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Current Concepts With Video Illustrations

Capsular Management During Hip Arthroscopy: FromFemoroacetabular Impingement to Instability

Asheesh Bedi, M.D., Gregory Galano, M.D., Christopher Walsh, M.D., and Bryan T. Kelly, M.D.

Abstract: Advances in the ability to treat various soft-tissue and osseous pathologic conditions of thehip arthroscopically have been predicated on an improved exposure of the pathology of the central,peripheral, and peritrochanteric compartments. The management of the capsule is critical and mustallow for an improved exposure without compromising stability and kinematics of the hip. Describedapproaches have included capsulectomy, limited capsulotomy, extensile capsulotomy, capsularplication, and capsular shift. The selected approach must consider various factors, including symp-tomatic complaints, underlying hyperlaxity, specific mechanical pathology, and surgical expertise.Universally using a single technique without consideration of the complex mechanical and anatomicfactors unique to each patient may result in incomplete treatment of the pathoanatomy or iatrogenicinstability. This article reviews the anatomy of the hip capsule and provide a diagnosis-basedconsideration of capsular management during hip arthroscopy. The senior author’s preferred tech-niques are also presented.

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Hip arthroscopy has gained considerable popu-larity in recent years as a minimally invasive

urgical approach to address various symptomaticisorders of the hip, including femoroacetabularmpingement (FAI), labral tears, snapping hip syn-romes, and instability. As such, there has been aapid evolution of both instrumentation and tech-iques used in hip arthroscopy. Advances in the abil-

From MedSport, Division of Sports Medicine and ShoulderSurgery, University of Michigan (A.B., C.W.), Ann Arbor, Michi-gan; and the Center for Hip Pain and Preservation, Hospital forSpecial Surgery (G.G., B.T.K.), New York, New York, U.S.A.

The authors report no conflict of interest.Received July 18, 2011; accepted August 9, 2011.Address correspondence to Asheesh Bedi, M.D., MedSport, Uni-

versity of Michigan, 24 Frank Lloyd Wright Dr, Lobby A, AnnArbor, MI 48106, U.S.A. E-mail: abedi@umich.edu

© 2011 by the Arthroscopy Association of North America0749-8063/11459/$36.00doi:10.1016/j.arthro.2011.08.288

Note: To access the videos accompanying this report, visit the

aDecember issue of Arthroscopy at www.arthroscopyjournal.org.

1720 Arthroscopy: The Journal of Arthroscopic and Related Surg

ty to treat various soft-tissue and osseous pathologiconditions of the hip arthroscopically have been pred-cated on an improved exposure of the pathology ofhe central, peripheral, and peritrochanteric compart-ents. In this regard, surgical management of the

apsule is critical and must allow an improved expo-ure without compromised stability of the hip (Table). Described approaches have included capsulec-omy, limited capsulotomy, extensile capsulotomy,apsular plication, and capsular shift. The selectedpproach must consider various factors, includingymptomatic complaints, baseline hyperlaxity, spe-ific mechanical pathology, and surgical expertise.niversally using a single technique without con-

ideration of the complex mechanical and anatomicactors unique to each patient may result in incom-lete treatment of the pathoanatomy or iatrogenicnstability. This article will review the anatomy ofhe hip capsule and provide a diagnosis-based con-ideration of capsular management during hip ar-hroscopy. The senior author’s preferred techniques

re also presented.

ery, Vol 27, No 12 (December), 2011: pp 1720-1731

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1721CAPSULAR MANAGEMENT DURING HIP ARTHROSCOPY

CAPSULAR ANATOMY

The hip capsule is a fibrous lining that providesstability, protection, and the blood supply for the hipjoint. From its acetabular attachment, it extends later-ally to surround the femoral head and neck and isattached anteriorly to the intertrochanteric line, supe-riorly to the base of the femoral neck, posteriorlysuperomedial to the intertrochanteric crest, and in-feriorly to the femoral neck near the lesser trochan-ter.1 The anterosuperior portion of the capsule ishickest, because this is where maximal stress oc-urs while one is standing, whereas the posteroin-erior capsule is thinner and more loosely attached.he thick anterosuperior capsule often needs to beddressed with arthroscopy for FAI, because this istypical location for focal rim impingement and

oss of femoral offset.The capsule is composed of internal and external

bers. The internal fibers comprise the circular zonarbicularis, which forms a collar around the femoraleck.2,3 The fibers of the zona orbicularis are partiallylended with fibers from the ischiofemoral ligament.4

The internal fibers of the capsule are lined with syno-vium and contact the femoral head. The external fibersrun longitudinally and are made up of the iliofemoral,ischiofemoral, and pubofemoral ligaments.1,4 Each ofthese ligaments has distinct functions that are impor-

TABLE 1

The management of the capsule is critical and must allow for anthe hip.

Universally using a single technique may result in incomplete treaPreservation or repair of the iliofemoral ligament is critical during

instability, and/or dysplasia.The zona orbicularis provides hip stability against distraction forcThe medial femoral circumflex artery is the main vascular supply

arises near the femoral attachment of the capsule and can sustaThe indirect head of the rectus tendon can be visualized through

landmark to guide rim resection, anchor placement, and labral rArthroscopic visualization in the peripheral compartment is critica

intermuscular plane between the inserting fibers of the gluteus mIf the plane for T-capsulotomy is accurately identified, the medial

lateral capsule translates laterally from the gluteus minimus toThe T-capsulotomy should stop proximal to the zona orbicularis t

artery.The T-capsulotomy provides an excellent view of the head-neck j

circumferential restoration of femoral offset. It is reparable withOverzealous capsulotomy without repair or capsulectomy can resu

tant to the capsule (Fig 1). m

LIGAMENTS

Iliofemoral Ligament

The iliofemoral ligament (Y ligament of Bigelow)makes up the anterior part of the capsule and is shapedlike an inverted “Y.” It originates in the area betweenthe anteroinferior iliac spine (AIIS) and acetabular rimand divides into superior and inferior branches as itcrosses the joint.2,5 The superior-lateral branch has aorizontal course and inserts proximally along thentertrochanteric line anterior to the hip joint, whereashe inferior-medial branch has a more vertical coursend inserts distally along the intertrochanteric lineFig 1).4 The action of the iliofemoral ligament restricts

extension of the hip, providing a static restraint with fullhip extension, and allows upright posture to be main-tained without constant muscular action.2,6 Hewitt etl.5,6 showed that the iliofemoral ligament is stiffer and

withstands greater force than either the ischiofemoralligament or the pubofemoral ligament, suggesting that itsinsufficiency is associated with anterior hip instabilityand dislocations. In this regard, preservation or repair ofthe iliofemoral ligament may be of critical importanceduring hip arthroscopy, particularly for patients withhyperlaxity, anterior instability, and/or anterior acetabu-lar undercoverage (dysplasia).

Martin et al.4 recently studied the anatomy anduantitative contributions of the hip capsular liga-

y Points

ed exposure without compromising stability and kinematics of

of FAI or iatrogenic instability.throscopy, particularly for patients with hyperlaxity, anterior

ng like a locking ring around the neck of the femur.femoral head. The blood supply of the femoral head thereforeage in overzealous, distal transverse capsulotomies.portal capsulotomy and is a very important arthroscopic

ide placement of an ideal T-capsular incision in thes and iliocapsularis.e translates medially from the pull of the iliocapsularis, and thee separation of the 2 limbs of the iliofemoral ligament.

injury to the terminal branch of the lateral femoral circumflex

as distal as the intertrochanteric line and allows foro-side stitches to restore joint anatomy and stability.trogenic hip instability after arthroscopy.

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1722 A. BEDI ET AL.

observed to originate between the AIIS and the iliacportion of the acetabular rim. Its insertion was consis-tently noted to be on a bump located on the distalintertrochanteric line (Fig 2). The lateral arm originatessuperior to the medial arm, closer to the AIIS, andtraverses more horizontally along the neck of the femur,covering the orbicular ligamentous fibers running per-pendicular to the lateral arm at its distal portion. Thelateral arm of the iliofemoral ligament was shown toinsert on the anterior greater trochanteric crest and hasdual control of external rotation in flexion and bothinternal rotation and external rotation in extension.

Ischiofemoral Ligament

The ischiofemoral ligament makes up the posteriorpart of the capsule. It originates from the ischial rim ofthe acetabulum, follows the spiral of the iliofemoralligament as it crosses the joint, and inserts around theposterior aspect of the femoral neck (Fig 1).1,2,5 Theschiofemoral ligament crosses the hip capsule in 2ands, with the more superior band arching across theemoral neck to blend with the zona orbicularis,

hereas the inferior band inserts more posteriorly

long the intertrochanteric crest (Fig 2).4 The mainaction of the ischiofemoral ligament is to resist inter-nal rotation as well as adduction.2,4,6 The ischiofem-oral ligament is significantly weaker than the iliofem-oral ligament, with either the superior or inferior halfof the iliofemoral ligament being stronger than theischiofemoral ligament in its entirety.5

Pubofemoral Ligament

The pubofemoral ligament resembles a sling, run-ning inferior to the medial arm of the iliofemoralligament and medial and inferior to the iliopectinealeminence, originating at the pubic portion of the ace-tabular rim and the obturator crest of the pubic boneand attaching distally to the femoral neck (Fig 1).Fibers from the pubofemoral ligament blend with themedial arm of the iliofemoral ligament. The sling ofthe pubofemoral ligament also wraps inferiorly aroundthe neck of the femur and inserts inferior to the is-chiofemoral ligament along the posterior intertrochan-teric crest (Fig 2). The pubofemoral ligament controlsexternal rotation in extension together with the medial

IGURE 1. (A) Anteroposterior view of hip showing ilio-emoral and pubofemoral ligament. The capsular insertionistally to the intertrochanteric line should be noted. (B)osterior view of hip showing ischiofemoral ligament andelation to obturator externus tendon. (Reprinted with per-ission from Wesley Norman, Ph.D.)

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and lateral arms of the iliofemoral ligament.4

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1723CAPSULAR MANAGEMENT DURING HIP ARTHROSCOPY

Zona Orbicularis

Unlike the longitudinally oriented fibers of the outercapsule, the inner capsule fibers of the zona orbicularisrun in a circular pattern. The zona orbicularis encirclesthe femoral neck, comprising the narrowest area withinthe capsule. It provides hip stability against distractionforces, acting like a locking ring around the neck of thefemur (Fig 3).3 The zona orbicularis is an importantlandmark during hip arthroscopy and may need to bedivided and repaired after extensile capsulotomies thatare performed to address peripheral compartment pathol-ogy that may extend distally to the level of the intertro-chanteric line.

Ito et al.3 recently studied the contribution of thezona orbicularis to hip stability in distraction. In 7cadaveric hip specimens from male donors, the femurwas distracted from the acetabulum in a directionparallel to the femoral shaft with the hip in the neutralposition. Eight sequential conditions were assessed: (1)intact specimen (muscle and skin removed), (2) capsulevented, (3) incised iliofemoral ligament, (4) circumfer-entially incised capsule, (5) partially resected capsule

FIGURE 2. (A) Line drawing of left hip anterior ligaments. A,intertrochanteric knob, insertion of iliofemoral ligament medialarm; B, intertrochanteric crest, insertion of iliofemoral ligamentlateral arm; C, iliopectineal eminence, medial to insertion ofpubofemoral ligament. The arrows indicate the orbicular ligament.(B) Line drawing of left hip posterior ligaments. A, insertion ofsuperior band of ischiofemoral ligament, which is anterior tomidaxis of greater trochanter; B, inferior band of ischiofemoralligament; C, point at which zona orbicularis blends with ischio-femoral ligament; and D, origin of lateral arm of iliofemoralligament. The arrow indicates the sling of the pubofemoral liga-ment and inferior orbicular ligament. (Reprinted with permissionfrom Martin et al.4)

(distal to the zona orbicularis), (6) completely resected

capsule, (7) radially incised labrum, and (8) completelyresected labrum. The reduction of the distraction loadwas greatest between the partially resected capsule phaseand completely resected capsule phase at 1-, 3-, and5-mm joint distraction. The proximal to middle part ofthe capsule, which includes the zona orbicularis, acts likea locking ring around the neck of the femur and is a keystabilizing structure of the hip in distraction.

VASCULAR SUPPLY

In addition to providing ligamentous stability, amajor function of the hip capsule is to deliver thevascular supply to the acetabulum and femoral head.A cadaveric study by Kalhor et al.7 showed that 4main vessels provide the blood supply to the hipcapsule in a periacetabular vascular ring: the superiorgluteal artery, the inferior gluteal artery, the medialfemoral circumflex artery, and the lateral femoral cir-cumflex artery (Figs 4-6). The hip capsule receives itsproximal blood supply from the superior and inferiorgluteal arteries, which supply the posterior and pos-terosuperior aspect of the hip capsule. The distal bloodsupply arises from the medial and lateral femoralcircumflex arteries, which supply the anterior cap-sule.7,8 The medial femoral circumflex artery is the

ain supplier of the femoral head,7,9 although in 2 of0 specimens, Kalhor et al. noted an anatomic varia-ion in which the inferior gluteal artery was the mainupplier of the femoral head. The blood supply of theemoral head therefore arises near the femoral attach-ent of the capsule and can sustain damage in over-

FIGURE 3. Inner surface of capsule, showing the zona orbicularis

wrapped around the femoral neck, constituting a narrow areawithin the capsule. (Reprinted with permission from Ito et al.3)

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1724 A. BEDI ET AL.

zealous, distal transverse capsulotomies (Figs 4-6).7

Capsulotomies or capsulectomies that are performedfor improved exposure and instrumentation of the hipduring arthroscopy must respect these vascular planesto minimize the risk of avascular necrosis or devas-cularized periarticular soft tissues. If an extensile cap-sulotomy to address peripheral compartment pathol-ogy is necessary, it should be made between the lateraland medial synovial folds and parallel with the fem-oral neck to avoid injury to the retinacular perfusingbranches of the medial and lateral femoral circumflexarteries. The distal-most extent of a capsulotomy T-cut overlying the femoral head-neck junction as itapproaches the intertrochanteric groove will run intothe terminal ascending branch of the lateral femoralcircumflex artery, which should be avoided if possible

FIGURE 4. Anterolateral aspect of right hip after detachment ofbductor, rectus femoris, and tensor muscles, showing a capsularranch and an anastomosis between the ascending branch of theateral femoral circumflex artery and the supra-acetabular branch ofhe superior gluteal artery. 1, greater trochanter; 2, vastus lateralisuscle; 3, vastus intermedius muscle; 4, tensor fasciae latae mus-

le (turned medially and distally); 5, lateral femoral circumflexrtery; 6, iliopsoas muscle; 7, ascending branch of lateral femoralircumflex artery; 8, hip joint capsule (femoral attachment); 9,nterior end of supra-acetabular branch of superior gluteal arterynastomosing with lateral femoral circumflex artery; and 10, infe-ior iliac spine (rectus femoris tendon detached). (cran, cranial; lat,ateral.) (Reprinted with permission from Kalhor et al.7)

to avoid excessive bleeding.

MUSCULAR ATTACHMENTS

Of the many muscles that span the hip joint, therere a select few that play a critical role in the functionf the hip capsule. The first is the iliocapsularis, aesser-known muscle overlying the anteromedial hipapsule.10,11 The iliocapsularis originates from the in-

ferior border of the AIIS and the anteromedial hipcapsule and inserts just distal to the lesser trochan-ter10,11 (Fig 7). Research has shown that contraction ofthe iliocapsularis muscle tightens the hip capsule andcan help to stabilize the femoral head.10,11 Ward etal.11 observed a more prominent iliocapsularis musclein dysplastic hips compared with nondysplastic hipsduring surgery. This finding was recently supportedby Babst et al.,10 who found less fatty infiltration andhypertrophy of the iliocapsularis muscle in dysplastichips compared with hips with excessive acetabularcoverage. Apart from its function as a dynamic stabi-lizer of the joint, the iliocapsularis is an importantlandmark intraoperatively in that its anterolateral bor-der is described as the ideal location for the capsu-lotomy in anterior total hip arthroplasty12 and its an-eromedial border can be used during a modifiedmith-Peterson approach to periacetabular osteotomy

o identify the joint capsule.13 In addition, the iliocap-sularis is helpful in identifying the iliopsoas tendonduring anterolateral or direct lateral approaches.14

FIGURE 5. Posterolateral aspect of right hip after retraction ofgluteal muscles and short external rotators to show periostealarteries as well as supra-acetabular branch of superior gluteal arterybefore capsulotomy. 1, greater trochanter; 2, hip capsule; 3, sciaticnerve; 4, short external rotators (obturator internus and gemellusmuscles) detached from greater trochanter and retracted; 5, acetab-ular branch of inferior gluteal artery; and 6, supra-acetabular

branch of superior gluteal artery. (cran, cranial; med, medial.)(Reprinted with permission from Kalhor et al.7)

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1725CAPSULAR MANAGEMENT DURING HIP ARTHROSCOPY

Similarly, arthroscopic visualization in the peripheralcompartment is of paramount importance to guideplacement of an ideal T-capsular incision in the inter-muscular plane between the inserting fibers of thegluteus minimus and iliocapsularis (Fig 7).

The iliopsoas consists of the psoas muscle and theiliacus muscle. The psoas muscle originates at thetransverse processes of T12 to L5. The iliacus muscleoriginates at the superior two-thirds of the iliac fossa.The muscle belly of the iliopsoas is formed from thecombined psoas and iliacus, and the attachment of theiliopsoas is to the lesser trochanter. The iliopsoasmuscle functions as a hip flexor and plays a role inmaintaining erect posture. The iliopsoas tendon islocated lateral to the iliopectineal eminence when thehip is in full flexion.15 When the hip is extended, theendon is displaced medially and is intimately associ-ted with the anteromedial joint capsule.15

During hip arthroscopy, the iliopsoas tendon isfound in the space between the anterior zona orbicu-laris and anterior labrum proximal and anterior to themedial synovial fold. Understanding this anatomy can

FIGURE 6. Hip from posterior view, showing periacetabular vas-cular ring and anastomoses between distal and proximal vessels. 1,superior gluteal artery; 2, inferior gluteal artery; 3, medial femoralcircumflex artery; 4, lateral femoral circumflex artery; and 5,perforating vessels (cut surface). (Reprinted with permission fromKalhor et al.7)

help to guide an accurate psoas tendon lengthening

through a transcapsular approach in the central com-partment or in the peripheral compartment.

The gluteus minimus muscle originates from boththe external surface of the ilium and the inside of thepelvis at the sciatic notch.16 It inserts on the antero-superior hip capsule, as well as its main insertion onthe greater trochanter (Fig 7). Depending on the po-sition of the hip, the gluteus minimus can act as aflexor, internal rotator, external rotator, or abductor.The inserting fibers of the gluteus minimus muscle onthe anterosuperior hip capsule are an important land-mark that can be reproducibly visualized in the pe-ripheral compartment during arthroscopy. Identifica-tion of the intermuscular plane between the insertingfibers of the minimus and the iliocapsularis is rou-tinely performed by the senior authors and allows forprecise capsular incision that avoids iatrogenic injuryto these muscle-tendon units and the underlying vas-cular supply to the hip (Fig 7). This T-capsulotomyprovides an excellent view of the head-neck junctionas distal as the intertrochanteric line and allows forcircumferential restoration of femoral offset. Further-more, it is easily reparable with side-to-side stitches torestore the anatomy and stability to the joint.

CAPSULAR MANAGEMENT IN FAI

The successful arthroscopic treatment of FAI ispredicated on accurate diagnosis as well as a completeintraoperative exposure and correction of the soft-tissue and osseous pathology. Recent studies haveestablished that an incomplete correction and the per-sistence of residual deformity comprise the most com-mon cause of failed arthroscopic surgery.17,18 Inade-quate capsulotomy and retraction are frequentlycontributory to the inadequate correction. In this re-gard, capsular management during hip arthroscopy iscritical to allow for complete exposure without com-promise of postoperative hip stability and kinematics.

A capsulectomy is one described approach for vi-sualization in the peripheral compartment. With thistechnique, standard arthroscopic portals are used toaccess the central compartment in traction. Labraltears, chondral defects, loose bodies, and synovitis areaddressed, and areas of focal rim impingement areidentified and confirmed based on the location oflabral and chondral injury. A limited, interportal cap-sulotomy may be performed to expose the extracap-sular side of the rim to allow for recession and anchorplacement for labral repair under direct visualization.After central compartment pathology is treated, the

traction is removed and the hip flexed to create po-

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1726 A. BEDI ET AL.

tential space in the peripheral compartment. With anoscillating shaver blade or radiofrequency probe, theanterior and/or superior capsule overlying the camdeformity is resected. The amount of resected capsuleis variable and is the minimum required to fully visu-alize and correct the osseous deformity. Capsulectomyoffers the benefit of reasonable exposure of the camdeformity without the need to retract capsular tissue.Furthermore, it eliminates pathologic capsular tissuethat may generate pain and contribute to soft-tissueimpingement or stiffness of the hip in certain cases.However, capsulectomy does irreversibly alter theanatomy and integrity of the ligaments. As discussedin the previous review of the capsular anatomy, com-promised integrity of the iliofemoral ligament mayresult in iatrogenic pain or instability in certain termi-nal positions of hip range of motion, particularly inpatients with underlying hyperlaxity or dysplasia.

OUR PREFERREDAPPROACH: CAPSULOTOMY

We have used a controlled and reproducible se-quence of capsulotomy followed by capsular repair to

FIGURE 7. (A) The gluteus minimus (1) lies on the lateral limb ohe medial limb of the T-cut. The T-cut (yellow line) uses this intermf the plane is accurately identified, the medial capsule translates meaterally from the gluteus minimus to further facilitate separationlane for T-capsulotomy (yellow line) between abductors and ilio

thoroughly expose and address all pathology of the

central and peripheral compartment while preservingthe anatomy and integrity of the ligaments. We typi-cally use a standard anterolateral portal and modifiedanterior portal to safely access the central compart-ment in traction. Whereas preoperative imaging (includ-ing 3-dimensional computed tomography) is used todefine the precise location and geometry of rim andfemoral impingement lesions, intraoperative findings ofsynovitis as well as chondral and labral injury are used toconfirm the location of symptomatic osseous patho-logy (Video 1, available at www.arthroscopyjournal.org). By use of a beaver blade, an interportal capsulot-omy is created with meticulous attention to remain in theplane between the labrum and femoral head. We preferto use a beaver blade rather than radiofrequency ablator,because this minimizes the risk of iatrogenic injury tothe labrum and chondral surfaces and preserves full-thickness capsular edges for repair. The length of theinterportal capsulotomy is adjusted by the findings of thecentral compartment and can be extended as posteriorlyas the piriformis tendon and as anteromedially as thepsoas tendon as needed. The indirect head of the rectustendon is visualized through the capsulotomy, with in-sertion directly lateral at the 12-o’clock position on the

-cut. The iliocapsularis capsular insertion of the iliacus (2) lies onr plane to achieve an extensile exposure of the head-neck junction.from the pull of the iliocapsularis, and the lateral capsule translates

limbs of the iliofemoral ligament. (B) Cadaveric photo showingris.

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1727CAPSULAR MANAGEMENT DURING HIP ARTHROSCOPY

landmark to guide rim resection, with most lesions lo-cated anterosuperiorly in the 12-o’clock to 2-o’clocklocation (Fig 8).

The interportal capsulotomy offers several advan-tages. Primarily, it allows for exposure of the extra-articular side of the labrum, rim, and/or pathologicimpingement lesions related to the AIIS (“subspine”impingement). This allows for controlled and preciseresection under direct visualization and protection ofthe periarticular soft tissues (including abductor mus-culature and direct and indirect heads of the rectustendon) from iatrogenic injury associated with limitedaccess from portals or entrapment within the bur.Furthermore, the interportal capsulotomy allows foranchor placement and suture passage for labral repairunder direct visualization, confirming a safe trajectoryfor drilling and allowing for a non-everting stitch thatpreserves labral function (Fig 8). The approach alsoallows for precise psoas or piriformis tendon length-ening through a transcapsular approach in select,symptomatic cases.

After the central compartment pathology has beenaddressed, the traction is removed and the camera ispositioned in the modified anterior portal for viewingdistally along the head-neck junction. The hip isflexed to enlarge the potential space of the peripheralcompartment. The anterior and anterosuperior capsuleoverlying the cam deformity and loss of offset can bedirectly visualized. A distal anterolateral portal is sub-sequently established, and a Wissinger rod is intro-

FIGURE 8. (A) Arthroscopic photo after interportal capsulotomyshaver tip (proximal anterolateral portal) shows the indirect head ofat a 12-o’clock position. The capsule (2) is reflected to expose the exdetachment of the labrum (3). (B) After rim recession, drill holeslabrum is indicated by an asterisk. (C) Non-everting stitch (arrowsfunction.

duced to identify the plane immediately superficial to

the capsule. There is a fat plane that separates themedial and lateral limbs of the iliofemoral ligamentthat represents the separation between the insertingfibers of the iliocapsularis tendon medially and thegluteus minimus tendon laterally. Once the fat plane isidentified, a clear separation between the 2 muscleplanes can be developed. There is a broad attachmentof the iliocapsularis tendon onto the capsule, and theinitial cut is made with a radiofrequency probe tosimultaneously define the intercapsular plane andachieve hemostasis, because the capsule can be in-flamed and erythematous particularly in the setting ofsevere impingement. If the plane is accurately identi-fied, the medial capsule translates medially from the pullof the iliocapsularis, and the lateral capsule translateslaterally from the gluteus minimus to further facilitateseparation of the 2 limbs of the iliofemoral ligament.The final cut is made sharply with a beaver bladeknife (Video 2, available at www.arthroscopyjournal.org). It is important to avoid medial or lateral deviationof the cut to avoid inadvertent muscle trauma, and the cutshould stop proximal to the zona orbicularis to avoidinjury to the terminal branch of the lateral femoral cir-cumflex artery. In cases where loss of femoral offsetextends distally, the capsulotomy can be extended dis-tally through the zona orbicularis to the intertrochantericline and originating fibers of the vastus intermedius aslong as the crossing vessel of the lateral femoral circum-flex artery is visualized and avoided.

The T-capsulotomy affords several advantages. The

hip. The camera is positioned in the modified anterior portal. Thetus tendon (1) inserting at the most lateral aspect of the acetabulumicular side of the hip joint and can allow for a rim recession without) for labral repair can be prepared under direct visualization. Theto repair the labrum without eversion to maintain the suction-seal

of leftthe rectra-art

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1728 A. BEDI ET AL.

tion of the medial-lateral and proximal-distal marginsof the femoral deformity without irreversibly compro-mising ligament integrity (Fig 9). Elevation of thelateral flap and internal rotation of the hip allow fordirect visualization of the superior and posterosuperiorhead-neck junction, whereas external rotation and el-evation of the medial flap allow access to the antero-medial and inferior head-neck junction. In this regard,the exposure and correction of femoral and acetabulardeformity that can be achieved are not dissimilar tothose which can be achieved through an open surgicaldislocation (Fig 9). Recently, Bedi et al.19 comparedhe efficacy of arthroscopic osteoplasty using thisechnique with open surgical dislocation to treat FAIysmorphology in a consecutive series of 60 patients.rthroscopic osteoplasty was found to restore head-eck offset and achieve depth, arc, and proximal-distalesection with equivalent efficacy to open surgicalislocation for anterior and anterosuperior cam andocal rim impingement lesions.

At the conclusion of the procedure, the medial andateral capsular flaps are anatomically reduced. By usef a suture passer through the distal anterolateral por-

al and a tissue penetrator through the proximal an-erolateral portal, anatomic side-to-side stitches arelaced from distal to proximal until a complete clos-re is achieved (Fig 9, Video 3 [available at wwwarthroscopyjournal.org]). Typically, 3 to 4 stitches areequired. This preserves the integrity and structure ofhe iliofemoral ligament. Furthermore, in cases ofnderlying hyperlaxity, overlapping stitches can belaced to perform a functional capsulorrhaphy at theime of repair. The degree of overlap is defined forach individual patient based on symptoms and de-ired restriction of external rotation (Fig 9).

CAPSULAR MANAGEMENT OFHIP INSTABILITY

Hip instability from both traumatic and atraumaticauses is a recognizable source of pain and disability.he traumatic type can occur from high-energy inju-

ies such as motor vehicle accidents or sporting inju-ies in rugby, American football, soccer, biking, andkiing. Traumatic hip instability in athletes with asso-iated capsular injury has been well documented and

FIGURE 9. (A) Extensile exposure offemoral head-neck junction of left hipachieved by T-capsulotomy. The cam-era is positioned in the modified ante-rior portal. The well-preserved medial(M) and lateral (L) flaps for later re-pair should be noted. (B) Exposureallows for complete correction of fem-oral deformity in medial-lateral andproximal-distal planes to the safe mar-gin of both the superolateral and me-dial perfusing retinacular vessels. Thebur is positioned in the distal antero-lateral portal. The proximal margin ofosteoplasty is indicated by an arrow.(C) An anatomic side-to-side repair ofthe capsule is performed from distal toproximal, restoring the native tensionand anatomy of the iliofemoral liga-ment. The arrow shows a side-to-sidesuture shuttle loop. (D) Completed re-pair of T-capsulotomy, with side-to-sidestitches of medial and lateral flaps indi-cated by arrows. (asterisk, labrum.)

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1729CAPSULAR MANAGEMENT DURING HIP ARTHROSCOPY

illustrated in the literature. Moorman et al.20 identifiedhe triad of hemarthrosis, posterior acetabular rimracture, and iliofemoral ligament injury in a series ofmerican football players who had undergone hipislocation events. Atraumatic hip instability has aess discrete onset and may be associated with devel-pmental hip dysplasia or generalized hyperlaxityonditions, such as Ehlers-Danlos syndrome, Downyndrome, and arthrochalasis multiplex congenita. Al-hough the hip generally relies less on the soft tissuend more on bony constraints to maintain stability,eviation from the normal osseous anatomy, as occursn dysplasia, may place greater demands on the cap-ule and labrum. A hypertrophic labrum, enlargedigamentum teres, and thickened capsule are fre-uently encountered in the setting of underlying dys-lasia.21 Compromised collagen architecture in the

setting of generalized ligamentous laxity and mic-rotrauma from repetitive external rotation and axialloading can produce capsular redundancy overtime.22,23 In addition, injury to the soft tissues sur-rounding the hip may lead to persistent capsular re-dundancy resulting in recurrent instability.24,25 Recentstudies have also suggested that FAI may predisposepatients to instability in certain cases, because osseousimpingement in positions of terminal motion mayprecipitate levering of the femoral head, chondralshear injury (“contrecoup” injury), and secondary sub-luxation or dislocation.

Arthroscopic techniques for addressing the capsulein patients with hip instability have been described inthe literature.26 To reduce the volume of the capsule,hermal capsulorrhaphy and/or capsular plicationay be performed. Thermal capsulorrhaphy uses

adiofrequency energy to increase the temperaturef collagen in the capsule. The collagen fibers in theapsule are denatured and restructured by the highemperatures and produce a smaller capsule withnchanged mechanical strength.27 There is a short-erm loss of mechanical properties of the capsulehat is ideally restored through the tissue’s healingesponse.28 Philippon29 reported good results usinghermal capsulorrhaphy to reduce capsular volumen patients with hip capsular laxity, with an 82%eturn to preinjury, high-level athletics with mini-al or no pain. Currently, the senior authors do not

se thermal capsulorrhaphy because of concernsbout high failure rates and iatrogenic chondrolysishat have been reported in the shoulder litera-

ure.30-34

OUR PREFERRED APPROACH:CAPSULAR PLICATION

Capsular plication is the careful placement of su-tures to remove redundant capsular tissue and de-crease the volume of the joint capsule. Currently, mostauthors advocate arthroscopic suture capsular plica-tion to treat hip instability.26,35,36 Our preferred tech-ique for anterior capsular plication is to perform thetandard interportal capsulotomy as well as the verti-al limb of the T-capsulotomy as described earlier.he vertical and the horizontal limbs can then beverlapped with the repair to restore tension in theliofemoral ligament. We typically use a curveduture-passing device to penetrate 1 flap and grasphe passing suture loop with a penetrator throughhe other end. The side-to-side stitches are retrievednd tied arthroscopically in a standard fashion. Typi-ally, 3 or 4 sutures are placed in the vertical limb andor 3 in the horizontal. Care should be taken to not

ver-tighten the capsule, because this can limit exter-al rotation postoperatively. This arthroscopic “cap-ular shift” not only restores tension to the iliofemoraligament but also allows for augmentation in cases ofodest tissue quality by overlapping of the medial and

ateral capsular flaps.

COMPLICATIONS

Poor capsular management may predispose patientso certain complications after hip arthroscopy. Heter-topic ossification (HO) around the hip joint is notncommon after the open treatment of acetabular frac-ures as well as after hip arthroplasty. It occurs as newone formation in the capsule and musculature sur-ounding the hip as a response to trauma from injuryr surgery.37 Randelli et al.38 observed an overall HOate of 1.6% in a series of FAI patients who underwentip arthroscopy. In addition to postoperative chemicalrophylaxis with indomethacin, avoiding iatrogenicuscle trauma with passage of instruments and per-

orming capsulotomy in the intermuscular planes canelp to minimize the risk of HO with hip arthroscopyFig 10).

Overzealous capsulotomy without repair or capsu-ectomy can result in iatrogenic hip instability afterrthroscopy. Several case reports exist in the litera-ure on postoperative hip instability after arthros-opy.23,39,40 The first case involved an immediate dis-

location after FAI surgery that required supranormaltraction intraoperatively for retrieval of a broken

probe.23 In this case a capsulotomy with partial cap-

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1730 A. BEDI ET AL.

sulectomy had been performed, and the hip was sta-bilized only after mini-open capsular repair. The au-thor concluded that he would proceed with selectivecapsular repair in the future. The second case of post-operative instability occurred in a patient with re-cognized capsular laxity that had undergone caps-ulorrhaphy at the index procedure.40 Benali andKatthagen39 reported a case of postoperative hip sub-uxation after labral and lateral acetabular rim resec-ion that actually required conversion to a total hiprthroplasty. The importance of the labral “suctioneal” and zona orbicularis in restraining against axialistraction should be recognized, highlighting the im-ortance of capsular preservation and repair.This review is by no means exhaustive; additional

nformation on these topics may be found in the recentiterature.41-57

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