- Email: [email protected]
Hip Instability and Capsular Laxity
Hip Instability and Capsular Laxity Jennifer L. Bayer, MD, and Jon K. Sekiya, MD Hip instability causes pain and impairment for patients. Traumatic instability results from a distinct dislocation or subluxation event. Atraumatic instability results from overuse, generalized ligamentous laxity, inherited collagen disorders, or developmental dysplasia of the hip. Patients present with vague symptoms that make diagnosis difficult. Hip examination findings can demonstrate increased external rotation in neutral and extension, as well as apprehension with hyperextension and external rotation. Secondary impingement caused by capsular laxity is observed when impingement physical examination findings are present without cam or pincer bony anomalies on radiographs. Patients who respond to diagnostic hip injection and easily distract with manual traction under fluoroscopy are candidates for an arthroscopic anterior capsular placation with suture. After capsular plication, patients regain full range of motion at 3 months and return to full activity between 4 and 6 months postoperatively. Capsular plication with suture is an effective and safe method for treating hip instability. Oper Tech Orthop 20:237-241 © 2010 Elsevier Inc. All rights reserved. KEYWORDS arthroscopy, capsular laxity, capsular placation, hip, instability
H
ip instability causes hip pain and impairment for patients. This diagnosis, in conjunction with capsular laxity, is a relatively new and emerging condition. Because of the intrinsic hip stability provided by osseous anatomy and surrounding soft-tissue structures, instability of the hip joint is relatively uncommon. In addition, the labrum increases joint stability by deepening the acetabular socket. Surrounding the bony anatomy and labrum are the capsuloligamentous structures. The iliofemoral ligament, also known as the Y ligament of Bigelow, is the anterior most structure providing resistance to anterior translation in extension and external rotation.1,2 The iliofemoral ligament is the strongest hip ligament and is ⬎1 cm in thickness. The ischiofemoral ligament is located posteriorly and prevents posterior translation during hip internal rotation and adduction.1,2 The pubofemoral ligament is located at the medial and inferior aspect of the joint and is the weakest of the 3 ligaments. It provides resistance against extension and abduction forces.1,2 Bony anomalies or disruption of these soft-tissue structures can result in instability and patient disability. Department of Orthopaedic Surgery, University of Michigan, Medical Center, Ann Arbor, MI. Dr Bayer has no conflict of interest. Dr Sekiya: Consultant, receives royalties and has equity stakes in Orthodynamix, LLC. Address reprint requests to Jon K. Sekiya, MD, Associate Professor and MedSport, Department of Orthopaedic Surgery, University of Michigan, Medical Center, 24 Frank Lloyd Wright Drive, PO Box 0391, Ann Arbor, MI 48106-0391. E-mail: [email protected]
1048-6666/10/$-see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1053/j.oto.2010.09.019
Hip instability can result from either traumatic or atraumatic causes. Traumatic instability results from a distinct dislocation or subluxation event. The cause can be high energy, such as a motor vehicle collision, or a lower energy accident from contact sports, such as football or hockey.3-7 Ninety percent of traumatic dislocations are posteriorly directed and caused from an axial force applied to a flexed knee.4,8 Traumatic dislocations require immediate reduction to prevent avascular necrosis. Most traumatic dislocations can be treated nonoperatively. Operative treatment is reserved for patients with an acetabular fracture ⬎25% or intra-articular bony fragments.5 Individuals with recurrent traumatic instability, because of posterior capsular or labral injury, may require further intervention after the initial recovery period.5,9,10 Atraumatic instability, unlike its traumatic counterpart, does not have a clear inciting event. Atraumatic instability can originate from overuse, generalized dysplasia of the hip.3,11-13 Atraumatic instability from overuse is frequently seen in athletes participating in golf, baseball, football and gymnastics.3,13 This microinstability is created by repetitive axial loading with external rotation. The microtrauma caused by these instability events can lead to elongation of the anterior capsule and labral tears.5 As the capsule becomes lax, the iliopsoas and iliotibial band become important hip stabilizers. Stress on these structures leads to snapping, bursitis, and flexion contractures.5 237
238
J.L. Bayer and J.K. Sekiya
Clinical Assessment Patients with capsular laxity often present to clinic with vague symptoms that can make diagnosis difficult. Patient complaints can include pain, iliopsoas or iliotibial band snapping, and frequent subluxation events. On physical examination all patients should be evaluated for generalized ligamentous laxity by checking bilateral elbow hyperextension, bilaterally fifth metacarpal hyperextension, bilateral knee hyperextension, bilateral thumb to forearm apposition and forward palm to floor flexion.12 Hip examination may demonstrate increased external rotation with the hip in neutral or extended position, anterior hip pain with prone passive extension and external rotation, and apprehension with hyperextension and external rotation.13,14 In addition, patients can develop secondary impingement as the result of capsular laxity.11,13,14 These patients will have impingement examination findings without noted cam or pincer abnormalities on imaging studies.
Imaging All patients with hip complaints receive a weight-bearing anteroposterior pelvis, anteroposterior and cross-table lateral hip radiographs to assess for any bony anomalies. In patients with high clinical suspicion, magnetic resonance imaging or magnetic resonance arthrography can also be used to evaluate labral tears, cartilage defects, stress fractures, or soft tissue injury. A diagnostic intra-articular hip injection is given to all patients with hip pain and instability symptoms. A solution of 6 mL of 1% lidocaine, 6 mL of 0.25% bupivacaine HCl and 80 mg of triamcinolone are injected into the hip joint with the use of fluoroscopic assistance. If done in conjunction with magnetic resonance arthrography, the gadolinium is simply added to this solution instead of saline. Patients are encouraged to participate in aggravating activities for 2 hours after injection. At or before the 2-hour mark, patients record the percentage of pain relief provided by the injection. Patients with a high percentage of post injection pain relief and clinical examination consistent with hip instability are candidates for hip arthroscopy and anterior capsular plication.
Operative Technique The patient is placed into bilateral thigh high compression hoses before arrival in the operative suite. General anesthesia is induced with adequate muscular relaxation. The patient is positioned on an operating room table with lower extremity attachments (Smith & Nephew, London, UK) that allow for manual traction and countertraction (Fig. 1). The patient’s groin region is adjusted to allow broad approximation across the well-padded peroneal post. Each foot is put into a foam boot and placed into the traction frame foot holder. To prevent foot migration during the surgical procedure, both feet are secured using cloth tape in a circumferential and figure of 8 fashion. The operative hip is examined fluoroscopically (Fig. 2). Manual traction is applied on the operative side with the hip
Figure 1 (A) Patient positioned supine on operating room table with lower-extremity attachments (Smith & Nephew, London, UK). The operative limb is placed in slight abduction with manual traction during fluoroscopic examination. (B) The operative limb is then adducted to lever off the well-padded peroneal post and provide a lateral vector of force as well and longitudinal force with maximal internal rotation before start of the surgical procedure.
neutral rotation and slight abduction. Gentle countertraction is applied to the nonoperative side. Patients with moderateto-severe displacement of the operative hip with minimal traction force confirm the diagnosis of hip laxity and instability and are candidates for anterior capsular plication. The operative hip is adducted with maximum internal rotation to assist with portal placement. The manual traction is adjusted accordingly to allow approximately 10 mm of distraction to prevent any chondral or labral injury during the procedure. Intravenous antibiotics are given before surgical incision. The patient’s hip is prepped and draped using a standard hip fracture drape. The anterolateral portal is established first. A spinal needle is placed 1 cm anterior to the proximal aspect of the greater trochanter. Fluoroscopic guidance is used while directing the spinal needle into the hip joint. The spinal needle enters the joint at a point two-thirds from the acetabulum and one-third from the femoral head to avoid injuring the labrum. A guide wire is placed through the spinal needle.
Hip instability and capsular laxity
Figure 2 (A) Fluoroscopic image before application of manual traction. (B) Fluoroscopic view demonstrating moderate distraction of the hip joint with minimal manual traction. This ease of distraction is confirmation of hip capsular laxity.
Fluoroscopy is used to confirm intra-articular placement of the guide wire and the spinal needle is removed. An arthroscopic cannula is placed over the guide wire, the guide wire is removed, and a 70 degree arthroscope is placed into the hip joint. The anterior portal is created under arthroscopic guidance. A spinal needle is used to enter the joint 1 cm lateral to a distally directed line with the anterior inferior iliac spine and in line or distal with the anterolateral portal. The spinal needle is adjusted as needed to obtain the best working portal position for treatment of any associated hip pathology. A guidewire is passed through the spinal needle, the spinal needle is removed, and a working cannula is placed. After portal placement, the hip joint is evaluated to assess any osseous, chondral, labral, or soft-tissue defects. To optimize visualization, a capsulectomy is made in line with the femoral neck with a debrider. Procedures to treat intra-articular and peripheral compartment pathology can be com-
239 pleted as necessary. These include chondral debridement, iliopsoas lengthening, labral repair or debridement, osteoplasty and acetabular rim trim. To complete the anterior capsular plication, the operative hip is placed in 30 degrees of flexion with adduction and internal rotation. The 70° arthroscope is moved to the anterior portal and an 8.25-mm or larger working cannula is placed into the anterolateral portal. This configuration allows for easier piercing of the lateral portion of the iliofemoral ligament during suture plication. If needed, the anterior portal can be used as the working portal when soft tissue swelling or adipose tissue prevent instrumentation from reaching the iliofemoral ligament from the anterolateral portal. When using the anterior portal as the working portal, there is increased difficulty for piercing the lateral portion of the iliofemoral ligament due to a steep angle. A curved spectrum is placed into the working cannula and passed through the medial limb of the iliofemoral ligament (Fig. 3). Size 0 polydiaxone monofilament suture (PDS; Ethicon, Somerville, NJ) is advanced through the medial ligament limb and the spectrum is removed. A suture retriever is inserted into the working cannula. We prefer using a 22° bird beak (Arthrex, Naples, FL) for an anterolateral working portal and a 44° bird beak (Arthrex, Naples, FL) when using an anterior working portal because the angle to obtain the lateral limb of the iliofemoral ligament is difficult from this portal, although sometimes necessary, because of the presence of too much soft tissue or fluid and swelling laterally. The suture retriever is passed through the lateral iliofemoral ligament fibers and grabs the polydiaxone monofilament suture. The suture retriever is removed and a Size 2 braided nonabsorbable suture (FiberWire; Arthrex) is shuttled through the iliofemoral ligament limbs using the polydiaxone monofilament suture (Fig. 4). Arthroscopic knots are placed to secure the capsular plication. We prefer using the Weston knot with 3 half-hitches.15 The capsular plication is then evaluated, and
Figure 3 An arthroscopic view from the anterior portal demonstrating the passing of a curved spectrum through the medial limb of the iliofemoral ligament during capsular plication. The hip is out of traction and flexed approximately 20-30 degrees.
J.L. Bayer and J.K. Sekiya
240 the process can be repeated until the capsule has been tightened to the desired effect (Fig. 5). Very commonly, hip laxity is accompanied by a snapping iliopsoas or snapping iliotibial band, which we will lengthen if present, as an associated condition. In addition, secondary femoral neck impingement has been described11,14 in association with hip hyperlaxity, and should be addressed with osteoplasty in conjunction with the capsular plication. At completion, all fluid and debris are removed from the joint and local anesthetic is injected. Following closure of the portals, cryotherapy and postoperative hip brace (Bledsoe Brace Systems, Grand Prairie, TX) are applied to the patient before recovery room transport. In addition, we use the padded boots and peroneal post from surgery to strap the feet together distally and in internal rotation to be used when sleeping for 2 weeks after surgery (oral communication, Marc Philippon, August 2007).
Postoperative Care Patients are 30% weight bearing on the operative limb with crutches immediately following the procedure. A continuous passive motion device and passive range of motion exercises are initiated to prevent capsulolabral adhesions. Patients are placed on anterior hip precautions which include no external rotation, no extension past neutral and no abduction beyond 20°. Crutches are weaned at 2-3 weeks postoperatively only if a capsular plication is completed. If additional procedures are performed at time of surgery, crutches are weaned at 4-6 weeks. Anterior hip precautions are removed 6 weeks postoperatively and full hip range of motion is attained by 3 months following plication. Patients return to full activity between 4 and 6 months postoperatively.
Figure 5 An arthroscopic view from the anterior portal demonstrating closure of the anterior capsule with suture. Additional capsular plication stitches can be placed until an appropriate plication is achieved.
Conclusions Good outcomes with capsular plication are documented in the literature using arthroscopic and open techniques. 3,9-11,13 Despite reports of complications using thermal capsular shrinkage in the shoulder, successful treatment of hip capsular laxity with this technique is published.3 We prefer using a suture capsular plication technique, similar to plication techniques for shoulder instability, because it allows the surgeon to tailor the amount of capsular tightening under arthroscopic visualization. In comparison with central compartment plications, we complete our capsular plication in the peripheral compartment to reduce the morbidity of prolonged traction on the operative limb. In addition, we believe that we can position the capsular a little tighter when the hip is not in traction. Although there is a steep learning curve for this procedure, capsular plication with suture can be a safe and effective measure for treating hip instability and capsular laxity.
References
Figure 4 An arthroscopic view from the anterior portal showing the polydiaxone monofilament suture through both limbs of the iliofemoral ligament before shuttling a Size 2 braided nonabsorbable suture.
1. Ito H, Song Y, Lindsey DP, et al: The proximal hip joint capsule and the zona orbicularis contribute to the hip joint stability in distraction. J Orthop Res 8:989-995, 2009 2. Hewitt JD, Glisson RR, Guilak F, et al: The mechanical properties of the human hip capsule ligaments. J Arthroplasty 17:82-89, 2002 3. Philippon MJ: The role of arthroscopic thermal capsulorrhaphy in the hip. Clin Sports Med 20:817-829, 2001 4. Moorman CT 3rd, Warren RF, Hershman EB, et al: Traumatic posterior hip subluxation in American football. J Bone Joint Surg Am 85-A:11901196, 2003 5. Shindle MK, Ranawat AS, Kelly BT: Diagnosis and management of traumatic and atruamatic hip instability in the athletic patient. Clin Sports Med 25:309-326, 2006 6. Bellabarba C, Sheinkop MB, Kuo KN: Idiopathic hip instability. An unrecognized cause of coax saltans in the adult. Clin Orthop Relat Res 355:261-271, 1998 7. Scopp JM, Moorman CT: Acute athletic trauma to the hip and pelvis. Orthop Clin North Am 33:555-563, 2002
Hip instability and capsular laxity 8. Boyd KT, Peirce NS, Batt ME: Common hip injuries in sport. Sports Med 24:273-288, 1997 9. Liebenberg F, Dommisse GF: Recurrent post-traumatic dislocation of the hip. J Bone Joint Surg Br 51:632-637, 1969 10. Nelson CL: Traumatic recurrent dislocation of the hip. Report of a case. J Bone Joint Surg Am 52:128-130, 1970 11. Ranawat AS, McClincy M, Sekiya JK: Anterior dislocation of the hip after arthroscopy in a patient with capsular laxity of the hip. A case report. J Bone Joint Surg Am 91:192-197, 2009
241 12. Beighton P, Horan F: Orthopaedic aspects of the Ehlers–Danlos syndrome. J Bone Joint Surg Br 51:444-453, 1969 13. Smith MV, Sekiya JK: Hip instability. Sports Med Arthrosc 18:108-112, 2010 14. Tibor LM, Sekiya JK: Differential diagnosis of pain around the hip joint. Arthroscopy 24:1407-1421, 2008 15. Elkousy HA, Sekiya JK, Stabile KJ, et al: A biomechanical comparison of arthroscopic sliding and sliding-locking knots: an analysis of knot security and strength. Arthroscopy 21:204-210, 2005
H
ip instability causes hip pain and impairment for patients. This diagnosis, in conjunction with capsular laxity, is a relatively new and emerging condition. Because of the intrinsic hip stability provided by osseous anatomy and surrounding soft-tissue structures, instability of the hip joint is relatively uncommon. In addition, the labrum increases joint stability by deepening the acetabular socket. Surrounding the bony anatomy and labrum are the capsuloligamentous structures. The iliofemoral ligament, also known as the Y ligament of Bigelow, is the anterior most structure providing resistance to anterior translation in extension and external rotation.1,2 The iliofemoral ligament is the strongest hip ligament and is ⬎1 cm in thickness. The ischiofemoral ligament is located posteriorly and prevents posterior translation during hip internal rotation and adduction.1,2 The pubofemoral ligament is located at the medial and inferior aspect of the joint and is the weakest of the 3 ligaments. It provides resistance against extension and abduction forces.1,2 Bony anomalies or disruption of these soft-tissue structures can result in instability and patient disability. Department of Orthopaedic Surgery, University of Michigan, Medical Center, Ann Arbor, MI. Dr Bayer has no conflict of interest. Dr Sekiya: Consultant, receives royalties and has equity stakes in Orthodynamix, LLC. Address reprint requests to Jon K. Sekiya, MD, Associate Professor and MedSport, Department of Orthopaedic Surgery, University of Michigan, Medical Center, 24 Frank Lloyd Wright Drive, PO Box 0391, Ann Arbor, MI 48106-0391. E-mail: [email protected]
1048-6666/10/$-see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1053/j.oto.2010.09.019
Hip instability can result from either traumatic or atraumatic causes. Traumatic instability results from a distinct dislocation or subluxation event. The cause can be high energy, such as a motor vehicle collision, or a lower energy accident from contact sports, such as football or hockey.3-7 Ninety percent of traumatic dislocations are posteriorly directed and caused from an axial force applied to a flexed knee.4,8 Traumatic dislocations require immediate reduction to prevent avascular necrosis. Most traumatic dislocations can be treated nonoperatively. Operative treatment is reserved for patients with an acetabular fracture ⬎25% or intra-articular bony fragments.5 Individuals with recurrent traumatic instability, because of posterior capsular or labral injury, may require further intervention after the initial recovery period.5,9,10 Atraumatic instability, unlike its traumatic counterpart, does not have a clear inciting event. Atraumatic instability can originate from overuse, generalized dysplasia of the hip.3,11-13 Atraumatic instability from overuse is frequently seen in athletes participating in golf, baseball, football and gymnastics.3,13 This microinstability is created by repetitive axial loading with external rotation. The microtrauma caused by these instability events can lead to elongation of the anterior capsule and labral tears.5 As the capsule becomes lax, the iliopsoas and iliotibial band become important hip stabilizers. Stress on these structures leads to snapping, bursitis, and flexion contractures.5 237
238
J.L. Bayer and J.K. Sekiya
Clinical Assessment Patients with capsular laxity often present to clinic with vague symptoms that can make diagnosis difficult. Patient complaints can include pain, iliopsoas or iliotibial band snapping, and frequent subluxation events. On physical examination all patients should be evaluated for generalized ligamentous laxity by checking bilateral elbow hyperextension, bilaterally fifth metacarpal hyperextension, bilateral knee hyperextension, bilateral thumb to forearm apposition and forward palm to floor flexion.12 Hip examination may demonstrate increased external rotation with the hip in neutral or extended position, anterior hip pain with prone passive extension and external rotation, and apprehension with hyperextension and external rotation.13,14 In addition, patients can develop secondary impingement as the result of capsular laxity.11,13,14 These patients will have impingement examination findings without noted cam or pincer abnormalities on imaging studies.
Imaging All patients with hip complaints receive a weight-bearing anteroposterior pelvis, anteroposterior and cross-table lateral hip radiographs to assess for any bony anomalies. In patients with high clinical suspicion, magnetic resonance imaging or magnetic resonance arthrography can also be used to evaluate labral tears, cartilage defects, stress fractures, or soft tissue injury. A diagnostic intra-articular hip injection is given to all patients with hip pain and instability symptoms. A solution of 6 mL of 1% lidocaine, 6 mL of 0.25% bupivacaine HCl and 80 mg of triamcinolone are injected into the hip joint with the use of fluoroscopic assistance. If done in conjunction with magnetic resonance arthrography, the gadolinium is simply added to this solution instead of saline. Patients are encouraged to participate in aggravating activities for 2 hours after injection. At or before the 2-hour mark, patients record the percentage of pain relief provided by the injection. Patients with a high percentage of post injection pain relief and clinical examination consistent with hip instability are candidates for hip arthroscopy and anterior capsular plication.
Operative Technique The patient is placed into bilateral thigh high compression hoses before arrival in the operative suite. General anesthesia is induced with adequate muscular relaxation. The patient is positioned on an operating room table with lower extremity attachments (Smith & Nephew, London, UK) that allow for manual traction and countertraction (Fig. 1). The patient’s groin region is adjusted to allow broad approximation across the well-padded peroneal post. Each foot is put into a foam boot and placed into the traction frame foot holder. To prevent foot migration during the surgical procedure, both feet are secured using cloth tape in a circumferential and figure of 8 fashion. The operative hip is examined fluoroscopically (Fig. 2). Manual traction is applied on the operative side with the hip
Figure 1 (A) Patient positioned supine on operating room table with lower-extremity attachments (Smith & Nephew, London, UK). The operative limb is placed in slight abduction with manual traction during fluoroscopic examination. (B) The operative limb is then adducted to lever off the well-padded peroneal post and provide a lateral vector of force as well and longitudinal force with maximal internal rotation before start of the surgical procedure.
neutral rotation and slight abduction. Gentle countertraction is applied to the nonoperative side. Patients with moderateto-severe displacement of the operative hip with minimal traction force confirm the diagnosis of hip laxity and instability and are candidates for anterior capsular plication. The operative hip is adducted with maximum internal rotation to assist with portal placement. The manual traction is adjusted accordingly to allow approximately 10 mm of distraction to prevent any chondral or labral injury during the procedure. Intravenous antibiotics are given before surgical incision. The patient’s hip is prepped and draped using a standard hip fracture drape. The anterolateral portal is established first. A spinal needle is placed 1 cm anterior to the proximal aspect of the greater trochanter. Fluoroscopic guidance is used while directing the spinal needle into the hip joint. The spinal needle enters the joint at a point two-thirds from the acetabulum and one-third from the femoral head to avoid injuring the labrum. A guide wire is placed through the spinal needle.
Hip instability and capsular laxity
Figure 2 (A) Fluoroscopic image before application of manual traction. (B) Fluoroscopic view demonstrating moderate distraction of the hip joint with minimal manual traction. This ease of distraction is confirmation of hip capsular laxity.
Fluoroscopy is used to confirm intra-articular placement of the guide wire and the spinal needle is removed. An arthroscopic cannula is placed over the guide wire, the guide wire is removed, and a 70 degree arthroscope is placed into the hip joint. The anterior portal is created under arthroscopic guidance. A spinal needle is used to enter the joint 1 cm lateral to a distally directed line with the anterior inferior iliac spine and in line or distal with the anterolateral portal. The spinal needle is adjusted as needed to obtain the best working portal position for treatment of any associated hip pathology. A guidewire is passed through the spinal needle, the spinal needle is removed, and a working cannula is placed. After portal placement, the hip joint is evaluated to assess any osseous, chondral, labral, or soft-tissue defects. To optimize visualization, a capsulectomy is made in line with the femoral neck with a debrider. Procedures to treat intra-articular and peripheral compartment pathology can be com-
239 pleted as necessary. These include chondral debridement, iliopsoas lengthening, labral repair or debridement, osteoplasty and acetabular rim trim. To complete the anterior capsular plication, the operative hip is placed in 30 degrees of flexion with adduction and internal rotation. The 70° arthroscope is moved to the anterior portal and an 8.25-mm or larger working cannula is placed into the anterolateral portal. This configuration allows for easier piercing of the lateral portion of the iliofemoral ligament during suture plication. If needed, the anterior portal can be used as the working portal when soft tissue swelling or adipose tissue prevent instrumentation from reaching the iliofemoral ligament from the anterolateral portal. When using the anterior portal as the working portal, there is increased difficulty for piercing the lateral portion of the iliofemoral ligament due to a steep angle. A curved spectrum is placed into the working cannula and passed through the medial limb of the iliofemoral ligament (Fig. 3). Size 0 polydiaxone monofilament suture (PDS; Ethicon, Somerville, NJ) is advanced through the medial ligament limb and the spectrum is removed. A suture retriever is inserted into the working cannula. We prefer using a 22° bird beak (Arthrex, Naples, FL) for an anterolateral working portal and a 44° bird beak (Arthrex, Naples, FL) when using an anterior working portal because the angle to obtain the lateral limb of the iliofemoral ligament is difficult from this portal, although sometimes necessary, because of the presence of too much soft tissue or fluid and swelling laterally. The suture retriever is passed through the lateral iliofemoral ligament fibers and grabs the polydiaxone monofilament suture. The suture retriever is removed and a Size 2 braided nonabsorbable suture (FiberWire; Arthrex) is shuttled through the iliofemoral ligament limbs using the polydiaxone monofilament suture (Fig. 4). Arthroscopic knots are placed to secure the capsular plication. We prefer using the Weston knot with 3 half-hitches.15 The capsular plication is then evaluated, and
Figure 3 An arthroscopic view from the anterior portal demonstrating the passing of a curved spectrum through the medial limb of the iliofemoral ligament during capsular plication. The hip is out of traction and flexed approximately 20-30 degrees.
J.L. Bayer and J.K. Sekiya
240 the process can be repeated until the capsule has been tightened to the desired effect (Fig. 5). Very commonly, hip laxity is accompanied by a snapping iliopsoas or snapping iliotibial band, which we will lengthen if present, as an associated condition. In addition, secondary femoral neck impingement has been described11,14 in association with hip hyperlaxity, and should be addressed with osteoplasty in conjunction with the capsular plication. At completion, all fluid and debris are removed from the joint and local anesthetic is injected. Following closure of the portals, cryotherapy and postoperative hip brace (Bledsoe Brace Systems, Grand Prairie, TX) are applied to the patient before recovery room transport. In addition, we use the padded boots and peroneal post from surgery to strap the feet together distally and in internal rotation to be used when sleeping for 2 weeks after surgery (oral communication, Marc Philippon, August 2007).
Postoperative Care Patients are 30% weight bearing on the operative limb with crutches immediately following the procedure. A continuous passive motion device and passive range of motion exercises are initiated to prevent capsulolabral adhesions. Patients are placed on anterior hip precautions which include no external rotation, no extension past neutral and no abduction beyond 20°. Crutches are weaned at 2-3 weeks postoperatively only if a capsular plication is completed. If additional procedures are performed at time of surgery, crutches are weaned at 4-6 weeks. Anterior hip precautions are removed 6 weeks postoperatively and full hip range of motion is attained by 3 months following plication. Patients return to full activity between 4 and 6 months postoperatively.
Figure 5 An arthroscopic view from the anterior portal demonstrating closure of the anterior capsule with suture. Additional capsular plication stitches can be placed until an appropriate plication is achieved.
Conclusions Good outcomes with capsular plication are documented in the literature using arthroscopic and open techniques. 3,9-11,13 Despite reports of complications using thermal capsular shrinkage in the shoulder, successful treatment of hip capsular laxity with this technique is published.3 We prefer using a suture capsular plication technique, similar to plication techniques for shoulder instability, because it allows the surgeon to tailor the amount of capsular tightening under arthroscopic visualization. In comparison with central compartment plications, we complete our capsular plication in the peripheral compartment to reduce the morbidity of prolonged traction on the operative limb. In addition, we believe that we can position the capsular a little tighter when the hip is not in traction. Although there is a steep learning curve for this procedure, capsular plication with suture can be a safe and effective measure for treating hip instability and capsular laxity.
References
Figure 4 An arthroscopic view from the anterior portal showing the polydiaxone monofilament suture through both limbs of the iliofemoral ligament before shuttling a Size 2 braided nonabsorbable suture.
1. Ito H, Song Y, Lindsey DP, et al: The proximal hip joint capsule and the zona orbicularis contribute to the hip joint stability in distraction. J Orthop Res 8:989-995, 2009 2. Hewitt JD, Glisson RR, Guilak F, et al: The mechanical properties of the human hip capsule ligaments. J Arthroplasty 17:82-89, 2002 3. Philippon MJ: The role of arthroscopic thermal capsulorrhaphy in the hip. Clin Sports Med 20:817-829, 2001 4. Moorman CT 3rd, Warren RF, Hershman EB, et al: Traumatic posterior hip subluxation in American football. J Bone Joint Surg Am 85-A:11901196, 2003 5. Shindle MK, Ranawat AS, Kelly BT: Diagnosis and management of traumatic and atruamatic hip instability in the athletic patient. Clin Sports Med 25:309-326, 2006 6. Bellabarba C, Sheinkop MB, Kuo KN: Idiopathic hip instability. An unrecognized cause of coax saltans in the adult. Clin Orthop Relat Res 355:261-271, 1998 7. Scopp JM, Moorman CT: Acute athletic trauma to the hip and pelvis. Orthop Clin North Am 33:555-563, 2002
Hip instability and capsular laxity 8. Boyd KT, Peirce NS, Batt ME: Common hip injuries in sport. Sports Med 24:273-288, 1997 9. Liebenberg F, Dommisse GF: Recurrent post-traumatic dislocation of the hip. J Bone Joint Surg Br 51:632-637, 1969 10. Nelson CL: Traumatic recurrent dislocation of the hip. Report of a case. J Bone Joint Surg Am 52:128-130, 1970 11. Ranawat AS, McClincy M, Sekiya JK: Anterior dislocation of the hip after arthroscopy in a patient with capsular laxity of the hip. A case report. J Bone Joint Surg Am 91:192-197, 2009
241 12. Beighton P, Horan F: Orthopaedic aspects of the Ehlers–Danlos syndrome. J Bone Joint Surg Br 51:444-453, 1969 13. Smith MV, Sekiya JK: Hip instability. Sports Med Arthrosc 18:108-112, 2010 14. Tibor LM, Sekiya JK: Differential diagnosis of pain around the hip joint. Arthroscopy 24:1407-1421, 2008 15. Elkousy HA, Sekiya JK, Stabile KJ, et al: A biomechanical comparison of arthroscopic sliding and sliding-locking knots: an analysis of knot security and strength. Arthroscopy 21:204-210, 2005