ORIGINAL PAPER Clinical outcomes following arthroscopic treatment of femoro-acetabular impingement using a minimal traction approach and an initial capsulotomy. Minimum two year follow-up Elhadi Sariali 1,2 & Filippo Vandenbulcke 1 Received: 22 November 2017 /Accepted: 13 March 2018 # SICOT aisbl 2018 Abstract Purpose Although the arthroscopic management of femoroacetabular impingement (FAI) is increasing, severe complications have been reported due to traction. We developed an arthroscopic technique based on an initial capsulotomy and a minimal traction approach. The main purpose of this study was to analyze the clinical outcomes of FAI treatment using this technique after at least two years of follow-up. Methods Forty-seven consecutive patients underwent surgery for FAI. There were two initial portals: a proximal anterolateral portal and a distal anterior instrumental portal. An anterior working space was created and a T-shaped incision was made in the anterior capsule to relieve joint distraction. Short traction (less than 20 mn) made it possible to approach the central compartment. Acetabuloplasty was performed in the presence of pincer impingement. Traction was then released. A head-neck femoral osteochondroplasty was performed in case of bump impingement. All patients underwent a mean 3.3 ± one years of follow-up based on two self-administered questionnaires: the Harris hip score and the QOL Oxford score. None of the patients were lost to follow-up. Results There were three complications: two ossifications and one case of injury to the femoral cutaneous nerve with good clinical outcomes at the final follow-up. Five patients (10%) underwent surgical revision after a mean 1.4 years of follow-up: three total hip arthroplasties, one peri-acetabular osteotomy, and one repeat arthroscopic hip debridement. The Harris score increased significantly from 60 ± 10 to 86 ± 15 (p < 0.0001) and the Oxford score improved from 34 ± 15 to 50 ± 11. Only 25% of patients had a Bforgotten hip^ at the final follow-up. Conclusion Our clinical results were comparable to previously reported outcomes with other surgical techniques for the man- agement of FAI. However, it should also be noted that despite these good clinical outcomes, the percentage of patients with a Bforgotten hip^ is low, and patients should be informed of this. Keywords Hip arthroscopy . Femoro-acetabular . Impingement . Traction . Outcomes . Forgotten hip Introduction Femoro-acetabular impingement is an anatomic factor that can result in cartilage damage, labral lesions, and early osteo- arthritis [1]. Arthroscopy is increasingly used to manage this entity. Most existing surgical techniques require traction dur- ing the initial approach. However, severe complications have been reported due to traction [2, 3] especially at the beginning of the surgeon’ s learning curve. Indeed, successful hip distrac- tion can be difficult even with curare, causing surgeons to increase the force of traction. Pudendal nerve dysfunction fol- lowing traction for hip arthroscopy has been reported in up to 9% of patients [4]. Furthermore, Sher et al. [5] have reported that excessive traction can generate avascular femoral head necrosis. Some authors have suggested the use of an external pelvic-femoral distractor [2] for a safe arthroscopic approach to the hip. However, the operating time is increased with this device and it may also result in infection along the broach. Cadaveric studies have shown that an interportal capsulotomy decreases the force required for hip distraction Level of evidence: Therapeutic Level IV * Elhadi Sariali hedisari@yahoo.fr 1 Orthopedic Surgery Department, Hopital Pitié Salpétrière, 47-83 Bd de l’Hôpital, 75013 Paris, France 2 Laboratoire d’imagerie Biomédicale, Université Pierre et Marie Curie, Paris VI, France International Orthopaedics https://doi.org/10.1007/s00264-018-3904-0