Proximal Anterolateral Accessory Portal Use Improves Peripheral Compartment Access and Capsular Management with T-Capsulotomy

A standard, supine post-less hip arthroscopy preparation (Guardian; Stryker Corp, Greenwood Village, CO) is used with patients under general anesthesia. Central compartment access of the hip joint is established via standard anterolateral (AL) and modified-anterior (MA) portals with the assistance of fluoroscopy. Central compartment pathology is then addressed using an interportal capsulotomy with the addition of a distal anterolateral accessory (DALA) portal made approximately 4 cm distal to the AL for anchor placement. The location of each of these portals is shown in Fig 1. Capsular retention sutures are placed to facilitate central compartment work in a fashion similar to a previously published technique. Instruments that are necessary for the procedure are listed in Table 1.

After central compartment work has been completed, traction is released, boot bindings are loosened, and the operative leg is flexed to approximately 30° of flexion. Viewing from the MA portal, a retrograde suture passer (Injector; Stryker Corp) loaded with a nonabsorbable no. 2 suture (Force Fiber; Stryker Corp) is inserted through the AL portal, and the suture is passed through the distal capsular limb of the previously-made interportal capsulotomy. Typically, this is placed in-line with the gluteus minimus muscle on the lateral aspect of the interval between the gluteus minimus and iliocapsularis muscles. Because the interportal capsulotomy is sized to address the central compartment pathology, this first suspension stitch is typically placed as far posterior as possible with the Injector. We will call this the distal lateral capsular (DLC) suture. A clamp is placed on this suture to facilitate identification, but it is not yet placed under constant tension. The retrograde suture passer loaded with a second nonabsorbable no. 2 suture is now inserted through the DALA portal. The suture is again passed through the distal capsular limb about 5 mm anteriorly to the previously placed suture and adjacent to the iliocapsularis insertion. This will be the distal medial capsular (DMC) suture. A clamp is again placed on this suture to facilitate identification. The T-limb capsulotomy will be made between these 2 distal capsular sutures (Video 1). Placement of these sutures at this point in the procedure has 2 advantages. First, it allows visualization of the femoral neck and CAM morphology so the T-capsulotomy can be made in-line with the neck of the femur at the midpoint of the CAM morphology. Second, it creates balanced tension during the T-capsulotomy that promotes precision. The tension allows the beaver blade (Samurai; Stryker Corp) to cut more efficiently and accurately. These sutures also retract/suspend the T-capsulotomy limbs as the cut is made so that visualization and access can be assessed as the T-capsulotomy is being made. This allows the T-capsulotomy to be no larger than necessary. With tension applied through both sutures, a judgement is made about whether a perpendicular capsulotomy centered over the femoral neck can be more effectively made through the AL or DALA portal. The authors most often make this T-limb capsulotomy through the AL portal but also use the DALA portal. Facilitation of a perpendicular angle, in-line with the capsule fibers and in the interval are the criteria for portal selection. Fig 2 demonstrates the Samurai blade appropriately oriented perpendicular to the capsule just before making the T-limb capsulotomy. The T-limb capsulotomy is then made using a beaver blade (Samurai) to obtain complete access to the CAM morphology. The exposure obtained with the T-capsulotomy with the original capsular suspension vectors through the AL and DALA portals is seen in Fig 3.

At this time, a scalpel (often the beaver blade that was just used for the T-capsulotomy) is used to make a small PALA portal, approximately 4 cm proximal to the AL portal (in line with AL and DALA). Portal size is made just large enough to accommodate the loop grasper. The Samurai creates the ideal-sized portal, and the transition from the blade to shaft allows for an incision through the dermis and epidermis only. The Samurai will not be used again in the procedure, and thus there is no concern for contamination in the joint. The loop grasper is then inserted through the PALA portal and used to retrieve both limbs of the DLC suture (Fig 4). The loop grasper should enter the peripheral compartment in the posterior aspect of the capsulotomy so that the capsule limb is retracted posterior. To facilitate visualization, it can be helpful to release traction on this suture during this step. A clamp is again used to facilitate traction through these sutures after they have been retrieved through the PALA portal. This redirection of the vector of pull-through of these capsular retention sutures pulls this capsular limb posteriorly and optimizes peripheral compartment exposure, especially visualization of the posterolateral aspect of the CAM, which is obtained from a well-placed T-capsulotomy (Fig 5). At this time, peripheral compartment work, including femoral osteoplasty, is completed. The optimized exposure from the use of the capsular retention suture redirected through the PALA portal also improves capsular management by minimizing any capsular damage that may occur from the use of the burr during the femoral osteoplasty.

After peripheral compartment work has been completed, the capsule is closed using 3 figure-of-eight stitches with 1.4 mm suture tape. One figure-of-eight is placed in the medial interportal, one in the descending limb of the T-capsulotomy, and one in the posterior interportal capsulotomy that extends across the junction of the descending limb of the T-capsulotomy to optimize closure of this junction. The orientation of the 3 figure-of-eight sutures across the T-capsulotomy is depicted in Fig 6. One additional simple stitch can be used in the descending or posterior limb of the T-capsulotomy for larger capsulotomies. All stitches are passed before tying. Different color sutures are used for each stitch to facilitate suture identification and retrieval for tying later. Capsular closure is began viewing from the MA portal and working through the DALA portal. A suture passer (Stryker Slingshot) loaded with suture tape (Styrker XBraid) is inserted through the DALA portal to pass the suture in a figure-of-eight configuration in the T-limb of the capsulotomy. Using the DMC and DLC sutures, the T-limb can be tensioned to provide resistance to facilitate suture passage. The line of pull of the DLC and DMC stitches holds the capsule out to length with tension. This facilitates precise and efficient suture placement. The suture passer is then inserted through the AL portal to place a second suture tape in a figure-of-eight configuration in the lateral limb of the interportal capsulotomy. This stitch is used to bridge the T-capsulotomy, with the figure-of-eight configuration securing the interportal on both sides of the T-limb. The DLC suture can be tensioned to provide resistance to facilitate suture passage. Finally, the arthroscope is switched to the AL portal, and the suture passer is placed in the MA portal to place a third suture tape in a figure-of-eight configuration in the medial limb of the interportal capsulotomy. Again, the DMC suture can be tensioned to provide resistance to facilitate suture passage. At this time, previously placed capsular retention sutures are removed, and the leg is straightened before the sutures are tied to decrease risk of overtightening the capsular closure. A cannula is then placed through the DALA portal, and the sutures are independently and sequentially retrieved and tied (Table).