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Address correspondence to Stephen K. Aoki, M.D., Department of Orthopaedic Surgery, University of Utah Orthopedic Center, University of Utah, 590 Wakara Way, Salt Lake City, UT, U.S.A.
Department of Orthopaedic Surgery, University of Utah Orthopedic Center, University of Utah, Salt Lake City, Utah, U.S.A.Department of Orthopaedic Surgery, Osaka Sangyo University, Daito, Osaka, Japan
Hip arthroscopy techniques have continued to evolve for femoroacetabular impingement and other intra-articular pathologies. However, there is still debate about the importance and technique of routine capsular closure. We present an efficient and reliable technique for creating a watertight capsular closure to prevent iatrogenic macro and microinstability. This Technical Note details our stepwise technique using figure of eight sutures to obtain a complete and secure capsular closure.
Technique Video
See video under supplementary data.
Hip arthroscopy has quickly become the treatment of choice for femoroacetabular impingement and intra-articular hip pathology.
More recently, there has been a surge in the literature supporting the importance of maintaining the capsular envelope. Biomechanical studies have shown altered hip kinematics after capsulotomy including excessive hip rotation and translation.
Capsule closure or plication has been reported to be an independent predictor of improved patient outcome in several series of revision hip arthroscopy.
Arthroscopic hip revision surgery for residual femoroacetabular impingement (FAI): Surgical outcomes compared with a matched cohort after primary arthroscopic FAI correction.
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.
showed improved functional outcomes and patient satisfaction as well as a decreased need for revision surgery after complete capsular closure compared with partial closure. In addition, McCormick et al.
found that 78% of their patients who underwent revision hip arthroscopic surgery had evidence of capsular and iliofemoral defects on preoperative magnetic resonance arthrography. Although no consensus has been reached, an increasing number of surgeons are routinely performing capsular closure.
Advocates of capsular closure note the importance of capsular integrity for hip stability and the prevention of anterior hip dislocations and subluxations.
Catastrophic failure of hip arthroscopy due to iatrogenic instability: Can partial division of the ligamentum teres and iliofemoral ligament cause subluxation?.
As hip arthroscopy is increasingly used for the treatment of femoroacetabular impingement, we have identified and treated several patients with postoperative instability after hip arthroscopic surgery.
As such, we believe that a watertight capsular closure after routine hip arthroscopy is important for preventing postoperative instability and improving patient outcomes. We detail our technique for primary capsular closure of an intraportal capsulotomy using figure of eight sutures to obtain a watertight capsular seal.
Surgical Technique
Patient Positioning and Gaining Access to the Hip
The patient is placed in the supine position on the traction table (Smith & Nephew, Andover, MA). We obtain access to the hip as previously described, starting with the anterior-lateral portal (AL) and then using the modified anterior portal (MA), which will be used as our main working portal.
A distal anterolateral portal is used for all labral repairs.
Capsulotomy and Addressing Intra-articular Pathology
After access is obtained, an interportal capsulotomy to connect the AL and MA portals is performed using a radiofrequency ablation device (Super TurboVac 90°; ArthroCare, Austin, TX). Extracapsular fat is removed to improve visualization in the extracapsular space and facilitate capsular closure at the end of the case. Preparation of the pericapsular tissue and meticulous hemostasis improves visualization throughout the case. A T-capsulotomy is not routinely performed; however, it is an option for improved visualization if needed. At this point, all intra-articular, acetabular, and labral pathology is addressed with the hip in traction.
Peripheral Compartment and Femoral-sided Cam Lesion Osteochondroplasty
After completion of the intra-articular portion of the procedure, traction is released and the femoral head-neck deformity is identified. If present, the cam lesion is identified and an osteochondroplasty is performed as previously described.
After completion of the osteochondroplasty, the joint is copiously irrigated to remove bony debris. At this point, a complete capsular closure is performed in all cases (Video 1). We first identify the capsule on the femoral side and remove the extracapsular fat to assist in visualization. Once the femoral side is free, the acetabular capsule is dissected free from the rectus until the capsular tissue is mobile. This is done using a combination of a 4.5-mm full radius shaver (Smith & Nephew) and radiofrequency ablation (Super TurboVac 90°; ArthroCare) to maintain meticulous hemostasis. To facilitate suture management and passing without creating tissue bridges, an 8-mm TransPort Cannula (Stryker, Kalamazoo, MI) is placed in the MA portal. The 70° SlingShot suture passer (Stryker) is then used to close the capsule with 4 to 5 No. 2 Ultrabraid sutures (Smith & Nephew) of alternating colors in a figure of eight pattern (Fig 1).
Fig 1A left hip as viewed from the anterolateral portal with a 70° arthroscope along the plane of the femoral neck. A figure of eight stich is passed using the 70° SlingShot suture passer (Stryker, Kalamazoo, MI) via the modified anterior portal. The first pass is through the acetabular-sided capsular limb and the suture is then released from the device. The device is passed in the femoral-sided limb directly across from the previous pass and the suture is then retrieved. This process is then repeated traveling approximately 1 cm from the first pass to complete the figure of eight suture configuration. (CA, acetabular capsule; CF, femoral capsule; FH, femoral head; L, labrum.)
The hip is first placed in 30° of flexion to relax the capsule. This makes it easier to mobilize the capsule. The camera remains in the AL portal and the sutures are placed through the MA portal. Sutures are passed in a figure of eight pattern, beginning on the inferior side of the capsulotomy (closest to the MA portal) and working up toward the superior end (closest to the AL portal) (Fig 2). All sutures are passed before tying them to maintain a working space and allow adequate visualization of the entire capsular rent (Fig 3). If sutures are tied after each pass, it becomes more difficult to visualize the articular side and more technically challenging to visualize suture passing.
Fig 2A left hip as viewed from the anterolateral portal with a 70° arthroscope along the plane of the femoral neck (A) showing the completed figure of eight suture configuration spanning the capsulotomy. The arthroscope is then rotated to top down (B) showing the crossing figure of eight suture configuration. (CA, acetabular capsule; CF, femoral capsule; FH, femoral head.)
Fig 3(A) A left hip as viewed from the anterolateral portal with a 70° arthroscope along the plane of the femoral neck. A series of figure of eight sutures are passed from a proximal medial to distal lateral direction in alternating suture colors. Typically 4 No. 2 high-strength nonabsorbable figure of eight sutures are used for the interportal capsule closure. (B) After all sutures are passed, they are tensioned through the modified anterior portal to ensure that the capsule will approximate without gaps before knot tying and is not placed on undue tension. (CA, acetabular capsule; CF, femoral capsule.)
We recommend first passing the sutures through the acetabular side, because the capsule on the acetabular side is less mobile. The suture passer penetrates the iliofemoral ligament near the medial corner of the capsulotomy, taking care not to capture the underlying labrum. The suture is deployed on the articular side of the capsule and the passer is then retracted from the superior capsular limb. The suture passer is then passed through the femoral side of the capsule to grab the free suture limb. It is technically easier to grab the suture limb when the second pass is through the femoral-sided capsule, as this tissue is more mobile. The suture limb is pulled out of the cannula and is reinserted into the cannula. The third pass is made through the acetabular side of the capsule approximately 2 to 4 mm from the first pass. The suture is released on the articular side of the capsule where the suture passer is retracted, and then penetrates the femoral side of the capsule for a fourth pass to retrieve the free suture limb to complete the figure of eight stitch.
The suture is then pulled out of the cannula and is examined through the arthroscope to ensure that it is not locked or looped. If the limbs are overlapping, this is easily corrected using a crab-claw grasper. The crab claw can unloop the stitch by grabbing the suture limb at the suture free ends. Once complete, the cannula is removed from the portal and the sutures are removed from the cannula and clipped to the drapes using a hemostat. The cannula is then replaced and the next suture is passed. The next set of sutures can be placed close to the previous stitch, allowing for a watertight seal. This process is repeated until the intraportal capsulotomy is fully spanned by the sutures. We visualize this step using the arthroscope to confirm that we will obtain a watertight capsular closure. The hip is then flexed to 15°; sutures are individually hand tied in the reverse order they were placed using a series of alternating half-hitch knots (Fig 4).
Fig 4(A) A left hip as viewed from the anterolateral portal with a 70° arthroscope along the plane of the femoral neck. The sutures are tied through the modified anterior portal in reverse order from the direction they were passed moving from a distal-lateral to proximal-medial direction (arrow). (B) After all knots are tied and cut, the capsule repair is inspected to confirm complete closure without gapping. The outlined area shows the watertight closure obtained along the previous plane of the capsulotomy. (CA, acetabular capsule; CF, femoral capsule.)
Once the capsular repair is complete, any remaining fluid is aspirated from the extracapsular space and the portals are closed using a 3-0 monocryl suture in a buried, interrupted fashion. Steristrips are applied to the portals and a sterile dressing is secured with tape.
Postoperative Management
Patients are given crutches and are touch-toe weight bearing for 5 to 7 days, after which they may progress to heel-toe partial weight bearing with crutches until 4 weeks postoperatively. During this time, they may advance their hip flexion and circumduction range of motion as tolerated while avoiding hyperextension of the hip to protect the capsule. Patients are also given a home exercise program to follow for the first 4 weeks, which includes heel slides, quad sets, straight leg raises, biking with a high seat and low resistance, mini-squats, and isometric core, gluteal, quad, adductor, and abductor exercises.
Four to 12 weeks postoperatively patients may wean from crutches and advance weight bearing to tolerance. They may also work on full range of motion with controlled hyperextension to achieve a normal walking gait, but any further anterior hip stretching is limited. Further strengthening, including core, gluteal, quadriceps, hamstring, adductor, and abductor exercises, and low impact activities, such as swimming and increasing biking resistance, are allowed.
Twelve weeks postoperatively patients are allowed unrestricted range of motion with a gradual return to full and sport-specific activities with an anticipated return to full sporting activities at 4 to 6 months.
Discussion
Multiple authors have published techniques for capsular closure after routine hip arthroscopy using several different suture shuttling techniques and devices.
Although these techniques vary in the instrumentation used, as well as the sequence of knot-tying and closure, they all use simple sutures. In the past, we have performed our capsular closure in a similar technique to that described by Camp et al.,
which uses a series of simple, interrupted sutures. However, we have refined this technique as a result of our experience in treating patients with postarthroscopy hip instability to use a series of interrupted figure of eight sutures to provide a more robust capsular closure, which creates a watertight seal without overtightening the capsule. Table 1 discusses advantages and disadvantages of the procedure. The technique highlighted in this Technical Note differs in 2 regards. First, by passing figure of eight sutures one is able to overlap passes thus allowing for a complete watertight closure after final tying. Secondly, our suture management strategy allows for a 2-portal-only technique and efficiently manages sutures during suture passage and facilitates tying without entangling the suture limbs.
Table 1Advantages and Potential Disadvantages of the Figure of Eight Capsular Repair Technique
Advantages
More robust capsular closure without overtightening
Watertight closure to minimize joint fluid leakage
The technique follows a systematic order to ensure appropriate capsular closure
Table 2 details the steps to our hip arthroscopy technique. To perform an efficient and watertight capsular closure, it is important to not inadvertently resect capsular tissue while performing the osteochondroplasty portion of the procedure and to take appropriately spaced capsular “bites” while performing the capsular repair. Meticulous suture management throughout the capsular repair is key to prevent overlapping sutures and unnecessary steps. Table 3 highlights important pearls and potential pitfalls of the procedure. Video 1 provides a step-by-step technique of closure of an interportal capsultomy.
Table 2Steps of the Figure of Eight Capsular Repair Technique
1. Patient positioning and accessing hip
2. Interportal capsulotomy to connect anterior-lateral and modified anterior portals
3. Address central and peripheral compartment pathology
4. Irrigation of hip joint to remove debris
5. Capsular closure using figure of eight sutures to maintain the capsular integrity
Table 3Pearls and Pitfalls for the Figure of Eight Capsular Repair Technique
Pearls
Meticulously prepare the interportal capsulotomy to minimize capsular injury.
Resection the extracapsular fat to improve visualization and identification of the rectus tendon.
Avoid inadvertent capsular injury during peripheral compartment surgery.
Flex the hip to 30° to relax the capsule during suture passing.
Visualize from the anterior-lateral portal and pass sutures through the modified anterior portal.
Begin passing sutures on the inferior aspect of the interportal capsulotomy (3 o'clock).
The first pass should begin on the acetabular side, as the acetabular capsule is less mobile.
Each figure of eight stitch can be placed closely to one another to obtain a watertight seal.
Use alternating colored sutures to assist in suture management.
Identify and correct overlapping or looped sutures before moving to the next step.
Extracapsular and intra-articular capsular edges will be better visualized if all sutures are passed first and tied at the end, although meticulous suture management is key.
Tie sutures in 15° of flexion to prevent overtightening.
Pitfalls
Overaggressive resection of the capsule during capsulotomy and capsule preparation can result in considerable tension on the capsule during final capsule closure and place at risk for early failure. Use of a nontoothed shaver and judicious use of the ablate function of the radiofrequency device can help mitigate this risk.
An inadequate capsule preparation removing the pericapusluar fat between the capsule and the surrounding periaceatbular muscle will increase visualization and decrease the chance of soft tissue bridges.
In summary, we have detailed our technique for capsular closure after hip arthroscopy through an interportal capsulotomy. Through the use of multiple interrupted sutures passed in a figure of eight fashion we create a watertight capsular closure that may help prevent postoperative microinstability and improve patient functional outcomes.
Arthroscopic figure of eight closure of a left hip interportal capsulotomy. The patient is placed in the supine position on the hip arthroscopy table. At this point in the procedure, the operative leg is off traction and the hip is placed in 30° of flexion to relax the capsule. The 70° arthroscope is used for viewing a left hip from the anterolateral portal oriented along the axis of the femoral neck in the peripheral compartment of the hip. The capsule is first prepared using both shaver and radiofrequency device taking care of removing all pericapsular fat above the capsule and define capsule edges. A series of figure of eight sutures are passed from a proximal medial to distal lateral direction in alternating suture colors from the modified anterior (MA) portal. After each suture is passed any loops are removed and the suture limbs are then taken outside of the cannula and snapped to the drapes. The cannula is then replaced and the process repeated. The sutures are then tied in reverse order that were passed by sequentially shuttling the suture limbs back through the cannula and tying directly on the capsule through the cannula in the MA portal. Finally, the repair is inspected to assure a watertight closure.
References
Bedi A.
Kelly B.T.
Khanduja V.
Arthroscopic hip preservation surgery: Current concepts and perspective.
Arthroscopic hip revision surgery for residual femoroacetabular impingement (FAI): Surgical outcomes compared with a matched cohort after primary arthroscopic FAI correction.
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.
Catastrophic failure of hip arthroscopy due to iatrogenic instability: Can partial division of the ligamentum teres and iliofemoral ligament cause subluxation?.
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