Well, thank you guys. I'll be speaking on capsular management. My disclosures can be found on the Academy website. So capsular management is a hot topic. And I think when I talk to people about capsular management, I usually tell them that the capsular management strategy really begins with your capsulotomy. And so I think when you're dealing with these types of things, you want to think about what types of capsulotomy you're going to do, whether size, type, location. I think the thing that's most important is how large is your inner portal capsulotomy, because I think that is the most relevant structure that is violated when you're cutting through perpendicularly through the capsule. You want to know what you're cutting through. The capsular management strategy must allow for complete visualization, as well as correction of the FAI deformity. In addition, it must allow for restoration of the biomechanical characteristics of the iliofemoral ligament. There are some different types of capsulotomies, and certainly they're not all equal. The most common ones are the periportal capsulotomy, what I would call the extensile inner portal capsulotomy, which usually is about 12 to 3 o'clock. And the T-cut is also popular as well. When you do a very far anteromedial capsulotomy that goes from 12 o'clock to like 3 or 4 o'clock, and you don't repair it, oftentimes what will happen is that the iliofemoral ligament just doesn't have the capability of repairing itself. And so in these cases, certainly I think a repair is very important. Otherwise, the possibility of instability may exist. The other possibility is if you make a really large interportal capsulotomy, I would say roughly greater than 5 centimeters, that the length tension relationship is violated. And oftentimes what will happen is the capsule will kind of heal to the neck itself. And so it just doesn't have the ability to go back to the acetabulum with such a large interportal capsulotomy. I think this is what Steve was identifying in his study that he published on 33 patients that develop instability after surgery. After the index surgery, there is no difference in terms of their patient report outcome from baseline. But once he went in the second time and repaired the capsule, he did find that the patients had significant improvement in terms of their patient report outcomes. Certainly, if an extensive capsulectomy is performed, all bets are off. And this is a case where you can actually see subluxation of the hip itself. And if you do have this situation, you just have to be prepared for a potential capsule reconstruction if there's no viable tissue anywhere near. In terms of technical consideration of the capsule, certainly if you're dealing with someone that's hypermobile, that could have very delicate tissue, you just want to be very gentle, as the capsular tissue may be very unforgiving. The other thing to consider is that if you're going to make a capsulotomy, I would recommend that you leave about 8 millimeters between the labrum of your capsulotomy. In addition to that, you want a nice perpendicular capsular incision, so you've got very good tissue to repair. I like to also utilize capsular suspension tissues. This will then be able to retract the capsular tissue away from the labrum. This will allow you to really get as medial as possible, so you can elevate the labrum, get to the pincer deformity, and repair the labrum with preserving as much labral tissue as possible. And so I think these are some strategies that could help with your visualization, as well as your capsular management strategy. And certainly, not all capsular repairs are equal. I think the goal is anatomic repair of the ilioformal ligament to restore the biomechanical characteristics to maintain stability of the joint, both in translation, rotation, as well as strain. You also want to create that fluid separation between the joint and outside the joint, as well as prevent the possibility of muscle herniation as well. Certainly, there's a variety of different ways to repair the capsule. You can use different devices that are available. But I think the goal should be an anatomic repair, as well as a watertight seal. And I think what we have found is that when you don't repair the capsule, that oftentimes there could be a lot of scar tissue between the cartilage, labrum, and capsule. There's really no differentiation in tissue type. However, if you do maintain the soft tissue integrity of the joint, when you do go back in, oftentimes what you'll see is that that normal anatomy has been restored. The biomechanical data does seem to support capsular instability with larger capsular incisions. But with repair, oftentimes you're able to get it near, close to the native intact state. MRI studies also show that there's probably a 92%, 93% rate of healing with repair. However, Omer Maydan also published this recent article on an RCT comparing capsule repair versus not repair. And he did find that by 24 weeks, that all capsules were repaired. The only caveat I would say is that he makes a very small capsulotomy, and the mean size was about 23 millimeters. So unless your capsulotomy is that small, I think that this study might be difficult to translate. We recently published our series on capsular management with labor repair as well as comprehensive correction of FAI and found significant improvement in terms of PROs, as well as a 98% survivorship in terms of reoperation and conversion to hip replacement. Ben's group also published on capsular repair versus capsular release and found that the repair group had a 10.5% conversion to hip replacement rate versus an 18.5% conversion to hip replacement rate in the capsular release group. Certainly there can be complications related to capsular repair. Adhesions, heterotopic ossification certainly can happen. There can be early re-tear, usually within the first three months of surgery, or later in the rehab course if there's a high-energy trauma associated with it. So in summary, what I would say is that not all capsulotomies are created equal. There are certainly differences between small periportal incisions versus large T-cuts, and not all capsular repairs are also created equal. My recommendation is that you should have one stitch for every one to two centimeters of interportal capsulotomy that's been performed. Clinical outcomes after repair does reveal significant improvement in terms of PROs with a lower complication rate. It does appear to be more durable with a lower risk of conversion to hip replacement as well as a lower revision rate. Thank you.

capsular management

hip surgery

capsulotomy

inner portal capsulotomy

capsule repair