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Suspension technique provides superior visualization, capsular protection
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Hip arthroscopy has recently become a common procedure to treat central and peripheral hip pathology including femoroacetabular impingement and labral tears. Capsulotomy is inherent in these procedures, and negotiating adequate visualization in conjunction with capsular preservation is a challenge. A capsular suspension technique eliminates the need for additional personnel for retracting, prevents iatrogenic injury to the capsule, eliminates the need for excessive capsular debridement and allows for capsular closure under minimal tension.
A growing body of literature supports the importance of capsular repair to decrease the risk of instability, decrease revision rates and improve sports-specific outcome scores. Intraoperative visualization and access issues often lead to excessive debridement of the capsule, and repeated instrument manipulation often leaves the capsule edges difficult to repair under physiologic tension, if at all. This suspension technique allows for adequate visualization of the central and peripheral compartments in the setting of a T-capsulotomy while preserving the native hip capsule for later, tension-free repair.
Technical pearls
We have described the technique in detail in a technical paper by Federer and colleagues currently in press. Several pearls to the technique are described herein. Throughout the procedure, there is an emphasis on staging the central and peripheral compartments for, both, hassle-free visualization and work, in addition to capsular preservation.
Standard supine hip arthroscopy technique is utilized for setup and for labral repair, osteochondroplasty. Capsulotomy and exposure of the central then peripheral compartments are the time-points within a case during which suspension takes place. Suture placement is delineated in the Table.
Central compartment capsulotomy demonstrating the reflected head of the rectus femoris in the medial aspect of the capsulotomy. Asterisk denotes reflected head of the rectus femoris.
Images: Mather RC, Karas V
Placement of the first (A) and second limb (B) of the proximal suspension suture in the central compartment is shown. This is done with the AP as the working portal viewing from the ALP. This suture is placed in a horizontal mattress fashion and will be suspended out of the AP portal.
Central compartment
The central compartment is accessed with an anterolateral portal (ALP) and a modified anterior portal (AP). An interportal capsulotomy is performed through the ALP, taking care to visualize gluteus minimus at the lateral aspect of the capsulotomy (Figure 1). We, most often, terminate the capsulotomy prior to visualization of the iliopsoas. It is crucial that enough capsule is retained on the proximal (acetabular side) for subsequent suspension and repair, thus we only touch up the capsule with an arthroscopic shaver. The goal is to achieve smooth, full-thickness capsular edges for placement of sutures while preserving as much capsule as possible.
Portal and suspension clamp setup on left hip of patient supine is shown. The cranial aspect of the patient is on the right of the image.
We place the first suspension suture on the medial portion of the proximal capsule. Using the AP as the working portal, a suture shuttling device of choice is used to pass a horizontal mattress suture (Figure 2a). Adequate slack is crucial when passing the second limb of the mattress stitch to ensure the suture shuttling device can grab and pass the suture through the tissue (Figure 2b). Once both limbs of the mattress stitch are passed, the cannula is removed and the two free ends of suture are drawn out of the AP portal and snapped in tension against the skin with a medium sized clamp (Figure 3). The tension of the clamp against the skin controls and retracts the capsule upwards, allowing for central compartment visualization. This creates capsular suspension for the medial portion of the proximal capsule while allowing for future manipulation or tightening of the capsular retraction throughout the case. We use the same technique to place a mattress stitch in the lateral portion of the proximal capsule through the AL working portal. Once suspension technique of the central compartment is complete, we have two horizontal mattress stitches are used to suspend the proximal (acetabular sided) capsule. The central compartment can be visualized and the proximal capsule is well-controlled to allow access to the acetabular rim and subspinous region while protecting the capsule for repair with this technique. (Figures 4a and b).
Visualization of the central compartment with the anterolateral portal as the viewing portal demonstrates a clear view to the labrum with retracted capsule (a). Visualization of subspine from anterolateral portal (b) is shown.
Peripheral compartment
We prefer to use a distal anterolateral (DALA) portal that is typically in line with the ALP and 4 cm distal. Through the DALA portal, RF ablation is used to clear pre-capsular fat and visualize the interval between the iliocapsularis muscle (ICM) and gluteus minimus. A T-capsulotomy is extended perpendicularly from the interportal capsulotomy to the intertrochanteric line. Once again, focus is placed on making a single, smooth longitudinal “T” cut in the capsule.
Peripheral compartment viewed through the anterior portal with initiation of osteochrondroplasty with excellent visualization of the cam lesion as well as medial and lateral base of the femoral neck is shown.
Capsular suspension is achieved with the suture shuttling device inserted through the DALA portal. Again mattress sutures are used for suspension. Sutures are placed on tension in the AL portal, lateral leaflet first (Figure 5). We typically suspend the medial leaflet with a single suture through the DALA portal. Of note, the medial leaflet is retracted under less tension than the aforementioned capsular leaflets to allow for mobility of surgical instruments during femoral osteochondroplasty. On occasion, after both the lateral and medial leaflets are suspended, the proximal portion of lateral leaflet obstructs proper visualization (Figure 6a). If this is the case, a single additional retraction suture may be placed and retrieved through the ALP just lateral to the apex of the lateral leaflet to achieve better visualization (Figures 6 b and c).
Proximal portion of the lateral leaflet of the peripheral compartment obstruction visualization after one medial and one lateral suspension suture visualization through the anterior portal (a) is shown. Placement of second stitch in the lateral capsule viewing from the anterior portal (b) is seen. Suspension of lateral capsule with visualization of cam lesion as well as lateral synovial folds (c) is shown.
After using two or three sutures for adequate exposure of the peripheral compartment, the ALP is used as the working portal for addressing peripheral compartment pathologies (Figure 7). Typically, the medial leaflet is more mobile and the bur can be brought through the ALP to reach the furthest lateral portions of cam lesions.
Capsular repair
When repairing the capsule, all traction is released from capsular suspension. Though existing sutures can be used, we find that efficient use of a suture shuttling device allows the sutures to be replaced faster than using existing sutures — the time savings is due primarily to reducing the risk of suture entanglement. In addition, passing new sutures allows for optimal placement to maximize the quality of the closure. The longitudinal T-capsulotomy incision is repaired first with three evenly placed sutures, distally to proximally, with stand arthroscopic knot-tying technique. We typically use five single-stitch sutures to close the full T-capsulotomy.
Capsular suspension is a safe, reproducible and beneficial on many levels. As a newly described approach to capsule retraction, there are several pearls to help avoid possible difficulties. Increasing evidence demonstrates the critical role of the iliofemoral ligament and capsular closure in normal hip biomechanics. There is often difficulty in creating proper visualization while still leaving enough capsule to be adequately repaired, particularly when concomitant subspinous decompression is indicated. Our simple capsular suspension technique allows for reliable retraction of the capsule while preserving the native capsule edge for an anatomic repair after treatment of central and peripheral compartment pathology.
References:
Benali Y, et al. Arthroscopy. 2009; doi: 10.1016/j.arthro.2009.01.012.
Chow RM, et al. Arthrosc Tech. 2013; doi: 10.1016/j.eats.2013.08.006.
Federer, et al. Arthroscopy Tech. 2015; In press.
Frank RM, et al. Am J Sports Med. 2014; doi: 10.1177/0363546514548017.
Harris JD, et al. Arthrosc Tech. 2013; doi: 10.1016/j.eats.2012.11.007.
Martin HD, et al. Arthroscopy. 2008; doi: 10.1016/j.arthro.2007.08.024.
Matsuda DK. Arthroscopy. 2009; doi: 10.1016/j.arthro.2008.12.011.
Myers CA, et al. Am J Sports Med. 2011; doi: 10.1177/0363546511412161.
Suslak AG, et al. Arthrosc Tech. 2012; doi: 10.1016/j.eats.2012.02.001.
Peripheral compartment viewed through the anterior portal after labral repair and prior to osteochondroplasty within the peripheral compartment is seen.
For more information:
Richard C. Mather III, MD; Vasili Karas, MD, MS; and Andrew E. Federer, MD, can be reached at Department of Orthopaedics, Duke University School of Medicine, 2301 Erwin Rd., Durham, NC 27710. Mather’s email: chad.mather@gmail.com; Karas’s email: vasili.karas@duke.edu; Federer’s email: andrew.federer@dm.duke.edu.
Struan H. Coleman MD, PhD, can be reached at Hospital for Special Surgery, 535 East 70th St., New York, NY 10021; email: colemans@hss.edu.
Shane J. Nho, MD, MS, can be reached at Healthy Hip Clinic, Section of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Midwest Orthopedics at Rush, 1611 W. Harrison St., Suite 300, Chicago, IL 60612; email: sjaynho@rushortho.com.
Disclosures: Mather reports he has stock or stock options for MD, and is a paid consultant for Pivot Medical, Smith & Nephew, Stryker and KNG Health Consulting. Coleman reports he receives IP royalties from and has stock or stock options in Blue Belt Technologies, has stock or stock options in Cymedica Orthopedics and is a paid consultant for Stryker Pivot Medical. Nho reports he receives research support from Allosource, Arthrex Inc., Athletico, DJ Orthopaedics, Stryker, Linvatech, Miomed and Smith & Nephew; and is a paid consultant for Ossur and Stryker. Karas and Federer report no relevant financial disclosures.