Name: Hip Arthroscopy Using a Novel, Capsule-Sparing Management Technique
Uploaded: 2026-09-17T00:00:00Z
Channel: Arthrex
Description: Craig S. Mauro, MD (Pittsburgh, PA), explains a capsule-sparing technique for accessing the joint during hip arthroscopy cases. Dr. Mauro discusses key anatomy and presents a case in which he used this novel capsulotomy technique to perform a cam resection.

<p>Craig S. Mauro, MD (Pittsburgh, PA), explains a capsule-sparing technique for accessing the joint during hip arthroscopy cases. Dr. Mauro discusses key anatomy and presents a case in which he used this novel capsulotomy technique to perform a cam resection.</p>

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VID1-010348-en-US | A | Hip Arthroscopy Using a Novel, Capsule-Sparing Management Technique

Craig Mauro

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Hip Arthroscopy Using a Novel, Capsule-Sparing Management Technique

Speaker  Hi, my name is Craig Morrow. I come from the University of Pittsburgh Medical Center, and I'm here today to discuss hip arthroscopy via a novel capsule sparing management technique. As we know, the hip capsule is a very important structure, including thickenings of the capsule that form the ligaments around the hip joint, much like the glenohumeral ligaments support the shoulder. The iliofemoral ligament. The ischiofemoral ligament. The pubofemoral ligaments support the hip joint with restraint in different degrees of rotation, and tensions provide function for the hip joint. Most importantly, the key anatomy for surgeons is that the iliofemoral ligament is the strongest inverted Y-shaped ligament that provides ultimate load to failure of about 320 to 350 Newtons. The iliofemoral ligament provides important rotational stability. It resists extension and external rotation, whereas the ischiofemoral ligament resists internal rotation and flexion, and the pubofemoral ligament stabilizes extension and abduction. Importantly for the surgeon as well, is that the Zona orbicularis provides a circumferential constraint and particularly is helpful with distraction stability. The ligaments provide important translational stability as well. The iliofemoral ligament is a primary restraint to anterior femoral head translation, and what we know from studies is that the capsulectomy, or inadequately repaired capsulotomies, lead to increased laxity, even with an intact labrum. The capsule also for function, provides important proprioception. The capsule is richly innervated with mechanical receptors, and disruption of the capsule may impair joint proprioception sense. Importantly for the rehabilitation, we know that the iliofemoral ligament reduces hip flexor workload by up to about 50% during walking. Speaker  And so for the surgeon, a complete capsular repair is associated with better clinical outcomes, lower revision rates. We know that location and size of the Capsulotomy and the repair success rates can also contribute to the post-operative state. The success of the postoperative hip arthroscopy or failure. Many studies have shown the importance of capsule function and capsule repair after hip arthroscopy. This study by Waterman et al showed that incomplete closure of the hip capsule can lead to decreased patient reported outcomes, increased conversion to total hip replacement, as well as other functional decline from inadequately treated hip capsule. This meta analysis by Cohen et al. Showed that complete capsule closure, regardless of capsulotomy type, was associated with improved patient reported outcomes across hip arthroscopy patients. So the capsulotomy options that we're discussing here include these three different types that are classically used for hip arthroscopy. The left image shows a periportal approach to hip arthroscopy, where small portals are utilized to access the central compartment. These may be expanded medially and laterally, but oftentimes not connected. The middle image shows an interportal capsulotomy in which those two access portals are connected, and again, this can be extended anteriorly or posteriorly to facilitate more mobility to the capsule, but also leads to a larger capsulotomy when that's performed. The right hand image shows a T shaped capsulotomy, in which case the Interportal capsulotomy primarily is used for access of the central compartment and the labrum, and the more distal limb is used to access the cam lesion for a T shaped capsulotomy. Speaker  The technique we're discussing here today is a combination of these techniques, where a periportal approach is used for the central compartment work and the labral repair, and a more distal limb through the iliofemoral ligament is performed to access the cam lesion. So the case I'll present today is a young adult male right. Groin pain in a C-shaped fashion. He's tried extensive physical therapy NSAIDs mildly improved the symptoms, but he's very limited with his sport which is primarily wrestling. His exam demonstrates very classic cam type impingement findings with loss of internal rotation pain with fader position. His imaging, as is shown here on the right side of the screen, demonstrates bilateral cam lesions right more significant than left, with well covered hip joints without evidence of dysplasia or other abnormalities. He underwent a local anesthetic injection, which provided complete relief of his symptoms for a short time, indicating a positive diagnostic effect. So our plan was to proceed with a diagnostic arthroscopy labral repair, as indicated as there was evidence of likely labral tear on the MRI and femoroplasty through the new novel capsule sparing approach. So this diagnostic arthroscopy, we access the hip through the standard anterolateral and Mid-anterior portals. Speaker  The flush fit cannulas are utilized through a five millimetres portal. This probe is being used through the Mid-anterior portal, and the diseased injured labrum and Chondrolabral junction are shown here with the probing. So in this case we elected to proceed with a labral repair. I made a third portal, a distal anterolateral portal, in which case the FiberTak drill guide is placed through the distal anterolateral portal and accesses the central compartment through that same five millimeter capsulotomy that was initially performed from the Mid-anterior portal. Once the anchor is placed, we. Then we use our CapsuleStitch to pass the shuttling suture for the labral repair. Care is taken when placing the anchor to not disrupt the capsule on the acetabular side. I do not in this technique expose the acetabular rim. So this is not a technique to be used when a pincer resection is done, but rather when we are focusing on an isolated labral repair without capsular disruption. So in this case, once the suture is passed, I then use a tape grasper to retrieve both the final repair suture, as well as the shuttling suture through the Mid-anterior portal. This facilitates any unwinding of the sutures so that they can be easily passed without any undue tension or compromise. We then do the final tensioning, which facilitates compression of the labrum back to the acetabular rim via the final repair suture. Speaker  So in this case we use two sutures and they are sequentially tensioned facilitating anatomic repair of the acetabular labrum. Elimination of the wave sign with complete preservation of the acetabular side of the capsule. Once the labrum has been completely repaired, the remainder of any central compartment work can be performed at this time before we access the Cam lesion distally. So at this point, we have moved the camera to the Mid-anterior portal. And I'm accessing the extracapsular space with my Apollo wand through the distal anterolateral portal. This is an important part of this technique. I need a complete exposure of the capsule to facilitate an accurate capsulotomy to the cam lesion. So in this case I'm taking my time exposing approximately to the level of the rectus tendon. Laterally, we take special care not to violate the gluteus medius and minimus muscle bellies, and immediately we access this to the iliocapsularis. As is seen here, the camera is in the Mid-anterior portal and the wand is being utilized through the distal anterolateral portal. And I am exposing the Extracapsular region to facilitate a safe access through the distal capsule. Once we've achieved full exposure of the capsule, I use my CapsuleCut blade to perform the distal capsulotomy. This is the key portion of the case which facilitates access to our Cam lesion. We utilize the CapsuleCut blade in longitudinally from the distal anterolateral portal, with the hip in about 45 degrees of flexion. Speaker  To facilitate a distal exposure of the cam lesion, I use fluoroscopy as well to confirm the level of the physeal scar. The capsulotomy begins at about the level of the zona orbicularis and travels distally down the femoral neck. Once the capsulotomy is performed, the key next step is to place traction sutures in the medial and lateral limbs of the Capsulotomy. In this case, I used the CapsuleStitch passer to pass one stitch from the distal anterolateral portal into the more medial limb and one stitch from the Anterolateral portal into the more superior lateral limb. This facilitates a window into the cam lesion working space. Once we have created these traction sutures, the camera is then placed inside the Capsulotomy to facilitate full access to the cam lesion. We then use our Apollo wand to remove any residual periosteum and disease tissue on the femur to fully expose the cam lesion and to understand the anatomy through this approach. Superiorly, we take this exposure and resection to the level of the retinacular vessels medially to the synovial fold, medially and proximally. Utilize fluoroscopy to help us to understand the proximal extent of the cam lesion. As we expose this to the level of the physeal scar. Once the full exposure is performed, then we use our five millimetres round Bur to perform the femoroplasty. Special care is taken to understand throughout the entire femoroplasty the location of the Retinacular vessels. Speaker  This facilitates a complete superior resection of the Cam lesion, but safely avoids any iatrogenic injury to the retinacular vessels. Once we have established the margins and boundaries of the Cam lesion, a complete femoroplasty is performed. We use fluoroscopy to help guide. We ensure we begin distally. This is a key function of a complete femoroplasty in my hands. Distal starting point, which facilitates a smooth transition between the normal femoral neck and the cam lesion. As we move up proximally on the femur. The hip at this point can be moved through ranges of motion and rotations to facilitate access to the different spots of the Cam lesion. Hip flexion provides access to the more distal portion of the Cam lesion. Oftentimes 40 to 50 degrees of flexion can be utilized for access distally. The hip can then slowly be brought into extension using the Arthrex hip arthroscopy table to facilitate more proximal resection and access to the physeal scar region. Internal and external rotation facilitates access to the medial and lateral portions of the Cam lesion as well, using a combination of extension and internal rotation access. Most proximally can be achieved and flexion external rotation allows more medial access to the cam lesion. This approach to the Hip is performed via a post hip arthroscopy technique. The benefit of this technique is that the superior cam lesions oftentimes need to be accessed with the hip in traction. Speaker  So at this point in the case while the femoroplasty is being performed, a post lis traction technique can allow and facilitate fine traction and distalization of the Cam lesion to access more of these more superior proximal lesions as well. Once the Femoroplasty has been performed and final radiographic images completed, I generally take the hip through a range of motion to ensure that there is no residual impingement. We then move toward our capsular closure. So in this case we use our CapsuleStitch to pass a FiberWire. In this case, this can be done with simple stitches or as seen here, a figure of eight type configuration can be used to anatomically close what is typically about a two centimetre distal capsulotomy. You can also use this opportunity to employ capsular plication techniques such as with LoopLoc, where the capsule volume can be shortened to provide a placation in the medial lateral direction. So in this case, a figure of eight suture was employed to provide an anatomic, appropriately tensioned repair of the distal capsulotomy technique. So special care is taken to use the CapsuleStitch to pass the FiberWire suture and visualize this both from the Intracapsular and extracapsular position to ensure an anatomic repair of the capsule. Once the sutures have been passed, the FiberWire sutures are tied down to complete the repair, or the LoopLoc is deployed to ensure that an anatomic repair is performed. Speaker  We then visualize the entirety of the capsule to ensure there are no areas of deficiency, especially proximally, where those five millimetres poke holes were performed to perform the labral repair. This capsule technique allows us to proceed with our very aggressive early rehabilitation. My post-operative protocol involves weight bearing as tolerated with normalization of the gait and discontinuation of crutches, usually at one week postoperatively we begin exercise post-operative day number one with a stationary bike with our physical therapists and a battery of home exercises. This distal capsule approach facilitates progression back to activity and running in sports at the 3 to 6 month mark very reliably. In conclusion, we have presented a minimally invasive approach that preserves capsular integrity for hip arthroscopy. It provides excellent access to the deformity, including large and distal cam deformities. It enables labral repair through a periportal approach. It enables a complete capsule repair with single sutures or a figure of eight suture with anatomic restoration of the distal iliofemoral ligament. This technique avoids the use of a complete interportal capsulotomy, which may compromise capsular integrity and may lead to poorer patient outcomes. The benefit of this technique is in the rehabilitation as well, which facilitates early weight bearing and rehabilitation. So in summary, I thank you for this opportunity to provide our hip arthroscopy technique via a novel capsule sparing management technique. Thank you.

Hip Arthroscopy Using a Novel, Capsule-Sparing Management Technique

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