Loose bodies in the hip

1. High-Yield Summary

Loose bodies in the hip represent free-floating or pedunculated intra-articular fragments of cartilage, bone, or fibrinous tissue that compromise normal joint kinematics and trigger severe mechanical symptoms.

• Etiologic Spectrum: Intra-articular hip loose bodies originate from primary synovial proliferative disorders (primary synovial chondromatosis), traumatic shear fractures (posterior hip dislocations and Pipkin fracture-dislocations), femoral head osteochondritis dissecans (OCD), subchondral avascular necrosis (AVN) collapse, or secondary degenerative third-body osteochondral wear.
• Chondral Scuffing and Third-Body Wear: Entrapment of loose bodies between the weight-bearing femoral head and the acetabular lunate surface acts as high-contact mechanical stress risers, causing accelerated Outerbridge Grade III to IV chondral scuffing, delamination, and rapid progression toward secondary osteoarthritis.
• Diagnostic Imaging Hierarchy: Plain radiographs fail to identify up to 20% to 30% of chondral bodies due to absent calcification. Non-contrast thin-slice CT with 3D reconstructions serves as the gold standard for spatial mapping of ossified bodies, while MRI or MR arthrography is mandatory for identifying radiolucent cartilaginous fragments, active synovial disease, and chondral shear defects.
• Arthroscopic Surgical Standard: Hip arthroscopy provides definitive, minimally invasive management, requiring a systematic visual sweep of both the central compartment under axial distraction and the peripheral compartment in 30 to 45 degrees of hip flexion. Concurrent partial or complete synovectomy is required for active primary synovial chondromatosis.
• Open Dislocation Threshold: Ganz surgical hip dislocation via a trochanteric flip osteotomy is indicated for massive fragment burdens exceeding 50 to 100 loose bodies, extensive extra-articular or acetabular protrusio involvement, or when concomitant structural femoral head reconstruction is necessary.

2. Anatomy

Surgical access and comprehensive clearance of hip loose bodies require precise anatomical compartmentalization of the coxofemoral joint into central and peripheral spaces, alongside rigorous protection of surrounding neurovascular structures.

The hip joint is functionally divided into two distinct operative compartments:

• Central Compartment: Bound externally by the acetabular labrum, this space encompasses the articular cartilage of the acetabular lunate surface, the femoral head within the cotyloid rim, the ligamentum teres, and the cotyloid fossa (acetabular notch). Direct visualization requires 8 to 12 mm of mechanical axial joint distraction under traction. Loose bodies frequently settle within the deep recess of the cotyloid fossa or hide behind the pulvinar fat pad and transverse acetabular ligament.
• Peripheral Compartment: Located outside the labral seal but entirely within the fibrous hip capsule, this space surrounds the femoral neck. It is subdivided into the anterior gutter, the medial synovial fold, the lateral retinacular gutter, and the posterior capsular reflection. Crucially, access to the peripheral compartment requires complete release of axial traction with the hip positioned in 30 to 45 degrees of flexion to relax the iliofemoral ligament.
• Zona Orbicularis: A circular condensation of deep capsular fibers constricting around the mid-femoral neck. Its inferior and posterior reflections form tight circumferential recesses where gravity-dependent loose bodies lodge, frequently escaping detection unless viewed with a 70-degree arthroscope during dynamic rotation.

Safe portal placement and exposure mandate strict awareness of the adjacent neurovascular danger zones:

• Lateral Femoral Cutaneous Nerve (LFCN): Crosses the anterior hip joint line superficial to the tensor fasciae latae and sartorius. The anterior portal and modified mid-anterior portal (MAP) present the highest risk of iatrogenic LFCN branch injury, passing within 2 to 10 mm of its arborizations. Establishing the anterolateral (AL) portal 1 cm superior and 1 cm anterior to the tip of the greater trochanter establishes safe initial access.
• Sciatic Nerve: Courses 2 to 3 cm posterior to the posterolateral (PL) portal. Risk of iatrogenic injury increases dramatically if the limb is placed in extreme internal rotation or if posterior capsulotomies are performed blindly.
• Femoral Neurovascular Bundle: Located 3 to 4 cm medial to the anterior portal track. Instrument trajectory must never be angled medially across the sagittal plane of the anterior superior iliac spine to avoid catastrophic arterial or venous laceration.
• Medial Femoral Circumflex Artery (MFCA) Deep Branch: Traverses between the obturator externus and quadratus femoris along the posterolateral femoral neck, penetrating the capsule at the 12 to 2 o’clock position to supply the lateral retinacular subsynovial vessels to the femoral head. Aggressive posterolateral capsulotomy or blind radiofrequency ablation along the superior-lateral femoral neck risks lateral retinacular arterial injury and femoral head osteonecrosis.
• Safe Traction Parameters: Axial traction must not exceed 50 lbs (22 kg) of continuous force, with total traction duration strictly limited to under 120 minutes (optimally less than 60 to 90 minutes). A dedicated, well-padded perineal post with a minimum diameter of 9 cm must be positioned lateralized against the proximal medial thigh of the operative limb, preventing direct compression of the pudendal nerve against the pubic ramus and avoiding transient perineal numbness or erectile dysfunction.

3. Pathogenesis

The pathogenesis of intra-articular loose bodies in the hip encompasses primary neoplastic or metaplastic processes, acute mechanical trauma, subchondral ischemia, and secondary degenerative breakdown.

• Primary Synovial Chondromatosis (Reichel Syndrome): A benign, monoarticular proliferative disorder of the subsynovial mesenchyme characterized by clonal chondroid metaplasia. Genetic analyses demonstrate recurrent recurrent cytogenetic rearrangements involving chromosome 6 (such as FN1-ACVR2A fusions). Subsynovial mesenchymal progenitor cells differentiate into hyaline cartilage clusters that pedunculate, detach into the synovial fluid, and continue to enlarge via synovial fluid nutrient diffusion before undergoing secondary central enchondral ossification.
• Traumatic Osteochondral Shear Fractures (Pipkin Injuries): High-energy posterior hip dislocations subject the femoral head to catastrophic tangential shear forces against the rigid posterior acetabular rim. This produces cleavage fractures of the femoral head articular cartilage and subchondral bone plate (Pipkin Type I infracotylar or Pipkin Type II supracotylar), or avulsion fragments from the posterior acetabular wall and cotyloid notch. Incarcerated osteochondral fragments frequently dislodge into the cotyloid notch during closed joint reduction.
• Osteochondritis Dissecans (OCD) of the Femoral Head: Focal vascular insufficiency in the anterosuperior weight-bearing dome leads to subchondral bone necrosis. Repetitive microtrauma results in subchondral bone plate delamination and subsequent separation of an osteoarticular crater fragment into the joint space.
• Secondary Osteochondral Wear (Degenerative Third-Body Wear): In primary or secondary hip osteoarthritis, mechanical shearing of marginal osteophytic ridges, combined with full-thickness chondral fissuring and delamination, sheds calcified cartilage and bone flakes into the synovial space. These secondary loose bodies are nourished by synovial fluid and demonstrate concentric calcified rings on histology.
• Avascular Necrosis with Subchondral Collapse: Progressive ischemic osteonecrosis culminates in fatigue microfractures of the necrotic subchondral bone bed (the radiographic crescent sign). Structural collapse under physiologic weight-bearing detaches the overlying articular cartilage and necrotic subchondral plate, releasing structural loose bodies into the central compartment.

4. Natural History

The natural history of untreated loose bodies in the hip is characterized by progressive, irreversible mechanical destruction of articular cartilage and accelerated end-stage degenerative joint disease.

Epidemiologically, primary synovial chondromatosis demonstrates a predilection for males (male-to-female ratio of 2:1 to 3:1), presenting predominantly in the third to fifth decades of life (ages 30 to 50 years). In contrast, traumatic osteochondral fragments occur most frequently in young active males following high-energy motor vehicle collisions or athletic collisions, whereas degenerative loose bodies align with elderly populations exhibiting established osteoarthritis.

Regardless of primary etiology, free intra-articular bodies undergo hydrodynamic transport throughout the joint during normal gait. When interposing between the femoral head and the acetabulum during heel strike or rotational stance phase, the rigid fragments function as high-load focal stress risers. This creates repetitive mechanical “scuffing”, plow-like linear gouging, and full-thickness shear delamination of the lunate and femoral head cartilage.

In primary synovial chondromatosis, the untreated biological disease progresses through relentless active metaplasia. Hips can harbor hundreds to thousands of calcified nodules that distend the fibrous capsule, erode the cortical margins of the femoral neck (so-called “apple-core” pressure scalloping), and produce secondary acetabular protrusio. Although extremely rare (incidence under 1%), chronic longstanding primary synovial chondromatosis carries documented malignant transformation potential into secondary chondrosarcoma, heralded by rapid cortical destruction and aggressive soft-tissue invasion.

5. Clinical Presentation

5.1 History

Patients with hip loose bodies characteristically describe an insidious or post-traumatic onset of deep, sharp groin pain punctuated by unpredictable mechanical events:

• Mechanical Locking and Catching: Sudden, episodic joint seizure where the hip transiently jams in a specific arc of flexion or rotation, requiring manual shaking or passive circumduction to release.
• Giving Way Episodes: Reflex quadriceps inhibition and sudden hip buckling caused by acute incarceration of a fragment between articulating surfaces.
• Migratory Symptoms: Patients frequently report shifting locations of clicking, popping, or localized tenderness as mobile loose bodies transition between the central joint space and the peripheral gutters.
• Aggravating Factors: Pain intensifies during deep flexion (e.g., tying shoes, sitting in low chairs), pivoting under load, or ascending stairs.

5.2 Physical Exam

Physical examination focuses on provocative maneuvers that reproduce mechanical impingement, fragment entrapment, and intra-articular shear:

• FADIR Test (Flexion, Adduction, Internal Rotation): The examiner flexes the hip to 90 degrees, followed by passive adduction and maximal internal rotation to compress the anterior labrum and femoral head-neck junction. Positive Finding: Sudden, sharp anterior groin pain reproducing mechanical catching [Sensitivity 94% to 99%, Specificity 10% to 25%].
• FABER Test (Flexion, Abduction, External Rotation / Patrick Test): The ipsilateral foot is placed on the contralateral knee, and a downward stabilizing force is applied to the knee and contralateral anterior superior iliac spine. Positive Finding: Groin pain or restricted range of motion compared to the contralateral side [Sensitivity 81% to 88%, Specificity 16% to 25%].
• McCarthy Test: Both hips are initially brought into full passive flexion; the symptomatic hip is extended while held in internal rotation, then repeated in external rotation. Positive Finding: A painful, reproducible click, pop, or mechanical apprehension as a loose fragment is trapped against the acetabular rim [Sensitivity 80% to 85%, Specificity 60% to 70%].
• Stinchfield Test (Resisted Straight Leg Raise): The patient actively elevates the extended leg to 30 degrees while the examiner applies downward manual resistance to the distal thigh. Positive Finding: Deep groin pain induced by elevated intra-articular contact pressures [Sensitivity 85%, Specificity 58%].
• Dynamic Circumduction Compression Test: The hip is taken through a wide arc of circular motion under continuous axial load applied through the knee and femoral shaft. Positive Finding: Audible or palpable crepitus, clunking, or abrupt mechanical locking [Sensitivity 75% to 80%, Specificity 70% to 75%].

6. Imaging and Diagnostic Studies

Accurate identification and comprehensive spatial mapping require a coordinated radiographic and advanced cross-sectional imaging pathway.

Plain Radiographs: Initial radiographic evaluation includes an AP pelvis, 45-degree and 90-degree Dunn lateral views, cross-table lateral, and false-profile projections. Classic plain film findings reveal multiple well-corticated, round or faceted calcified radiodensities clustered within the cotyloid fossa, along the inferior femoral neck, or within the posterior capsular reflection. In primary synovial chondromatosis, calcifications often display a punctate “popcorn” or concentric laminated ring-like pattern. However, clinicians must recognize that 20% to 30% of chondral loose bodies (particularly Milgram Stage 1 lesions and acute post-traumatic cartilage shears) lack mineralized subchondral bone and remain completely radiolucent on conventional radiography.

Non-Contrast Thin-Slice CT with 3D Reconstructions: High-resolution CT (slice thickness 0.5 to 1.0 mm) represents the gold standard for spatial enumeration, size quantification, and precise anatomical localization of calcified loose bodies. Multiplanar and 3D volumetric reconstructions differentiate central cotyloid notch fragments from peripheral gutter deposits and detect subtle cortical pressure erosions along the femoral neck, preventing incomplete intraoperative retrieval.

Magnetic Resonance Imaging (MRI) and MR Arthrography (MRA): MRI is essential for identifying radiolucent, purely cartilaginous loose bodies, appraising full-thickness articular cartilage loss, and defining the extent of active synovial proliferation. Non-calcified chondral bodies present as low-to-intermediate signal foci on T1-weighted sequences and hyperintense signal on fluid-sensitive T2-weighted or proton-density sequences. When calcified, they demonstrate hypointense rims with central hyperintense fatty marrow. In primary synovial chondromatosis, nodular, mass-like synovial hyperplasia displays prominent blooming artifacts on gradient-echo (GRE) sequences due to microscopic hemosiderin and microcalcifications. MR arthrography provides superior capsular distension, outlining mobile loose bodies against gadolinium contrast and identifying concomitant acetabular labral tears.

7. Classification

Pathological staging of synovial chondromatosis relies on the classic Milgram classification, which directly guides the necessity and extent of operative synovectomy alongside fragment extraction.

Etiological classification categorizes hip loose bodies according to their primary pathophysiologic origin, dictating prognosis and structural joint preservation requirements.

8. Treatment

8.1 Medical and Nonoperative Management

Nonoperative management has a minimal role in the definitive management of intra-articular hip loose bodies. Conservative measures including physical therapy, activity modification, non-steroidal anti-inflammatory drugs (NSAIDs), and protected weight-bearing provide temporary symptomatic relief during acute inflammatory synovitis. However, conservative measures cannot resorb calcified or chondral bodies, cannot arrest mechanical third-body abrasion, and fail to prevent progressive Outerbridge Grade III to IV chondral scuffing and accelerated joint deterioration.

Intra-articular injections of corticosteroids or viscosupplementation may temporarily diminish inflammatory pain but carry the risk of iatrogenic intra-articular inoculation and do not address mechanical block. Consequently, the presence of confirmed intra-articular loose bodies associated with mechanical catching or locking constitutes a direct failure of nonoperative management and establishes an indication for surgical intervention.

8.2 Operative Treatment

The primary goals of surgery are complete extraction of all intra-articular loose bodies, eradication of active proliferative synovium in Milgram Stage 1 and 2 disease, stabilization of associated chondral shear defects, and preservation of the labrum.

Hip Arthroscopy: Arthroscopic retrieval represents the gold standard for standard loose body burdens. Using a traction table in the supine or lateral decubitus position, anterolateral (AL) and modified mid-anterior (MAP) portals are established under fluoroscopic guidance.

• Central Compartment Exploration: Under 8 to 12 mm of axial distraction, the central articular surfaces, cotyloid fossa, and ligamentum teres are systematically inspected. Loose bodies hidden within the pulvinar fat pad are mobilized using blunt probes or radiofrequency wands. Concomitant labral tears are repaired, and unstable chondral flaps are treated with stabilization chondroplasty.
• Peripheral Compartment Sweep: Traction is completely released, and the hip is flexed 30 to 45 degrees. A dedicated 70-degree arthroscope is utilized to inspect the anterior gutter, the medial synovial plica, the lateral retinacular recess, and the dependent collar beneath the zona orbicularis. Dynamic rotation of the femur under direct visualization dislodges occult fragments trapped within capsular folds.
• Extraction Instrumentation: Small fragments (<5 mm) are cleared efficiently using motorized mechanical shavers connected to high-flow suction with an in-line specimen trap ("loose body vacuum" technique). Larger fragments are extracted using specialized curved pituitary-type arthroscopic graspers. If a calcified fragment exceeds portal diameter, the capsulotomy is gently widened, or the body is morselized under direct visualization to prevent portal entrapment.
• Synovectomy: For patients with Milgram Stage 1 or 2 synovial chondromatosis, partial or radical synovectomy is mandatory. Motorized full-radius shavers combined with bipolar radiofrequency ablation wands are used to resect hyperemic, nodular synovial tissue, taking care to protect the lateral retinacular vascular entry zone along the posterosuperior femoral neck.

Ganz Surgical Hip Dislocation: Open dislocation via a digastric trochanteric flip osteotomy is indicated for massive loose body burdens (>50 to 100 bodies), extensive extra-articular or acetabular protrusio involvement, or when concomitant structural femoral head reconstruction is necessary. By mobilizing the greater trochanter anteriorly with the vastus lateralis and gluteus medius attached, the obturator externus is preserved, protecting the deep branch of the medial femoral circumflex artery (MFCA). A Z-shaped or stepped capsulotomy permits complete 360-degree dislocation of the femoral head, enabling unrestricted visual access to the cotyloid notch, pulvinar, and complete capsular circumference.

8.3 Indications and Contraindications

Surgical Indications:

• Documented intra-articular loose bodies on imaging associated with mechanical symptoms (locking, catching, sharp rotational pain).
• Primary synovial chondromatosis (Milgram Stages 1, 2, or 3).
• Traumatic osteochondral shear fragments following posterior hip dislocation or Pipkin injury with fragment displacement > 2 mm or mechanical incarceration.
• Detached osteochondral fragments from femoral head osteochondritis dissecans or subchondral collapse in avascular necrosis.

Surgical Contraindications:

• Absolute: Active local joint sepsis or systemic bacteremia; severe cardiopulmonary instability prohibiting anesthesia.
• Relative (for Hip Arthroscopy): Advanced, end-stage osteoarthritis (Tönnis Grade 3, diffuse joint space narrowing < 2 mm), where joint preservation fails to restore function and total hip arthroplasty (THA) is the primary indicated procedure; severe acetabular protrusio or dense fibrous ankylosis preventing safe axial distraction (indication for Ganz surgical hip dislocation or THA).

9. Outcome

Surgical extraction of hip loose bodies yields reliable mechanical symptom relief and substantial improvements in validated patient-reported outcome measures (PROMs).

Following arthroscopic loose body excision and synovectomy, patients demonstrate significant, durable gains across the modified Harris Hip Score (mHHS), the Hip Outcome Score – Sport Specific Subscale (HOS-SSS), and the international Hip Outcome Tool (iHOT-33). Patient satisfaction rates consistently exceed 80% to 90%, with immediate resolution of mechanical locking and giving way episodes.

Recurrence rates for primary synovial chondromatosis range between 5% and 20% in contemporary arthroscopic series. Recurrence is predominantly driven by incomplete synovectomy during active Milgram Stage 1 or 2 disease or retained occult cartilaginous nodules within the peripheral recesses.

The long-term joint survivorship and preservation rate are overwhelmingly dictated by the baseline condition of the articular cartilage at the time of index surgery. Patients with pristine articular cartilage or superficial chondromalacia (Outerbridge Grade I to II) achieve joint preservation rates exceeding 85% to 90% at mid- to long-term follow-up. Conversely, patients presenting with extensive pre-existing full-thickness chondral loss (Outerbridge Grade III to IV) demonstrate significantly higher rates of secondary osteoarthritic progression and subsequent conversion to total hip arthroplasty.

10. Complications

Complications associated with surgical management of hip loose bodies are categorized by their operative timeframe, encompassing traction-related neurological morbidity, fluid extravasation, and residual fragment retention.

11. Pearls and Pitfalls

Expert-level execution avoids diagnostic pitfalls and ensures complete intra-articular clearance through structured technical maneuvers:

• Dynamic Fluoroscopic Sweep: Prior to final portal closure, disengage traction and rotate the hip through complete arcs of flexion, extension, internal rotation, and external rotation under live C-arm fluoroscopy. Mobile calcified bodies that evaded arthroscopic visual fields readily displace into radiographic profile.
• The “Peripheral Sweep” in 45-Degree Flexion: Once central compartment work is finished, release traction completely and flex the hip to 30 to 45 degrees to relax the anterior iliofemoral ligament. Introduce a 70-degree arthroscope to systematically sweep the dependent recesses formed by the zona orbicularis and the medial synovial fold.
• Subpulvinar Debridement: Never conclude a procedure without thoroughly probing the cotyloid notch. Loose bodies frequently bury themselves beneath the pulvinar fat pad and wrap around the base of the ligamentum teres, escaping superficial inspection.
• In-Line Specimen Trap: Connect the arthroscopic outflow or motorized shaver directly to a closed, in-line specimen trap. High-flow suction can evacuate dozens of small chondral fragments within seconds, preventing loss into the hospital waste system.
• Pitfall: Reliance on Normal Radiographs: Dismissing intra-articular pathology because plain radiographs are negative represents a critical clinical pitfall; up to 30% of chondral bodies are non-calcified and require MRI or non-contrast CT for identification.
• Pitfall: Incomplete Synovectomy in Milgram Stage 2: Focusing solely on loose body retrieval while ignoring hyperemic, active subsynovial metaplasia guarantees rapid disease recurrence.
• Pitfall: Excessive Traction Duration: Allowing continuous traction time to exceed 120 minutes risks permanent pudendal nerve neuropraxia and perineal pressure necrosis.

12. Controversy

Two primary controversies dominate the current literature regarding operative management of hip loose bodies:

Routine Capsular Closure Versus Therapeutic Capsulectomy in Synovial Chondromatosis: In contemporary hip preservation for femoroacetabular impingement (FAI), complete interportal capsular closure is routinely performed to restore native joint mechanics and prevent iatrogenic microinstability. However, in the setting of primary synovial chondromatosis, some surgeons advocate for partial capsulectomy or leaving the interportal capsulotomy open. Proponents argue that aggressive capsular resection eliminates diseased subsynovial tissue and diminishes postoperative capsular contracture and stiffness. Conversely, critics caution that unrepaired large capsulotomies in young, ligamentously lax individuals risk iatrogenic microinstability, anterior hip subluxation, and extra-articular fluid leakage.

Hip Arthroscopy Versus Ganz Surgical Hip Dislocation for Massive Fragment Burden: While hip arthroscopy has largely superseded open surgery due to lower morbidity and faster rehabilitation, the management threshold for massive loose body burdens (>50 to 100 bodies) remains controversial. Advocates of arthroscopy emphasize that with specialized loose body vacuums, 70-degree optics, and meticulous peripheral sweeping, virtually all intra-articular bodies can be extracted with minimal tissue trauma. Proponents of Ganz surgical hip dislocation counter that arthroscopy for massive burdens leads to prolonged operative times, elevated fluid extravasation risks, and high rates of retained occult fragments, whereas open surgical dislocation provides unmatched 360-degree visualization and allows complete synovectomy with an intact blood supply via preservation of the medial femoral circumflex artery.

13. Evidence-Based Synthesis

Modern clinical decision-making is grounded in high-quality randomized controlled trials and prospective registry analyses, corroborated by seminal biomechanical and anatomical descriptions.

14. References

• Stevens MS, Legay DA, Glazebrook MA et al. The evidence for hip arthroscopy: grading the current indications. Arthroscopy. 2010. doi:10.1016/j.arthro.2010.07.016 [Level I: Systematic Review / Meta-Analysis]
• de Sa D, Stephens K, Parmar D et al. A Comparison of Supine and Lateral Decubitus Positions for Hip Arthroscopy: A Systematic Review of Outcomes and Complications. Arthroscopy. 2016. doi:10.1016/j.arthro.2015.12.028 [Level I: Systematic Review / Meta-Analysis]
• Boyer T, Dorfmann H. Arthroscopy in primary synovial chondromatosis of the hip: description and outcome of treatment. J Bone Joint Surg Br. 2008. doi:10.1302/0301-620X.90B3.19664 [Level IV: Clinical Case Series / Cohort Study]
• Marchie A, Panuncialman I, McCarthy JC. Efficacy of hip arthroscopy in the management of synovial chondromatosis. Am J Sports Med. 2011. doi:10.1177/0363546511414014 [Level IV: Clinical Case Series / Cohort Study]
• Ferro FP, Philippon MJ. Arthroscopy provides symptom relief and good functional outcomes in patients with hip synovial chondromatosis. J Hip Preserv Surg. 2015. doi:10.1093/jhps/hnv044 [Level IV: Clinical Case Series / Cohort Study]
• Zhu Y, Gao G, Luan S et al. Longitudinal Assessment of Clinical Outcomes After Arthroscopic Treatment for Hip Synovial Chondromatosis and the Effect of Residual Loose Bodies: Minimum 4-Year and 8-Year Follow-up. Am J Sports Med. 2024. doi:10.1177/03635465241260354 [Level IV: Clinical Case Series / Cohort Study]

15. Master Class Pro-Tip

During arthroscopic extraction for extensive hip loose bodies, the single most common location for occult residual fragments is the posterior and inferior reflection of the zona orbicularis and the deep subpulvinar recess of the cotyloid notch. After completing central compartment clearance under traction, completely release traction, flex the hip to 45 degrees, and perform a systematic 360-degree ‘peripheral sweep’ with a 70-degree arthroscope while an assistant applies dynamic internal and external rotation. Conclude with multi-angle dynamic fluoroscopic verification across the full arc of motion; loose bodies that evade visual detection will readily displace into radiographic profile during dynamic stress maneuvering.

Master Class Surgical Pearl: Dynamic Fluoroscopic Verification and the Systematic Peripheral Sweep