Hi everybody. My topic today is management of capsule. Disclosures. First of all, thinking about the capsule, most important thing in my mind is stability. Capsule ligaments that actually make up the capsule, iliofemoral ligament, ischiofemoral, pubofemoral, and then within that, the zona orbicularis. They all have different functions. There's an excellent paper, 2019, JBJS, Paul Bollé, current ISHA president, talking about all the different contributions to stability. A really great paper, Art lands it nicely. Part of that paper as well shows you what the portals do, the T-capsulotomy or the interportal, how it creates instability and what the effects are basically. Then the other, contributors to instability. There's a paper, so if you want to delve into this, this would be a great start. Capsulotomy. Well, not everybody's doing it, but more and more people are doing it. Since I've been trained doing a capsulotomy, I've been doing an interportal in practice myself. In training, I started T-capsulotomy with one of my mentors, Dr. Noh, Shane Noh, Chicago. Shout out to him. Then I also trained with Mark Philpon, who only did the interportal. I did my own technique with suspension technique as well, which I'll show you, allowing me to get good visualization, but only utilizing interportal. Why do I only do interportal T? Because I figured if I don't need to disrupt normal anatomy, then why do it? I'm worried about instability. That brings me to the main concern, again, instability. If you have a capsulotomy and you don't close it, there were initially case reports about iatrogenic macro-instability. Then later on, also had more concerns about micro-instability. Here, Dr. Noh published a paper, the evidence of capsular defects following regular hypertroscopy. You see in the bottom right a picture with a defect, a spinal needle going through a capsular defect. Again, the concern here is instability. Going back to my fellowship days, I figured I'd take that case. A 20-year-old female head, so I was in fellowship 2013-14, at the time had a October 2011 scope, outside facility, femorostoconoplasty, capsule was not closed. Then the outside facility, I had to do a revision a little bit later, iliopsoas lengthening, also didn't close the capsule. That, in my mind, now just screams instability. Then she was not doing well. I think she was also somewhat borderline dysplastic, so that's something that later on people focused a little bit more on. Basically, instability was what's going on. This was a video we took back then. Into a particular view, you saw a big capsular defect in the front, here a spinal needle. Again, status goes prior femoroplasty. Then going back up front to that big hole to the right, that's the iliopsoas. There's no capsule, big, big defect. Now, how do we figure that out in the end and treat that? Well, it was actually capsule closure, nice mobilization of the capsule leaflets and then able to close, not a capsular reconstruction. Again, instability. This is a video of Dr. Aoki, a friend of mine, axial strain here, showing easily. He's a strong dude, but he's only using a few fingers here. See how easily distractible this case or revision he was doing where no capsule closure had been done previously. Now, again, a close-up of the same case, easy, distractible. Then going on during the case, he does a wonderful technique with a figure of eight closure and also a placation. Again, nicely closed and able to mobilize everything. This is afterwards, no distraction, no gapping, and they had to pull much harder. Rationale for capsule closure, again, instability is a concern. You want to understand the underlying anatomy and see what you're cutting through when you're doing a capsulotomy. Here's the interportal capsulotomy. See the ileofemal ligament underneath, and this would be a T. When would I do a T? Well, if I have a very large cam deformity and I need to be able to get to everything, I think it's been about six years since I've done a T capsulotomy in large cam cases. I've seen a few large cam cases since then. What I've been using is, again, suspension technique, lifting up the capsule. Again, if you need to do it, if you can't get to the cam otherwise, do it, and then you can close afterwards. Some people also say, if you do a T capsulotomy in somebody who's unstable, it allows you to do a better, more tighter capsule placation. Here, if you look at the video on the right, this is an instrument I'm using to get underneath the capsule and pass a suture. Then you see how it can lift up the capsule, same thing on the bottom right, and passing sutures and then lifting up. You can see nicely down the neck here, going around, and see what you need to see. That is a suspension technique where you lift up the capsule leaflet to distal. I tried to have a minimal capsulotomy, as small as possible, as whatever I need, so we'll be able to visualize the move. Those suspension sutures help to improve visualization, but also protect the capsule. In a revision setting, those suspension sutures help also to develop the play between the capsule and labrum. You can then also, with tension on the capsule, you can use a blunt dissection with a probe or sharp dissection curve capsule out of your blade or tissue elevator. Again, for revision settings, you want to be able to mobilize the capsule, you can close it, so the decreased tension, same thing, same concept to the shoulder or cuff repairs, for example. Again, suspensions help with mobilization, figure of eight or augmentation if you can't close everything. I usually use three to four sutures to close, some people up to six, and again, figure of eight can be helpful as well. For a capsule blockation, I use a suture pass device that allows me to go more distal to tighten it more, but also do a capsular shift. Here you see an interportal capsulotomy on the top of the labrum that gets converted to a T-capsulotomy, so going down the femoral neck, going all the way down, so it's a capsulotomy blade. Then going down the femoral neck, you see how thick that capsule is. Here, a nice view around the femoral neck, medial synovial fold. It's great. It allows you to do a fairly easy from osteochondroplasty because you see easily around and also can mobilize and move the burn easily. It's a nice view. Great dynamic examination, make sure there's no more can, and then start closing. After that, because you certainly don't want to leave open a T-capsulotomy. First, you just close the vertical limbs past this, so placation because you tighten it a little bit. Then once you're closed with a vertical, you close the interportal limb. You create from a T-capsulotomy to an interportal base with closure. Let's look a little bit at outcomes. Steve Aoki, again, he reported outcomes and revision cases. Capsular repair can help improve outcomes. Prospective randomized comparison showed also improved outcomes with complete closure. That's a repair of the capsulotomy would be favorable for capsular management. Again, it matched a pair analysis. This was Shane Ngo. It's shown also improved outcomes with complete repair. Then Ben Dome published five-year outcomes, also suggesting improved outcomes and more durable outcomes with closure. Now, what happens if you have a defect? Either it was not repaired before or it was repaired and it didn't work out. You can augment a repair with a patch, so a bio-adductive implant. You're still going to mobilize, close the gap, and then on top of that, you can place this non-structural graft to provide some stability overall with healing in the long-term, not the short-term stability since it's non-structural graft, but it will help with healing, so augmentation. Then Mike Banfie also published this similar paper, bio-adductive collagen implant. Again, that's structural just to promote healing. This excellent arthroscopy techniques paper, Dr. Bird published in 2021, showed a large defect here as an example, and then putting a structural allograft on top of it, bridging that gap, resulting in good stability and closure. Why should we? Probe capsular closure, minimize the risk of instability, improve the biomechanics, normalize the eight-branch motion, maybe also minimize the risk of heterotopic ossification, so now that intra-articular, whatever is left of bone debris can go in extra-articular space. Minimize risk of adhesion, since you do close the capsule, there's more tension on it, so maybe it doesn't stick as much to the labrum, so whenever you do revisions, you often see a scar wall between the caps and the labrum, so if you have tension on it, maybe it'll minimize the risk of adhesions. Better patient-reported outcomes shown, less conversion to lip replacement, improved PROs after capsule closure, less instability. So T-capsulotomy, complete closure, shown to have better PROs as well. For borderline hip dysplasia, micro-instability, glycation increases the anterior strain and may reduce the injury to the condylobal junction. Why wouldn't you do a capsule closure? Well, I don't know, but let's think about possibly maybe increased stiffness on those rare cases where you have a lot of stiffness, maybe it's better to leave open. Technically challenging, well, if you don't have the right tools, you don't do it often enough, then it's technically challenging. I mean, a straightforward capsule closure could be done in five minutes. Possible adhesions to non-absorbable sutures could be a reason, you could over-tighten it, so something maybe you also want to consider in dancers, for example. You could also have some hydrogenic cartilage damage. Obviously, there's a learning curve. The more often you do it, the better you get, and the faster and more facile it becomes. Increased cost, well, those sutures are not very expensive, so I'm not sure that's a major issue. So all in all, I would propose nowadays that a capsule closure has become the standard of care. So you want to be facile with it, be comfortable with different instruments to use it. There's a bunch of different instruments out there from different companies. Try them all in the lab, figure out what works for you, and just use it. Thank you very much. Thank you.

stability management

capsule disclosure

capsule closure techniques

augmentation strategies

capsule closure benefits

hip surgeries

capsule management

stability

capsulotomy risks