Excellent talk, thank you, Andrea. Next up is Dr. Ben Dome from the American Hip Institute in Chicago, talking about his management of the capsule. Thanks Tom. Thanks to Anna for the invitation, and also thanks to Anna for putting the hip session in a room where my head is in the ductwork, I appreciate that. So on capsular management during hip arthroscopy, my disclosures are listed with the AOS. I will advocate to not struggle through limited access in hip arthroscopy, because there's so much complexity to the things we can and probably should do. So making a sufficient capsulotomy really allows us to have the maneuverability to do a lot of those things. Now, there are a lot of ways to skin this cat, capsulotomies that look like an I or an L or a T or an inverted T or H. But in general, the advantages of a reasonable capsulotomy are that it provides exposure, it allows easier instrument maneuverability, and it allows better joint distraction, especially in the difficult-to-distract cases. So it's been a long history. And back in about 2010, I was slated for a debate at what is now the OSET meeting against Tom Sampson, who was then one of the giants in the field. And I was relatively young in my career, and I was very nervous for this debate, because he was debating why capsulotomy need not be repaired, and I was debating this newfangled approach that we ought to repair the capsulotomy at a time when it really hadn't been talked about at all. And Tom Sampson's quote at the time was, because of some difficulties with exposure, we settled on an anterior capsulectomy for the best exposure. On one patient, follow-up MRI showed a brilliant capsular healing response within six weeks. So Tom has since changed his own position on this, and so has, I think, the rest of the field, because we've realized that extensive unrepaired capsulotomies may lead to iatrogenic subluxations, dislocations, and subtle instability. So this really has been a long journey over the course of a decade and a half. And we've seen some of the complications that can occur with unrepaired capsulotomies, including catastrophic failures, evidence of capsular defects on MRIs, as well as, in the most extreme cases, dislocations, which have been reported by multiple authors. So my personal preference is an interportal capsulotomy, and this, for me, allows excellent exposure of the central compartment. The peripheral compartment visualization, for me, is equally as good with the use of a traction stitch or stitches. And this way, we don't violate the zona orbicularis, which is the thickest circumferential portion of the capsule. As I started out by saying, I think there are a lot of ways to skin this cat, and various types of capsulotomies, if repaired, may all do very well. The indications for closure, for me, I'll divide into the indications for a shift or plication versus the indications for a repair. So a shift or plication at our group is indicated for connective tissue disorders, those with ligamentous laxity or borderline dysplasia, or athletes who participate in flexibility sports like ballet or gymnastics. Repair is essentially for almost everyone else, except maybe very stiff people or people with arthritis, but we're probably not scoping them in the first place. So there's kind of a difference in orientation and sutures between a plication versus a repair. To do any of them, one of the keys to success is capsular preservation in the first place. So if we shave away part of the capsule to get visualization in order to get our labor repair or labor reconstruction or FAI work done, we're going to have a very hard time with a capsular repair afterwards. So I think one of the keys to development of this technique in the first place was developing the technique for the other stuff, where we could preserve the capsule and not shave it away. And that enabled capsular repairs and plications. So intraoperative capsular management is paramount, where we can use the shaver a little bit to remove synovium at the capsulolabral junction, where those blue arrows are, and then we'll use an electrocautery to very carefully elevate the capsule from the bone, sparing it on the acetabular side and then using traction stitches on the femoral side during FAI work. So it's now been, I can't believe it, over 10 years since we published this technique first on capsular closure slash plication. And the title of the article was Arthroscopic Capsulotomy Treated with Repair or Plication and its Relation to Atraumatic Instability. And I think that was kind of the key. Catevaric studies since then have proven that external rotation and anterior translation are increased when the iliofemoral ligament is sectioned and not repaired. So we've come to understand through the biomechanics, through the clinical studies, what we had proposed in the first place, which was that indiscriminate capsulotomy would compromise stability, capsulorophy could normalize the kinematics, and capsular plication could counteract capsular laxity and reduce atraumatic instability in those who are prone to it. So this is what the technique looked like. These are the pictures from that original article in 2012, where we'd used the interportal capsulotomy and we wanted to create a shift with a plication for instability or just a closure for those who are not prone to it. And we can accomplish that by titrating the obliquity of the sutures to titrate the shift and titrating the bite size to titrate the imbrication. So that's what it looks like when it's completed. In this article, we looked at what was then considered a very challenging group of patients, those with borderline dysplasia. And this was a pilot group where we treated people who had previously struggled to have good outcomes with hip arthroscopy and treated them with a labral repair and capsular plication in order to treat their atraumatic instability. And we're able to do so with very successful results. We've then followed them over longer periods of time, and I'll get to that. We've looked at return to sport. This article was in AJSM showing very high rates of return to sport. It was as high as 100% in the professional athlete group. And in this study in arthroscopy, looked at athletes, competitive athletes who underwent arthroscopy with capsular repair versus those who did not and found substantially better results in those who did undergo a capsular repair. So now in this study, these were non-dysplastic patients, not borderline dysplastic patients. We compared capsular repair versus capsulotomy in the minimum five-year outcomes. We did the same study at two-year outcomes and weren't able to show a difference. At five-year outcomes, it did show a difference. There was superior durability of the PROs in the capsular repair group and a significantly lower risk of conversion to THA over that first five years. And then finally, hot off the press in this month's JBJS is our 10-year outcomes of borderline dysplasia treated with capsular placation and labral preservation, showing greater than 80% survivorship at 10 years and about an 80% rate of achieving MCID. Very important for me and my personal journey and our personal journey that we've published this article because when we started doing arthroscopy for some of these patients, certainly there were a lot of stones thrown by the surgeons who did not do arthroscopy and stones that looked something like the short-term outcomes might be OK, but the long-term, they'll all fail. And clearly, we've found that if we have the right indications and the right surgical technique, we can achieve long-term successful outcomes. So in conclusion, sufficient capsulotomy enables advanced procedures such as labral reconstruction, anatomic labral repairs, and precise treatment of FAI. Preservation of the capsule is paramount in order to achieve good capsular management, and this is aided by the use of retraction stitches. Routine capsular closure is performed at our institution in most cases, and capsular placation with inferior shift is very helpful to treat micro-instability. Thank you.

hip arthroscopy

capsulotomy

capsular preservation

capsulotomy repair

capsular closure