 0.69%
• Heterotopic ossification: 0.60%

---

OUTCOMES

• FAI arthroscopy gives rapid recovery vs. open surgery
• Radiographic and clinical parameters of impingement effectively treated
• Risk factors for conversion to THA:
  • Male sex
  • Age >40 years
  • Microfracture treatment
  • Preoperative joint space <2 mm
  • Tonnis grade 2-3 preoperative arthritis
• Steep learning curve - mentored training is essential

---

ADVANTAGES OVER OPEN SURGERY

---

SUMMARY BOX (for quick recall in exam)

Hip arthroscopy = Minimally invasive hip surgery. Main use = FAI + labral tears. Setup = supine, 50 lb traction, ± perineal post. Three portals: AL + MAP + DALA. Three compartments: central (traction), peripheral (no traction), lateral (extra-articular). Main complications = traction neuropraxia, iatrogenic cartilage injury, heterotopic ossification. Contraindicated in dysplasia, AVN, advanced OA.

---

---

RECENT ADVANCES IN HIP ARTHROSCOPY

10-Mark Postgraduate Exam Answer

---

OVERVIEW FLOWCHART

RECENT ADVANCES IN HIP ARTHROSCOPY
               │
     ┌─────────┼──────────────────────┐
     ▼         ▼                      ▼
TECHNIQUE   TECHNOLOGY            BIOLOGICS
     │         │                      │
     ▼         ▼                      ▼
- Postless  - 3D MRI / CT        - PRP therapy
  technique  - AI & ML            - Stem cells
- Labral     - Augmented reality  - Biological
  recon-     - Robotic-assisted     scaffolds
  struction    arthroscopy
- Capsular  - 4K/3D visualization
  management - Navigation systems
     │         │                      │
     └─────────┴──────────────────────┘
                    │
                    ▼
         EXPANDING INDICATIONS
         - Pediatric/adolescent
         - Deep gluteal syndrome
         - Hamstring / gluteal tendons
         - Snapping hip / PVNS
                    │
                    ▼
         OUTCOME PREDICTION
         - PRO scoring
         - Machine learning models
         - Patient-specific factors

---

1. ADVANCES IN TECHNIQUE

A. Postless Hip Distraction (2024-2026 Consensus)

• Traditional perineal post causes pudendal nerve palsy, perineal soft-tissue injury
• Post-related complication rate: 7.1% in prospective studies
• Expert Consensus (2026) - Wang et al. [PMID: 42014935] published 20 evidence-based recommendations for the Trendelenburg postless technique using GRADE methodology
• Methods include:
  • Yoga mat technique
  • Tutankhamun technique
  • Jimenez technique (Trendelenburg + foam pad)
• Result: zero pudendal nerve or perineal injuries; growing adoption (~33% of hip arthroscopists)

B. Labral Reconstruction (vs. Repair)

• Traditional labral debridement → superseded by labral repair → now evolving to labral reconstruction
• Reconstruction indicated when labrum is irreparable (deficiency, prior resection, severe damage)
• Rosenthal et al. (2023) [PMID: 37493964] - systematic review confirms labral reconstruction restores joint stability and gives good clinical outcomes
• Graft options (still debated):
  • Iliotibial band autograft
  • Ligamentum teres autograft
  • Gracilis tendon autograft
  • Fascia lata
  • Allograft (cadaveric)
• Consistently restores labral sealing function and hip stability
• Superiority over repair is still being established - more RCT data needed

C. Capsular Management

• Capsulotomy is standard for access but unrepaired capsulotomy → instability risk
• Capsular plication / closure now recommended, especially in:
  • Borderline dysplasia (LCE 20-24°)
  • Hyperlaxity / connective tissue disorders
  • Revision cases
• Interportal vs. T-type capsulotomy - interportal preferred for preserving capsular integrity

D. Hip Arthroscopy in Pediatric / Adolescent Patients

• Shah, Stavinoha, Nepple (2024) [PMID: 40433284] - review of evolving role in children
• Indications: FAI (post-SCFE, Perthes), labral tears, loose bodies, osteochondral lesions
• Technical modifications needed: smaller instruments, open physes consideration, different traction limits
• Growing evidence supporting safe use with good outcomes in skeletally immature patients

---

2. TECHNOLOGICAL ADVANCES

A. Advanced Imaging

• Chen & Chen (2024) [PMID: 37746892] - radial plane MRI sequences give superior labral assessment vs. standard planes

B. Artificial Intelligence & Machine Learning

• AI-driven outcome prediction - [PMID: 38182802, Spencer & Hagen 2024]:
  • ML models trained on PRO scores, demographic data, imaging parameters
  • Can predict conversion to THA, revision rates, satisfaction scores
  • Personalised pre-operative risk profiling possible
• AI video analysis during arthroscopy:
  • Live camera-derived video analysis to improve diagnostic accuracy
  • Tracking surgical performance metrics
  • Identifying labral tears and chondral lesions in real time
• AI-identified research trends (2025) [PMID: 40692938] - Hip arthroscopy/FAI identified as one of the 3 most rapidly growing publication areas in orthopaedic surgery

C. Augmented Reality (AR)

• CT/MRI overlay projected onto live arthroscopic image
• Guides precision resection of cam deformity to exact planned depth
• Reduces risk of over- or under-resection
• Currently in research/development phase; not yet mainstream for arthroscopy

D. Robotic-Assisted Arthroscopy

• Still largely in R&D phase for arthroscopy (unlike arthroplasty where it is established)
• Promises:
  • Enhanced precision and stability of instruments
  • Reduced hand tremor effect
  • Planned osteochondroplasty depth guided by pre-op imaging
  • Voice/ocular movement control of limb positioners

E. Improved Visualization Systems

• 4K ultra-HD arthroscopes - superior image resolution vs. standard HD
• 3D arthroscopic visualization - depth perception for complex intra-articular work
• 70° wide-angle scopes - better peripheral compartment visualization
• Single-use arthroscopes - reduce infection risk, eliminate sterilisation burden

---

3. BIOLOGICAL ADVANCES

BIOLOGICAL THERAPIES IN HIP ARTHROSCOPY
                │
    ┌───────────┼──────────────┐
    ▼           ▼              ▼
   PRP        STEM CELLS    SCAFFOLDS /
  THERAPY                   GRAFTS
    │           │              │
    ▼           ▼              ▼
Growth      MSCs from      Collagen matrix
factors     bone marrow    Decellularized
→ enhance   or adipose     labral allografts
tissue      tissue         Synthetic augments
healing     concentrate
    │           │              │
    └───────────┴──────────────┘
                │
                ▼
    AIM: CARTILAGE REGENERATION +
    LABRAL HEALING + DELAY OF OA

• PRP (Platelet-Rich Plasma): Injected intra-articularly at time of surgery; growth factors (PDGF, TGF-β, VEGF) enhance healing of labrum and cartilage
• Bone Marrow Aspirate Concentrate (BMAC): Contains mesenchymal stem cells; used with microfracture to improve quality of cartilage repair tissue
• Microfracture evolution: Traditional microfracture → augmented with BMAC/scaffold → autologous chondrocyte implantation (ACI) for larger lesions
• Early evidence: biologics improve tissue healing and may delay arthritis onset - RCTs ongoing

---

4. EXPANDING INDICATIONS

---

5. OUTCOME PREDICTION - PATIENT SELECTION ADVANCES

• Female sex
• Age <40 years
• Joint space >2 mm
• Tonnis grade 0-1
• Pre-op PRO scores not too low
• Positive diagnostic injection response

• Male sex
• Age >40
• Joint space <2 mm
• Tonnis grade 2-3
• Microfracture treatment
• Severe chondral damage

---

6. REHABILITATION ADVANCES

• Accelerated protocols: Weight-bearing as tolerated from Day 1 (vs. 6-week protected WB historically)
• Blood Flow Restriction (BFR) training: Maintains muscle mass during early recovery phase with low loads
• Tele-rehabilitation: Remote physiotherapy monitoring post-discharge
• Evidence: Updated protocols reduce stiffness, muscle weakness; faster return to sport vs. older restrictive protocols

---

SUMMARY TABLE

---

EXAM QUICK RECALL BOX

Recent advances = "TIBERS"

• T = Technique (postless, labral reconstruction, capsular plication)
• I = Imaging (3D MRI, dynamic CT, MRI arthrogram)
• B = Biologics (PRP, BMAC, stem cells, scaffolds)
• E = Expanding indications (PVNS, gluteal tendon, pediatric, deep gluteal)
• R = Robotics/AR/AI (visualization, outcome prediction, guided resection)
• S = Selection/outcome prediction (ML-based patient profiling)

---

---

HIP ARTHROSCOPY

10-Mark Postgraduate Exam Answer — Complete Combined Answer

---

DEFINITION

---

ANATOMY RELEVANT TO HIP ARTHROSCOPY

• Hip joint is deeply recessed within a thick fibrocapsular and muscular envelope - unique challenge compared to other joints
• Key structures visualized: femoral and acetabular articular cartilage, acetabular labrum, ligamentum teres, head-neck junction, synovium, peritrochanteric space
• Steep learning curve - mentored training is essential for safe independent practice

---

INDICATIONS

• Femoroacetabular impingement (FAI) - cam, pincer, mixed - most common current use
• Acetabular labral tears
• Loose bodies / synovial chondromatosis
• Ligamentum teres disorders
• Snapping hip syndrome (coxa saltans)
• Synovitis / inflammatory conditions
• Septic arthritis - washout and debridement

• Gluteal tendon tears
• Proximal hamstring tears
• Ischiofemoral impingement (endoscopic lesser trochanter resection)
• Deep gluteal syndrome (sciatic nerve decompression)
• Pigmented villonodular synovitis (PVNS)
• Pediatric/adolescent hip conditions (post-SCFE, Perthes)

---

CONTRAINDICATIONS

Special note on borderline dysplasia: Arthroscopy may be done if capsular plication is performed concurrently; otherwise periacetabular osteotomy (PAO) preferred.

---

PREOPERATIVE WORKUP

PREOPERATIVE ASSESSMENT
        │
   ┌────┴──────────────┬──────────────────┐
   ▼                   ▼                  ▼
X-RAY              MRI/MRA              CT SCAN
AP pelvis +        Labral tears         3D recon:
Lateral            Chondral damage      Alpha angle
Alpha angle        Ligamentum teres     Acetabular
LCE angle          Head-neck junction   version
Tonnis grade                            Cam extent
Crossover sign
        │
        ▼
DIAGNOSTIC INJECTION
Image-guided intra-articular
local anesthetic ± steroid
(confirms intra-articular source;
positive response validates surgery)

---

PATIENT POSITIONING & SETUP

Standard (with perineal post):

• Post provides counterforce for distraction
• Complication rate: ~7.1% (pudendal nerve palsy, perineal injury)
• Post-related neuropraxia risk

Postless Technique (Recent Advance - 2026 Expert Consensus):

• Eliminates all perineal/pudendal complications
• Adopted by ~33% of hip arthroscopists
• Table in 10-15° Trendelenburg + foam/yoga mat

---

PORTALS

PORTAL POSITIONS (surface anatomy)
─────────────────────────────────
         ASIS
          │
   AP ●───┤  ← Level of ASIS
          │
     MAP ●│  ← Midpoint AP–AL
          │
DALA ●────● AL  ← 1 cm ant/sup to GT
          │
          ● PL  ← Posterior to GT
      Greater
     Trochanter

• Standard: AL + MAP ± DALA (2-3 portals)
• AL portal established first under fluoroscopic guidance with spinal needle

---

THREE COMPARTMENTS

┌─────────────────────────────────────────────────────┐
│              HIP ARTHROSCOPY COMPARTMENTS           │
├──────────────────┬──────────────────┬───────────────┤
│   CENTRAL        │   PERIPHERAL     │    LATERAL    │
│  COMPARTMENT     │   COMPARTMENT    │  COMPARTMENT  │
├──────────────────┼──────────────────┼───────────────┤
│ Intra-articular  │ Lateral to labrum│ Extra-        │
│ cartilage zone   │ along femoral    │ articular     │
│                  │ neck/acetab. rim │ peritroch.    │
├──────────────────┼──────────────────┼───────────────┤
│ REQUIRES TRACTION│ NO TRACTION NEEDED│ NO TRACTION  │
├──────────────────┼──────────────────┼───────────────┤
│ Articular        │ Head-neck jxn    │ Trochanteric  │
│ cartilage        │ (cam resection)  │ bursa         │
│ Labrum           │ Capsule          │ Gluteal       │
│ Ligamentum teres │ Peripheral rim   │ tendons       │
│ Synovium         │                  │               │
└──────────────────┴──────────────────┴───────────────┘

---

SURGICAL STEPS (FAI - Most Common Operation)

STEPS OF HIP ARTHROSCOPY FOR FAI
          │
    1. GA or spinal anesthesia
          │
    2. Supine on distraction table
       Fluoroscopy C-arm positioned
          │
    3. Traction applied → 8–10 mm
       joint distraction confirmed
          │
    4. AL portal with spinal needle
       under fluoroscopy; arthroscope
          │
    5. MAP established under
       direct vision
          │
    6. CENTRAL COMPARTMENT WORK
       (traction maintained)
       ├── Labral assessment
       ├── Labral repair / reconstruction
       ├── Chondral debridement/microfracture
       ├── Loose body removal
       └── Ligamentum teres assessment
          │
    7. Traction RELEASED
       PERIPHERAL COMPARTMENT WORK
       ├── Cam resection
          (osteochondroplasty of
           femoral head-neck junction)
       ├── Pincer trimming
          (acetabular rim reduction)
       └── Capsular management
          │
    8. Capsular closure
       (plication if needed)
          │
    9. Wound closure; post-op check

---

COMPLICATIONS

• Iatrogenic labral damage (most common - 0.69%)
• Iatrogenic chondral injury (0.69%)
• Neurovascular injury (portal-related)
• Instrument breakage

---

OUTCOMES & PREDICTORS

• Male sex
• Age >40 years
• Joint space <2 mm
• Tonnis grade 2-3
• Microfracture treatment
• Severe chondral/labral damage at surgery

• Female sex, age <40
• Tonnis grade 0-1
• Joint space >2 mm
• Positive diagnostic injection
• Good pre-op PRO scores

---

RECENT ADVANCES (High-Yield for Exam)

RECENT ADVANCES - "TIBERS" MNEMONIC
              │
    ┌─────────┼──────────────────────────┐
    ▼         ▼            ▼             ▼
TECHNIQUE  IMAGING    BIOLOGICS     EXPANDING
                                   INDICATIONS
    │         │            │             │
    ▼         ▼            ▼             ▼
Postless   3D MRI      PRP + BMAC    Pediatric
technique  radial      Stem cells    PVNS
Labral     planes      Scaffolds     Deep gluteal
recon-     MRI         ACI           syndrome
struction  arthrogram  Biological    Proximal
Capsular   (3T)        labral        hamstring
plication  Dynamic CT  grafts        Gluteal
                                     tendons
    │         │            │
    ▼         ▼            ▼
  ROBOTICS / AR / AI
    │
    ├── AI outcome prediction (ML models - PMID 38182802)
    ├── AI video analysis (intraop lesion detection)
    ├── Augmented reality (CT/MRI overlay on arthroscope)
    ├── Robotic-assisted precision resection (R&D phase)
    └── 4K/3D visualization systems

Key Recent Evidence:

---

REHABILITATION (Recent Advances)

• Accelerated WB protocols: Weight-bearing as tolerated from Day 1 (vs. historical 6-week restriction)
• Blood Flow Restriction (BFR) training: Maintains muscle bulk during early recovery with low loads
• Tele-rehabilitation: Remote physiotherapy monitoring post-discharge
• Return to sport: 4-6 months for most; sport-specific criteria replacing time-based criteria

---

ADVANTAGES OVER OPEN SURGERY

---

COMPLETE SUMMARY DIAGRAM

HIP ARTHROSCOPY — COMPLETE OVERVIEW
               │
    ┌──────────┼──────────────────┐
    ▼          ▼                  ▼
PATIENT    SETUP &           WHAT IS
SELECTION  PORTALS           TREATED
    │          │                  │
    ▼          ▼                  ▼
Indications: Supine          Central:
FAI, labral  distraction     Labrum
tears,       table           Cartilage
loose        50 lb traction  Lig teres
bodies,      ± perineal post
PVNS,        OR              Peripheral:
septic       Postless        Cam/Pincer
arthritis    (modern)        resection
    │          │
    ▼          ▼              Lateral:
Contra-    3 portals:        Gluteal
indications AL + MAP + DALA  tendons
Dysplasia  Fluoroscope-      Bursa
AVN        guided
Advanced OA
    │
    ▼
COMPLICATIONS:
Neuropraxia → Chondral injury → HO → Instability → THA conversion
    │
    ▼
RECENT ADVANCES:
Postless → Labral Reconstruction → AI → AR → Robotics → Biologics

---

EXAM QUICK-RECALL BOX

Hip Arthroscopy = Minimally invasive. Main use = FAI + labral pathology. Setup = supine, 50 lb traction, postless preferred (2026 consensus). 3 portals: AL + MAP + DALA. 3 compartments: central (traction), peripheral (no traction), lateral (extra-articular). Main complications = traction neuropraxia, iatrogenic chondral injury, heterotopic ossification (prevent with NSAIDs). Contraindicated in dysplasia, AVN, advanced OA. Recent advances = TIBERS (Technique - Imaging - Biologics - Expanding indications - Robotics/AI/AR - Selection/prediction).

---

---

FAI MANAGEMENT: OPEN vs. ARTHROSCOPIC SURGERY

Comprehensive Comparison Table — PG Exam Format

---

MASTER COMPARISON TABLE

---

ACCESS & VISUALIZATION

---

WHAT CAN BE TREATED

---

CLINICAL OUTCOMES (Evidence-Based)

Key 2026 evidence: Migliorini et al., Die Orthopädie, Springer 2026 (systematic review, PRISMA) - mini-open and arthroscopic achieve similar clinical outcomes at ~34 months; mini-open associated with lower reoperation rate; arthroscopic associated with lower instability/dislocation risk.

Key 2025 evidence: Orthopedic Reviews retrospective cohort (n=2,725) - 5-year outcomes equal THA conversion rate (2.4%); arthroscopic = lower instability; open = lower OA progression.

---

COMPLICATIONS

---

SPECIAL SITUATIONS: WHICH IS PREFERRED?

DECISION FLOWCHART: OPEN vs. ARTHROSCOPIC FOR FAI
                    │
         ┌──────────┴──────────┐
         ▼                     ▼
   ARTHROSCOPIC           OPEN / MINI-OPEN
   PREFERRED              PREFERRED
         │                     │
   ┌─────┴─────┐         ┌─────┴──────────┐
   │           │         │                │
Anterior     Labral   Posterior-       Complex
cam/pincer   tears    superior         proximal
deformity    Loose    cam lesion       femoral
Chondral     bodies   (behind          deformity
lesions      Synovial retinacular      (SCFE,
Most FAI     disease  vessels)         Perthes)
in adults    Septic   Posterior        Femoral
<40 years    arthritis wall pincer     retrotorsion
             Deep      Global          Borderline
             gluteal   deformity       dysplasia
             syndrome  Femoral         requiring PAO
                       osteotomy
                       needed

---

REHABILITATION COMPARISON

---

COST & RESOURCE COMPARISON

---

SUMMARY DECISION TABLE

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QUICK RECALL BOX

Arthroscopic = better for: anterior cam/pincer, labral work, soft tissue, most routine FAI, lower instability risk, faster recovery, day case.

Open = better for: posterior-superior cam, complex deformity, SCFE/Perthes sequelae, femoral osteotomy, lower reoperation rate, lower OA progression at 5 years.

Key fact: At 34 months, clinical outcomes (mHHS, VAS) are equivalent. Open has lower reoperation; arthroscopic has lower instability/dislocation.

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