Hip arthroscopy has evolved over the past 20 years to address a number of intra-articular abnormalities that result in disabling hip pain. They include symptomatic labral tears, chondral lesions, loose bodies, synovitis, crystalline hip arthropathy, infection, and many more.^1,2,4 Complications associated with hip arthroscopy have also been well documented.⁵ Clarke et al.¹ reported a 1.4% complication rate. They included sciatic neurapraxia, femoral neurapraxia, portal hematoma, infection, failure of adequate access or observation, and arthrotomy. In his series of 1,054 hip arthroscopies, hip access was considered difficult in 18% of the cases. In 2.8% (30 hips) of the cases, the hip joint could not be entered. Two cases, open arthrotomies, had to be preformed for removal of a loose body or for intra-articular debridement. Sekiya et al.^6,7 described hip arthroscopy using the anterior mini-open approach. It was felt that because an open dissection is performed down to the hip capsule, the risk of neurovascular injury is decreased.⁶ Also the iatrogenic injury to the articular cartilage or acetabular labrum is potentially reduced. Hawkins⁸ described a small anterior exposure to the hip with mini-arthrotomy and subluxation of the femoral head to allow introduction of the arthroscope. Goldman et al.⁹ described a limited posterior approach, exposing the posterior hip capsule by releasing the short external rotators to allow the placement of an arthroscope to facilitate the removal of a bullet. In our experience, we have found that hip arthroscopy using the anterior mini-open technique has been an excellent addition to our armamentarium in the management and treatment of hip pathology.

Hip arthroscopy, using a limited anterior exposure, has similar indications as a standard hip arthroscopy. It is primarily advantageous in the removal of loose bodies or labral tears, patients with synovial chondromatosis, avascular necrosis, infection, and most importantly in patients in which hip access is deemed difficult by standard arthroscopic techniques.^{2,4,10,11,12,13,14,15} In addition, this procedure allows easy conversion to an open technique should it be required. We also feel that patients who are greater than 1.5 times ideal body weight may be best served with this procedure. It allows greater scope mobility and a decreased risk to the neurovascular structures. Sekiya⁷ reported no complications in his case series in which a limited anterior exposure was performed. Rehabilitation is extended 2 to 3 weeks to allow for wound healing. Other patients who may be best served with this technique include those with advanced osteoarthritis. These patients have joint capsular contraction, making hip distraction difficult, and thus are at increased risk for articular cartilage damage.

A relative contraindication would include patients in which an altered anterior anatomy exists. These are individuals who have had prior surgery, specifically an osteotomy. Anterior heterotopic bone formation may also be a contraindication for this technique, unless a concomitant open removal is planned.

In accordance to the American Academy of Orthopedic Surgeon’s recommendation, the operative hip is identified
and signed by the surgeon in the holding room. The patient is then brought to the operating room and placed supine on a radiolucent operative table. The patient is than anesthetized as per anesthesia. We prefer a general anesthetic with complete muscle relaxation. A spinal anesthetic can be adequate, but it must provide completed muscle relaxation. Our concern with a spinal anesthetic intraoperatively is that if it begins to wears off, some of the early signs of increased muscle tone can ultimately affect hip exposure. Also, postoperatively the surgeon is unable to perform an immediate neural exam. Once the patient is anesthetized, the sacrum is padded with foam or a gel pad to protect from the development of a sacral decubiti. All the nerves and vessels of the patient’s extremities are padded and protected throughout the operation. The arm on the operative side is placed over the patient’s chest on top of a pillow. This protects the extremity and chest and removes the extremity from the operative side. The operative leg is then placed in the traction boot. The leg is abducted between 0 degrees and 20 degrees, depending on the patient’s hip anatomy. The foot is maintained in a neutral rotated position. The orientation of the traction must be in line with the perineal post. Otherwise, it may be difficult to generate enough force to adequately distract the hip joint. Also, if the force is not in line with the perineal post, the patient may rotate on the post and again compromise distraction. We prefer to place the nonoperative leg in a traction boot as well to counteract this possible rotation on the perineal post; however, use of a well-leg holder for the nonoperative leg can also be utilized^6,7 (Fig. 61-1A,B,C,D).