Abstract
This article describes the use of sutures to enhance visualization while protecting the capsule in both the central and peripheral compartments during hip arthroscopy. We describe first a technique to preserve the proximal capsule cuff while working in the central compartment and then an alternative to the T-capsulotomy while maintaining excellent visualization of the peripheral compartment during femoroplasty of cam-type femoroacetabular impingement. By use of suture suspension of the capsule, multiple goals are achieved: The integrity of the proximal capsule cuff is maintained while aiding in visualization of the central compartment; the iliofemoral ligament is spared, which plays a critical role in preventing microinstability; the necessary space is created to obtain adequate visualization of the peripheral compartment for complete femoroplasty; and operative time is reduced because creation and subsequent repair of the T-capsulotomy can be avoided.
Hip arthroscopy has become an effective means to surgically treat symptomatic labral tears, femoroacetabular impingement, and other intra-articular and even extra-articular hip pathology. The evolution of arthroscopic techniques to include both an interportal capsulotomy and T-capsulotomy has greatly improved visualization and the ease of performing arthroscopic surgery on the hip. Although many surgeons previously left these capsulotomies unrepaired, we have learned that improved outcomes result from closure of the capsulotomy. Patients who undergo only a partial repair of the interportal capsulotomy and T-capsulotomy have been shown to have a high rate of revision surgery (13%) and to have lower Hip Outcome Score–Sports Specific functional outcome scores and lower satisfaction than patients whose capsulotomies are repaired completely.1 Capsulotomy closure requires technical skill and additional operative time. Proper closure also requires maintenance of capsular tissue integrity throughout the arthroscopic procedure. We present a suture suspension technique that improves visualization of the central compartment, aids in maintaining proximal capsular tissue integrity, and provides an alternative to the T-capsulotomy for distal exposure of the femoral neck. This ultimately preserves the native stability of the hip joint capsule and saves the operative time required to make and repair the T-capsulotomy (Video 1).
Technique
A standard supine hip arthroscopy setup with a traction table and conventional hip arthroscopic instrumentation is utilized (Fig 1). After applying traction and creating the standard anterolateral and modified anterior portals, the surgeon makes an interportal capsulotomy between the 2 portals using a beaver blade (Samurai; Stryker, Kalamazoo, MI).
Fig 1.
The patient is positioned supine on a standard hip arthroscopy traction table using a large, padded peroneal post. After preparation and draping, key anatomic landmarks are identified. These include the anterior superior iliac spine with a line drawn distally to demarcate the lateral border of the neurovascular bundle, as well as the greater trochanter. These landmarks are used to guide localization of the anterolateral portal (ALP), anterior to the tip of the greater trochanter, and the midanterior portal (MAP), distal and anterior to the ALP but lateral to the line drawn from the anterior superior iliac spine on this right hip.
Central Compartment
After diagnostic arthroscopy, gentle debridement is performed using a 4.0-mm shaver, with care taken to preserve as much of the capsular cuff as possible. Labral pathology is then assessed. Labral repair requires preparation of the acetabular rim to a bleeding bony surface. We do not routinely elevate the labrum from the chondrolabral junction; rather, we prepare the bony rim and resect any pincer lesions or an overriding anterior inferior iliac spine with the labrum in place. To obtain the best visualization possible while protecting this proximal capsular cuff, we pass an Orthocord arthroscopic suture (DePuy Synthes, Warsaw, IN) through the proximal cuff with a slingshot suture passer (Pivot Slingshot; Stryker) at approximately the 12-o'clock position. The suture is brought through the modified anterior portal, and as an assistant applies gentle traction, the suture is clamped to the peroneal foam post to provide continuous upward tension (Fig 2A). The capsule is then carefully separated from the labrum in the subspine region with an arthroscopic shaver and electrocautery (Fig 2B, Video 1). Rim resection and labral repair are completed in the usual fashion using arthroscopic anchors and suture. After completion of the central compartment portion of the procedure, the traction suture is removed.
Fig 2.
With the camera in the anterolateral portal (ALP) in this right hip, the suspension suture is placed in the proximal cuff of the capsulotomy, through the midanterior portal (MAP), and the suture limbs are retrieved through the MAP. (A) The suture is tensioned and clamped to the peroneal post. (B) Electrocautery and an arthroscopic shaver are used through the MAP to elevate the proximal capsule from the bone, providing access to the subspine region of the acetabulum, which is easily seen when viewing this right hip from the ALP.
Peripheral Compartment
Next, leg traction is released, and the hip is flexed 30° to 40° in neutral rotation. The plane between the gluteus minimus and iliocapsularis muscles is developed down to the capsule. Centered in this plane, 2 traction sutures are placed into the femoral side of the interportal capsulotomy. The first is placed in the more medial aspect of the capsule using the Slingshot suture passer through the anteromedial portal, and the second is placed more laterally. Sutures are initially retrieved through the anteromedial portal. A separate stab incision is made distal to the anterolateral portal, and an arthroscopic suture retriever is placed through this portal to retrieve the 4 strands of the 2 capsular sutures. A hemostat is placed on the sutures, and traction is applied by an assistant, who is pulling the sutures distally (Fig 3A). This capsular retraction provides excellent visualization of the anterior femoral neck from the 6-o'clock to the 12-o'clock position (Fig 3 B and C). A standard cam resection is then completed using a 5.0-mm arthroscopic burr (Video 1). After completion of the cam resection in the flexed position, the hip is extended, and further lateral debridement is completed up to the lateral epiphyseal vessels to ensure no residual cam deformity. Intraoperative fluoroscopy is used to confirm complete resection of the cam lesion. After completion of the cam resection, the 2 capsular suspension sutures are removed, and the capsule falls back into place.
Fig 3.
The peripheral compartment suspension sutures are placed through the midanterior portal into the distal limb of the capsule after the hip is taken off traction and flexed to 30° to 40° in neutral rotation. (A) The free ends of the suture are retrieved through a small distal accessory portal, which is created with a No. 15 blade stab incision. These are tensioned and held by an assistant. (B) When one is viewing this right hip from the anterolateral portal, the femoral head and neck are easily exposed. This capsular suspension technique allows exposure of the femoral neck down to the intertrochanteric line. (C) In these simultaneous fluoroscopic (left) and arthroscopic (right) views of the right hip, a shaver is placed at the distal-most extent of the femoral neck exposure.
Interportal Capsular Repair
The interportal capsulotomy is closed using 2 sutures (No. 2 Orthocord) that are passed from the femoral to acetabular side using the Slingshot device. The sutures are tied arthroscopically (Fig 4), the joint is thoroughly irrigated, and instruments are removed. The 3 portals are closed with nylon suture.
Fig 4.
Once the peripheral compartment work is completed, the distal suspension sutures are released and the capsule easily reduces. The interportal capsulotomy is closed with simple sutures in a simple, interrupted fashion from medial to lateral through the midanterior portal. As can be observed when viewing this right hip from the anterolateral portal, the robust closure has nicely secured the proximal and distal limbs as the final, lateral-most suture is about to be tied.
Discussion
Hip arthroscopy is an evolving field in which substantial improvements have been made over the past decade in both instrumentation and surgical technique. The most common reason for hip arthroscopy failure and revision is inadequate cam or pincer resection.2, 3 Inadequate visualization of the femoral neck during the peripheral compartment portion of the procedure is the most likely cause of inadequate resection.
The role of the capsule in maintaining hip joint congruity has been well established. The capsule is a confluence of the iliofemoral (or Y-ligament of Bigelow), pubofemoral, and ischiofemoral ligaments, as well as the zona orbicularis.4, 5, 6 Creating a T-capsulotomy is a common technique used to improve the visualization of the peripheral compartment. Use of the T-capsulotomy requires either partial or complete repair of the capsulotomy to avoid iatrogenic hip instability. Improved results have been shown at 2 years using a complete repair of the capsulotomy.1 Repair of the capsulotomy is technically demanding because visualization deteriorates as the repair progresses.
Other authors have advocated using only an interportal capsulotomy, but this may lead to inadequate visualization and incomplete resection of the cam deformity in the peripheral compartment. The iliofemoral ligament is one of the thickest ligaments in the body and has been shown to tolerate greater force than the ischiofemoral or pubofemoral ligament.7, 8, 9 Limiting dissection of the iliofemoral ligament to prevent the occurrence of microinstability or, rarely, gross hip instability is ideal as long as adequate cam resection can be achieved.
The use of traction sutures in the capsule may be a method of preserving anterior capsular integrity while providing adequate visualization to ensure complete cam resection. We describe our method of using traction sutures to preserve both the proximal capsule cuff and the iliofemoral ligament during hip arthroscopy (Table 1).
Table 1.
Pearls and Pitfalls for Capsular Management With Suture Suspension Technique
| Pearls |
| After gentle and sparing debridement of the proximal capsular cuff edge, suture is passed and suspended from a perineal foam post. |
| Suture is removed from the proximal capsular limb when central compartment management is complete. |
| To access the peripheral compartment, leg traction is released and the hip is flexed to relax the capsule. |
| The plane between the gluteus minimus and iliocapsularis muscles is developed down to the capsule. |
| Two distal capsule retraction sutures are centered in the aforementioned plane, spaced approximately 2 cm from one another, and these retraction sutures are retrieved through a distal accessory portal. |
| The sutures are removed when the peripheral compartment work is complete. |
| Pitfalls |
| If an adequate amount of tissue is not preserved at the proximal cuff during interportal capsulotomy, the proximal suture cannot adequately expose the central compartment and capsule repair at the completion of the case will be difficult. |
| Adequate tension must be placed on the suspension sutures to achieve optimal visualization—with a clamp to the peroneal post for the central compartment sutures and distal retraction in the peripheral compartment by an assistant. |
| If intraoperative fluoroscopy shows a cam lesion distal to the extent of exposure provided by the suspension suture technique, a T-capsulotomy to provide more exposure can be considered. |
There are multiple advantages to this technique. First, the proximal cuff of the capsule is protected during rim preparation, ensuring that there is adequate tissue to repair the interportal capsulotomy at the end of the case. The suspension suture used on this proximal tissue cuff also improves the visualization of the acetabular rim during central compartment work.
Second, the 2 suspension sutures in the distal capsule overlying the femoral neck preserve the iliofemoral ligament integrity by avoiding the T-capsulotomy. We are still able to achieve adequate peripheral compartment visualization required for complete cam resection. Given the importance of the capsule and iliofemoral ligament integrity in preventing iatrogenic microinstability or gross hip instability, by avoiding the T-capsulotomy, the native stability of this ligament is maintained. Lastly, we have noted decreased operative time when repairing only the interportal capsulotomy rather than creating and repairing the T-capsulotomy.
This technique has limitations in the case of very distal cam lesions. If intraoperative fluoroscopy shows cam extension beyond the reach of arthroscopic instruments within the capsule, more exposure of the femoral neck is required than can be provided by the 2 peripheral compartment suspension sutures. In this scenario, a T-capsulotomy can be created between the 2 peripheral compartment suspension sutures, and the sutures can then be used to retract the capsule flaps (Tables 2 and 3).
Table 2.
Advantages and Limitations
| Advantages |
| Suspension of the proximal cuff preserves and protects tissue for later interportal capsulotomy closure. |
| There is improved visualization of the subspine region and acetabular rim by suspending the proximal cuff. |
| Iliofemoral ligament native integrity is preserved by avoiding a T-capsulotomy. |
| The operative time is decreased because one can avoid the creation and repair of a T-capsulotomy. |
| Limitations |
| Rarely, very distal cam lesions may extend beyond the exposure provided by our technique, in which case a T-capsulotomy may be required (and can be created between the peripheral compartment suspension sutures). |
Table 3.
Equipment Required
| Suture passer: Slingshot, Nanopass (Pivot Medical) |
| Suture: Orthocord |
| Radiofrequency ablator: ArthroCare (Sunnyvale, CA)/Smith & Nephew (London, England) |
| Shaver: 4-mm Tomcat (Stryker) |
| Beaver blade: Samurai (Pivot Medical) |
| Cannula: Transport (Pivot Medical) |
| 5-mm round burr (Pivot Medical) |
Footnotes
The authors report the following potential conflict of interest or source of funding: S.H.C. receives support from Stryker Pivot Medical (paid consultant), Blue Belt Technologies (IP royalties, stock options), and Cymedica Orthopedics (stock options).
Supplementary Data
Our technique for capsular preservation using a suspension suture traction technique in both the central and peripheral compartments is shown in a right hip in the supine position. The anterolateral viewing portal and midanterior working portal (MAP) allow us to first create the interportal capsulotomy. A traction suture is then placed in the proximal limb of the capsule, retrieved through the midanterior portal, and clamped to the peroneal post. This allows access to the acetabular rim and subspine region. For the peripheral compartment, traction is removed from the leg and 2 sutures are placed in the distal limb of the capsule through the MAP and are retrieved through a small, distal accessory portal. These are held by an assistant, providing exposure to the femoral head and neck. On completion of cam femoroplasty, all suspension sutures are released and the capsulotomy is repaired in a simple, interrupted fashion.
References
- 1.Frank R.M., Lee S., Bush-Joseph C.A., Kelly B.T., Salata M.J., Nho S.J. Improved outcomes after hip arthroscopic surgery in patients undergoing T-capsulotomy with complete repair versus partial repair for femoroacetabular impingement: A comparative matched-pair analysis. Am J Sports Med. 2014;42:2634–2642. doi: 10.1177/0363546514548017. [DOI] [PubMed] [Google Scholar]
- 2.Philippon M.J., Schenker M.L., Briggs K.K., Kuppersmith D.A., Maxwell R.B., Stubbs A.J. Revision hip arthroscopy. Am J Sports Med. 2007;35:1918–1921. doi: 10.1177/0363546507305097. [DOI] [PubMed] [Google Scholar]
- 3.Sardana V., Philippon M.J., de Sa D. Revision hip arthroscopy indications and outcomes: A systematic review. Arthroscopy. 2015;31:2047–2055. doi: 10.1016/j.arthro.2015.03.039. [DOI] [PubMed] [Google Scholar]
- 4.Domb B.G., Philippon M.J., Giordano B.D. Arthroscopic capsulotomy, capsular repair, and capsular plication of the hip: Relation to atraumatic instability. Arthroscopy. 2013;29:162–173. doi: 10.1016/j.arthro.2012.04.057. [DOI] [PubMed] [Google Scholar]
- 5.Myers C.A., Register B.C., Lertwanich P. 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. doi: 10.1177/0363546511412161. [DOI] [PubMed] [Google Scholar]
- 6.Elkins J.M., Stroud N.J., Rudert M.J. The capsule's contribution to total hip construct stability—A finite element analysis. J Orthop Res. 2011;29:1642–1648. doi: 10.1002/jor.21435. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Bedi A., Galano G., Walsh C., Kelly B.T. Capsular management during hip arthroscopy: From femoroacetabular impingement to instability. Arthroscopy. 2011;27:1720–1731. doi: 10.1016/j.arthro.2011.08.288. [DOI] [PubMed] [Google Scholar]
- 8.Hewitt J., Guilak F., Glisson R., Vail T.P. Regional material properties of the human hip joint capsule ligaments. J Orthop Res. 2001;19:359–364. doi: 10.1016/S0736-0266(00)00035-8. [DOI] [PubMed] [Google Scholar]
- 9.Hewitt J.D., Glisson R.R., Guilak F., Vail T.P. The mechanical properties of the human hip capsule ligaments. J Arthroplasty. 2002;17:82–89. doi: 10.1054/arth.2002.27674. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Our technique for capsular preservation using a suspension suture traction technique in both the central and peripheral compartments is shown in a right hip in the supine position. The anterolateral viewing portal and midanterior working portal (MAP) allow us to first create the interportal capsulotomy. A traction suture is then placed in the proximal limb of the capsule, retrieved through the midanterior portal, and clamped to the peroneal post. This allows access to the acetabular rim and subspine region. For the peripheral compartment, traction is removed from the leg and 2 sutures are placed in the distal limb of the capsule through the MAP and are retrieved through a small, distal accessory portal. These are held by an assistant, providing exposure to the femoral head and neck. On completion of cam femoroplasty, all suspension sutures are released and the capsulotomy is repaired in a simple, interrupted fashion.