Hi there, this is Steve Aoki, I'm at the University of Utah, I'll be talking about capsular technical pearls in revision hip arthroscopy. This is my disclosure. So I thought it would be worthwhile to go over some of the reasons as to why we have hip pain after a previous arthroscopy, whether it be bone over or under resection, including the femur and or the acetabulum, labral pathology, chondral lesions or further wear, adhesions and stiffness, we're going to focus on instability for this talk. Now in the revision setting, there's a lot of different reasons as to why we technically may have issues of instability after a previous hip scope. We disrupt the capsule with a capsulotomy, we may do a rim trim, may resect some of the labrum, muscular releases with psoas release, all of these may add to the hip wanting to extrude out anteriorly. Now these patients that have hip pain due to capsular atrogenic hip instability after a previous hip scope, they're really difficult patient populations to diagnose and I think it's just because we're just getting into this realm of understanding these patients a little bit better. We just recently published this paper, all of these patients in the study had an MR arthrogram with a capsular defect and under anesthesia, the exam under anesthesia showed an easily distractible hip joint with axial distraction. When we looked at these patients, 87% of them had pain with their activities of daily living, 100% of them had pain with sports. Interestingly, only about 25% of them described a looseness or an instability on their history. We introduced the axial distraction test in this where we look at pulling on a hip in a slightly flexed position and we're looking for three components, pain, objective toggle of the hip or apprehension and we compare it to the contralateral hip and 77% of the patients had one or more of these findings on their exam. We looked at these patients at four years average follow-up and by doing a capsular repair, isolated capsular repair, 87% of them showed improvement with their activity and 78% showed improvement with pain. So this is the axial distraction test. I'm starting off on the contralateral hip. I start off pulling just slightly and then gradually increasing the force of the pull. I have them slightly flexed, put my knee at the ischium. This is the side that had a previous hip scope. You can see the apprehension there when she's twitching to kind of protect her hip and then you'll see on this last pull that the hip will toggle out of joint right there. She underwent an isolated capsular repair and then this is her at six months post-op doing the axial distraction test again on that side that we did the isolated capsular repair on. You can see that she no longer has apprehension and I can't get that hip to toggle. Now as far as the workup, I had mentioned earlier that we did MR arthrograms on the previous series. I've just found it to be more helpful. This is a patient that I saw just a few weeks ago. These are selective cuts of her MRI that she came in to see me with and I reordered her study and got a MR arthrogram and then this is her MR arthrogram showing the obvious capsular defect and the retraction of the capsule. Now this is an older video. This is one of the first patients that I took back for an isolated capsular repair. So you can see that just doing a light axial distraction with a couple of fingers and I'm able to really distract that hip. Now this is also an older video. This is another patient where I'm pulling with just a couple of finger distraction and you can see the distraction scene where the hip easily comes out of joint and then this is doing an isolated capsular repair with at this time period just a couple simple sutures side to side and then this is after I've done that capsular repair pulling distraction on the hip. You can see that the pelvis is moving with that femur at this point. Now this was a paper that we published back in 2016 looking at those individuals that had symptomatic hip instability where we did an isolated capsular repair. We took our first 20 patients, a minimum of a one-year follow-up with some having two-year follow-up. Most of these were females and if you look at our outcomes, 19 of 20 of them perceived a functional improvement on their Likert scale and if you look at the patient reported outcomes, if you compare the index scores to their score after their first surgery, there really wasn't any improvement and then after we did a revision capsular repair at a minimum of one to two-year follow-ups, we're able to get those PROs to be much better. So I just wanted to take you through one of my cases. This is a patient that I've more recently taken care of in the last couple of years. I did a labral repair, femoral osteochondroplasty and then a routine capsular repair where at this time I was doing three figure of eight stitches so that I could get a watertight closure. Now at two months out from her surgery, she was in her backyard and she was walking, slipped into her window well and her operative side got caught behind her and she hyperextended and had pain afterwards, followed her for a little bit. She just did not turn the corner, did not improve. So we got this MRI showing this capsular defect and this is some of her pictures. After we found the capsular defect, we went back in, re-scoped her and did an isolated capsular repair on her. This is looking at her video. This is the area where she tore out her capsular repair, took out the stitches, cleaned up to an area where we got back to good, robust capsular tissue and then we placed our stitches. I will start on the apex on the medial side and I'll close as much as I can and then I'll look to make sure I can bring the tissue together. If I feel any tension between my capsular leaflets on the acetabular side and the femoral side, I'll do an augment with a dermal allograft. This is just placing my side-to-side stitches on the acetabular side and I'll place two to three of these on the side depending on the size of the defect. After I place them on the acetabular side, I'll go over to the femoral side and do the same thing. Just kind of work my way from medial over to lateral and place my stitches in a side-to-side fashion. This is placing the one most medial and then taking the bite and grabbing the other stitch end so it's the side-to-side so I can parachute the graft down into position. Now after I place all these stitches, I will bring my stitches together and try to do as much of a capsular repair as I can in between my stitches for the capsular reconstruction prior to floating this graft down. That's my dermal allograft. I'll parachute that graft down and then I'll just tie my stitches and augment that capsular repair if there's any tension on the native tissue or if there's any signs of a defect where I'm unable to get that tissue together. This is just showing that final product of that graft being tied down and bridging the gap. If I don't have any capsular tissue on the acetabular side, I'll use anchors. Last couple of technical pearls, especially if it's not your case, obviously you want to track down your previous op notes and pictures just so you know how the surgeon previously dealt with the capsule. Did they do an interportal? Did they do a T? Did they take their capsular tissue off of the acetabular side? That's really important to know that because it does get a little bit more challenging and more technically involved if you have to do anchors on the acetabulum. I always use a non-tooth shaver and that helps protect the intact capsule because it's pretty selective and doesn't take down good capsule. I will release the scar until I get back into healthy muscle or fat and that helps mobilize that capsular tissue, sort of like how you're doing a mobilization for a chronic rotator cuff. I'll close the capsule and I'll leave that leg in a neutral position and neutral extension. Then if I can get that tissue over, great, I'll do a capsular repair. If I can't get it over without tension and it feels tight or if I see a gap, then I'll start thinking about doing a capsular reconstruction if needed. Thank you and I appreciate the invitation to speak to you guys. Thanks.

capsular technical pearls

revision hip arthroscopy

hip pain

instability

capsular repair