Capsular Management During Hip Arthroscopy: from Femoroacetabular Impingement to Instability

Home , Hip, Iliofemoral ligament, Intertrochanteric crest, Ischiofemoral ligament, Ligament, Pubofemoral ligament

Current Concepts With Video Illustrations Capsular Management During Hip Arthroscopy: From Femoroacetabular Impingement to Instability

Asheesh Bedi, M.D., Gregory Galano, M.D., Christopher Walsh, M.D., and Bryan T. Kelly, M.D.

Abstract: Advances in the ability to treat various soft-tissue and osseous pathologic conditions of the hip arthroscopically have been predicated on an improved exposure of the pathology of the central, peripheral, and peritrochanteric compartments. The management of the capsule is critical and must allow for an improved exposure without compromising stability and kinematics of the hip. Described approaches have included capsulectomy, limited capsulotomy, extensile capsulotomy, capsular plication, and capsular shift. The selected approach must consider various factors, including symptomatic complaints, underlying hyperlaxity, speciﬁc mechanical pathology, and surgical expertise. Universally using a single technique without consideration of the complex mechanical and anatomic factors unique to each patient may result in incomplete treatment of the pathoanatomy or iatrogenic instability. This article reviews the anatomy of the hip capsule and provide a diagnosis-based consideration of capsular management during hip arthroscopy. The senior author’s preferred techniques are also presented.

ip arthroscopy has gained considerable popu- ity to treat various soft-tissue and osseous pathologic Hlarity in recent years as a minimally invasive conditions of the hip arthroscopically have been pred- surgical approach to address various symptomatic icated on an improved exposure of the pathology of disorders of the hip, including femoroacetabular the central, peripheral, and peritrochanteric compart- impingement (FAI), labral tears, snapping hip syn- ments. In this regard, surgical management of the dromes, and instability. As such, there has been a capsule is critical and must allow an improved expo- rapid evolution of both instrumentation and tech- sure without compromised stability of the hip (Table niques used in hip arthroscopy. Advances in the abil- 1). Described approaches have included capsulectomy, limited capsulotomy, extensile capsulotomy, capsular plication, and capsular shift. The selected approach must consider various factors, including From MedSport, Division of Sports Medicine and Shoulder Surgery, University of Michigan (A.B., C.W.), Ann Arbor, Michi- symptomatic complaints, baseline hyperlaxity, spe- gan; and the Center for Hip Pain and Preservation, Hospital for ciﬁc mechanical pathology, and surgical expertise. Special Surgery (G.G., B.T.K.), New York, New York, U.S.A. Universally using a single technique without con- The authors report no conﬂict of interest. Received July 18, 2011; accepted August 9, 2011. sideration of the complex mechanical and anatomic Address correspondence to Asheesh Bedi, M.D., MedSport, Uni- factors unique to each patient may result in incom- versity of Michigan, 24 Frank Lloyd Wright Dr, Lobby A, Ann plete treatment of the pathoanatomy or iatrogenic Arbor, MI 48106, U.S.A. E-mail: [email protected] © 2011 by the Arthroscopy Association of North America instability. This article will review the anatomy of 0749-8063/11459/$36.00 the hip capsule and provide a diagnosis-based con- doi:10.1016/j.arthro.2011.08.288 sideration of capsular management during hip ar- Note: To access the videos accompanying this report, visit the throscopy. The senior author’s preferred techniques December issue of Arthroscopy at www.arthroscopyjournal.org. are also presented.

1720 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 27, No 12 (December), 2011: pp 1720-1731 CAPSULAR MANAGEMENT DURING HIP ARTHROSCOPY 1721

TABLE 1. Key Points

The management of the capsule is critical and must allow for an improved exposure without compromising stability and kinematics of the hip. Universally using a single technique may result in incomplete treatment of FAI or iatrogenic instability. Preservation or repair of the iliofemoral ligament is critical during hip arthroscopy, particularly for patients with hyperlaxity, anterior instability, and/or dysplasia. The zona orbicularis provides hip stability against distraction forces, acting like a locking ring around the neck of the femur. The medial femoral circumflex artery is the main vascular supply of the femoral head. The blood supply of the femoral head therefore arises near the femoral attachment of the capsule and can sustain damage in overzealous, distal transverse capsulotomies. The indirect head of the rectus tendon can be visualized through an interportal capsulotomy and is a very important arthroscopic landmark to guide rim resection, anchor placement, and labral repair. Arthroscopic visualization in the peripheral compartment is critical to guide placement of an ideal T-capsular incision in the intermuscular plane between the inserting fibers of the gluteus minimus and iliocapsularis. If the plane for T-capsulotomy is accurately identified, the medial capsule translates medially from the pull of the iliocapsularis, and the lateral capsule translates laterally from the gluteus minimus to facilitate separation of the 2 limbs of the iliofemoral ligament. The T-capsulotomy should stop proximal to the zona orbicularis to avoid injury to the terminal branch of the lateral femoral circumflex artery. The T-capsulotomy provides an excellent view of the head-neck junction as distal as the intertrochanteric line and allows for circumferential restoration of femoral offset. It is reparable with side-to-side stitches to restore joint anatomy and stability. Overzealous capsulotomy without repair or capsulectomy can result in iatrogenic hip instability after arthroscopy.

CAPSULAR ANATOMY LIGAMENTS

The hip capsule is a fibrous lining that provides Iliofemoral Ligament stability, protection, and the blood supply for the hip The iliofemoral ligament (Y ligament of Bigelow) joint. From its acetabular attachment, it extends later- makes up the anterior part of the capsule and is shaped ally to surround the femoral head and neck and is like an inverted “Y.” It originates in the area between attached anteriorly to the intertrochanteric line, supe- the anteroinferior iliac spine (AIIS) and acetabular rim riorly to the base of the femoral neck, posteriorly and divides into superior and inferior branches as it superomedial to the intertrochanteric crest, and in- crosses the joint.2,5 The superior-lateral branch has a feriorly to the femoral neck near the lesser trochan- horizontal course and inserts proximally along the 1 ter. The anterosuperior portion of the capsule is intertrochanteric line anterior to the hip joint, whereas thickest, because this is where maximal stress oc- the inferior-medial branch has a more vertical course curs while one is standing, whereas the posteroin- and inserts distally along the intertrochanteric line ferior capsule is thinner and more loosely attached. (Fig 1).4 The action of the iliofemoral ligament restricts The thick anterosuperior capsule often needs to be extension of the hip, providing a static restraint with full addressed with arthroscopy for FAI, because this is hip extension, and allows upright posture to be main- a typical location for focal rim impingement and tained without constant muscular action.2,6 Hewitt et loss of femoral offset. al.5,6 showed that the iliofemoral ligament is stiffer and The capsule is composed of internal and external withstands greater force than either the ischiofemoral fibers. The internal fibers comprise the circular zona ligament or the pubofemoral ligament, suggesting that its orbicularis, which forms a collar around the femoral insufficiency is associated with anterior hip instability neck.2,3 The fibers of the zona orbicularis are partially and dislocations. In this regard, preservation or repair of blended with fibers from the ischiofemoral ligament.4 the iliofemoral ligament may be of critical importance The internal fibers of the capsule are lined with syno- during hip arthroscopy, particularly for patients with vium and contact the femoral head. The external fibers hyperlaxity, anterior instability, and/or anterior acetabu- run longitudinally and are made up of the iliofemoral, lar undercoverage (dysplasia). ischiofemoral, and pubofemoral ligaments.1,4 Each of Martin et al.4 recently studied the anatomy and these ligaments has distinct functions that are impor- quantitative contributions of the hip capsular liga- tant to the capsule (Fig 1). ments. The medial arm of the iliofemoral ligament was 1722 A. BEDI ET AL.

FIGURE 1. (A) Anteroposterior view of hip showing iliofemoral and pubofemoral ligament. The capsular insertion distally to the intertrochanteric line should be noted. (B) Posterior view of hip showing ischiofemoral ligament and relation to obturator externus tendon. (Reprinted with permission from Wesley Norman, Ph.D.)

observed to originate between the AIIS and the iliac along the intertrochanteric crest (Fig 2).4 The main portion of the acetabular rim. Its insertion was consis- action of the ischiofemoral ligament is to resist inter- tently noted to be on a bump located on the distal nal rotation as well as adduction.2,4,6 The ischiofem- intertrochanteric line (Fig 2). The lateral arm originates oral ligament is significantly weaker than the iliofem- superior to the medial arm, closer to the AIIS, and oral ligament, with either the superior or inferior half traverses more horizontally along the neck of the femur, of the iliofemoral ligament being stronger than the covering the orbicular ligamentous fibers running per- ischiofemoral ligament in its entirety.5 pendicular to the lateral arm at its distal portion. The lateral arm of the iliofemoral ligament was shown to Pubofemoral Ligament insert on the anterior greater trochanteric crest and has The pubofemoral ligament resembles a sling, run- dual control of external rotation in flexion and both ning inferior to the medial arm of the iliofemoral internal rotation and external rotation in extension. ligament and medial and inferior to the iliopectineal Ischiofemoral Ligament eminence, originating at the pubic portion of the acetabular rim and the obturator crest of the pubic bone The ischiofemoral ligament makes up the posterior and attaching distally to the femoral neck (Fig 1). part of the capsule. It originates from the ischial rim of Fibers from the pubofemoral ligament blend with the the acetabulum, follows the spiral of the iliofemoral medial arm of the iliofemoral ligament. The sling of ligament as it crosses the joint, and inserts around the the pubofemoral ligament also wraps inferiorly around posterior aspect of the femoral neck (Fig 1).1,2,5 The the neck of the femur and inserts inferior to the is- ischiofemoral ligament crosses the hip capsule in 2 chiofemoral ligament along the posterior intertrochan- bands, with the more superior band arching across the teric crest (Fig 2). The pubofemoral ligament controls femoral neck to blend with the zona orbicularis, external rotation in extension together with the medial whereas the inferior band inserts more posteriorly and lateral arms of the iliofemoral ligament.4 CAPSULAR MANAGEMENT DURING HIP ARTHROSCOPY 1723

capsule, (7) radially incised labrum, and (8) completely resected labrum. The reduction of the distraction load was greatest between the partially resected capsule phase and completely resected capsule phase at 1-, 3-, and 5-mm joint distraction. The proximal to middle part of the capsule, which includes the zona orbicularis, acts like a locking ring around the neck of the femur and is a key stabilizing structure of the hip in distraction.

VASCULAR SUPPLY In addition to providing ligamentous stability, a major function of the hip capsule is to deliver the vascular supply to the acetabulum and femoral head. A cadaveric study by Kalhor et al.7 showed that 4 main vessels provide the blood supply to the hip capsule in a periacetabular vascular ring: the superior FIGURE 2. (A) Line drawing of left hip anterior ligaments. A, intertrochanteric knob, insertion of iliofemoral ligament medial gluteal artery, the inferior gluteal artery, the medial arm; B, intertrochanteric crest, insertion of iliofemoral ligament femoral circumflex artery, and the lateral femoral cir- lateral arm; C, iliopectineal eminence, medial to insertion of cumflex artery (Figs 4-6). The hip capsule receives its pubofemoral ligament. The arrows indicate the orbicular ligament. (B) Line drawing of left hip posterior ligaments. A, insertion of proximal blood supply from the superior and inferior superior band of ischiofemoral ligament, which is anterior to gluteal arteries, which supply the posterior and pos- midaxis of greater trochanter; B, inferior band of ischiofemoral terosuperior aspect of the hip capsule. The distal blood ligament; C, point at which zona orbicularis blends with ischiofemoral ligament; and D, origin of lateral arm of iliofemoral supply arises from the medial and lateral femoral ligament. The arrow indicates the sling of the pubofemoral liga- circumflex arteries, which supply the anterior cap- ment and inferior orbicular ligament. (Reprinted with permission sule.7,8 The medial femoral circumflex artery is the 4 from Martin et al. ) main supplier of the femoral head,7,9 although in 2 of 20 specimens, Kalhor et al. noted an anatomic varia- Zona Orbicularis tion in which the inferior gluteal artery was the main supplier of the femoral head. The blood supply of the Unlike the longitudinally oriented fibers of the outer femoral head therefore arises near the femoral attach- capsule, the inner capsule fibers of the zona orbicularis ment of the capsule and can sustain damage in over- run in a circular pattern. The zona orbicularis encircles the femoral neck, comprising the narrowest area within the capsule. It provides hip stability against distraction forces, acting like a locking ring around the neck of the femur (Fig 3).3 The zona orbicularis is an important landmark during hip arthroscopy and may need to be divided and repaired after extensile capsulotomies that are performed to address peripheral compartment pathology that may extend distally to the level of the intertrochanteric line. Ito et al.3 recently studied the contribution of the zona orbicularis to hip stability in distraction. In 7 cadaveric hip specimens from male donors, the femur was distracted from the acetabulum in a direction parallel to the femoral shaft with the hip in the neutral position. Eight sequential conditions were assessed: (1) intact specimen (muscle and skin removed), (2) capsule vented, (3) incised iliofemoral ligament, (4) circumfer- FIGURE 3. Inner surface of capsule, showing the zona orbicularis entially incised capsule, (5) partially resected capsule wrapped around the femoral neck, constituting a narrow area (distal to the zona orbicularis), (6) completely resected within the capsule. (Reprinted with permission from Ito et al.3) 1724 A. BEDI ET AL.

MUSCULAR ATTACHMENTS Of the many muscles that span the hip joint, there are a select few that play a critical role in the function of the hip capsule. The first is the iliocapsularis, a lesser-known muscle overlying the anteromedial hip capsule.10,11 The iliocapsularis originates from the inferior border of the AIIS and the anteromedial hip capsule and inserts just distal to the lesser trochan- ter10,11 (Fig 7). Research has shown that contraction of the iliocapsularis muscle tightens the hip capsule and can help to stabilize the femoral head.10,11 Ward et al.11 observed a more prominent iliocapsularis muscle in dysplastic hips compared with nondysplastic hips during surgery. This finding was recently supported by Babst et al.,10 who found less fatty infiltration and hypertrophy of the iliocapsularis muscle in dysplastic hips compared with hips with excessive acetabular coverage. Apart from its function as a dynamic stabilizer of the joint, the iliocapsularis is an important landmark intraoperatively in that its anterolateral border is described as the ideal location for the capsulotomy in anterior total hip arthroplasty12 and its an- FIGURE 4. Anterolateral aspect of right hip after detachment of teromedial border can be used during a modified abductor, rectus femoris, and tensor muscles, showing a capsular branch and an anastomosis between the ascending branch of the Smith-Peterson approach to periacetabular osteotomy lateral femoral circumflex artery and the supra-acetabular branch of to identify the joint capsule.13 In addition, the iliocap- the superior gluteal artery. 1, greater trochanter; 2, vastus lateralis sularis is helpful in identifying the iliopsoas tendon muscle; 3, vastus intermedius muscle; 4, tensor fasciae latae mus- 14 cle (turned medially and distally); 5, lateral femoral circumflex during anterolateral or direct lateral approaches. artery; 6, iliopsoas muscle; 7, ascending branch of lateral femoral circumflex artery; 8, hip joint capsule (femoral attachment); 9, anterior end of supra-acetabular branch of superior gluteal artery anastomosing with lateral femoral circumflex artery; and 10, inferior iliac spine (rectus femoris tendon detached). (cran, cranial; lat, lateral.) (Reprinted with permission from Kalhor et al.7)

zealous, distal transverse capsulotomies (Figs 4-6).7 Capsulotomies or capsulectomies that are performed for improved exposure and instrumentation of the hip during arthroscopy must respect these vascular planes to minimize the risk of avascular necrosis or devas- cularized periarticular soft tissues. If an extensile capsulotomy to address peripheral compartment pathology is necessary, it should be made between the lateral and medial synovial folds and parallel with the femoral neck to avoid injury to the retinacular perfusing branches of the medial and lateral femoral circumﬂex FIGURE 5. Posterolateral aspect of right hip after retraction of arteries. The distal-most extent of a capsulotomy T- gluteal muscles and short external rotators to show periosteal arteries as well as supra-acetabular branch of superior gluteal artery cut overlying the femoral head-neck junction as it before capsulotomy. 1, greater trochanter; 2, hip capsule; 3, sciatic approaches the intertrochanteric groove will run into nerve; 4, short external rotators (obturator internus and gemellus the terminal ascending branch of the lateral femoral muscles) detached from greater trochanter and retracted; 5, acetabular branch of inferior gluteal artery; and 6, supra-acetabular circumﬂex artery, which should be avoided if possible branch of superior gluteal artery. (cran, cranial; med, medial.) to avoid excessive bleeding. (Reprinted with permission from Kalhor et al.7) CAPSULAR MANAGEMENT DURING HIP ARTHROSCOPY 1725

through a transcapsular approach in the central compartment or in the peripheral compartment. The gluteus minimus muscle originates from both the external surface of the ilium and the inside of the pelvis at the sciatic notch.16 It inserts on the anterosuperior hip capsule, as well as its main insertion on the greater trochanter (Fig 7). Depending on the position of the hip, the gluteus minimus can act as a flexor, internal rotator, external rotator, or abductor. The inserting fibers of the gluteus minimus muscle on the anterosuperior hip capsule are an important landmark that can be reproducibly visualized in the peripheral compartment during arthroscopy. Identifica- tion of the intermuscular plane between the inserting fibers of the minimus and the iliocapsularis is rou- tinely performed by the senior authors and allows for precise capsular incision that avoids iatrogenic injury to these muscle-tendon units and the underlying vascular supply to the hip (Fig 7). This T-capsulotomy provides an excellent view of the head-neck junction as distal as the intertrochanteric line and allows for circumferential restoration of femoral offset. Further-

FIGURE 6. Hip from posterior view, showing periacetabular vas- more, it is easily reparable with side-to-side stitches to cular ring and anastomoses between distal and proximal vessels. 1, restore the anatomy and stability to the joint. superior gluteal artery; 2, inferior gluteal artery; 3, medial femoral circumflex artery; 4, lateral femoral circumflex artery; and 5, perforating vessels (cut surface). (Reprinted with permission from CAPSULAR MANAGEMENT IN FAI Kalhor et al.7) The successful arthroscopic treatment of FAI is predicated on accurate diagnosis as well as a complete Similarly, arthroscopic visualization in the peripheral intraoperative exposure and correction of the soft- compartment is of paramount importance to guide tissue and osseous pathology. Recent studies have placement of an ideal T-capsular incision in the inter- established that an incomplete correction and the per- muscular plane between the inserting fibers of the sistence of residual deformity comprise the most com- gluteus minimus and iliocapsularis (Fig 7). mon cause of failed arthroscopic surgery.17,18 Inade- The iliopsoas consists of the psoas muscle and the quate capsulotomy and retraction are frequently iliacus muscle. The psoas muscle originates at the contributory to the inadequate correction. In this re- transverse processes of T12 to L5. The iliacus muscle gard, capsular management during hip arthroscopy is originates at the superior two-thirds of the iliac fossa. critical to allow for complete exposure without com- The muscle belly of the iliopsoas is formed from the promise of postoperative hip stability and kinematics. combined psoas and iliacus, and the attachment of the A capsulectomy is one described approach for vi- iliopsoas is to the lesser trochanter. The iliopsoas sualization in the peripheral compartment. With this muscle functions as a hip flexor and plays a role in technique, standard arthroscopic portals are used to maintaining erect posture. The iliopsoas tendon is access the central compartment in traction. Labral located lateral to the iliopectineal eminence when the tears, chondral defects, loose bodies, and synovitis are hip is in full flexion.15 When the hip is extended, the addressed, and areas of focal rim impingement are tendon is displaced medially and is intimately associ- identified and confirmed based on the location of ated with the anteromedial joint capsule.15 labral and chondral injury. A limited, interportal cap- During hip arthroscopy, the iliopsoas tendon is sulotomy may be performed to expose the extracap- found in the space between the anterior zona orbicu- sular side of the rim to allow for recession and anchor laris and anterior labrum proximal and anterior to the placement for labral repair under direct visualization. medial synovial fold. Understanding this anatomy can After central compartment pathology is treated, the help to guide an accurate psoas tendon lengthening traction is removed and the hip flexed to create po- 1726 A. BEDI ET AL.

FIGURE 7. (A) The gluteus minimus (1) lies on the lateral limb of the T-cut. The iliocapsularis capsular insertion of the iliacus (2) lies on the medial limb of the T-cut. The T-cut (yellow line) uses this intermuscular plane to achieve an extensile exposure of the head-neck junction. If the plane is accurately identified, the medial capsule translates medially from the pull of the iliocapsularis, and the lateral capsule translates laterally from the gluteus minimus to further facilitate separation of the 2 limbs of the iliofemoral ligament. (B) Cadaveric photo showing plane for T-capsulotomy (yellow line) between abductors and iliocapsularis. tential space in the peripheral compartment. With an central and peripheral compartment while preserving oscillating shaver blade or radiofrequency probe, the the anatomy and integrity of the ligaments. We typi- anterior and/or superior capsule overlying the cam cally use a standard anterolateral portal and modified deformity is resected. The amount of resected capsule anterior portal to safely access the central compart- is variable and is the minimum required to fully visu- ment in traction. Whereas preoperative imaging (includ- alize and correct the osseous deformity. Capsulectomy ing 3-dimensional computed tomography) is used to offers the benefit of reasonable exposure of the cam define the precise location and geometry of rim and deformity without the need to retract capsular tissue. femoral impingement lesions, intraoperative findings of Furthermore, it eliminates pathologic capsular tissue synovitis as well as chondral and labral injury are used to that may generate pain and contribute to soft-tissue confirm the location of symptomatic osseous patho- impingement or stiffness of the hip in certain cases. logy (Video 1, available at www.arthroscopyjournal However, capsulectomy does irreversibly alter the .org). By use of a beaver blade, an interportal capsulot- anatomy and integrity of the ligaments. As discussed omy is created with meticulous attention to remain in the in the previous review of the capsular anatomy, com- plane between the labrum and femoral head. We prefer promised integrity of the iliofemoral ligament may to use a beaver blade rather than radiofrequency ablator, result in iatrogenic pain or instability in certain termi- because this minimizes the risk of iatrogenic injury to nal positions of hip range of motion, particularly in the labrum and chondral surfaces and preserves full- patients with underlying hyperlaxity or dysplasia. thickness capsular edges for repair. The length of the interportal capsulotomy is adjusted by the findings of the OUR PREFERRED central compartment and can be extended as posteriorly APPROACH: CAPSULOTOMY as the piriformis tendon and as anteromedially as the psoas tendon as needed. The indirect head of the rectus We have used a controlled and reproducible se- tendon is visualized through the capsulotomy, with in- quence of capsulotomy followed by capsular repair to sertion directly lateral at the 12-o’clock position on the thoroughly expose and address all pathology of the rim. The indirect head is a very important arthroscopic CAPSULAR MANAGEMENT DURING HIP ARTHROSCOPY 1727

FIGURE 8. (A) Arthroscopic photo after interportal capsulotomy of left hip. The camera is positioned in the modified anterior portal. The shaver tip (proximal anterolateral portal) shows the indirect head of the rectus tendon (1) inserting at the most lateral aspect of the acetabulum at a 12-o’clock position. The capsule (2) is reflected to expose the extra-articular side of the hip joint and can allow for a rim recession without detachment of the labrum (3). (B) After rim recession, drill holes (arrows) for labral repair can be prepared under direct visualization. The labrum is indicated by an asterisk. (C) Non-everting stitch (arrows) used to repair the labrum without eversion to maintain the suction-seal function. landmark to guide rim resection, with most lesions lo- the capsule. There is a fat plane that separates the cated anterosuperiorly in the 12-o’clock to 2-o’clock medial and lateral limbs of the iliofemoral ligament location (Fig 8). that represents the separation between the inserting The interportal capsulotomy offers several advan- fibers of the iliocapsularis tendon medially and the tages. Primarily, it allows for exposure of the extra- gluteus minimus tendon laterally. Once the fat plane is articular side of the labrum, rim, and/or pathologic identified, a clear separation between the 2 muscle impingement lesions related to the AIIS (“subspine” planes can be developed. There is a broad attachment impingement). This allows for controlled and precise of the iliocapsularis tendon onto the capsule, and the resection under direct visualization and protection of initial cut is made with a radiofrequency probe to the periarticular soft tissues (including abductor mus- simultaneously define the intercapsular plane and culature and direct and indirect heads of the rectus achieve hemostasis, because the capsule can be in- tendon) from iatrogenic injury associated with limited flamed and erythematous particularly in the setting of access from portals or entrapment within the bur. severe impingement. If the plane is accurately identi- Furthermore, the interportal capsulotomy allows for fied, the medial capsule translates medially from the pull anchor placement and suture passage for labral repair of the iliocapsularis, and the lateral capsule translates under direct visualization, confirming a safe trajectory laterally from the gluteus minimus to further facilitate for drilling and allowing for a non-everting stitch that separation of the 2 limbs of the iliofemoral ligament. preserves labral function (Fig 8). The approach also The final cut is made sharply with a beaver blade allows for precise psoas or piriformis tendon length- knife (Video 2, available at www.arthroscopyjournal ening through a transcapsular approach in select, .org). It is important to avoid medial or lateral deviation symptomatic cases. of the cut to avoid inadvertent muscle trauma, and the cut After the central compartment pathology has been should stop proximal to the zona orbicularis to avoid addressed, the traction is removed and the camera is injury to the terminal branch of the lateral femoral cir- positioned in the modified anterior portal for viewing cumflex artery. In cases where loss of femoral offset distally along the head-neck junction. The hip is extends distally, the capsulotomy can be extended dis- flexed to enlarge the potential space of the peripheral tally through the zona orbicularis to the intertrochanteric compartment. The anterior and anterosuperior capsule line and originating fibers of the vastus intermedius as overlying the cam deformity and loss of offset can be long as the crossing vessel of the lateral femoral circum- directly visualized. A distal anterolateral portal is sub- flex artery is visualized and avoided. sequently established, and a Wissinger rod is intro- The T-capsulotomy affords several advantages. The duced to identify the plane immediately superficial to exposure is extensile and allows for complete defini- 1728 A. BEDI ET AL. tion of the medial-lateral and proximal-distal margins tal and a tissue penetrator through the proximal an- of the femoral deformity without irreversibly compro- terolateral portal, anatomic side-to-side stitches are mising ligament integrity (Fig 9). Elevation of the placed from distal to proximal until a complete clos- lateral flap and internal rotation of the hip allow for ure is achieved (Fig 9, Video 3 [available at www direct visualization of the superior and posterosuperior .arthroscopyjournal.org]). Typically, 3 to 4 stitches are head-neck junction, whereas external rotation and el- required. This preserves the integrity and structure of evation of the medial flap allow access to the antero- the iliofemoral ligament. Furthermore, in cases of medial and inferior head-neck junction. In this regard, underlying hyperlaxity, overlapping stitches can be the exposure and correction of femoral and acetabular placed to perform a functional capsulorrhaphy at the deformity that can be achieved are not dissimilar to time of repair. The degree of overlap is defined for those which can be achieved through an open surgical each individual patient based on symptoms and de- dislocation (Fig 9). Recently, Bedi et al.19 compared sired restriction of external rotation (Fig 9). the efficacy of arthroscopic osteoplasty using this technique with open surgical dislocation to treat FAI CAPSULAR MANAGEMENT OF dysmorphology in a consecutive series of 60 patients. HIP INSTABILITY Arthroscopic osteoplasty was found to restore head- neck offset and achieve depth, arc, and proximal-distal Hip instability from both traumatic and atraumatic resection with equivalent efficacy to open surgical causes is a recognizable source of pain and disability. dislocation for anterior and anterosuperior cam and The traumatic type can occur from high-energy inju- focal rim impingement lesions. ries such as motor vehicle accidents or sporting inju- At the conclusion of the procedure, the medial and ries in rugby, American football, soccer, biking, and lateral capsular flaps are anatomically reduced. By use skiing. Traumatic hip instability in athletes with asso- of a suture passer through the distal anterolateral por- ciated capsular injury has been well documented and

FIGURE 9. (A) Extensile exposure of femoral head-neck junction of left hip achieved by T-capsulotomy. The camera is positioned in the modified anterior portal. The well-preserved medial (M) and lateral (L) flaps for later repair should be noted. (B) Exposure allows for complete correction of femoral deformity in medial-lateral and proximal-distal planes to the safe margin of both the superolateral and medial perfusing retinacular vessels. The bur is positioned in the distal anterolateral portal. The proximal margin of osteoplasty is indicated by an arrow. (C) An anatomic side-to-side repair of the capsule is performed from distal to proximal, restoring the native tension and anatomy of the iliofemoral ligament. The arrow shows a side-to-side suture shuttle loop. (D) Completed repair of T-capsulotomy, with side-to-side stitches of medial and lateral flaps indicated by arrows. (asterisk, labrum.) CAPSULAR MANAGEMENT DURING HIP ARTHROSCOPY 1729 illustrated in the literature. Moorman et al.20 identified OUR PREFERRED APPROACH: the triad of hemarthrosis, posterior acetabular rim CAPSULAR PLICATION fracture, and iliofemoral ligament injury in a series of Capsular plication is the careful placement of su- American football players who had undergone hip tures to remove redundant capsular tissue and de- dislocation events. Atraumatic hip instability has a crease the volume of the joint capsule. Currently, most less discrete onset and may be associated with devel- authors advocate arthroscopic suture capsular plica- opmental hip dysplasia or generalized hyperlaxity tion to treat hip instability.26,35,36 Our preferred tech- conditions, such as Ehlers-Danlos syndrome, Down nique for anterior capsular plication is to perform the syndrome, and arthrochalasis multiplex congenita. Al- standard interportal capsulotomy as well as the verti- though the hip generally relies less on the soft tissue cal limb of the T-capsulotomy as described earlier. and more on bony constraints to maintain stability, The vertical and the horizontal limbs can then be deviation from the normal osseous anatomy, as occurs overlapped with the repair to restore tension in the in dysplasia, may place greater demands on the cap- iliofemoral ligament. We typically use a curved sule and labrum. A hypertrophic labrum, enlarged suture-passing device to penetrate 1 flap and grasp ligamentum teres, and thickened capsule are fre- the passing suture loop with a penetrator through quently encountered in the setting of underlying dys- the other end. The side-to-side stitches are retrieved plasia.21 Compromised collagen architecture in the and tied arthroscopically in a standard fashion. Typi- setting of generalized ligamentous laxity and mic- cally, 3 or 4 sutures are placed in the vertical limb and rotrauma from repetitive external rotation and axial 2 or 3 in the horizontal. Care should be taken to not loading can produce capsular redundancy over over-tighten the capsule, because this can limit exter- time.22,23 In addition, injury to the soft tissues sur- nal rotation postoperatively. This arthroscopic “cap- rounding the hip may lead to persistent capsular re- sular shift” not only restores tension to the iliofemoral dundancy resulting in recurrent instability.24,25 Recent ligament but also allows for augmentation in cases of studies have also suggested that FAI may predispose modest tissue quality by overlapping of the medial and patients to instability in certain cases, because osseous lateral capsular flaps. impingement in positions of terminal motion may precipitate levering of the femoral head, chondral COMPLICATIONS shear injury (“contrecoup” injury), and secondary subluxation or dislocation. Poor capsular management may predispose patients Arthroscopic techniques for addressing the capsule to certain complications after hip arthroscopy. Heter- in patients with hip instability have been described in otopic ossification (HO) around the hip joint is not the literature.26 To reduce the volume of the capsule, uncommon after the open treatment of acetabular frac- thermal capsulorrhaphy and/or capsular plication tures as well as after hip arthroplasty. It occurs as new may be performed. Thermal capsulorrhaphy uses bone formation in the capsule and musculature sur- radiofrequency energy to increase the temperature rounding the hip as a response to trauma from injury 37 38 of collagen in the capsule. The collagen fibers in the or surgery. Randelli et al. observed an overall HO rate of 1.6% in a series of FAI patients who underwent capsule are denatured and restructured by the high hip arthroscopy. In addition to postoperative chemical temperatures and produce a smaller capsule with prophylaxis with indomethacin, avoiding iatrogenic unchanged mechanical strength.27 There is a short- muscle trauma with passage of instruments and per- term loss of mechanical properties of the capsule forming capsulotomy in the intermuscular planes can that is ideally restored through the tissue’s healing help to minimize the risk of HO with hip arthroscopy 28 29 response. Philippon reported good results using (Fig 10). thermal capsulorrhaphy to reduce capsular volume Overzealous capsulotomy without repair or capsu- in patients with hip capsular laxity, with an 82% lectomy can result in iatrogenic hip instability after return to preinjury, high-level athletics with mini- arthroscopy. Several case reports exist in the litera- mal or no pain. Currently, the senior authors do not ture on postoperative hip instability after arthros- use thermal capsulorrhaphy because of concerns copy.23,39,40 The first case involved an immediate dis- about high failure rates and iatrogenic chondrolysis location after FAI surgery that required supranormal that have been reported in the shoulder litera- traction intraoperatively for retrieval of a broken ture.30-34 probe.23 In this case a capsulotomy with partial cap- 1730 A. BEDI ET AL.

FIGURE 10. HO (asterisk) with bony deposition in capsule and abductors after right hip arthroscopy: lateral (A) and posterolateral (B) view of 3-dimensional computed tomography reconstruction of right hip. Iatrogenic trauma to the muscle and capsule may increase the risk of HO.

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