My name is Dr. Shane Ngo from Rush University Medical Center in Chicago, Illinois. I'll be speaking on primary capsule repair techniques. My disclosures can be found on the Academy website. The evolution of the treatment of the capsule has certainly changed over the past couple of decades. From initially our focus was on safe access and then transition to complete correction of femoral SMR impingement. And thereafter we realized that the soft tissue structures were important and the focus has been on both labral and capsular preservation. This is a case example of a patient that I'd seen in my office who had failed two prior hip scopes, complaining of persistent pain, weakness, and inability to perform either occupational or athletic demands. Interoperably you can see that while the posterior capsule is intact, when you view anteriorly you can see that there is complete obliteration of the anterior capsule. In this case it kind of made me realize that micro instability was a real entity and that while this patient never dislocated, she certainly was having signs of clinical failure. Hip instability is certainly very rare, but I believe that the hip dislocations and macro instability events are largely underreported. There are 11 cases reported in the literature so far, but I think micro instability is certainly much more common and very much underreported. Capsular anatomy really must be understood as this is why capsular repairs must be performed. The iliofemoral ligament is the most commonly violated structure and it's important for extension and extra rotation restrainment. And this really goes back to understanding both the structure and the function of the iliofemoral ligament in terms of translation, rotation, and strain. Dr. Philippon's group conducted an excellent biomechanical study using body planar floral performing sectioning of both labrum and the iliofemoral ligament and finding that this would increase translation. But with subsequent repair, he was also able to demonstrate that the amount of translation was back to normal and native intact state. However, he did find that the iliofemoral ligament was more important than the labrum in terms of restraining translation as well as extra rotation. As far as rotation, there's been a number of studies that have reported on the size of capsulotomy increasing the amount of rotation of the hip joint itself. This video is from Dr. Chawla and Dr. Philippon and what we found is that when you exceeded the certain amount of rotational moment that you're actually able to rupture the stitches themselves. And what they found was that the increased capsulotomy increased the amount of rotation. My recommendation is that there should be one capsular stitch for every hour of size of capsulotomy that's required. Our group has also published that as you increase the amount of capsulotomy, this will increase the amount of strain. We conducted a study looking at the amount of force that's required to produce the amount of distraction. And you can see with intact, there's a significant amount of distraction that is also being affected when capsulotomies are performed. And this has a linear relationship, but with capsular repair, you're able to restore the amount of force back to its native intact state. Baha and his colleagues also published a study that had demonstrated that complete capsular repair restores native kinematics after both interportal and T capsular types. So it's intuitive that once a capsulotomy is performed, that a capsulotomy should be repaired. And you can see how this both affects rotation, translation, and the amount of strain involved. And I think that this very easily makes the case why capsular repair should be performed after every capsulotomy. And the evidence is quite good. There are a number of level three studies that have been published by my group and others demonstrating the clinical effectiveness of capsular repair compared to non-capsular repair. So how do we repair it? Well, the most common capsulotomy types are the periportal, interportal, and the T-cut. And there certainly are advantages or disadvantages to each type. My personal feeling is that I think the interportal does give you a better view of the central compartment, but requires a four to six center interportal capsulotomy. The T-cut, you can minimize that interportal cut to about two to four centimeters, and I think the peripheral compartment does become much easier with a T-type capsulotomy. The T-type certainly is my workhorse, so we'll start with that. And again, here's the cut and repair. In general, I try to make a small interportal capsulotomy if I can. I would say in general, mine is approximately two centimeters. Once we make a nice full thickness capsular incision, we'll go ahead and place traction stitches both through the anterolateral as well as the modified anterior portals. Next, we'll focus on the peripheral compartment. Here we'll remove the pararticular fat pad. At this point, we'll make a capsular incision and brought it to 50 yard line. It'll be right down the femoral neck and will be full thickness in nature. We'll go ahead and place our traction stitches both on the medial leaflet, then on the lateral leaflet. Once it's performed, then we'll use a hemostat to provide complete retraction of the entire peripheral compartment. Once we're able to do that, you can see that we've got a nice visualization of the entire peripheral compartment. At this point, the camera section can be done very easily and very efficiently. Capsular repair. This is a technique that was published by myself and Chad Mather using a capsular repair device. Here after a T-capsulotomy, you can see a capsular repair device is in place on the lateral leaflet and then the medial leaflet. In this particular technique, you can go ahead and pass your stitches and tie sequentially using whatever arthroscopic techniques you'd like to employ. Generally, there are three stitches involved for the vertical portion of the T-capsulotomy. There's a third one that's being placed and subsequently tied. Once the vertical limb of the T-capsulotomy is performed, now the inner portal can then be repaired. This can be done again with the same device. Here we're starting medially and then working our way laterally. You can see you've got a nice bite at the femoral side, followed by the ostabular side, and then this is repeated at least three stitches in total. Again, follow my recommendation, one stitch for every hour of capsular incision that is performed. Here if you do a three-hour incision, we'll go ahead and place three stitches. Upon repair, you can see you've got nice thick tissues, nice shoulder tissues. With capsular repair, you can see you got a nice primary repair and there's no evidence of a capsular defect upon completion. The intraportal capsulotomy, again, is a single incision. Here's a case example of a failed prior hip scope. In this case, we used a hip map in order to understand the pathomorphology a little bit better. What we found was that the surgical correction of the initial femorisome pinion was well employed. At this point, we can see a large capsular defect using the MR Arthrogram. Here is the initial inspection inside the joint. I really like to use the clues here to understand where the problem is. Here I look in the anterior compartment, you'll see that there's a lot of scarring. There's a little bit of residual FAI, but the capsular adhesions between the labrum capsule seems to be pretty noticeable. Cardioid surface thankfully appears to be well maintained. As far as what to do about the labrum, I'll use my diagnostic clues. I'll go ahead and palpate and I'll see if there's a suction seal. Here, actually, the primer repair actually appeared to be suitable. The main issue to me, in my opinion, was there's a little bit of residual impingement. Most importantly, there was a large capsular defect here. In this case, I want to go ahead and place my capsulotomy as far lateral and as far medial as I can to get back to normal tissue. If I see adhesions or a capsular defect, I want to go as far to that extent. Usually in this situation, this will show you a pretty nice view of the peripheral compartment. A T-cut is usually unnecessary, but really placing traction stitches on the femoral side of the ileofermal ligament will give you excellent visualization of the entire peripheral compartment. Once the osteochondroplasty is performed, next the capsular repair can be performed. In this situation, we'll place our camber in the anterolateral portal. We'll go ahead and place one cannula through the modified anterior portal and a second cannula through the distal accessory anterolateral portal. In this case, we'll go ahead and pass a series of stitches going from medial to lateral. In most cases, when there's a large interportal defect like this, I'll go ahead and pass all of my stitches first. In this case, I just tied the first one, but then I'll go ahead and pass a series of stitches going from medial to lateral, and then I'll use a hemostat outside the joint, and then go ahead and pass, again, use that principle of one stitch for every hour of capsulotomy that is required. In this case, I would say that this is probably a six-centimeter or a six-hour capsulotomy, so I want to use at least six stitches to go across in order to complete the repair in order to get a watertight seal. I stand corrected, actually. In this particular case, we went ahead and passed our stitches and tied sequentially. Either technique, I think, can be employed. The one benefit of tying sequentially is that suture management is not as difficult. If you do pass them all first and then tie at the end, sometimes suture management can be a little bit tricky, but here you can see a nice capsular repair of a interportal capsulotomy. The early clinical outcomes, when you look at failure rate, you find that the conversion to hip replacement using complete capsular repair is about 1.2 percent, revision rate about 2.5 percent, but there's been a couple of level three studies by Dohm and Bollius Group, and what they found was that there's a 10 percent difference when you repair the capsule as far as conversion to total hip replacement in both of those studies. I think my thought is that if we can decrease the amount of conversion to hip replacement rate by 10 percent, I think that that's a pretty significant finding. In conclusion, the capsule plays a clinical biomechanical role in the hip. The capsulotomy disrupts both translation, rotation, and strain. In addition to that, capsular repair restores the native hip kinematics regardless of capsulotomy type. Capsular repair is level three evidence to date, and clinical outcomes favor capsular repair. Thank you.

primary capsule repair techniques

hip surgeries

labral preservation

capsular repair

clinical outcomes