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The arthroscopic management of hip dysplasia has been controversial and has historically demonstrated mixed results. Studies on patients with borderline dysplasia, emphasizing the importance of the labrum and capsule as secondary stabilizers, have shown improvement in patient-reported outcomes (PROs).The purpose was to assess whether the results of hip arthroscopic surgery with labral preservation and concurrent capsular plication in patients with borderline hip dysplasia have lasting, positive outcomes at a minimum 5-year follow-up. It was hypothesized that with careful patient selection, outcomes would be favorable.Case series; Level of evidence, 4.Data were prospectively collected and retrospectively reviewed for patients aged <40 years who underwent hip arthroscopic surgery for intra-articular abnormalities. Inclusion criteria included lateral center-edge angle (LCEA) between 18° and 25°, concurrent capsular plication and labral preservation, and minimum 5-year follow-up. Exclusion criteria were severe dysplasia (LCEA ≤18°), Tönnis grade ≥2, pre-existing childhood hip conditions, or prior hip surgery. PRO scores including the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), and Hip Outcome Score Sport-Specific Subscale (HOS-SSS) and the visual analog scale (VAS) score for pain were collected preoperatively, at 3 months, and annually thereafter. Complications and revisions were recorded.Twenty-five hips (24 patients) met the inclusion criteria. Twenty-one hips (19 patients, 84%) were available for follow-up. The mean age at surgery was 22.9 years. The mean preoperative LCEA and Tönnis angle were 21.7° (range, 18° to 24°) and 6.9° (range, –1° to 16°), respectively. The mean follow-up was 68.8 months. The mean mHHS increased from 70.3 to 85.9 (P < .0001), the mean NAHS from 68.3 to 87.3 (P < .0001), and the mean HOS-SSS from 52.1 to 70.8 (P = .0002). The mean VAS score improved from 5.6 to 1.8 (P < .0001). Four hips (19%) required secondary arthroscopic procedures, all of which resulted in improved PRO scores at latest follow-up. No patient required conversion to total hip arthroplasty.While periacetabular osteotomy remains the standard for treating true acetabular dysplasia, hip arthroscopy may provide a safe and durable means of managing intra-articular abnormalities in the setting of borderline acetabular dysplasia at midterm follow-up. These procedures should be performed by surgeons with expertise in advanced arthroscopic techniques, using strict patient selection criteria, with emphasis on labral preservation and capsular plication.