Enjoy the next 33 slides. So here are my disclosures. And so let's go to the next slide. And so Winston asked me if I could do this talk in one slide. And I think it kind of goes with what Andre was saying earlier. A lot of these problems like capsular disasters or over-resection, under-resection, it's much better to prevent these things than to treat them once they happen. And so to sum up my love for one-liners, if you open it up, you should close it. If you can't see it, you can't treat it. Make it big enough to see, but no bigger. If it's loose, make it tight. If it's tight, make it loose. Get it right the first time. Get it right the only time. And do your last surgery first. And so next slide. And so I think one of the first things is that we've become pretty good at closing the capsule, plicating the capsule, repairing the capsule. But don't use capsular surgery. Don't use a capsule or plication to treat real structural instability. That needs structural surgeries. Don't create dysplasia. Don't leave the capsule open. If there's instability going on, don't cut the psoas and don't debris the ligamentary. Next slide. And so one of my co-fellows wrote this really cool editorial commentary that sums up the literature over the last 10 years. And as you can see, there's been a lot more literature over the past decade. Without repairing the hip capsule after arthroscopy, what were we thinking? Next slide. And so the clinical data supports this. And so the largest meta-analysis that's been published on this topic, 30 studies last year, AJSM, showed significantly better patient-reported outcomes in clinical literature. Next slide. Significantly better outcomes with biomechanical literature as well. Next slide. And so how do you go about doing this? And so this is from Steve's talk from a couple of years ago. I'm not sure if you remember this, but it's a really good way to show that there are many different ways to go about addressing a capsule, managing a capsule, opening it up, closing it. And you can choose really what works best for you. And so next slide. And so your goal is basically, the end goal is achieving a stable impingement-free hip. And however you go about doing that with managing the capsule, the destination will remain the same. And so next slide. And so the big goal is structural correction. And so you're trying to make sure that you have a round ball, round socket. And if you can't see it, you can't treat it. This is what I learned in my fellowship. And so I'm a big believer in a T-capsulotomy. And so next slide. And so an interportal capsulotomy is a perpendicular cut to the ligament. And remember, this is a capsulotomy, and you're cutting a ligament, and you're repairing a ligament. And remember how ACL repairs versus reconstructions go. So you're cutting a ligament, repairing it, and trying to get it to heal. So try to minimize perpendicular cuts of ligament. And if you're going to cut the ligament, cut it parallel to the fibers. And that's why I prefer the T-capsulotomy, as you can see here. Go to the next slide. And so you don't need to make a huge interportal. And so you can make this 10, 15, 20 millimeters max. And you want to leave enough proximally to repair at the end of the case. And so only disrupt as much as you need. Next slide. And so even if it's a small interportal, you can make your T-capsulotomy. Next slide. And you can still get this view. If you use suspension sutures, traction stitches, even with a really tiny interportal, you can see everything in the peripheral compartment to accurately correct your CAM morphology. Next slide. And so one of the tips that I use in the operating room is I'll actually figure out how much volume the joint holds. And so before we even pull distraction, I put air into the joint, and I actually measure how much air is going in. This is a primary hip. Go to the next slide. And if you go to a revision case, as you're going to see here, if the capsule is disrupted, you're going to see the air go everywhere but the hip. And I think that's one clue that you're going to find capsular disruption. Go to the next slide. And so invariably you're going to find amounts of adhesions both in the joint, outside the joint. Oftentimes these are capsulolabral. And that's the part that you really have to make sure you reestablish a normal plane. You can actually even see it here going into the joint on the acetabular side onto an articular cartilage defect. And making sure that you basically resect every adhesion that's there will properly allow you to mobilize your capsule so you can close the capsule. Next slide. And so for performing a lysis of adhesions, there's so many different instruments that you can use. I use a variety of different flexible and straight and rigid instruments to really reestablish that capsulolabral interval as you can see here. Next slide. And so one of the clues that the medial side of your capsule is dysfunctional or even oftentimes absent is look for psoas herniation as you can see here. Even just turning my suction on and off you can see the psoas coming into the joint. That's a red flag for me. And so next slide. And so if you have this situation, what I'll oftentimes do is put a single or double-loaded anchor in the inferior spine right at the inferior facet where the origin of the capsule is located proximally. Next slide. And then I'll pass these sutures both in the proximal and distal side. You'll have two, four or six sutures that can then reestablish that distal medial and bring it up to the top and close this gap. And then establish a tissue plane so that your psoas and your rectus aren't rubbing on an exposed joint. Next slide. And this is that repair. And so next slide. I think if you have a big tissue gap, though, be careful with this. If you mobilize the capsule too much, I think you possibly can make this too tight. And then you end up with premature coupling. Patients will oftentimes present between three and six months. They'll have back pain. They'll have SI pain because you're locking the femur and the pelvis together because the front of the hip joint is just too tight. And so next slide. So for the distal side, that was the proximal side. For the distal side, if they've had a previous T-capsulotomy or a capsulectomy and you're missing distal tissue, you can actually reestablish your zona by placing an anchor, a single or a double-loaded anchor as you can see here, at the base of the femoral neck right above the intertrochanteric line, passing your sutures on each side and reestablishing the capsule to bone contact that restores the bellows of the zona. Next slide. And one of the things is sometimes even with a subtle defect, your capsule can actually be fairly dysfunctional. And so this is the drive-through sign just like you see in the knee. If you inject air at this point, what you'll see is even though it's not a big capsular defect, the capsule is basically blotting. It's actually coming up. And even with just simple air, it's showing a dysfunctional capsule. And that's someone who probably needs a capsular placation or a capsular reconstruction. Next slide. And so you have to be prepared in this revision situation to augment or reconstruct your capsule. So click through. Next slide. And so this is a bovine graft that you place on top of a repair capsule to augment collagen. Next slide. And this is a good video from Femi Aini who shows an Achilles graft in a dysfunctional and absent capsule anteriorly. Next slide. And I think one of the things that we have gotten really good at is actually looking at the correction of the CAM and doing what's called a dynamic arthroscopic exam. You can do the exact same thing for the capsule. I think, I guess we're clicking through. So if you do a dynamic capsular exam, you can extend and externally rotate to assess the functional integrity of your capsular repair. And that's what I was doing in the video there. So next slide. And I think one of the things is whether or not you use a brace. That was obviously a controversial topic this past hour. Make sure that the patient is educated. Make sure the team that is taking care of them is educated so you avoid causing this potentially catastrophic complication post-op. And so next slide, last slide. And so it's best to avoid or prevent capsular disasters and it's best to preserve the native anatomy and function for a stable impingement free joint. Thank you guys.

capsular disasters

hip surgery

native anatomy

arthroscopy

patient education