History and Background

Over the last few years, several authors have provided reviews on the history and clinical indications for hip arthroscopy.1-3 It is interesting to note that some of the early reports on hip arthroscopy were in children, where it mainly served a diagnostic role as well as for debridement of articular damage.4,5

Byrd attributes the first record of hip arthroscopy to Burman in 1931. Burman’s description was based on a cadaveric study of arthroscopic techniques applied to various joints of the human body. In regards to the hip, he felt that "visualization of the hip joint is limited to the intracapsular part of the joint. It is manifestly impossible to insert a needle between the head of the femur and the acetabulum." These comments obviously limited the evolution of hip arthroscopy for a significant period of time, with most of the experience being acquired in the peripheral compartment.

This also led some of the early developers of hip arthroscopy to adopt the lateral position in order to achieve proper distraction of the hip joint.1,2 In their classic description of the lateral position for hip arthroscopy, Glick and associates justified the lateral position because of the inability to remove loose bodies in the posteroinferior aspect of the hip joint with the patient in the supine position. Having said that, some of the early reports were on hip arthroscopy done in the supine position with the use of an orthopaedic fracture table.4,5

Thomas Byrd has since perfected the supine approach for performing hip arthroscopy which provides the added advantage of facilitating an anterior hip arthrotomy to address pathologies within the peripheral compartment.7,8 Other initial major contributors to hip arthroscopy are Joseph McCarthy and Richard Villar who both expanded our understanding of intra-articular hip disease as well as refined the indications for hip arthroscopy through their publications.9-12


Hip arthroscopy, like other arthroscopic techniques, was initially used as a diagnostic tool and for removal of loose bodies. As surgeons started to investigate more intra-articular sources of hip pain, pathologies of the labrum were often identified, leading to a natural evolution for treating labral lesions by hip arthroscopy.10,13,14

With the advent of more advanced imaging technique such as MR arthrography 15-17 as well as multiplanar imaging, the role of hip arthroscopy as a diagnostic tool is minimal, whereas its usage as an effective technique in treating pre-arthritic conditions has become significant. This is evident in the growing body of literature on the use of hip arthroscopy, as well as recent industry reports that project an average annual growth rate of 15% for the procedure through 2013.18

As with any relatively new orthopaedic technique, making an accurate diagnosis will remain a key factor in maximizing the clinical outcome in the management of patients with pre-arthritic hip pain. In a recent paper, Burnett and associates 19 documented that patients visited on average 3.3 health care providers prior to being correctly diagnosed with a labral tear and waited an average of 21 months for the diagnosis. More importantly, 33% of patients (22 of 66 patients) received an alternate diagnosis prior to being diagnosed with a labral tear.

In addition, it is clear that the majority of patients presenting with a labral tear have underlying bony abnormality such as dysplasia or femoroacetabular impingement (FAI) (Table 1).20-22 Not dealing with the underlying bony abnormality and treating the labral lesions in isolation carries a high risk of reoperation.23 Some bony abnormalities associated with FAI can also be addressed at the time of the hip arthroscopy.

This is the case for the cam lesion where a femoral chondro-osteoplasty can be effectively done either purely arthroscopically,24 or by means of mini anterior hip arthrotomy. Conversely, addressing acetabular over coverage (retroversion, coxa profunda) associated with pincer deformity should be approached with greater caution as postoperative hip instability after acetabular rim trimming has been reported.25,26

Further research is required to determine how to address combined deformities in FAI. These are present in about 40%27,28 of the cases, with correction of cam deformities providing most predictable outcome.

Current Indications for Hip Arthroscopy

  • Central compartment, done with in hip traction:
    • Labral tears (debridement and/or refixation)
    • Acetabular chondral flaps
    • Loose body/pigmented villonodular synovitis
    • Inflammation of the ligamentum teres
  • Peripheral compartment, no traction with hip slightly flexed:
    • Osteochondroplasty of femoral head/neck junction
    • Release of iliopsoas tendon
    • Synovectomy
  • Extra-articular:
    • Release of snapping iliotibial band
    • Repair gluteus medius avulsion


Hip arthroscopy is a rapidly evolving surgical field in orthopaedic surgery with a definite role in the treatment of pre-arthritic hip pain. However, research is still required to better delineate the appropriate indications of this surgical procedure with regard to pain relief for patients suffering from pre-arthritic pain, and delay or prevention of the onset of hip arthritis. I strongly recommend that surgeons who are interested in hip arthroscopy visit surgeons with a vast experience with this procedure and be sure to use arthroscopy instruments specifically designed for the hip.

Table 1. Key Radiographic Features of Dysplasia and Femoroacetabular Impingement

Type of Radiograph


Femoroacetabular Impingement

Pincer Type

Femoroacetabular Impingement

Cam Type

Anterior-posterior pelvis

Centre edge angle < 25

Tonnis angle > 10

Cross over and/or posterior wall sign

Ischial sign

Coxa profunda

Pistol grip deformity

Lateral hip



Alpha angle > 50 degrees

Offset ratio < 0.15

False profile view

Anterior centre edge angle < 25

Narrowing of the posterior articular surface



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Reprinted with permission from the Winter 2009 issue of the COA Bulletin