Thank you for joining us tonight for the AOSSM Fellows webinar, Hip Capsule Management, with moderator and panelists, Dr. Alan Zhang, Dr. Michael Banfie, Dr. Richard C. Mather, and Dr. Shane Ngo. Dr. Alan Zhang is Associate Professor in Residence, Director of the Hip Preservation Center, Fellowship Director of Sports Medicine and Shoulder Surgery at the University of California, San Francisco, and practices at the Orthopedic Institute, San Francisco. Dr. Zhang also serves as a member of the AOSSM Fellowship Committee. I will turn this over to Dr. Zhang to begin and introduce the panelists. Thank you, Meredith. Thanks, everybody, for joining us. I want to introduce Dr. Michael Banfie next. He comes from the Curlin-Jobe Orthopedic Clinic, and he is a, as you can see, team physician for the Los Angeles Rams, as well as the Los Angeles Dodgers. He's also the Fellowship Director of the Curlin-Jobe Sports Medicine Fellowship, and he's an Associate Professor with the Cedars-Sinai Curlin-Jobe Institute. Following him, we'll have Dr. Shane Ngo give his portion of the talk, and he is an Associate Professor at Rush. He's part of the Midwest Orthopedics Group at Rush University. He's the Co-Director of their Sports Medicine Fellowship, the Section Head of their Young Adult Surgery Center. Okay, I'm going to get tired reading all of your titles, so you guys need to shorten this a little bit. And then, just kidding, Team Physician for the White Sox, Bulls, Fire, and the Steel. And then, of course, Dr. Chad Mather, who's from Duke. He's the Vice Chairman there of the Practice Innovation Section. And then he's also a part of the Duke Orthopedic Sports Medicine Center and specializing in hip arthroscopy. So we've got a great esteemed panel here with us today, and we're going to take you through quite a few things about the hip capsule. And then, okay, so this is how to submit a question. So Meredith, did you want to go through that, or do you want me to? Sure, I'll just describe. To submit a question on the platform, you will click the questions drop-down arrow on the right-hand side, and then you can submit your question through that. And I will send that to Dr. Zhang as the moderator. Right. And then, you know, as we're going through these talks, feel free to send it real-time, and I'll be happy to interrupt during the talks, as well, if there's a particular slide or something very interesting, or something that just doesn't make sense to you, just let us know, and we'll chime in and have a real-time discussion. Okay? All right, thanks. So let me start first. Okay. Let me just see here. Is everybody seeing my screen? Okay. All right. Okay, so here, let me shrink this. Okay, so first, I'm going to give a little bit of an introduction for the – let me shrink this guy here – there we go – okay, about the hip capsule. And then, so again, these are our panelists. We've got myself, Dr. Banfi, Dr. Ngo, and Dr. Mather. And I'm going to talk about a little bit of an introduction, as well as the periportal capsulotomy approach. Dr. Banfi is going to talk about the interportal capsulotomy. Dr. Ngo is going to talk about the T-capsulotomy. And then, Dr. Mather is going to talk about revision and reconstruction for the hip capsule. And then, we'll have some time for Q&A. And then, of course, if there's time, we'll also have a case that we can run through together. Okay, so in terms of the hip capsule, so this is the strongest ligament of the body, the iliofemoral ligament, also known as the Y ligament of Bigelow. So you can see here the iliofemoral ligament splits as it comes distally onto the femur. And then, there's kind of like a confluence of the ligament as it attaches onto the acetabulum. And then, this is the main part of the hip capsule that we're most concerned with when we're doing hip arthroscopy. The ischiofemoral ligament is the posterior extent of the capsule, and then the pubofemoral ligament on the inferior aspect of it. And then, in terms of the hip capsule, why is it important? Why does it matter? For one, it's very important for hip joint stability. So the iliofemoral ligament is a significant factor in terms of limiting extension and external rotation of the hip, in addition to the bony anatomy of the hip for helping stabilize the joint, as well as the labrum and the negative suction seal. The capsule is an important driving force because what we've seen is that as we've done more hip arthroscopy surgeries, there's been a lot of instances of iatrogenic post-operative instability after hip arthroscopy, and probably even more commonly, micro-instability. And so, this can happen when you do an excessive capsulotomy or capsulectomy, where you remove parts of it, over resection of the bone, especially the acetabulum, if you're debriding the labrum, you can lose the suction seal. And then even over-distraction, especially in people that are hypermobile, where you can really over-distract the joint too much, and that can affect their connective tissue underlying it. And then Dr. Safran wrote about micro-instability, so this is something good to keep in mind in terms of the exam for it, because it is pretty hard to pick up post-operatively when you're looking for some of these signs. A lot of patients may come in with hip pain after a hip scope, but you're not really sure what's going on. So, you want to definitely look out for some of the exams for the micro-instability of the hip. Okay. And then recently, we did a quantitative research analysis where we looked at MRIs of FAI patients, and we quantified the volume of the hip capsule, and then correlated that with patient symptoms. And we saw that thicker capsule volumes anteriorly was actually correlated with increased pain. So, at least to our knowledge, this is one of the first studies to show that there's some correlation with patient symptoms and actually anatomy of the hip capsule. Okay. So, in terms of the approach to capsule management, when you're doing a hip arthroscopy, these are some of our general principles. So, first, you want to minimize trauma during your hip distraction. Two, you want a pre-op plan for what type of joint injury, what kind of capsulotomy you might be doing based on what the hip arthroscopy procedure is. If it's going to be something relatively minimal, like a synovectomy, isolated labral repair, you may want to go for a more conservative capsule approach versus a large CAM lesion. You definitely want to be prepared to maximize your exposure. And then you also want to definitely protect the capsule during peripheral compartment work. So, when you're doing your burying, you don't want to eat up the capsule or accidentally resect it. So, being mindful of that. And we'll talk about some tips and pearls for that. And then at the end of the case, you want to evaluate your capsule. And more times than not, you're going to want to repair the capsule, especially if you're doing a bigger capsulotomy for it, just to make sure you don't run into those micro-instability problems as you're doing this in practice. Okay. So, in general, there's four main approaches to how you do a capsulotomy. The most conservative one is called puncture capsulotomy. And then the periportal capsulotomy, interportal, and T-capsulotomy. So, those go in order of small to larger capsulotomies. So, just to introduce to you guys, the puncture capsulotomy, this was described by Scott Martin. And in this case, you're not actually making any cuts in the capsule. You're only using the cannula in different orientation patterns to get into the capsule and do your work. So, you've got a proximal capsule portal that's kind of oriented more distally and laterally. So, you might do some of your CAM resection through this. You've got your normal anterolateral portal, both your mid and your direct anterior portal. So, basically, their papers show an image like this, where you've got multiple cannulas in there pointing in various directions for your orientation, and you're just kind of switching between these without doing anything major to the capsule. And the goal is to preserve the iliofemoral ligament. Okay. So, we looked at this, and then we did a little bit of a modification in terms of what we call the periportal capsulotomy. So, we use the anterolateral and the mid-anterior portals, two portals. And instead of cutting the iliofemoral ligament, we're still preserving it, but we do dilate around each capsule. So, the mid-anterior is the working portal, so you have to at least get your working cannula in there, which is about eight millimeters, sometimes like eight and a half millimeters. So, you're going to want to dilate that to about a centimeter, so you have room for that. And then the viewing portal, you can just dilate that to six to eight millimeters, just so you have enough room for your camera to move around without connecting the portals fully. So, the idea of the periportal, instead of an inner portal where you're connecting the two portals, you're leaving a bridge, a biliofemoral ligament there, and just dilating each side of it. Okay. And then, so this is essentially how we do it. We use an RF device to do it, so we're viewing from an anterolateral portal on the right hip here, and then we've got our RF in the mid-anterior portal, and we're just dilating a little bit in line. So, if we do actually need to make an inner portal cut, at least we can just connect those two in line with each other, and you can see we've got enough room for the cannula to move around, and it's quite mobile. And then here, we switch the camera, and now we're dilating the anterolateral portal, looking back on it, and then just kind of cleaning out some of the areas. And then you want to make sure you get peripheral on the capsule on the outer surface, so that it really gets loose. And then that's how we do the capsulotomy. And then once we're inside, so in this case on the left, you can see there's a lot of synovitis here, and a lot of times that kind of fills up the joint and can cloud some of your visualization. So here, we're just doing a synovectomy to increase our working space above the labrum, kind of mobilizing that capsular labral junction there approximately, and then opening that space up. And then here, after we've done a synovectomy, you can see there's a lot more space, and then you can kind of see the other fibers of the iliofemoral ligament coming across there as well. So those are kind of the first steps to creating our space. And then in terms of our outcomes, we reported this a couple of years ago, looking at two year outcomes, patients had a good improvement for this. And this is periportal capsulotomy for FAI patients without any hypermobility. BITEN scores all three or less, just regular FAI without joint laxity. So we didn't close any of these portals. And we saw that with this approach, patients were fine and they didn't have any signs of post-op instability or micro instability during the periportal on people without hypermobility. And then more recently, John Christopheretti's group in UT Southwestern came out with a study comparing their results for periportal versus interportal capsulotomy. And they saw that patients had similar results in terms of meeting MCID using each approach. And what they found was that for patients that had larger alpha angles, larger CAM lesions, those were the ones where they converted to an interportal capsulotomy. And of course, that leads to the hardest part about using a periportal capsulotomy is when you have to do a lot of peripheral compartment work in terms of taking down a large CAM lesion. So we just put out a technique approach about how we do our CAM resections for this, where you can still stay underneath the capsule and do a CAM resection. But it definitely takes a little bit more finagling compared to just doing an interportal or T-capsulotomy, where you can see that very clearly. So that's probably the hardest aspect. But in terms of a couple of technical pearls for that, we want to carefully undermine the capsule here. We're starting the thermoplasty after the labral repair, taking off the articular cartilage. I usually use an RF for that. That'll create some room. And at the same time, you'll mobilize the capsule a little bit. And then you take the hip through progressive flexion. So here the hips flex about 30 degrees and you can see how much more space that opens up for the burr. And then here we're starting our CAM resection. And you can see the capsule all around the screen here that's left intact. So I don't mind it anymore. But for some people, that could be really annoying for that to be in your field of view. But you can see we definitely have enough working room, especially as you start to progressively flex the hip. But we'll do 30 degrees, take the CAM, flex it more to 60 and then 90 degrees and then internal, external rotation to get the lateral extent as well as the anterior extent of the CAM. Okay. And then afterward, yes, we're going distal enough with this. And so, yeah, yeah, that's a changeover to interportal. Or so there are some times where I have changed over to interportal or even inadvertently, like just stretched it out over over the course of it where it's just like really loose and I just need to close it. There's a few times where the patient's just so tight. I don't have enough working room where I've just when I started doing the femoral plasty, I just cut it right away to just so I could at least connect it and just go straight to it. The hardest part is doing like getting to that gunstock deformity where it's like posterior, posterior, lateral slash inferior, that little edge there. So sometimes you can switch portals to get that or you just need to make the interportal. That's that's really hard to do. But then for other ones where even like anterior, that's never that's never a problem where as soon as you flex it up, you can really get all the way down here pretty easily with it. But it's really the superior extent and the posterior extent that's really hard with this. OK, and then afterward. So then you definitely when you're done with your resection, you want to check it. So here we've got the burn. I'm just lifting it up. Make sure it's not connected. Make sure you ensure that there's still an ileal femoral ligament that's that's intact there. And then, of course, if there's any compromise, you want to close the capsule. You don't want to leave it open. And then in some cases and so in some cases that they have ligamentous laxity or I've been a little bit more aggressive with this for people that are a little bit more hyper mobile, like four to six range. I've been just doing periportal and closing it so you can easily just put a stitch into each one. So here the first one I'm still viewing from the anterior lateral, the same setup as before. And I'm just doing a stitch. You could just do it from underneath and watch it come in here for the mid anterior portal. And it's relatively small. It doesn't even it's not even big enough usually to fit in like a self-passing device. So I have to use this retriever. So the self-grabbing device. So then I'll just put it in one side and then come on the more distal aspect and then retrieve it and then just tie that. And then when we tie, you'll see the capsule kind of shrink down. And then the second part of it will come out of it and then do from the outside in, do the mid anterior, sorry, the anterior lateral portal to view that part and close that if we need to. So that's how I approach periportal capsulotomy. And then stop sharing. And I think we can move on. I don't see any questions yet, but as they roll in, we'll kind of keep going with it and I'll stop Mike and anyone else going forward. Hey, Alan, can you give us a sense as to how long it takes? Sure. So, yeah, the arthroscopic part is normal. It's just undermining doing the synovectomy that takes like a couple of minutes. So my traction time is anywhere from like 30 to like 40, 50 minutes. If it's like a really hard case, like multiple big labral tear that can get up to 50 minutes. And then the femoroplasty part, that part's variable. It's a small femoroplasty, takes like 15, 20 minutes. If it's a large one where I'm really reaching and struggling, that could take like 40 minutes to do. So probably a full procedure time for me, anywhere from like 60 to like 100 minutes, maybe two hours for a really hard case for a hip scope. All right, well, can you see my screen? Yes. All right. So I'm going to just transition over to talking about interportal capsulotomy. And, you know, I think there is going to be a lot of similarities. And I'd like to thank Alan and Meredith, as well as AOSSM for hosting this. I think these these fellow webinars have been great as we move through and come out of this pandemic. My disclosures are on the Academy website. So, you know, as as we just discussed, you know, interportal capsulotomy does have some advantages. You know, it's going to allow for easier instrumentation into our compartments, prevent atrogenic injury. You know, getting that CAM lesion, it's clearly going to enhance the visualization, will make it a little bit easier to get to some of those places that might be a little bit tighter, thereby allowing us to correct these osseous deformities. And, you know, as I've been doing this, I think that that's that's a thing that I've been paying more and more attention to, is really getting that CAM lesion perfectly. I can't tell you how much it drives me up the wall to not have a perfect x-ray at the end. But, you know, the disadvantages is this question of atrogenic injury. And, you know, really the proponents of a periportal or the or the smaller capsulotomy, you know, think that you are potentially creating some instability or maybe just even changing the biomechanics of the hip by doing the interportal. So we'll talk about that. And, you know, obviously you're making that incision right across that iliopimeral ligament. And so it's going to be really important to repair that. If you look at the systematic review that came out back in 2017, the interportal is still the most common. Fifty five percent of those studies were still using that. So, you know, it probably is still the standard of care what most people are utilizing. But even back then, people were still only a quarter of them were still not repairing it. So I think that's likely changed over the last five years since this study came out. This is a paper that Tom Wirtz put out, I believe, when he was at Rush with Shane. And what he looked at was the size of that interportal capsulotomy and the instability that it could create. And they used range of motion as a surrogate of instability, which we frequently do when we look at capsular stability. And what they found is that, you know, the larger the capsulotomy, clearly the more range of motion, you know, four centimeters and six centimeters. But with that repair, you're going back to normal. So it appears at least at time zero in this biomechanical state, as long as everything's healed, that you really are not creating any instability if you do a nice, proper repair of your capsulotomy. We also know from this study by Steve Aoki that having an open capsule is problematic. And so he had this group of patients that had failed their hip arthroscopy, still had pain, and none of them had their capsule closed. So on his revision surgery, he simply went in and repaired their capsule. And not only did he have better distractibility or less distractibility at time zero after fixing this, but all of their PROs, their hip outcome scores, were much improved, including their specific hip outcome scores after this procedure. So clearly, again, we can access the joint very easily with that interportal capsulotomy, but we definitely need to repair it, which is what I'm showing right here. And this study that Alan already discussed, I just wanted to point out that in their interportal group, although they were the same as the periportal group, they had a great capsular closure in these patients. So I think that the most important thing to take out of this is in their periportal group, that they didn't have to close those portals, but interportal, it's going to be very important to close it. So I'll go over some of that, and I think that the most important part of capsular closure really begins with your capsulotomy. So I learned from Shane and Chad, and I believe it was Struen that came out with this, Struen Coleman from HSS, or kind of began this idea of capsular suspension stitches. And you can utilize retrograde suture passers. Every company seems to have one, or an integrated suture passer, or even a lasso to pass these stitches. And it really takes me the first five minutes of the case to put a couple of stitches in the front of the capsule, as well as in the back of the capsule through my mid-anterior and my anterolateral portal. So here on the left-hand side, I'm visualizing through my anterolateral portal. I'm going to create my interportal capsulotomy between my two portals, basically just right where the area of pathology is. So my interportal capsulotomy could only be two or three centimeters above a very small tear, and that's all I need to access, or I'll make it larger if it's a larger tear. And so I'll then switch my camera and connect the two sides. Another thing to point out is it's really important to use a very sharp knife to obviously protect the cartilage surfaces, but you also want to have a nice, thick, uniform cut across that capsule, and that's going to make repairing it substantially easier. Then, you know, once we've established our interportal capsulotomy, we'll place these tagging stitches in. So now I'm visualizing through that mid-anterior portal, looking towards my anterolateral portal, and I like to use this retrograde suture pastor. I generally will put two stitches in from the anterolateral, as well as two stitches in from the mid-anterior. And once you have these tagging stitches in, you really are able to basically just kite that capsule away from your labrum, utilize that 50-degree device for your heat ablation, and just elevate the capsule off of the acetabulum to do your bony work. It protects the labrum, protects the capsule, and you have a nice, large sleeve of tissue that you can repair at the end of this. And similarly, we do the exact same thing from the other side. So once we're done with this, we have the entirety of the acetabulum exposed, you have your entire area of your labrum exposed, where you need to place your anchors, or do your debridement, or whatever you need to do. And at the end of this, you're going to have a nice, large, thick leaflet of capsule to close. So again, the beginning of capsule closure begins with capsular suspension, and I really cannot emphasize that more. I think that in our learning curves, we've all gotten to the situation where, and I'm sure you fellows have seen this too, where you're working on a patient, or you're working on a cadaver, and you really want to close the capsule, but there's no more capsule left to close. And it's typically on this acetabular side where you have that issue. And then once you have those stitches in, you just place snaps against the skin. That takes the job away from your assistant. They can help you out with other things if you have the sutures snapped to the skin, and it really works out quite nicely. Now we've repaired our labrum. We've done our osteoplasty. I just want to go over a couple of techniques with regard to capsule closure. So very similar to how Alan showed, he closes his periporeal capsulotomies. What I like to do first is really define where my reflected head is. So I want to really restore normal anatomy. So once I've seen where my reflected head's coming in, I'm going to do a little bit of a debridement in between the reflected head and the capsule, just so I have a nice plane of tissue to stick my suture in. So this is a standard interporeal capsulotomy. In most cases, unless I'm trying to do a plication, I'm just going to put simple sutures across. I'm not going to always do figure of eights, but you can do, you know, simple interrupted sutures or figure of eights. And just like Alan showed, you pass through one side and then grab from the other. Now I always like to pass through the acetabulum side personally, because that still is going to be the weaker limb of the capsule. And if I need to really torque on the capsule to grab that stitch, I'd rather do that through the femoral limb than through the acetabulum. It's just safer. You have less risk of having the suture pull out. And, you know, in this circumstance, I believe I'm just going to do three sutures. Typically, I'll do three to four in an interporeal capsulotomy. If I do a T, sometimes I will use a T. If I have a very large cam, I'll usually do one to two stitches there or a figure of eight. I think that works quite nicely as well. But then what you can see is after we've passed all these stitches, which I've done from medial to lateral, kind of like when you're doing a rotator cuff, I'm now going to tie these from lateral to medial. And, you know, once everything's tied down, you have a very nice side-to-side apposition of the capsule. You can see the reflected head just sitting nicely over the capsular repair. And, you know, this comes out quite nicely. The other thing I want to talk about, though, is a capsular flication. So if you have someone that has some borderline dysplasia, they have preoperative micro instability that you're trying to correct. You're trying to compensate, you know, potentially a little bit of bony instability with some soft tissue stability. You want to try to make this as tight as possible. So what I've done here is I'm going to place a figure of eight sutures. I've placed one, you know, more lateral in the acetabular limb and grabbed that from the most medial aspect of the femoral side. And then utilizing that same suture, I've passed that again through the acetabulum. And as I pull this together, you can see that really does a nice screw-home mechanism. And so in these circumstances, I usually will use two to three of the figure of eight sutures. And that really gets a very nice, you know, inferior shift like Ben Dome described several years ago. But also with those figure of eight sutures, it closes up quite tightly. And then the last thing I just wanted to touch on, and I think we might have a case that we'll discuss this at the end, is just utilizing a bioinductive implant. So this is not doing a capsular reconstruction. This is after I've done a plication. So I'm only using it in my borderline dysplastics. But what I want to do is try to make their capsule just a little bit thicker. So this implant, it's bovine collagen. It will add about two millimeters of thickness to the capsule. It actually dissolves after a few months and you can't even see it anymore in there. And you're utilizing these PLA staples to stabilize it. We have a case series of approximately 15, I believe at this point, that are nearly two years out at the, I believe at the end of the year, that we currently have short-term outcomes published on this and we'll be doing the two-year outcomes once this is done. But we've had really good success with this too. But again, this is not trying to add additional mechanical stability at time zero. This is truly a biological augmentation that's going to thicken our capsule and just enhance that repair. And I think that's about all that I have with regard to interpolar capsulotomies. And I'll hand it over to Shane, unless there's any questions regarding this. You can talk to us about the T-capsulotomy. Yeah, no, I don't see any questions that have come up yet. So if you guys do have questions, please feel free to put it in the chat so we can stop. But I just assume Dr. Banfi and myself have done such a nice job that all the questions have been answered, which is totally fine too. All right, guys. Thanks, Alan, for putting this together. And thanks, Meredith and the academy for putting together the fellows' webinar. Can you guys see everything? Yep. Okay. So my task is to talk about T-capsulotomies. And I think this is a great complement to the previous lectures, talking about both the periportal and the interportal. And I think the message that we'll probably try to get across is that, you know, you don't want to be a one-trick pony. You want to be able to utilize all these different techniques, depending on, you know, what the patient pathology is, what the situation calls for. And I would say that the further that I've been in practice, I think the more I use each of these types of capsular incisions. And so you just want to be familiar with any of them. I am a consultant for Stryker. The rest of my disclosures can be found on the academy website. So hip arthroscopy obviously has evolved over the past couple of decades. Initially, it was focused on safe access. And then really, once we learned about FAI, our goal was to focus on correcting the FAI pathomorphology. But then we realized that the capsule probably had some role. And our goal at this point, not only is to correct, you know, the pathomorphology of FAI, we want to also correct the chondrolabral tissue. But in addition to that, we also want to preserve and repair the capsule. So why should we be repairing the capsule? We'll go through some of the studies that we've learned so far. And I think, you know, as Alan had mentioned, the iliofemoral ligament is the largest and strongest ligament in the body. It is responsible for restraining both extension and extortation of the hip joint itself. And really we, if we cut it, we certainly want to And really we, if we cut it, we certainly want to repair it. I think the thing to think about is that what is my visualization? And that's both relevant for both the central and the peripheral compartment. And how can I best see what I need to do in order to perform the task at hand? One thing to keep in mind is that if you are utilizing an interpolar capsulotomy, you want to recognize that you might have to make it somewhat larger in order to see what you need to see. As opposed to if you're using a T-capsulotomy, in many cases, we'll make a smaller horizontal limb of the T-cut and then take advantage of the vertical fibers of the iliofemoral ligament in order to get as good or better visualization. We actually did a study looking at the surface area, comparing the 2, 4, 6 interpolar capsulotomy versus a half T and a full T. And what we found was that there is no significant difference in terms of the surface area between 6, 8, and the half T. But the full T-cut really gave you significantly more surface area to visualize directly as you're performing your osteocounterplasty. And so I think these are things to keep in mind as you're thinking about what I should be utilizing. I think the other thing is that from a biomechanical perspective, we do want to preserve the anatomy as well as the structure and function of the iliofemoral ligament. And that is maintain translation, rotation, and strain. And so keep in mind that whenever we do perform an interportal or a T-cut, we are affecting all of these properties. Mark Philippon and his co-authors performed a in vitro biplane or fluoro study showing that there is increased translation rotation when doing a capsulotomy as well as a labral incision. But when you repair both, you're actually able to restore the translation back to its native intact state. The same group has also performed studies looking at capsulotomy size and showing that the larger the capsulotomy, the more rotation that might occur. And by the same token, the larger the capsulotomy, you also have to consider that you want to include more capsular stitches in order to repair it and keep it stable. And so my recommendation is that for every one centimeter of capsulotomy, you probably want about one stitch in order to repair it and try to get a watertight seal. And lastly, we want to talk about strain or distraction. Again, the same principle, the larger the capsulotomy. So in this graph, you can see we start with intact 2, 4, 6, and 8. It decreases the amount of force required, but when you repair it, you are able to return that back to its native intact state. And that's true for both the interportal and the T-capsulotomy at time zero. So how and why should I repair? So we're focusing on the T-cut. Mike and Alan talked about the interportal and the periportal capsulotomy incisions. So we'll talk about the T-cut. And very simply, when you look at the schematic, we want to create the T, we want to close it. As Mike had mentioned before, the most important thing when performing or thinking about capsular management is really the capsulotomy. So we elegantly talked about the interportal, you know, making sure you've got nice acetabular leaflets. You know, here we're utilizing traction stitches, you know, that I think Chad and Struen had kind of helped develop. And these have been really helpful in terms of, you know, visualizing as well as using soft tissue tension to identify the pincer as well as to get a good access to labrum as well. In the peripheral compartment, one of the pearls I would say is that you want to remove some of that pericapsular fat. And as the previous speakers have mentioned, you really want a nice perpendicular capsulotomy. And this will allow you good tissue edges so that you can have as good a tissue as possible to repair. Here we're doing a T-cut, we're placing traction stitches both on the medial and lateral leaflet. And you can see that once we place these traction stitches, and then we place tension on them, you get a great view of the entire peripheral compartment. The entire cam deforming is kind of right before you. And you can see rather than having to fight with the capsule the whole time, if you can see it all, it makes the repair much, I'm sorry, the osteoconoplasty and the repair, you know, much easier than trying to struggle through it. Okay. So here's an example of capsular plication with a T-capsulotomy. We've already went ahead and, you know, performed our osteoconoplasty. And now we're starting to do the repair. So here you can see we've got our antero, I'm sorry, arthroscope in the modified anterior portal. We're working through the distal accessory anterolateral portal. And actually when you use this suture passer and retriever device, you can actually do just a single portal technique. And here we're going ahead, we're passing our stitches through the vertical portion of the T-capsulotomy. Again, we're looking down with the camera and we're passing and tying as we go. And the nice thing about the vertical portion of the T-capsulotomy is that you don't have to pass all your stitches and then tie. You can actually tie sequentially, which just kind of allows for suture management. And so, you know, basically we'll just kind of work our way up from distal to proximal. Typically we'll use two or three stitches. You know, you can use either simple stitches, you can do figure eight configuration, whatever, you know, I think whatever the case calls for. So here we're doing this relatively in real time. So we're not, I think it's minimally edited in terms of the amount of time that's going on. So it, you know, I think once you kind of get facile with the instrumentation, the visualization, in most cases I think our repair probably takes about, you know, five minutes or so. And so, you know, I think that initially though it did take quite a while. I think early in the learning curve it probably took about 30 or 45 minutes. But, you know, as you become more facile in terms of visualization and instrumentation technique, I think it becomes much easier. And again, as we previously mentioned, once you are able to repair the vertical portion of the T-cut, it really leaves you with just the inner portal. And in most cases, I probably do about a two centimeter inner portal capsulotomy. So I'll typically do about two stitches, sometimes three, depending on the amount of laxity that's involved. And I think as the other speakers has kind of alluded to, it really depends on the capsular thickness. It depends on if there's evidence of hyper laxity, how much capsulotomy you need. So I think a lot of times we'll just tailor it depending on the patient's anatomy and pathology. So here we're passing our last set of stitches through the vertical portion of the T-cut. And then when you look back, you can basically see the inner portal cut. And we'll kind of show you right here. So here we're left with the inner portal cut. You know, again, we haven't moved the position of our camera. We're placing one stitch in by similar to the inner portal technique. We'll pass the astabular side first, then the femoral side. And then we'll kind of tie as we go until we get a nice watertight closure. I'll just kind of move us along here. But yeah, you can get a nice closure just as well with the T-cut as the inner portal cut. And I think that's the important thing is again, to restore the structure and function of the iliofemoral ligament. Yeah, I think that's a good segue. There's a question here, Shane. I think we can address that as you're talking about this point here is that the question is, do you believe you can close the capsule too tight causing issues with range of motion or patients feeling tightness post-op? And if so, how do you avoid doing this? And I think that goes for both inner portal and T. Yeah, I think you can definitely over-tighten the anterior capsule. I think one of the things that we try to do is, especially when we get to the inter-portal part, is that we'll go ahead and pass our stitches first. Here you can see we've passed the lateral stitch, and now we're going to pass the medial stitch. And this is called the suture injector device. And then here we're passing it on the astabular side. We'll go ahead and retrieve it and then pass it through the femoral side. And one of the things that we do now is that after we pass it, we'll take the hip out of flexion and tie an extension. And I think that that's helped quite a bit in terms of over-tightening the anterior capsule. But I think it's not uncommon for patients to complain of some anterior tightness. And just like with the shoulder stabilization, I'll try to protect it for the first couple of weeks. But as they start to get off crutches, really I want to emphasize getting that normal extension back. That terminal extension is really important. It's pretty similar to like when you're dealing with loss of extension for the knee. If you lose that, it really makes it difficult to get your normal gait back. That being said, I do think that it does stretch out over time. And so for some patients who might be tight for the first couple of months, usually they'll normalize their extension by a few months post-op. Do you guys have any perspective on that? Yeah. So Mike, what do you think in your experience with the inner portal? Yeah. I think that there certainly are patients that I try to make tight. The ones that have the elevated maintenance scores and those ones that I potentially try to make tight with the plication never really complain about it because they're probably stretching it out from time zero. But I completely agree with you with the tie-in extension. I think that's really important. I think that the only thing that can happen is if you tie in flexion, you may pop some of those stitches as they go into extension. So I think that's critical. Anterior hip pain a few months after hip arthroscopy isn't too uncommon, but I don't think that's because tightness. I think that's more just because of some hip flexor issues or something like that, that generally just resolves. Yeah. Are you still going with the talk, Shane? Do you want to- Oh yeah. I mean, you guys can keep talking. I mean, this is basically just showing like a one nowadays I'll just do like a mini T. And so especially for those who are lax, I mean, you can really make a small T cut, but it's basically the same technique. But why don't you kind of add your comments, Alan? Yeah. So I'll say for the PERI portal, like I know actually we had this comment come up a few months ago on our webinar, and I didn't feel like the patients had too much tightness, but then afterwards I really kind of looked for it. So like at the first post-op, one week, six weeks, I would ask them and like, really be like, do you have any tightness? Are you sure? And actually even with a PERI portal without closing it, they still feel tight within the first six weeks. So I think the hip is just a very tight joint. So even though we're not closing it or not over-tightening it, we're probably loosening it if anything by, you know, undermining that capsule, they still feel tight and they still get a little stiff at least the first six weeks. And then they loosen up, especially with the hip flexor. And then I don't really see a lot of problems with a range of motion long-term, but at least the first six weeks, I think even without closing it, your patients will feel a little bit tight just with this hip arthroscopy surgery in general. Yeah. I like to, I like to check them in with their knee flexed and knee extended. There's a lot of people, at least, I would say at least half people that are tight, it's primarily the rectus and their quad that they need to address. Yep. Okay, good. So yeah, Shane, why don't you keep going with your talk? Yeah. So I, you know, we did a clinical study just comparing a group of patients that did not have a capsule repair, which is, you know, kind of what we were all doing when we first started in comparing it to capsule repair and did find that the capsule repair group did better at six months and two years compared to the non-capsule repair group. And I think most importantly, we found that there was a higher rate of revision in the group that didn't undergo a capsule repair. And you can see when you look at the anatomy how indistinguishable the cartilage labrum capsule is. And I think all of us on the panel have seen hips that look like that. And when you see that to me, that just screams instability. Whereas on the right, this is one of my own patients that prepared the capsule. You can see that it really recapitulates the anatomy much nicer. And we did find that there was a 10% difference in terms of revision rate between non-capsule repair to capsule repair. So I think in summary, I would say, obviously the periportal, interportal, and T-cut are all options that you wanna just have in your armamentarium. And like I said, I think I use all of them. I don't know about you guys, but you wanna talk about how you utilize which and when and in what scenario. Yeah. Yeah, go ahead, Mike and Chad. You guys go first, yeah. I think that most often I'm doing an interportal, but if I'm just doing something that might be like a little loose body or a little sinusitis or if I'm going in and I'm suspecting some adhesion that I can just release, then I would do a periportal. But I would say that that's in the minority. Large cams, I probably go in less and less with the T, but I'll still usually, if it's a real large cam, I'll use the T. I just think that I'm better at fixing a capsule that I've protected than damage the capsule with the burr and then trying to put stuff back together. Then I would worry that I'm making them too tight if I've removed capsule and I'm trying to bring it all together. Yeah, I would say that that's definitely something over time that I've done more and more of is fine tune the placement of the capsulotomy. I'll change my initial portals before I make the capsulotomy just like Shane said to make that smaller and focus it on the central compartment pathology and then decrease the size of the T capsulotomy over time. But still use the T capsulotomy, I'd probably say at least maybe 80, 90% of the time. But yeah, I think adapting it to what's in front of you is a way to approach it rather than the same thing every time. And I think especially for revisions, I probably end up doing inner portal more often. And I think it's because that's probably what was done the first time around. But a lot of times like you'll just see like just a wall of adhesions from like four o'clock all the way to like 10 o'clock. And at that point, like once you've opened the capsule that much, you don't need a T cut. And so, and that's what I'm saying, like I still do the inner portal because I have to do it when I'm doing revision work. Or in some cases, I might find that the patient's just extremely ligamentously lax that I bring them into the peripheral compartment. I'm like, wow, I can see everything. I just put a couple of traction stitches and just kind of go away. And then as far as periportal, once in a while, I'll do a periportal. I think if it's, I've had some scenarios where if I'm doing just like a debridement, I've done some, I don't know if you guys have looked into subchondroplasties, but I've done some of those where I'll just do a debridement in the joint and just do a subchondroplasty. If I'm just looking at doing like a cartilage assessment and things like that. So there's certainly a role for each of them that I think you just wanna be ready to use whatever you need to do. Yeah, there is another question to follow up on that. So for Shane, so Dr. Ngo, make sure they wanted to know, what portal are you using to perform the vertical capsulotomy of the T portion and what portal are you using to repair the vertical portion? Yeah, great question. Sorry, I didn't clarify. So I usually use three portals for all of my procedures. I'll use an anterolateral portal, use a modified anterior portal and the inter, I'm sorry, the T capsulotomy is through the distal accessory anterolateral portal. Generally that is in line with the anterolateral portal, approximately three to four centimeters distal to that. And that's also the same portal that I'll use to repair the T-cut. Yeah, and then can you just make a comment for you guys? Like what's your time in terms of the thermoplasty peripheral compartment work, just for comparison, once you have that opened up the actual thermoplasty itself range? Yeah. Oh, I think it depends on what you're doing. I think to me, there's two types of thermoplasties. There's the, where you're just smoothing out something that's basically already there and you can see the shape of the neck. And then there's the ones where you're kind of making a new neck out of there. It's like carving the neck out of a block. And those are very different. So the first one, that might take 10 minutes, maybe even less, with the right exposure. And then the ones where you're having to carve it out, those definitely take a little bit longer, 25 minutes, 20 minutes, depends on how efficient my brain is working that day. Yeah, I agree. I mean, the only other thing is sometimes the bone's a little bit different. If you have somebody with really hard bone, your birth doesn't seem like it's making any progress, then obviously that can take a little bit longer. Or you'll have this big hulking male and he's got like the softest bone in the world. Then you gotta be careful you're not over-resecting and you gotta be very delicate with what you're doing. So that can sometimes affect it as well. But I think that the visualization actually that you had with your peri-portal doing that cam was pretty good, probably about very equivalent to what I get with an inner portal, because I'll use the same thing with 30 degrees of flexion and internal and external rotation to be able to get everything as well. Okay. All right, good. So well, it looks like we ran out of time for Chad once again. So thanks for trying and maybe we'll get you in another, just kidding. Okay, let's go on and finish Dr. Mather's talk. Yeah, thanks. Thanks, Allison. Appreciate you inviting me to talk about revision capsular management. We certainly do a lot of these at an academic center and have a growing experience with these revision cases. Here's my disclosures and the one that's most relevant is the consultancy for Stryker. So to start with, when you're, you think about paying at least- I can't see your screen. I'm only seeing a light screen. You can't see my screen? There we go. There it is. Oh, you can see, okay. I guess I can't, can't put it on screen share. Try your full screen. You just got to use regular presentation. That's what I, that's what I do. Let me try it again. Can you, can you see it there? No, it's just the white screen. It's like a portion of the screen, I think. All right. Try the little button at the bottom. That's what I did before. Maybe if I just do my main screen. Yeah, if you're split screen sharing, that might be, yeah, now it's fine. That works. Yeah. Okay. We don't want to do that. You can see it now? Yeah. Okay, great. So yeah, I was just starting to say that, you know, pain after hyperarthroscopy, I think is the, is the, you know, where you, where you first meet the capsule dehiscence and rupture. And, and so, you know, wanted to cover some of the keys for when to know it's the, it is the capsule and the, and therefore the subsequent instability. So one of the biggest ones is a, is a pain that is worse than before the surgery. Another big key is a patient with severe mechanical hip flexor symptoms. And then subsequently the patient who's had their, their second surgery has been a psoas release. So they'll have had a, you know, a regular hyperarthroscopy, then they'll get a psoas release and then there'll be absolutely miserable. You know, that, that, that patient, there there's pretty much no other, at least there may be other diagnoses, but there's no doubt that that patient has a capsule dehiscence. You know, after a traumatic event, you'll feel a pop and that's usually, you know, the, the caps coming apart. My experience with those patients is that they will have a capsule that hasn't healed. And as the sutures holding it in place, and then eventually, you know, that that's going to give way. I always worry about a two of patients that should be doing well, but might not be. So that would be your, your younger, younger patients, typically your non-hyper mobile patients, patients with big cams that typically would just do fantastic and or not. I was at a little higher threshold to look for that. And then of course, anybody that has excessive external rotation on their exam on a painful hip and, and one who's hyper mobile. I think the, the, you know, the patients that I've seen the vast majority of deficient capsules, they tend to be hyper mobile. And at least the ones that I've seen in my own practice. There we go. What does it look like? So on MRI, it takes a few forms, you know, this, this one to the left is a, is where you've got that big gap there. You can easily see the ends of the hip capsule. It's a pretty, pretty straightforward one. Here's one where, you know, the volume is an increase. If you look carefully, you'll see there's, there's no, you know, darker tissue along the muscle. And so this is a really extremely large defect, but it doesn't have that big, you know, a huge amount of dye that you, that you might be used to seeing. And then, and then here's like, you know, kind of the, you know, the floppy capsule side of the flat capsule sign here, where it actually looks like there's some, there's maybe some bridging scar, but if you look close, you'll see that the fluid does not lift up the zona in the distal capsule. And it's laying flat down scarred to the neck. And that's, that's also another, another large disruption there. I would say one of the problems I see with, with in the revision situation is recognition. So see a lot of patients who will have had an MRI. Of course, radiologists won't read it as anything because they don't realize it's of any significance. And, and, you know, and they will have not been diagnosed with it. And so the opportunity is there to see it and to diagnose it, but it's, it still gets, it gets missed a lot. You know, you'll have patients that, that, you know, that may have an adequate capsule in their coronal. It looks, looks fine there. And then they'll have a more focal defect immediately. This is, this is that patient there. You can see the psoas broken through, psoas rubbing against knots from the anchor. And then the reconstruction that covered that up. You know, one of the key take-homes I think of my talk is that when you're evaluating a painful hip after arthroscopy, you do want to get an arthrogram. This is the same patient here. This, this is a non-arthrogram study on the left and then the arthrogram on the right. And you can see the disruption with the arthrogram, which you, which you really can't see without it. And, and I've missed a couple there by, by not getting an arthrogram. I still don't, I still get a platelet MRI in the primary setting, but I do think that the diet is necessary to fully evaluate the ligament capsule. There, while the reconstruction is, is the workhorse for revision capsule issues in my practice, there are some alternatives. Suture anchor augmentation can, can work well where you put a suture anchor up in the subspine, pass that through both limbs of the, of the capsule. This helps take some of the stress off of, off the ends of the capsule when they're a little bit tight or hypermobile patient. You know, Shane taught me this T-capsulotomy slide. I like this idea a lot. This is, this is where you, where you have your T-capsulotomy and you repair the inner portal first. You tie that first, which is the opposite of what we do in the, in the primary setting. And that allows the capsule to advance forward a little bit. You then go and close the T-capsulotomy. It still often leaves a little bit of a gap at the top, but, but you, you know, you, you re, you re-approximated the, the ligament and then mechanically that functions better. Although again, for me that I use reconstruction majority of the time for these procedures. And, you know, the question is when, when to do that? Well, remember it's a revision or, you know, salvage procedure, you know, is important to keep in mind. So usually it's in that, in that revision setting. You want to do it when the tissue's bad. So when you have a hypermobile patient, you have a previous wide debridement or they're further from the index procedure. So when, you know, when it, when the everything is retracted down and it's stiff, even if there's tissue there, you often can't get them back. And then I think when the risk of rupture is high, so you've got a heavier or bigger leg, you want to put a little extra protection there, then the graft can be helpful. This is, this is a schematic of what, how I do it now. So I usually use either one or two to three anchors, depending on the size of it up in the, in the acetabulum. And I'll use a bridge technique across it, and then use a various combination of sutures distally and in the sides to sew the capsule into the, sew the graft into the distal capsule. Sometimes I use, you know, horizontal sutures, sometimes verticals like this. This is an overview of the technique. There's a couple of examples of some, some wide distances here. You see, this is one of the previous interportal. Sutures are still there. So just because the capsule was repaired does not mean it is healed and intact. And this is, this again, a big one with a big gap that you'll, that you'll, this is a pretty typical one you'll often see. The next example is going to be another one that looked pretty small in the MRI, but we got in there, you can see how much it's retracted. In this case, I'm going to show you, it's a case of a big piece of heterotopic ossification that when removed left a pretty sizable gap. So here we are, we've got the anchors up approximately there as they're shown in the schematic there. And then we've just slid the graft down them like the technique you would use in a super capsule reconstruction. Those purple stripe sutures are the ones that are in the anchors that we'll use for a bridge momentarily. And then the blue suture there is what ties it into the existing capsule medially. We're now retrieving one from each of these limbs out, and that's the rectus up above us there. And we will tie this outside the joint, slide this in, and again, in this bridge type fashion. I like this as it compresses the capsule, the graft over across the rim, and then we'll go to tie the next one. And you got to, you have a nice minimal amount of knots and a nice compression across here. You'll see as we lift up the rectus and you can see the graft in there that's now fixed completely approximately. We're then left with the distal portion. We've already passed all those sutures distally ahead of time. And then we use like a scorpion type device to pass this. We have found over time, the advantage of this is that you don't have to measure ahead of time and you can go in and kind of reapproximate where you want each of the sutures so that when you're done, you have a nice flat, even, well-distributed reconstruction. And this is that case there where we've got that tied in watertight around the circumference of it. What kind of graft are you using, Chad? Like, yeah, anything you'd use for super capsule reconstruction, so a dermal allograft. Yeah, but I didn't get any of them, any of the types are sufficient. I use the allosources matrix HD, but I think, I don't think you're splitting hairs there. Okay. You know, I gave this talk a couple of years ago. I was editing it for today. I noticed that I used to have a slide that said evidence and it was blank. And now we've worked the last couple of years to follow these patients to get some better idea of how they're doing. And so this was a study we did over the last five years when we've been doing this. It's, again, you see mostly women, average age is 30, and there are 22 capsule reconstructions in this group. 81% were combined with another procedure, the most commonly labeled reconstruction. And then before then, they had a reconstruction alone. And you can see that many of them were multiply operated on patients. We follow them with, measure them with PROMIS system in IHOP-12, and they were one year follow-up. We could attain some follow-up earlier. The PROMIS scores, you'll see that the pain interference and physical function had statistically significant improvement and clinically significant improvement, although neither of them returned to what would be considered a population-based norm. So the message to the patient is, that I send is, you will get better and you may not be normal. This is a salvage procedure, but you'll potentially get a lot of benefit. With the IHOP-12s. And then the IHOP-12 there is, shows that they do get a substantial amount of improvement. So 73% reaching the MCID, 55% achieving the substantial clinical benefit. Pre-operative IHOP is horrible, Chad. With the IHOP-12, six patients- They're terrible, terrible, Shane. I mean, these patients are terrible condition. And, but you'll see, you know, half of them, a lot of them do really, really well. I've got a number of them that are just, I mean, absolute home runs. Which is why over time, I probably lean to doing more reconstructions because many of them can do extremely well. Great. Okay. Yeah. And then, oops, sorry. And then, so in summary, I mean, one of the big takeaways is recognize these problems. I still see a number of them that are not recognized. And some of the keys are, again, use that MRA. Look for patients that are worse than before surgery that have really forward hip flexor issues. There's a lot of techniques you can use. You know, reconstruction is a challenging technique, but it has, I think, you know, good outcomes. And then really, I think excellent outcomes when you consider it as a salvage procedure where most of these patients have had over two previous arthroscopies. And I tend to favor reconstruction over time given the consistency. I think the consistency of the outcomes and then the efficiency of the technique that's improved over time. Great. Chad, have you tried any other grafts like bastilata, fulminova, or anything like that? I haven't. I had seen that being used once and it created, so, you know, I guess it gets fuzzy, lack of a, or swollen for lack of a better term. And the visualization was difficult. So I've always used the dermal allograft. Okay. Well, excellent. Well, I'm just want to be respectful of everyone's time because we're at the 631 mark, at least Pacific time. So thanks, everybody. We'll wrap this up. I don't see any other burning questions out there. So I want to just thank our panelists for such a great broad perspective on this topic. And obviously, you know, we still have a lot more we didn't even get to cases or anything like that. So maybe in the future, we'll have more time and we'll have more sessions like this. But thank you guys so much for doing this and hope it was helpful for all of our fellows out there. If there's any questions, feel free to reach out to any of us in the future as well. Okay. So we'll wrap up and adjourn. Thanks, guys. Thanks, everyone. Good night. Thanks, Meredith. Thank you. I'm just going to run through some closing slides of our upcoming education and online offerings. Thank you so much, Doctors Banfi, Mather, Ngo, and Zhang for your time and preparation for tonight's webinar. The AOSSM would like to remind the current Sports Medicine Fellows about candidate membership. If you have not already, you may apply online for free by clicking on the membership tab at sportsmed.org. Register today for the Anna AOSSM Evening Edition Virtual Specialty Day. This is taking place next week, March 17th through the 18th. Open for free registration for current fellows is the Pediatric Sports Medicine Webinar Series. In collaboration with PASNA, this is taking place April 7th, 14th, and 21st. For more online and on-demand education and resources, visit the online AOSSM playbook and surgical video library at sportsmed.org playbook. And we'll see you next month on April 13th. Thank you for participating. Good night. Good night. Thanks.

hip capsule management

hip arthroscopy

Dr. Alan Zhang

Dr. Michael Banfi

Dr. Richard C. Mather

Dr. Shane Ngo

periportal capsulotomy

interportal capsulotomy

T-capsulotomy

capsule repair