An Anatomic Arthroscopic Description of the Hip Capsular

Ligaments for the Hip Arthroscopist

Jessica J. M. Telleria, B.S., Derek P. Lindsey, M.S., Nicholas J. Giori, M.D., Ph.D.,
and Marc R. Safran, M.D.

Purpose: To examine and describe the normal anatomic intra-articular locations of the hip capsular
ligaments in the central and peripheral compartments of the hip joint. Methods: Eight paired
fresh-frozen human cadaveric hips (mean age, 73.3 years) were carefully dissected free of soft tissue
to expose the hip capsule. Needles were placed through the capsule along the macroscopic borders
of the hip capsular ligaments. Arthroscopy was performed on each hip, and the relations of the
needles, and thus the ligaments, to the arthroscopic portals and other soft-tissue and osseous
landmarks in the hip were recorded by use of a clock-face reference system. Results: The iliofemoral
ligament (ILFL) ran from 12:45 to 3 o’clock. The ILFL was pierced by the anterolateral and anterior
portals just within its lateral and medial borders, respectively. The pubofemoral ligament was located
from the 3:30 to the 5:30 clock position; the lateral border was at the psoas-U perimeter, and the
medial border was at the junction of the anteroinferior acetabulum and the cotyloid fossa. The
ischiofemoral ligament (ISFL) ran from the 7:45 to the 10:30 clock position. The posterolateral portal
pierced the ISFL just inside its superior/lateral border, and the inferior/lateral border was located at
the posteroinferior acetabulum. In the peripheral compartment the lateral ILFL and superior/lateral
ISFL borders were in proximity to the lateral synovial fold. The medial ILFL and lateral pubofemoral
ligament borders were closely approximated to the medial synovial fold. Conclusions: The hip
capsular ligaments have distinct and consistent arthroscopic locations within the hip joint and are
associated with clearly identifiable landmarks in the central and peripheral compartments. The
standard hip arthroscopy portals are closely related to the borders of the hip capsular ligaments.
Clinical Relevance: These findings will help orthopaedic surgeons know which structures are being
addressed during arthroscopic surgery and may help in the development of future hip procedures.

A lthough the first report of direct arthroscopic vi-

sualization of the hip joint appeared in 1931,1
clinical use of hip arthroscopy did not gain momentum
dures, debridement and repair of labral tears and chon-
dral lesions, and hip-stabilizing operations.
Early hip arthroscopists reported difficulties explor-
until the 1980s. Procedures performed arthroscopi- ing the whole joint, visualizing less than one-third of
cally about the hip include bony recontouring proce- the femoral head and acetabulum.2,3 Subsequently, in

From the Stanford University School of Medicine (J.J.M.T.), Stanford; Veterans Affairs Palo Alto Health Care System (D.P.L., N.J.G.),
Palo Alto; and Department of Orthopaedic Surgery, Stanford University School of Medicine (N.J.G., M.R.S.), Redwood City, California,
U.S.A.
Supported by the Office of Research and Development (Rehabilitation R&D Service), Department of Veterans Affairs, and Stanford
University Department of Orthopaedic Surgery Internal Research Grant and Stanford University School of Medicine Medical Scholars
Research Grants. Stanford Sports Medicine receives support from Smith & Nephew Endoscopy, ConMed Linvatec, and Ossur. M.R.S. is a
consultant for Ross Creek Medical, Ferring Pharmaceuticals, Cool Systems, Biomimetica, and Arthrocare.
Received February 3, 2010; accepted January 6, 2011.
Address correspondence to Marc R. Safran, M.D., Department of Orthopaedic Surgery, Stanford University, 450 Broadway St, M/C 6342,
Redwood City, CA 94063, U.S.A. E-mail: [email protected]
© 2011 by the Arthroscopy Association of North America
0749-8063/1092/$36.00
doi:10.1016/j.arthro.2011.01.007

628 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 27, No 5 (May), 2011: pp 628-636
 ARTHROSCOPIC HIP CAPSULOLIGAMENTOUS ANATOMY 629

1986 Eriksson et al.4 determined that good visualiza- METHODS

tion of the hip joint could be achieved with 300 to 500
N of distraction force in an anesthetized patient; Experimental Setup
shortly thereafter, several surgeons presented their This study used 8 paired fresh-frozen human ca-
experiences with hip arthroscopy.5-7 Since then a
daveric hips from 4 cadavers that included the en-
number of studies have reviewed the arthroscopic
tire pelvis and both complete femurs (mean age at
anatomy of the hip in detail.8-13 These authors identi-
time of death, 73.3 ⫾ 10.7 years; range, 61 to 88
fied and described the soft-tissue and osseous features
years; 2 male and 2 female specimens). The exclu-
of the central and peripheral compartments and the
peritrochanteric space. Dvorak et al.9 and, later, sion criterion was a known history of previous
Dienst et al.8 noted that the iliofemoral ligament trauma, disease, or surgical procedure affecting the
(ILFL) and ischiofemoral ligament (ISFL) could be hip. Each specimen was harvested with the muscu-
identified as thickenings in the capsule; however, the lature, ligaments, and joint capsule intact as a hemi-
individual fibers and exact location of the ligaments corpse and stored at –20°C until testing. The spec-
were difficult to specifically delineate arthroscopi- imens were thawed for approximately 12 to 24
cally. Several authors described the anatomic location, hours at room temperature (18°C). After thawing,
trajectory, and safety of the standard and accessory all periarticular skin and musculature were meticu-
hip arthroscopy portals.14,15 Although these studies lously dissected to expose the intact underlying hip
provided excellent reviews of the relation between the capsular ligaments. Each ligament was carefully
portals and relevant neurovascular and muscular struc- cleaned of non-ligamentous soft tissue and left in
tures, the hip capsular ligaments were discussed only situ. Careful examination was performed to identify
in generalized terms. the exact origin, insertion, course, and borders of
At present, hip arthroscopy routinely incorporates the ILFL, pubofemoral ligament (PFL), and ISFL,
capsulotomies and capsulectomies as part of the ar- and the perimeters were outlined with a surgical
throscopic procedure.16-20 These capsuloligamentous marking pen. Throughout preparation and testing,
incisions are often left unrepaired and may potentially the specimens were irrigated and wrapped with
compromise the integrity of the hip capsular liga- moist towels to prevent tissue desiccation.
ments. To highlight this point, recently, several re- The pelvis was stabilized in the supine position in a
ports have recognized instability after hip arthroscopy custom-made metal fixture with threaded Steinmann
and recurrent instability as potential sequela of these pins. A transepicondylar traction pin was placed
procedures.21-23 Furthermore, the hip ligaments can be through the distal femur, and the pin was hooked into
damaged during traumatic and atraumatic hip sublux- a custom-made traction system. The pelvic fixture and
ation and dislocation.24-29 There could potentially be traction device were secured to a sturdy table by use of
long-term degenerative consequences if the ligaments heavy-duty C-clamps.
are ignored, attenuated, or overzealously resected.
Eighteen-gauge syringe needles were inserted through
Moreover, some surgeons close or repair their capsu-
the capsule along the outlined borders of the hip
lotomies, which may over-tighten the ligaments of the
ligaments at the following locations: the medial and
hip, the consequences of which are unclear.
lateral borders of the ILFL, the medial and lateral
With the increase in hip-related arthroscopic proce-
dures and the growing interest in the function and borders of the PFL, and the superior/lateral and infe-
pathology of the nonarthritic hip, there is a need for a rior/medial borders of the ISFL entering the central
more precise understanding of arthroscopic hip anat- and peripheral compartments (Fig 1). An additional
omy for the surgeon. Therefore the purpose of this needle was placed at the lateral-most point of the
study was to describe the normal arthroscopic anat- acetabulum to serve as a reference point.
omy of the hip capsular ligaments in the central and The acetabulum was mapped into 12 sectors like a
peripheral compartments that the orthopaedic surgeon clock face by use of previously described methodol-
may expect to encounter at the time of surgery. We ogy18,30-33; III o’clock was anterior, VI o’clock was
hypothesize that from an arthroscopic standpoint, the inferior at the middle of the transverse acetabular
hip capsular ligaments, as well as other significant ligament, IX o’clock was posterior, and XII o’clock
structures, will have distinct and consistent relations was lateral. In the peripheral compartment, the medial
to the standard hip arthroscopy portals and ar- synovial fold (MSF) and lateral synovial fold (LSF)
throscopic landmarks about the hip. were used as reference points.
630 J. J. M. TELLERIA ET AL.

neutral rotation. The locations of the needles, and

therefore the borders of the hip capsular ligaments,
were qualitatively and quantitatively recorded relative
to each other and to common arthroscopic landmarks.
When 2 structures were within a few millimeters of
each other, precise measurements could be docu-
mented with a laser-etched probe of known dimen-
sions. However, because acetabular size varies be-
tween hips, and long curved measuring devices are not
generally available or technically applicable, the ace-
tabular clock-face system was used because it allowed
for standardization of ligament position regardless of
distance between structures. Bony landmarks were
used, such as the inferior margin of the articular sur-
face at the cotyloid fossa and the psoas-U, the recess
of the anterior acetabulum corresponding to the more
superficial psoas tendon.34-36 Digital photography and
video recording were also performed to maintain a
permanent record.
FIGURE 1. Annotated photograph showing a right acetabulum in
situ from 1 cadaveric specimen. The needles demarcate the borders Once all measurements in the central compartment
of the hip capsular ligaments. The roman numerals represent hours were recorded, traction was released and the hip was
on a clock face: III o’clock is anterior, VI o’clock is inferior, IX stabilized in 30° of flexion. Arthroscopy was per-
o’clock is posterior, and XII o’clock is lateral. (a, ILFL lateral
border; b, ILFL medial border; c, PFL lateral border; d, PFL medial formed in the peripheral compartment, and measure-
border; e, ISFL inferior/medial border; f, ISFL superior/lateral bor- ments were recorded.
der.) (Courtesy of Marc R. Safran, M.D.)

RESULTS
Arthroscopy An insufficiency fracture occurred in 1 hip speci-
Hip arthroscopy on all specimens was performed by men halfway through the experiment; data collected
the supine approach by the senior author, an experi- before the fracture are reported in this study. All
enced hip arthroscopist. Traction was applied to dis- reported distances to the arthroscopic portals were
tract the hip joint approximately 1 cm, as confirmed measured to the perimeter of the 5-mm cannulas;
by fluoroscopic imaging. An 18-gauge spinal needle therefore, the additional 2.5 mm to the center of the
was used to penetrate the capsule, and the hip joint cannula is not included.
was distended with saline solution by use of a gravity
flow system. The anterolateral portal (ALP) was used Portals
as the introductory portal as is customary during hip The clock-face locations and relations of the ALP,
arthroscopy procedures. Under fluoroscopic guidance, PLP, and AP to the hip capsular ligaments are re-
the spinal needle, a guidewire, and finally, a 5-mm ported in Table 1 and depicted in Fig 2.
cannulated trocar and sheath were introduced into the
joint to establish the portal; fluoroscopy was used to Iliofemoral Ligament
confirm that the portal was in the same position as is
observed during routine hip arthroscopy. Under direct The divergence of the ILFL medial and lateral arms
arthroscopic visualization from the ALP, the anterior occurred distal to the joint line, and the individual
portal (AP) and posterolateral portal (PLP) were es- arms could not be visualized arthroscopically. In the
tablished in a similar fashion. Standard 4.0-mm video- central compartment the ILFL lateral border was lat-
articulated arthroscopes with 30° and 70° lenses were eral to the ALP and the medial border was medial to
used to visualize the entire joint. the AP; both portals pierced the ligament (Figs 2 and
Arthroscopy of the central compartment was per- 3, Table 2). In the peripheral compartment the ILFL
formed first with traction applied with the hip posi- lateral border was anterior to the LSF at the level of
tioned at 0° of flexion, at 0° of abduction, and in the head and neck junction and the medial border was
 ARTHROSCOPIC HIP CAPSULOLIGAMENTOUS ANATOMY 631

TABLE 1. Arthroscopic Location of Standard Portals in Central Compartment

Distance to Ligament Border Clock Face Position
Portal Relation [Mean ⫾ SD (Range)] (mm) [Mean (Range)]

Anterolateral Pierces ILFL just inside lateral border 1.1 ⫾ 1.6 (0-3) 1:00 (12:30-1:30)
Posterolateral Pierces ISFL just inside superior/lateral border 5.3 ⫾ 5.8 (0-15) 10:30 (9:30-11:15)
Anterior Pierces ILFL just inside medial border 1.5 ⫾ 1.8 (0-5) 3:00 (2:30-3:00)

NOTE. Distances were measured from the perimeter of the 5.0-mm cannulas.

lateral to the MSF at the level of the zona orbicularis Ischiofemoral Ligament
(Table 3).
In the central compartment the ISFL inferior/medial
Pubofemoral Ligament border was near the most posteroinferior aspect of the
acetabulum and the superior/lateral border was pos-
In the central compartment the PFL lateral border
teromedial to the PLP; the PLP pierced the ISFL (Figs
was adjacent to the edge of the psoas-U and the medial
2 and 5, Table 2). In the peripheral compartment the
border was near the junction of the anteroinferior
acetabulum and the cotyloid fossa (Figs 2 and 4, Table ISFL inferior/medial border was not associated with a
2). In the peripheral compartment the PFL lateral consistent arthroscopic landmark and the superior/
border was lateral to the MSF at the level of the zona lateral border was posterior to the LSF at the level of
orbicularis and the medial border was not associated the head and neck junction (Table 3).
with a consistent arthroscopic landmark (Table 3). The individual fibers of the ILFL, PFL, and ISFL
could not be discerned arthroscopically in any speci-
men; however, through localization of the needles, the
exact locations of the ligaments could be determined.

FIGURE 2. The average locations of the hip capsular ligaments

and standard hip arthroscopy portals on the acetabular clock face in
a right hip. The roman numerals represent hours on a clock face: III
o’clock is anterior, VI o’clock is inferior, IX o’clock is posterior,
and XII o’clock is lateral. The larger dots represent the hours of a
clock face and the small dots, the half hour. The thick red lines
represent the average capsular entry site of the respective ar-
throscopic portals into the central compartment; the PLP, ALP, and FIGURE 3. Arthroscopic image of the central compartment as seen
AP all pierce their respective hip capsular ligament just inside the from the PLP with a 70° arthroscope. The ALP trocar is a few
border of the ligament. Variations in the ligament attachments are millimeters away from the lateral border of the ILFL. (12, 12-
not shown in this figure to simplify understanding. (Courtesy of o’clock needle at straight lateral position; L, ILFL lateral border;
Marc R. Safran, M.D.) FH, femoral head.) (Courtesy of Marc R. Safran, M.D.)
632 J. J. M. TELLERIA ET AL.

TABLE 2. Arthroscopic Location of Hip Capsular Ligaments in Central Compartment

Distance to Landmark Clock Face Position
Ligament Landmark [Mean ⫾ SD (Range)] (mm) [Mean (Range)]

Lateral ILFL Just lateral to ALP (landmark), pierced by portal 1.1 ⫾ 1.6 (0-3) 12:45 (12:30-1:30)
Medial ILFL Just medial to AP (landmark), pierced by portal 1.5 ⫾ 1.8 (0-5) 3:00 (2:30-3:00)
Lateral PFL Adjacent to psoas-U (landmark) 0.4 ⫾ 1.1 (0-3) 3:30 (2:30-4:45)
Medial PFL At junction (landmark) of anteroinferior 1.0 ⫾ 1.9 (0-5) 5:30 (5:00-6:00)
acetabulum and cotyloid fossa
Inferior/medial ISFL Near most posteroinferior aspect of acetabulum 5.5 ⫾ 4.2 (0-10) 7:45 (7:00-9:30)
(landmark)
Superior/lateral ISFL Border is just posteromedial to PLP (landmark), 5.3 ⫾ 5.8 (0-15) 10:30 (9:30-11:15)
pierced by portal

NOTE. Distances were measured from the perimeter of the 5.0-mm cannulas.

DISCUSSION With the marked increase in interest in the nonar-

thritic hip, the need for a concrete understanding of
This past decade has seen growing interest in less arthroscopic hip anatomy is clear. Yet, in our review
invasive joint-preservation surgery of the hip and a of the English-language literature, no study to date has
significant increase in the arthroscopic diagnosis and described the precise arthroscopic anatomy of the hip
treatment of nonarthritic hip disorders. This interest capsular ligaments or their relations to instrumentation
and rapid growth has been fueled by advances in or other pertinent soft-tissue and osseous landmarks in
arthroscopic and minimally invasive techniques, the the hip. Because the hip capsular ligaments are known
development of hip-specific instrumentation, and im- to contribute to hip stability38 and can potentially be
proved imaging and diagnostic modalities. Notably, in compromised during athletic activity,25-29,37,39 in hy-
addition to capsular injury associated with traumatic
dislocation and subluxation,25,26,29 atraumatic hip in-
stability and capsular laxity are being increasingly
recognized as significant sources of disability, espe-
cially in certain athletic populations.24,27,28,37 As a
result, indications for hip arthroscopy are growing,
and procedures such as debridement and repair of
labral tears and chondral lesions, bony recontouring
procedures, and even hip capsular plication are now
commonly performed by experienced hip arthrosco-
pists.

TABLE 3. Arthroscopic Location of Hip Capsular

Ligaments in Peripheral Compartment
Distance to Landmark
[Mean ⫾ SD (Range)]
Ligament Landmark (mm)

Lateral ILFL Anterior to LSF (landmark) at 3.1 ⫾ 3.8 (0-10)

level of head and neck
junction
Medial ILFL Lateral to MSF (landmark) at 6.0 ⫾ 5.0 (0-14)
level of zona orbicularis FIGURE 4. The central compartment as viewed from the ALP with
Lateral PFL Lateral to MSF (landmark) at 6.0 ⫾ 4.9 (0-14) a 70° arthroscope. The PFL lateral border is closely approximated
level of zona orbicularis to the psoas-U, and the PFL medial border is at the junction of the
Medial PFL No associated landmark — anteroinferior acetabulum and the cotyloid fossa. The long dashed
Inferior/medial No associated landmark — line represents the anterior and then distal margin of the anterior
ISFL acetabulum, and the dotted line represents the anterior border of the
Superior/lateral Posterior to LSF (landmark) at 11.7 ⫾ 5.8 (0-17)
ISFL level of head and neck
acetabulum at the indentation, often called the psoas-U. (CF,
junction cotyloid fossa; FH, femoral head; L, PFL lateral border; M, PFL
medial border.) (Courtesy of Marc R. Safran, M.D.)
 ARTHROSCOPIC HIP CAPSULOLIGAMENTOUS ANATOMY 633

ligament, from approximately the 5:30 to 7:45 clock

position, and the lateral aspect, from approximately
the 10:30 to 12:45 clock position. Given their large
size, these areas could potentially have implications
for procedures affecting the capsule, such as capsu-
lotomies, capsular plication, or thermal capsulor-
rhaphy. A smaller area in the anterior acetabulum, at
about the 3-o’clock to 3:30 clock position, also lacked
reinforcement by the hip capsular ligaments. How-
ever, the iliopsoas muscle overlies the hip capsule at
this point, as evidenced by the psoas-U being in the
general vicinity of the 3:30 clock position, and may
provide additional support to the capsule in this area.
Instability after hip arthroscopy is a rare but note-
worthy problem and can be attributed to a number of
factors including excessive acetabular rim trimming,
capsulotomy or capsulectomy, and overzealous labral
resection or lack of adequate labral repair.21 In many
arthroscopic procedures, capsulotomies and capsulec-
FIGURE 5. Arthroscopic image of the PLP and the needles de- tomies are routinely performed.16-20 During hip ar-
marcating both borders of the ISFL, as seen from the ALP with a
70° arthroscope. The ISFL superior/lateral border is adjacent to the throscopy for femoroacetabular impingement, for ex-
PLP. (S/L, ISFL superior/lateral border; I/M, ISFL inferior/medial ample, capsulotomies and capsular windows are
border; FH, femoral head.) (Courtesy of Marc R. Safran, M.D.) sometimes made by connecting the AP and ALP to aid
in acetabular rim trimming and labral surgery, as well
as to allow cam lesions to be addressed from the
perlaxity conditions,40,41 or during arthroscopic pro-
peripheral compartment.20 On the basis of our find-
cedures,21,23 a better understanding of the locations
ings, an incision between these points would almost
and relations of the ligaments is of clinical impor-
completely transect the ILFL near its acetabular ori-
tance.
The ILFL and ISFL were best visualized with the gin. Because the ILFL is reported to be a primary
70° arthroscope from the PLP. Several studies noted stabilizer in external rotation38,42 and contributes to
that the ILFL and ISFL could be identified as thick- stability in internal rotation,38 iatrogenic damage, at-
enings in the capsule8,9; our findings are in agreement tenuation, or intentional transection may lead to post-
with these authors and further specify the location of operative complications such as hip instability or dis-
these ligaments. The PFL was best visualized with the location.21 Highlighting this point are several recent
70° arthroscope from the AP and ALP. In the periph- case reports in which instability after hip arthroscopy
eral compartment, the PFL lateral border is located was attributed to violation of the anterior capsule and
slightly lateral to the MSF; the ILFL medial border is ILFL21,23; the instability in both cases resolved with
also just lateral to the MSF, although the ILFL travels repair of the anterior capsule, suggesting an important
laterally from the fold whereas the PFL courses me- stabilizing function for this ligament. In addition,
dially. Interestingly, because the ILFL and PFL are given the proximity of the PFL to the psoas-U, ap-
known to blend together on the anterior capsule,38 in proaching the psoas tendon from the central compart-
the peripheral compartment the MSF appears to ap- ment during transcapsular release43,44 may render the
proximately demarcate the arthroscopic transition PFL nonfunctional if the capsulotomy is extended too
point between these 2 ligaments. far anteroinferiorly.
From an arthroscopic standpoint, on the basis of Occasionally, smaller capsulotomies and capsulec-
these findings, just over one-half (approximately 60%) tomies are performed around the arthroscopy cannulas
of the hip capsule that can be addressed arthroscopi- to allow for greater instrumentation maneuverabil-
cally is reinforced by the hip capsular ligaments. ity.18 Our results indicate that ALP capsulotomies
There are 2 major areas of the capsule that are not extended anteriorly will likely incise into the body of
covered by these ligaments: the inferior/posteroinfe- the ILFL; AP capsulotomies extended laterally or
rior aspect in the region of the transverse acetabular inferiorly could violate the ILFL and PFL, respec-
634 J. J. M. TELLERIA ET AL.

tively; and PLP capsulotomies extended posteriorly midanterior and modified midanterior portals, to
may violate the ISFL. These capsuloligamentous in- better address specific hip pathology. Furthermore,
cisions are often left unrepaired, and because the hip whereas some surgeons, including the senior au-
capsular ligaments are known to play an important thor, prefer 30° of flexion to evaluate the peripheral
role in hip stability,38 these procedures may have a compartment,43 which was investigated in this
detrimental effect on hip stability. Incision or resec- study, others favor 40° to 45° of flexion during their
tion sites may also serve as a nidus for future capsular procedures. The relations of the hip ligaments can
injury; as an example, traumatic full-thickness tear of reasonably be expected to change in a consistent
the ILFL has been reported in the region of a previous manner with different hip positions, such as in-
AP capsulectomy.23 creasing flexion or internal rotation, and thus should
On the basis of these findings, it may be preferable be considered by the hip arthroscopist.
to avoid capsulotomies and capsulectomies when pos-
Therefore, given that many hip procedures are cur-
sible or to create the smallest possible incision when
rently being performed arthroscopically worldwide,
capsulotomy is deemed necessary for the completion
anatomic and functional descriptions using arthros-
of the arthroscopic procedure. When required, inci-
sions extended obliquely in line with the ligamentous copic methods may aid in the diagnosis and treatment
fibers are recommended because they will minimize of hip soft-tissue pathology.
the impact on ligamentous macrostructure and, there-
fore, stability. Consideration should be given to cap- Limitations
sular repair after significant capsulotomies, particu-
larly in individuals with ligamentous laxity. Further Although we believe that this study provides a
studies evaluating the effect of capsular and ligamen- comprehensive and detailed evaluation of the ar-
tous compromise on hip stability, including partial throscopic anatomy of the hip capsular ligaments,
sectioning of the individual hip ligaments, are war- there are a few potential factors that may limit the
ranted. generalizability of our data. First, this study only
Ligamentous disruption after low-velocity trauma used 4 cadavers, for a total of 8 hips. As a result,
in athletes has been reported if there is a failure in uncommon ligament variations in anatomy may be
normal capsular healing after hip trauma-laxity and, missed in our study or may be inadvertently present.
subsequently, instability may occur.25,26,29 Further- However, the results are relatively consistent
more, capsular redundancy has been found in patients among the 4 cadaveric specimens. Another limita-
with recurrent post-traumatic dislocation37,45,46; in tion is the difficulty in accurately measuring ar-
these cases capsular repair, alone or in combination throscopic distances of more than a few millimeters.
with other procedures, was shown to resolve the re- These measurements are partially limited by the hip
current instability.45-47 Capsular repair has also been arthroscopy equipment that is currently commer-
shown to resolve recurrent instability in patients after cially available, because the equipment needs to be
hip arthroscopy21,23,26 and even total hip arthroplasty calibrated, flexible, and curved to account for the
through the posterior approach,48,49 further highlight- 3-dimensional relations. In addition, this study only
ing the importance of the hip capsule. Thus knowing evaluated the hip in neutral rotation and 0° and 30°
the exact arthroscopic locations of the hip capsular
of flexion. Although we achieved our goal of de-
ligaments may help identify situations in which cap-
scribing normal arthroscopic anatomy, additional
sular repair or plication is prudent, could aid surgeons
studies exploring ligamentous anatomy through the
in localizing which structures may be deficient or in
need of arthroscopic repair, and may potentially help full hip range of motion are advisable to further
minimize complications such as hip subluxation or describe these ligaments. However, the description
dislocation after hip arthroscopy. of ligamentous anatomy in the central compartment
Of note, this study focused on the normal ar- is close to the fixed bony attachment of these liga-
throscopic anatomy of the hip ligaments in neutral ments, and it would not be expected to change as
rotation with respect to the AP, ALP, and PLP. As much as the peripheral definition of the ligaments
hip arthroscopy continues to gain popularity, and with changes in hip position. In addition, the liga-
surgeons gain more experience with the procedure, mentous relations to alternative arthroscopic portals
some arthroscopists are adopting a 2-portal ap- and in specimens with intact soft-tissue envelopes
proach or are using alternative portals, such as the would provide additional valuable information.
 ARTHROSCOPIC HIP CAPSULOLIGAMENTOUS ANATOMY 635

CONCLUSIONS 19. Sampson TG. Arthroscopic treatment of femoroacetabular im-

pingement: A proposed technique with clinical experience.
The hip capsular ligaments have distinct and con- Instr Course Lect 2006;55:337-346.
20. Byrd JW, Jones KS. Arthroscopic femoroplasty in the man-
sistent arthroscopic locations within the hip joint and agement of cam-type femoroacetabular impingement. Clin Or-
are associated with clearly identifiable landmarks in thop Relat Res 2009;467:739-746.
the central and peripheral compartments. The standard 21. Matsuda DK. Acute iatrogenic dislocation following hip im-
pingement arthroscopic surgery. Arthroscopy 2009;25:400-
hip arthroscopy portals are closely related to the bor- 404.
ders of the hip capsular ligaments. 22. Jones CW, Biant LC, Field RE. Dislocation of a total hip
arthroplasty following hip arthroscopy. Hip Int 2009;19:396-
398.
Acknowledgment: The authors thank Alexander H. 23. Ranawat AS, McClincy M, Sekiya JK. Anterior dislocation
Sox-Harris, Ph.D., for assistance in statistical analysis; of the hip after arthroscopy in a patient with capsular laxity
Mark Bracken and Smith & Nephew Endoscopy for use of of the hip. A case report. J Bone Joint Surg Am 2009;91:
arthroscopy equipment. 192-197.
24. Epstein DM, Rose DJ, Philippon MJ. Arthroscopic manage-
ment of recurrent low-energy anterior hip dislocation in a
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