Accurate portal placement is essential for optimal visualization and enabling of accurate anchor placement. The tip of the greater trochanter and the soft area between sartorius and tensor musculature are used as anatomic landmarks. The anterolateral portal is placed 1 cm superior and 1 cm anterior to the tip of the greater trochanter. The mid-anterior portal is localized in the soft spot between the sartorius and tensor musculature approximately 7 cm distal and medial to the anterolateral portal on a 45° plane (Figure). These portal locations are meant to avoid the branches of the lateral femoral cutaneous nerve and minimize trauma to the hip flexors (rectus femoris).

An arthroscopic needle is placed into the hip joint through anterolateral incision first. Once the arthroscope is introduced into the hip joint through the anterolateral cannula, the anterior triangle where the mid-anterior portal will enter the joint is visualized. To decrease the risk of damaging the cartilage of the femoral head or piercing the labrum, the placement of the mid-anterior portal is visualized through the arthroscope.

A diagnostic examination of the hip is thereafter performed. All aspects of both the central and peripheral compartments should be inspected in addition to performing a dynamic examination to determine where bony conflicts occur. The chondrolabral junction is inspected. A probe is used to determine if the labrum has been separated from the acetabular rim and if the chondrolabral junction has been disrupted. Delamination of the acetabular cartilage at the chondrolabral junction is common with cam-type impingement and usually occurs at the site of impingement and labral damage (Fig. 12.2). It is very important to thoroughly and carefully inspect the chondrolabral junction. If they are not addressed at the time of the initial surgery, they can be the source of recurrent pain and disability as the junction between the labrum and the delaminated cartilage can degenerate further [19].

To assess the labrum, the arthroscope is placed in the central compartment through the anterolateral portal. To improve visualization, a capsulotomy is performed. The capsulotomy connects the two portal sites in the capsule within the central compartment and should be kept as small as needed based on the need for visualization. In the peripheral compartment, visualization during the dynamic exam will evaluate the sealing function of the labrum and identify areas needing treatment. The bony abnormality of the femoral head-neck junction can be identified, and a cam osteoplasty can be performed. The vessels of the femoral neck can also be identified in the peripheral compartment and protected during cam resection. Once the cam resection is complete, a dynamic examination is again performed to make sure the entire impingement lesion has been addressed.

The arthroscope is then returned to the central compartment. If pincer impingement exists, a rim trimming is performed (Fig. 12.3). Measuring the width of the acetabulum and comparing this to the center-edge angle (CE angle) can help avoid over-resection of the rim [20]. The labrum is detached from the acetabular rim, and the rim or pincer lesion is trimmed. The goal of the rim resection should be to remove this area of the bone and restore the normal anatomy and relative position of the acetabulum with respect to the pelvis and femoral neck. A 5.5-mm motorized burr is used to perform the rim trimming (Fig. 12.4). With the labrum detached and safely out of the way, the bone is slowly removed from the anterior superior margin of the acetabular rim.

Proper reattachment of the labrum to the acetabular rim is critical to reestablish the seal for the hip joint, the proper tracking of the labrum on the femoral head cartilage, and increases the surface area for pressure distribution within the hip joint. Failure in any one of these three areas can lead to subsequent pain and potential instability.

If a rim trimming was not necessary, the acetabular rim should be prepared with limited decortication using a burr, for anchor placement and to improve the healing of the labrum to the acetabulum. The anchor should be placed perpendicular to the rim, and penetration of the acetabular surface must be avoided (Fig. 12.5). To help with the placement of the anchor, the acetabular rim angle should be determined for proper anchor placement [21]. The rim angle provides a safety margin when placing anchors and varies based on the location on the rim. Larger rim angles are seen with shorter drill depth and rim trimming. The smallest angle is at the 3-o’clock position [21]. The size of anchor and the type of suture are based on the location of fixation. A pierced suture, which goes through the body of the labrum, is used to invert the labrum when there is adequate tissue. A loop suture, which goes around the entire labrum, will typically cause the labrum to evert. The balanced use of the loop and through/intrasubstance sutures helps recreate the suction seal. For anchors in the 9-o’clock to 12-o’clock position, a 2.3 mm anchor is used with a pierced suture. At 12 o’clock, a 2.9 mm anchor with a loop suture is recommended. At 2–3 o’clock, a 1.7 mm anchor is used, and at greater than 3 o’clock, a 1.5 mm anchor is used with a pierced suture. Anchor size is based on the shape of the acetabulum as it varies based on the location. All knots are placed on the capsular side and buried in the drill hole to avoid contact with adjacent cartilage (Fig. 12.6).

After completion of the labral repair, the traction is released and the arthroscope is moved into the peripheral compartment. A dynamic examination is performed to evaluate the repair (Fig. 12.7). The labrum should lie on the femoral head and recreate the seal as the hip is taken through a normal range of motion. For athletes who use their hip in extreme ranges, the athletic maneuver should be replicated to ensure that the labrum functions during the “at risk” motion. If the labrum appears unstable, additional sutures are used. Full decompression of pincer and cam is also confirmed. If areas of conflict still exist, traction should be reestablished and additional osteoplasty performed as needed. If additional anchors are placed or further resection of the bone is performed, the dynamic examination should be undertaken again to ensure the labrum seals with the femoral head.