On a radiolucent bed, the limb to be operated on is left free so that the hip can be flexed during surgery if necessary. Through intraoperative x-rays, the AIIS is identified so the three endoscopic portals can be located: LP, DP, and IP. (Fig. 1).

Starting from the LP and DP portals, nitinol wires are introduced, and then the 30° optic and the radiofrequency are placed, respectively (Fig. 2A, B). The water pump is activated until a pressure of 40 mmHg is reached. Approaching the LP it is crucial to avoid being too lateral to the AIIS as there is a risk of entering the territory of the LFCN [2]; in fact, it emerges under the inguinal ligament, just medial to the ASIS and descends along the surface of the sartorius muscle, in case of injury there is a risk of causing paresthetic meralgia. On the medial side, femoral vascular-nervous structures are at risk, so care must be taken to locate the DP and IP portals.

Amplioscopic views, A and B nithinol wires and optic and radiofrequency insertion through DP and LP; C mobilization and debridement of the fragment, D reduction; E K-wire temporary fixation; F screw insertion

By endoscopic vision, the fracture is identified; through the use of a shaver and radiofrequency, an accurate debridement of the fracture's interface is performed, allowing it to be mobilized (Figs. 2C, 3A).

Endoscopic views, A interfragmentary debridement with radiofrequency (RF); B K-wire temporary fixation. AF: avulsed fragment, SB: AIIS base, KW: K-wire

Through the IP, a switching stick or a shaver is inserted, and it can be used for the reduction maneuver, with the aim of reducing the fragment as anatomically as possible. If there is difficulty in retracting the avulsed fragment, flexion of the hip can be helpful, detending the rectus femoris muscle (Fig. 2D).

Once anatomical reduction is achieved, a 2 mm k-wire is inserted perpendicular to the fracture by the same portal, and an intraoperative x-ray check is necessary to confirm adequate temporary reduction (Figs. 2E, 3B).

Finally, the definitive fixation can be performed with a partially threaded cannulated interfragmentary screw 4.5 mm in diameter inserted by the IP. (Fig. 2G). The correct anatomical reduction and screw insertion are ensured through x-rays control in Judet's iliac wing projection (Fig. 4A–C).

A–C fluoroscopic final controls; D–F XR postoperative controls

The skin is closed with resorbable wires and single stitches, and medication is applied.

The final result is evaluated with postoperative x-ray in Anterior–Posterior (AP), obturator, and Judet's wing projection (Fig. 4D–F).