Point/Counterpoint Capsulotomy During Hip Arthroscopy: to Close Or Not to Close by Sherwin Ho, MD

Arthroscopy Association of North America

Point/Counterpoint Capsulotomy During Hip Arthroscopy: To Close or Not to Close By Sherwin Ho, MD

CAM lesion that extends further similar to the athletic shoulder who Introduction: laterally, I will add a vertical “T” cut present with a posterior capsular s hip arthroscopy has along the neck of the femur, which contracture combined with anterior become more widespread, I will repair with non-absorbable #2 capsular laxity, while in the FAI hip Aanterior capsular release or sutures in patients with generalized in athletes we see just the opposite: capsulotomy has become more ligamentous laxity, normal or above an anterior capsular contracture and popular and well-accepted to allow normal abduction and external posterior capsular laxity. for better access, visualization, and rotation (ABER), and/or marked working space during labral repair femoral anteversion. I will only close Capsular Repair and decompression. There remains the entire capsulotomy in patients By Shane J. Nho, MD controversy, however, regarding with documented or suspected ver the past few years, the the pros and cons of repairing the instability. role of the hip joint capsule capsule at the conclusion of the Oand management of the hip procedure. The following Point/ However, in my experience, the capsule has been debated. The Counterpoint discussion presents vast majority of my patients with a surgeon that is performing hip the opinions of the 2 hip surgeons labral tear and FAI present with a arthroscopy has to understand the from Chicago, both of whom are thickened, tight and painful anterior anatomic structure and function of faculty members at their respective capsule, decreased ABER rotation the osseous and soft tissues being academic institutions. (increased knee-to-table distance), manipulated during surgery. and have difficulty regaining normal Capsulotomy: to close motion and flexibility of the anterior The iliofemoral ligament is the or not? capsule post-operatively, as opposed strongest ligament in the human to developing symptomatic body and is responsible for By Sherwin Ho, MD iatrogenic instability.A “water-tight” restraining hip extension and ounterpoint (why I don’t capsular closure will theoretically external rotation. It is clinically routinely repair my result in tightening of the capsule, relevant as this is the ligament that Ccapsulotomy): for the vast even more so as capsular tissue is is incised when capsulotomies are majority of patients with FAI, removed to gain better visualization. performed. There are wide variations capsulotomy is therapeutic, This iatrogenic tightening can lead in the location, size, and type of increasing post-operative range to a reduced range of motion and capsulotomy is performed, and of motion, and does not lead to flexibility post-operatively. While therefore, all capsulotomies are not instability. this may be beneficial in patients the same. I always perform a portal-to-portal with hip laxity or instability, the Biomechanical studies have recently (P2P) capsulotomy using an Arthrex majority of FAI patients present demonstrated that the iliofemoral reverse-cutting hook blade. In with decreased hip ABER, and a ligament is the primary stabilizer cases with evidence of iliopsoas capsulotomy can be therapeutic, of the hip joint. After sectioning snapping/capsular impingement, I improving their capsular flexibility the iliofemoral ligament, the hip extend the capsulotomy medially and range of motion. In our ongoing, increases in external rotation and to expose the iliopsoas and prospective study of 50 consecutive translation. Cadaveric studies have release the tendon within the labral repairs with capsulotomy also demonstrated that repairing the musculotendinous junction allowing and iliopsoas release, now at 2 iliofemoral ligament will restore the it to slide (fractional lengthening) years post-surgery, we have not stability of the hip joint close to an to relieve capsular impingement. encounter any cases with symptoms intact hip at time zero. Rarely, if visualization is still difficult, of instability or dislocation. I suspect particularly in a case with a large that the athletic hip will prove to be There are several cases of hip

6 Inside AANA First Quarter 2015 dislocation after hip arthroscopy in the published o’clock at approximately 8 mm from the labrum. I literature. Although this is thought to be a relatively rare identify the capsulolabral interval by debriding the complication, I believe is it a catastrophic complication, capsular tissue adjacent to the labrum while leaving the and the actual number of hip dislocations after hip majority of the capsular tissue intact to be repaired at arthroscopy is likely underreported. Some authors the conclusion of the case. have described cases of iatrogenically induced In the peripheral compartment, my preference is to microinstability after hip arthroscopy, and the number use a T-capsulotomy by using an arthroscopic scalpel of cases are thought to be much higher. perpendicular to the interportal capsulotomy and Our institution has recently published our experience extend distally between the gluteus minimus and the with partial repair of the hip capsule versus complete iliocapsularis. The peripheral compartment can be repair of the hip capsule during hip arthroscopy using visualized comprehensively from the lateral synoval a T-capsulotomy. In the partial repair group (repair of folds to the medial synovial folds; therefore, allowing the vertical limb only), we had 4 of 32 patients that a complete femoral osteochondroplasty. The capsule required revision hip arthroscopy. Although there was can be closed using three high strength sutures to no statistically significant difference between activities close the vertical portion of the T-cut. The interportal of daily living between the two groups, we did see a capsulotomy requires about two to three high strength significant difference in sports specific outcomes in sutures tom provide a complete closure. the complete repair group at 6 months and 2 years In summary, the hip joint capsular management is after surgery. a critical component of hip arthroscopy. In order to Given the present technology and constraints of the address the intra-articular and peripheral compartment hip joint, I do not believe that hip arthroscopy can be pathology, a capsulotomy is required for visualization preformed without a capsulotomy. Over the years, I have and instrument mobility. Scientific studies are being changed my capsular intervention to make it is minimal published to characterize the biomechanical role of the as possible to allow me to address the chondrolabral iliofemoral ligament in terms of translation, rotation, pathology as well as the FAI pathomorphology. For and strain. Recent clinical studies are also demonstrating my practice, I employ a comprehensive capsular a faster recovery, more predictable return to athletic management strategy that begins with a interportal activities, and lower revision rate with complete capsulotomy between 2-4 cm in length from 12 – 2 capsular repair.