- Email: [email protected]
Routine Complete Capsular Closure During Hip Arthroscopy
Routine Complete Capsular Closure During Hip Arthroscopy Joshua D. Harris, M.D., William Slikker III, M.D., Anil K. Gupta, M.D., M.B.A., Frank M. McCormick, M.D., and Shane J. Nho, M.D., M.S.
Abstract: The utility of hip arthroscopy has recently progressed beyond diagnostic to therapeutic purposes addressing central and peripheral compartment pathologies. Capsulotomy provides freedom of visualization and instrumentation. The contribution to hip stability of both dynamic and static hip structures is not fully understood. However, both basic science biomechanical and clinical outcome studies have exhibited a relevant role of the capsule in hip stability. Though rare, iatrogenic post-arthroscopy subluxation and dislocation have been reported. Therefore many surgeons have cautioned against aggressive capsulotomy or capsulectomy without repair, because of the potential for precipitation of iatrogenic hip instability. We typically perform a “T” capsulotomy and recommend complete capsular closure in conjunction with labral repair and osseous femoral and acetabular treatment. A safe, efficient, and effective method to accomplish complete capsular closure is presented to reduce iatrogenic postoperative hip instability.
A
rthroscopy is increasingly used to address hip pathology. Contrary to the knee and shoulder, capsulotomy is necessary to navigate the joint for diagnostic and therapeutic purposes. However, recent basic science1-3 and clinical4-6 literature has generated controversy over routine capsular closure (Table 1), implicating iatrogenic instability if left open (Fig 1). Although the capsular contribution to static stability of the joint has yet to be fully elucidated, we recommend complete closure to avoid potential postoperative complications, including instability and pain. The purpose of this technical note is to describe and illustrate complete capsule closure after capsulotomy during hip arthroscopy.
Surgical Technique General anesthesia is induced with muscle relaxation to allow for atraumatic axial distraction. An examination under anesthesia is performed to assess bilateral passive motion. Thorough preoperative evaluation From the Hip Preservation Center, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Rush Medical College, Rush University, Chicago, Illinois, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received October 4, 2012; accepted November 30, 2012. Address correspondence to Shane J. Nho, M.D., M.S., Midwest Orthopaedics at Rush, 1611 W Harrison St, Ste 300, Chicago, IL 60612, U.S.A. E-mail: [email protected] Ó 2013 by the Arthroscopy Association of North America 2212-6287/12653/$36.00 http://dx.doi.org/10.1016/j.eats.2012.11.007
should include assessment of ligamentous laxity. The patient is positioned supine on a traction table, with a well-padded perineal post and boots. The pelvis is slightly translated toward the contralateral hip, and gentle distraction is applied to the contralateral limb. Axial traction is applied to the surgical limb with the hip abducted and minimally flexed and then adducted and minimally extended, inducing a transverse vector cantilever moment to the proximal femur. It is important to note the force necessary to obtain sufficient distraction (approximately 10 mm). Internal rotation optimizes femoral neck length on the anteroposterior radiograph (reduction of femoral anteversion). The onset of hip distraction is noted by the circulating nursing staff to ensure a safe duration of traction time. Bony landmarks are marked with a sterile marker. A line is drawn vertically from the anterior superior iliac spine down the thigh. Fluoroscopic-assisted portal placement is performed. An anterolateral (AL) portal is first established, 1 cm proximal and 1 cm anterior to the anterolateral tip of the greater trochanter. Joint venting with a large-bore spinal needle allows for confirmation of appropriate placement through an air arthrogram. Standard cannulation allows for intra-articular visualization with a 70 arthroscope. The surgeon performs needle-localized placement of an anterior portal, ensuring safe entry without labral violation. The arthroscope is placed into the anterior portal, with visualization of the extra-labral location of the AL portal. The arthroscope is returned to the AL portal, and transverse interportal capsulotomy is performed from approximately
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Table 1. Summary of Basic Science and Clinical Observations of Hip Capsule Relative to Stability, Capsulotomy, and Iatrogenic Instability Study Design
Salient Conclusions
Myers et al.,1 2011
Study
Cadaveric biomechanical: Fluoroscopy
Martin et al.,2 2008
Cadaveric biomechanical: Motion tracking
Hewitt et al.,3 2002
Cadaveric biomechanical: Load to failure
Increased external rotation with IFL sectioning (increased 12.9 ) (P < .0001) Increased anterior translation with IFL sectioning (increased 1.8 mm) (P < .001) No difference in external rotation or anterior translation between intact and repaired state Release of medial and lateral arms of IFL gave greatest increase of motion in external rotation Lateral arm release provided more motion in flexion and neutral position Lateral arm release also provided more internal rotation, primarily in extension IFL was much stronger than ischiofemoral ligaments IFL had greater stiffness than ischiofemoral ligaments IFL had greater tensile load to failure than ischiofemoral ligaments 52-year-old woman with ligamentous laxity with labral tear Capsulotomy (2-3 cm), labral repair, cam osteochondroplasty, no pincer impingement, and capsular plication Anterior dislocation (2 mo) after fall with hyperextension mechanism, requiring revision plication 49-year-old woman with labral tear and moderate hip dysplasia Lateral acetabular rim resection and labral debridement Atraumatic subluxation (3 mo), requiring conversion to total hip arthroplasty 39-year-old woman with labral tear and mixed femoroacetabular impingement Interportal capsulotomy, labral debridement, cam osteochondroplasty, and acetabular rim resection Anterior dislocation in recovery room and failure of closed reduction, requiring mini-open capsulorrhaphy No recurrent instability at 15 mo after capsulorrhaphy
Ranawat et al.,4 2009
Clinical: Case report
Benali and Katthagen,5 2009
Clinical: Case report
Matsuda,6 2009
Clinical: Case report
10 o’clock to approximately 2 o’clock by use of an arthroscopic scalpel (Samurai Blade; Pivot Medical, Sunnyvale, CA). The capsulotomy is made approximately 5 to
Fig 1. Coronal magnetic resonance arthrogram of right hip. One should note the normal appearance of the left hip and the capsular opening from the acetabular rim with arthrography dye extrusion, after prior hip arthroscopy and capsulotomy left open.
8 mm from the labrum, measuring 12 to 15 mm in length (Fig 2A). The area adjacent to the acetabular labrum is exposed from the iliopsoas recess (approximately 3 o’clock) to the anterior inferior iliac spine (direct head of rectus femoris origin) (approximately 12 o’clock). Thermal soft-tissue ablation proximal to the labrum allows for acetabuloplasty rim trimming with an arthroscopic bur. The chondrolabral junction is maintained without formal labral detachment. Distal anterolateral accessory (DALA) portal placement (4 to 6 cm distal to and in line with AL portal) allows for suture anchorebased labral refixation. Generally, 2 to 4 anchors (NanoTack 1.4-mm Anatomic Labrum Restoration System; Pivot Medical) are placed as close to the articular cartilage as possible without penetration. At the conclusion of refixation, traction is released and the hip is flexed 30 . The surgeon extends a “T” capsulotomy (Fig 2B) down the center of the femoral neck, perpendicular to the interportal capsulotomy, to the intertrochanteric line (capsular reflection) between the iliocapsularis and gluteus minimus, exposing the peripheral compartment, allowing for cam osteochondroplasty from the 12- to 6-o’clock position. Figure 2C illustrates the cam lesion; Fig 2D illustrates the completed osteochondroplasty.
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Fig 2. (A) Interportal capsulotomy may be made 5 to 8 mm from the labrum with an arthroscopic scalpel (Samurai Blade). A right hip is shown in the supine position with traction, viewing from the AL portal. (B) T capsulotomy with an arthroscopic scalpel (Samurai Blade) made over the femoral neck, with pull from the iliocapsularis and gluteus minimus at each capsular edge. The T capsulotomy allows for a 180 view of the peripheral compartment, affording the ability to address the cam lesion through osteochondroplasty, as well as with open surgical hip dislocation. A right hip is shown in the supine position with traction, viewing from the AL portal. (C) After the T capsulotomy has been made, the femoral cam lesion can easily be visualized. A left hip is shown in the supine position with traction, viewing from the anterior portal. (D) Completed femoral osteochondroplasty from 12 o’clock to 6 o’clock (180 bony resection), shown in a left hip in the supine position with traction, viewing from the anterior portal.
Capsular closure may be accomplished with a variety of suture-passing devices, yielding side-to-side stitches (Video 1). A crescent SutureLasso (Arthrex, Naples, FL) (Fig 3A) may be used to pass a suture shuttle, while a tissue penetrator-passer (Fig 3B) retrieves the shuttle. Nonabsorbable, high-strength suture is passed and tied sequentially, with 4 to 6 sutures total usually required in both the vertical and transverse capsulotomy limbs (Fig 3C). A capsule-closure device (InJector II Capsule Restoration System; Pivot Medical) has been introduced recently, allowing closure through a single cannula (Fig 4A, 4B). When a suture shuttle device is used, one 8.25 90emm cannula is placed in the AL portal and one 8.25 110emm cannula is placed in the DALA portal. The longitudinal portion of the T capsulotomy is closed first at the base of the iliofemoral ligament (IFL). A crescent suture lasso is placed through the AL portal and passed through the lateral leaflet of the IFL. Nitinol wire is shuttled and retrieved with a tissue penetrator through the medial leaflet of the IFL. Successive suture placement and knot tying inherently tighten the capsule, and visualization requires greater precision with successive suture placement. Evaluation of ligamentous laxity determines the degree of “bite” with each capsular edge. Greater bites allow greater degrees
of plication. Although any sliding or non-sliding knot may be used, we prefer reversing half-hitches on alternating posts. The “T” is closed with 2 to 4 sutures. Once the IFL is closed to the interportal capsulotomy, the InJector device is used to close remaining capsule. To close the lateral capsulotomy, the InJector device is passed through the AL portal, and the first suture end is passed through the proximal IFL attached to the acetabular rim. The other suture end is placed in the InJector device and passed through the distal IFL. The stitch is then tied. To close the medial IFL, the InJector device is passed through the DALA portal, and the first suture end is passed through the proximal IFL attached to the rim. The other suture end is placed in the InJector device, passed through the distal IFL, and tied. Generally, 2 to 3 stitches are used to close the interportal capsulotomy. Complete capsular closure is verified by the inability to visualize the underlying femoral head/neck (Fig 3D). Postoperatively, the patient is placed into a hip orthosis (0 to 90 of flexion), with crutch-assisted gait with 20 lb of foot-flat weight bearing. Use of an abduction pillow at night prevents the feet from falling into external rotation. Extension and external rotation are avoided (because they can disrupt the capsulolabral repair). Continuous passive motion and stationary
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Fig 3. (A) Crescent suture lasso placed through AL portal and passed through lateral leaflet of IFL. Nitinol wire is shuttled out of the lasso. A left hip is shown in the supine position without traction, viewing from the anterior portal. (B) A tissue penetrator-passer retrieves the shuttle for side-to-side suture placement. A left hip is shown in the supine position without traction, viewing from the anterior portal. (C) Side-to-side high-strength nonabsorbable suture in each capsular limb before tying. (D) Side-to-side highstrength nonabsorbable suture in the interportal and vertical “T” capsulotomy limbs demonstrating the extra-articular appearance of complete capsular closure. A left hip is shown in the supine position without traction, viewing from the anterior portal.
Fig 4. Capsular closure device that grasps and passes high-strength nonabsorbable suture in (A) acetabular side of IFL and (B) femoral side of IFL. A left hip is shown in the supine position without traction, viewing from the anterior portal.
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Table 2. Advantages and Disadvantages of Routine Complete Capsular Closure Versus Leaving Capsulotomy Open During Hip Arthroscopy Complete Capsular Repair
Leaving Capsulotomy Open
Advantages Retention of hip stabilitydexternal rotation and anterior translation Prevention of iatrogenic subluxation and dislocation Prevention of edge loading of repaired labrum No loss of motion Disadvantages Technically demanding and may damage articular surfaces Multiple nonabsorbable sutures in anterior capsule Increased surgical time
Advantages May be therapeutic (preoperative tight anterior capsule) Reduced surgical time No risk of over-tightening anterior capsule and subsequent loss of motion Disadvantages May lead to iatrogenic instability, especially in ligamentously lax hypermobile individuals and in sport-specific athletes Exacerbated during excessive femoral osseous resection
bicycle use are recommended in the first 3 weeks. At 3 weeks after surgery, brace and crutch use is weaned. Muscle strengthening is progressed (slowly to avoid iliopsoas tendonitis). Closed- and open-chain exercises are begun at 6 weeks postoperatively. Treadmill running may commence at 12 weeks, with return to sport at 3 to 6 months.
Discussion We have presented a safe, efficient, and reliable technique for complete capsular closure during hip arthroscopy. The capsulotomy affords mobility for direct visualization and instrumentation. If left open, the potential exists for iatrogenic instability. Although frank dislocation is rare (6 cases reported),4-8 “microinstability” may be a source of postoperative pain and stress a repaired labrum.9 Thus many surgeons caution against aggressive capsulotomy/capsulectomy. There are advantages and disadvantages to capsular closure during hip arthroscopy (Table 2). Though technically demanding, several pearls may be helpful in performing capsular closure with avoidance of potential complications (Table 3). The first decision is the type and size of capsulotomy/capsulectomy. Next is the decision to perform a partial or complete closure.
Although reports in the literature are rare regarding dislocation, the complication is serious and potentially preventable (Table 1). Transformation of the hip into a “dysplastic configuration” has led to iatrogenic instability.5-8 However, despite capsular plication during primary arthroscopy, instability may still occur.4,6 Revision capsular plication has restored stability, illustrating the importance of the capsule for stability.4,6 In addition to clinical reports of post-arthroscopic dislocation, basic science evidence has described excessive external rotation and anterior translation that occur with isolated IFL sectioning.1-3 When repaired, normal motion and stability returned, further showing the importance of capsular repair. Yet unknown or undefined is the case of microinstability, a scenario that occurs postoperatively with pain, normal radiographs, no frank instability/apprehension, and no other explanation for symptoms.9 No studies have compared repair/plication versus capsulotomy left open.10 No study has illustrated the radiographic appearance or description of capsular capaciousness or dynamic imaging showing microinstability or macroinstability for capsules left open or repaired.9,10 Until proven otherwise, we believe that capsulotomy repair/plication is warranted.
Table 3. Technical Pearls and Pitfalls for Performance of Hip Arthroscopy Capsulotomy and Complete Capsular Closure Pearls Interportal and T capsulotomy B Enhanced central and peripheral compartment visualization Refixation of labrum B Suture anchor based; as close as possible to articular margin using DALA portal B Static stability restoration Femoral and acetabular osteochondroplasty B Reduces/eliminates impingement Complete capsular closure B Avoid aggressive capsulectomy B Begin closure at distal base of IFL and capsule undergoing T capsulotomy and progress proximally toward interportal capsulotomy B Customize degree of plication/bite based on patient’s ligamentous laxity status Postoperative rehabilitation B Avoid hip extension and external rotation
Pitfalls Poor visualization B Poor portal placement Failure to address bony pathology B Femoral cam and acetabular pincer impingement B Stresses labral/capsular repair Too aggressive capsulectomy B Prevents complete closure or requires too much tension upon repair that predisposes to stiffness postoperatively B Damaged capsular edges from mechanical shaver devices may preclude secure bite with sutures Avoid iatrogenic articular cartilage damage with passage of tissue penetrator/suture passer devices Postoperative rehabilitation B Hip extension or external rotation that stresses capsulolabral repair, with potential disruption Poor patient selection B Dysplasia, hyperlaxity, and coxa magna
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References 1. Myers CA, Register BC, Lertwanich P, et al. Role of the acetabular labrum and the iliofemoral ligament in hip stability: An in vitro biplane fluoroscopy study. Am J Sports Med 2011;39(suppl):85S-91S. 2. Martin HD, Savage A, Braly BA, Palmer IJ, Beall DP, Kelly B. The function of the hip capsular ligaments: A quantitative report. Arthroscopy 2008;24:188-195. 3. Hewitt JD, Glisson RR, Guilak F, Vail TP. The mechanical properties of the human hip capsule ligaments. J Arthroplasty 2002;17:82-89. 4. 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 2009;91:192-197. 5. Benali Y, Katthagen BD. Hip subluxation as a complication of arthroscopic debridement. Arthroscopy 2009;25:405-407.
6. Matsuda DK. Acute iatrogenic dislocation following hip impingement arthroscopic surgery. Arthroscopy 2009;25: 400-404. 7. Ilizaliturri VM Jr. Complications of arthroscopic femoroacetabular impingement treatment: A review. Clin Orthop Relat Res 2009;467:760-768. 8. Souza BG, Dani WS, Honda EK, et al. Do complications in hip arthroscopy change with experience? Arthroscopy 2010;26: 1053-1057. 9. Shu B, Safran MR. Hip instability: Anatomic and clinical considerations of traumatic and atraumatic instability. Clin Sports Med 2011;30:349-367. 10. Domb BG, Giordano BD, Philippon MJ. Arthroscopic capsulotomy, capsular repair, and capsular plication of the hip: Relation to atraumatic instability. Arthroscopy 2013;29:162-173.
Abstract: The utility of hip arthroscopy has recently progressed beyond diagnostic to therapeutic purposes addressing central and peripheral compartment pathologies. Capsulotomy provides freedom of visualization and instrumentation. The contribution to hip stability of both dynamic and static hip structures is not fully understood. However, both basic science biomechanical and clinical outcome studies have exhibited a relevant role of the capsule in hip stability. Though rare, iatrogenic post-arthroscopy subluxation and dislocation have been reported. Therefore many surgeons have cautioned against aggressive capsulotomy or capsulectomy without repair, because of the potential for precipitation of iatrogenic hip instability. We typically perform a “T” capsulotomy and recommend complete capsular closure in conjunction with labral repair and osseous femoral and acetabular treatment. A safe, efficient, and effective method to accomplish complete capsular closure is presented to reduce iatrogenic postoperative hip instability.
A
rthroscopy is increasingly used to address hip pathology. Contrary to the knee and shoulder, capsulotomy is necessary to navigate the joint for diagnostic and therapeutic purposes. However, recent basic science1-3 and clinical4-6 literature has generated controversy over routine capsular closure (Table 1), implicating iatrogenic instability if left open (Fig 1). Although the capsular contribution to static stability of the joint has yet to be fully elucidated, we recommend complete closure to avoid potential postoperative complications, including instability and pain. The purpose of this technical note is to describe and illustrate complete capsule closure after capsulotomy during hip arthroscopy.
Surgical Technique General anesthesia is induced with muscle relaxation to allow for atraumatic axial distraction. An examination under anesthesia is performed to assess bilateral passive motion. Thorough preoperative evaluation From the Hip Preservation Center, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Rush Medical College, Rush University, Chicago, Illinois, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received October 4, 2012; accepted November 30, 2012. Address correspondence to Shane J. Nho, M.D., M.S., Midwest Orthopaedics at Rush, 1611 W Harrison St, Ste 300, Chicago, IL 60612, U.S.A. E-mail: [email protected] Ó 2013 by the Arthroscopy Association of North America 2212-6287/12653/$36.00 http://dx.doi.org/10.1016/j.eats.2012.11.007
should include assessment of ligamentous laxity. The patient is positioned supine on a traction table, with a well-padded perineal post and boots. The pelvis is slightly translated toward the contralateral hip, and gentle distraction is applied to the contralateral limb. Axial traction is applied to the surgical limb with the hip abducted and minimally flexed and then adducted and minimally extended, inducing a transverse vector cantilever moment to the proximal femur. It is important to note the force necessary to obtain sufficient distraction (approximately 10 mm). Internal rotation optimizes femoral neck length on the anteroposterior radiograph (reduction of femoral anteversion). The onset of hip distraction is noted by the circulating nursing staff to ensure a safe duration of traction time. Bony landmarks are marked with a sterile marker. A line is drawn vertically from the anterior superior iliac spine down the thigh. Fluoroscopic-assisted portal placement is performed. An anterolateral (AL) portal is first established, 1 cm proximal and 1 cm anterior to the anterolateral tip of the greater trochanter. Joint venting with a large-bore spinal needle allows for confirmation of appropriate placement through an air arthrogram. Standard cannulation allows for intra-articular visualization with a 70 arthroscope. The surgeon performs needle-localized placement of an anterior portal, ensuring safe entry without labral violation. The arthroscope is placed into the anterior portal, with visualization of the extra-labral location of the AL portal. The arthroscope is returned to the AL portal, and transverse interportal capsulotomy is performed from approximately
Arthroscopy Techniques, Vol 2, No 2 (May), 2013: pp e89-e94
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Table 1. Summary of Basic Science and Clinical Observations of Hip Capsule Relative to Stability, Capsulotomy, and Iatrogenic Instability Study Design
Salient Conclusions
Myers et al.,1 2011
Study
Cadaveric biomechanical: Fluoroscopy
Martin et al.,2 2008
Cadaveric biomechanical: Motion tracking
Hewitt et al.,3 2002
Cadaveric biomechanical: Load to failure
Increased external rotation with IFL sectioning (increased 12.9 ) (P < .0001) Increased anterior translation with IFL sectioning (increased 1.8 mm) (P < .001) No difference in external rotation or anterior translation between intact and repaired state Release of medial and lateral arms of IFL gave greatest increase of motion in external rotation Lateral arm release provided more motion in flexion and neutral position Lateral arm release also provided more internal rotation, primarily in extension IFL was much stronger than ischiofemoral ligaments IFL had greater stiffness than ischiofemoral ligaments IFL had greater tensile load to failure than ischiofemoral ligaments 52-year-old woman with ligamentous laxity with labral tear Capsulotomy (2-3 cm), labral repair, cam osteochondroplasty, no pincer impingement, and capsular plication Anterior dislocation (2 mo) after fall with hyperextension mechanism, requiring revision plication 49-year-old woman with labral tear and moderate hip dysplasia Lateral acetabular rim resection and labral debridement Atraumatic subluxation (3 mo), requiring conversion to total hip arthroplasty 39-year-old woman with labral tear and mixed femoroacetabular impingement Interportal capsulotomy, labral debridement, cam osteochondroplasty, and acetabular rim resection Anterior dislocation in recovery room and failure of closed reduction, requiring mini-open capsulorrhaphy No recurrent instability at 15 mo after capsulorrhaphy
Ranawat et al.,4 2009
Clinical: Case report
Benali and Katthagen,5 2009
Clinical: Case report
Matsuda,6 2009
Clinical: Case report
10 o’clock to approximately 2 o’clock by use of an arthroscopic scalpel (Samurai Blade; Pivot Medical, Sunnyvale, CA). The capsulotomy is made approximately 5 to
Fig 1. Coronal magnetic resonance arthrogram of right hip. One should note the normal appearance of the left hip and the capsular opening from the acetabular rim with arthrography dye extrusion, after prior hip arthroscopy and capsulotomy left open.
8 mm from the labrum, measuring 12 to 15 mm in length (Fig 2A). The area adjacent to the acetabular labrum is exposed from the iliopsoas recess (approximately 3 o’clock) to the anterior inferior iliac spine (direct head of rectus femoris origin) (approximately 12 o’clock). Thermal soft-tissue ablation proximal to the labrum allows for acetabuloplasty rim trimming with an arthroscopic bur. The chondrolabral junction is maintained without formal labral detachment. Distal anterolateral accessory (DALA) portal placement (4 to 6 cm distal to and in line with AL portal) allows for suture anchorebased labral refixation. Generally, 2 to 4 anchors (NanoTack 1.4-mm Anatomic Labrum Restoration System; Pivot Medical) are placed as close to the articular cartilage as possible without penetration. At the conclusion of refixation, traction is released and the hip is flexed 30 . The surgeon extends a “T” capsulotomy (Fig 2B) down the center of the femoral neck, perpendicular to the interportal capsulotomy, to the intertrochanteric line (capsular reflection) between the iliocapsularis and gluteus minimus, exposing the peripheral compartment, allowing for cam osteochondroplasty from the 12- to 6-o’clock position. Figure 2C illustrates the cam lesion; Fig 2D illustrates the completed osteochondroplasty.
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Fig 2. (A) Interportal capsulotomy may be made 5 to 8 mm from the labrum with an arthroscopic scalpel (Samurai Blade). A right hip is shown in the supine position with traction, viewing from the AL portal. (B) T capsulotomy with an arthroscopic scalpel (Samurai Blade) made over the femoral neck, with pull from the iliocapsularis and gluteus minimus at each capsular edge. The T capsulotomy allows for a 180 view of the peripheral compartment, affording the ability to address the cam lesion through osteochondroplasty, as well as with open surgical hip dislocation. A right hip is shown in the supine position with traction, viewing from the AL portal. (C) After the T capsulotomy has been made, the femoral cam lesion can easily be visualized. A left hip is shown in the supine position with traction, viewing from the anterior portal. (D) Completed femoral osteochondroplasty from 12 o’clock to 6 o’clock (180 bony resection), shown in a left hip in the supine position with traction, viewing from the anterior portal.
Capsular closure may be accomplished with a variety of suture-passing devices, yielding side-to-side stitches (Video 1). A crescent SutureLasso (Arthrex, Naples, FL) (Fig 3A) may be used to pass a suture shuttle, while a tissue penetrator-passer (Fig 3B) retrieves the shuttle. Nonabsorbable, high-strength suture is passed and tied sequentially, with 4 to 6 sutures total usually required in both the vertical and transverse capsulotomy limbs (Fig 3C). A capsule-closure device (InJector II Capsule Restoration System; Pivot Medical) has been introduced recently, allowing closure through a single cannula (Fig 4A, 4B). When a suture shuttle device is used, one 8.25 90emm cannula is placed in the AL portal and one 8.25 110emm cannula is placed in the DALA portal. The longitudinal portion of the T capsulotomy is closed first at the base of the iliofemoral ligament (IFL). A crescent suture lasso is placed through the AL portal and passed through the lateral leaflet of the IFL. Nitinol wire is shuttled and retrieved with a tissue penetrator through the medial leaflet of the IFL. Successive suture placement and knot tying inherently tighten the capsule, and visualization requires greater precision with successive suture placement. Evaluation of ligamentous laxity determines the degree of “bite” with each capsular edge. Greater bites allow greater degrees
of plication. Although any sliding or non-sliding knot may be used, we prefer reversing half-hitches on alternating posts. The “T” is closed with 2 to 4 sutures. Once the IFL is closed to the interportal capsulotomy, the InJector device is used to close remaining capsule. To close the lateral capsulotomy, the InJector device is passed through the AL portal, and the first suture end is passed through the proximal IFL attached to the acetabular rim. The other suture end is placed in the InJector device and passed through the distal IFL. The stitch is then tied. To close the medial IFL, the InJector device is passed through the DALA portal, and the first suture end is passed through the proximal IFL attached to the rim. The other suture end is placed in the InJector device, passed through the distal IFL, and tied. Generally, 2 to 3 stitches are used to close the interportal capsulotomy. Complete capsular closure is verified by the inability to visualize the underlying femoral head/neck (Fig 3D). Postoperatively, the patient is placed into a hip orthosis (0 to 90 of flexion), with crutch-assisted gait with 20 lb of foot-flat weight bearing. Use of an abduction pillow at night prevents the feet from falling into external rotation. Extension and external rotation are avoided (because they can disrupt the capsulolabral repair). Continuous passive motion and stationary
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Fig 3. (A) Crescent suture lasso placed through AL portal and passed through lateral leaflet of IFL. Nitinol wire is shuttled out of the lasso. A left hip is shown in the supine position without traction, viewing from the anterior portal. (B) A tissue penetrator-passer retrieves the shuttle for side-to-side suture placement. A left hip is shown in the supine position without traction, viewing from the anterior portal. (C) Side-to-side high-strength nonabsorbable suture in each capsular limb before tying. (D) Side-to-side highstrength nonabsorbable suture in the interportal and vertical “T” capsulotomy limbs demonstrating the extra-articular appearance of complete capsular closure. A left hip is shown in the supine position without traction, viewing from the anterior portal.
Fig 4. Capsular closure device that grasps and passes high-strength nonabsorbable suture in (A) acetabular side of IFL and (B) femoral side of IFL. A left hip is shown in the supine position without traction, viewing from the anterior portal.
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Table 2. Advantages and Disadvantages of Routine Complete Capsular Closure Versus Leaving Capsulotomy Open During Hip Arthroscopy Complete Capsular Repair
Leaving Capsulotomy Open
Advantages Retention of hip stabilitydexternal rotation and anterior translation Prevention of iatrogenic subluxation and dislocation Prevention of edge loading of repaired labrum No loss of motion Disadvantages Technically demanding and may damage articular surfaces Multiple nonabsorbable sutures in anterior capsule Increased surgical time
Advantages May be therapeutic (preoperative tight anterior capsule) Reduced surgical time No risk of over-tightening anterior capsule and subsequent loss of motion Disadvantages May lead to iatrogenic instability, especially in ligamentously lax hypermobile individuals and in sport-specific athletes Exacerbated during excessive femoral osseous resection
bicycle use are recommended in the first 3 weeks. At 3 weeks after surgery, brace and crutch use is weaned. Muscle strengthening is progressed (slowly to avoid iliopsoas tendonitis). Closed- and open-chain exercises are begun at 6 weeks postoperatively. Treadmill running may commence at 12 weeks, with return to sport at 3 to 6 months.
Discussion We have presented a safe, efficient, and reliable technique for complete capsular closure during hip arthroscopy. The capsulotomy affords mobility for direct visualization and instrumentation. If left open, the potential exists for iatrogenic instability. Although frank dislocation is rare (6 cases reported),4-8 “microinstability” may be a source of postoperative pain and stress a repaired labrum.9 Thus many surgeons caution against aggressive capsulotomy/capsulectomy. There are advantages and disadvantages to capsular closure during hip arthroscopy (Table 2). Though technically demanding, several pearls may be helpful in performing capsular closure with avoidance of potential complications (Table 3). The first decision is the type and size of capsulotomy/capsulectomy. Next is the decision to perform a partial or complete closure.
Although reports in the literature are rare regarding dislocation, the complication is serious and potentially preventable (Table 1). Transformation of the hip into a “dysplastic configuration” has led to iatrogenic instability.5-8 However, despite capsular plication during primary arthroscopy, instability may still occur.4,6 Revision capsular plication has restored stability, illustrating the importance of the capsule for stability.4,6 In addition to clinical reports of post-arthroscopic dislocation, basic science evidence has described excessive external rotation and anterior translation that occur with isolated IFL sectioning.1-3 When repaired, normal motion and stability returned, further showing the importance of capsular repair. Yet unknown or undefined is the case of microinstability, a scenario that occurs postoperatively with pain, normal radiographs, no frank instability/apprehension, and no other explanation for symptoms.9 No studies have compared repair/plication versus capsulotomy left open.10 No study has illustrated the radiographic appearance or description of capsular capaciousness or dynamic imaging showing microinstability or macroinstability for capsules left open or repaired.9,10 Until proven otherwise, we believe that capsulotomy repair/plication is warranted.
Table 3. Technical Pearls and Pitfalls for Performance of Hip Arthroscopy Capsulotomy and Complete Capsular Closure Pearls Interportal and T capsulotomy B Enhanced central and peripheral compartment visualization Refixation of labrum B Suture anchor based; as close as possible to articular margin using DALA portal B Static stability restoration Femoral and acetabular osteochondroplasty B Reduces/eliminates impingement Complete capsular closure B Avoid aggressive capsulectomy B Begin closure at distal base of IFL and capsule undergoing T capsulotomy and progress proximally toward interportal capsulotomy B Customize degree of plication/bite based on patient’s ligamentous laxity status Postoperative rehabilitation B Avoid hip extension and external rotation
Pitfalls Poor visualization B Poor portal placement Failure to address bony pathology B Femoral cam and acetabular pincer impingement B Stresses labral/capsular repair Too aggressive capsulectomy B Prevents complete closure or requires too much tension upon repair that predisposes to stiffness postoperatively B Damaged capsular edges from mechanical shaver devices may preclude secure bite with sutures Avoid iatrogenic articular cartilage damage with passage of tissue penetrator/suture passer devices Postoperative rehabilitation B Hip extension or external rotation that stresses capsulolabral repair, with potential disruption Poor patient selection B Dysplasia, hyperlaxity, and coxa magna
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