Let's talk about repair, but also about reconstruction. How many of you in the audience have done a capsular reconstruction in any setting? So it's kind of a new procedure, so we'll just have early information, but I think it's important to really understand why we're doing this. These are my disclosures. So as Dr. Sanford mentioned, the hip capsule is very important for the health of the joint, and the iliofemoral ligament is extremely important. And for us, when we do our capsulotomy, it's laterally based. As Dr. Sanford was mentioning, for us, we go lateral to medial, try to preserve the iliofemoral ligament. Sometimes I'll incise a little bit of it, but our capsulotomy is really small, 25 millimeter parallel to the labrum. So the reason for that is, and the ischiofemoral ligament is also important, but truly you want to protect the iliofemoral ligament. And we did a study a few years back where we look at the thickness of the capsule, and the thickest portion was between 1 and 2 o'clock, and the maximum thickness was where the iliofemoral ligament. One time I remember doing some athletes, and just to get into the capsule with the needle was very difficult, and sometimes it can be even more than 2 centimeters. And I remember one time I had a patient, a colleague of mine was doing a case, and he had a hard time getting in the capsule. He had perfect fluoroscopy shot, his needle was in the right position, and he couldn't get through. So he stopped the case, and he ended up sending it over, and the patient had such a thick iliofemoral ligament that he couldn't get in with his needle. So he was worried he was going to do something heterogenic, and truly it was hard. We had to do an incision before we get in. So sometimes that ligament is very, very thick, especially in an athlete. So protecting anything is very important, strongest ligament in the body. So the capsule has proprioception role, structural support. We know that the iliofemoral ligament resists extralotation and extension. The escufermoral ligament is more for constriction, and the pubofemoral ligament resists extension and abduction. So as I was mentioning, our capsulotomy is usually 25 millimeter. We try to be about 15 millimeter from the distal tip of the labrum, and usually it's much better to have a larger capsulotomy to get good visualization. But if you can't maintain it small, and our fellows, I always tell them, you know, learn to maneuver with your camera. You can put a retraction stitch, but try to learn to maneuver to a smaller incision. But you have to have adequate visualization, otherwise you won't do the surgery properly. So I started to be interested in actually the iliofemoral ligament about 23 years ago. I always remember one of our golfer coming to see us telling me, like, when he was in his back leg, he had a hard time maintaining stability. And what we did back then with one of my therapists, we took him to a fluoroscopy, and we had him stand on his leg and do some rotation. And truly, when we ended up doing surgery on him, his anterior capsule was really stretched. So what we found also is sometimes a patient with chronic CAM, chronic pathology with labral pathology, they'll stretch iliofemoral ligament. So that's what Dr. Severin was talking about. When we closed most of our patients after the capsulotomy, we do a little bit of a placation. So this is a taekwondo. You can see, like, how most rotational sport can put a lot of stress on your capsule anteriorly. Martial artists, baseball player, football players, even golfers. So we close our capsule in most cases. And when I close it, actually, we like to put the hip flex at least 45 degrees. And the reason I'm doing that is I don't want to, it's a better angle for us. But when I extend afterward, I make sure that there's not too much tension on it. But I use two number two vicral suture. And I use a, we call it a Cabexia slider technique, where we double, it's a double number two vicral with one pass. And it's really, really structurally solid. And we test it in the lab. And the soft tissue will fail before our suture line. And we only, with a 25 millimeter capsulotomy, you only need two sutures. It's the same as three sutures, actually. So the Cabexia slider knot, we just kind of, in one pass, we have double suture line. And then we just slide, we put five half-hitches behind the knot. Like this is from the right hip coming from proximal to distal. I start proximal, and I put my distal limb after that, and then I tension that properly. So this is from one of our former researcher, Dr. Beaulieu, now she's a resident in California. We look at our capsule closure results, 42 non-repaired versus 84 repaired. Average age was 38, fairly younger group. We had 14% patient converted to THA in the non-repair group, 4% in the THA were converted in the repair group. There was no difference in the vision rate. And the mean follow-up was 7.3 years for the non-repair versus 6.4 years. And we had a 90% retention as far as surveys. So I used to use, now I use a different technique, but usually we use a suture-related technique to capture as much tissue, especially medially. Sometimes for me, I cannot go as far as I want to in the medial gutter, so I still use a couple stripes of monopolar radiofrequency to get a little tension medially. Because sometimes it's very hard to get the suture there. This is an old video, but I still use it. And for us, like I said, you have to be very careful doing it. It's monopolar, but I just do a couple stripes and it really helped create a little contracture there. This is an old capsular placation model in a Novain-Scholler model. And looking at the histology where there's evidence of remodeling. So we'll talk about, now we're going to talk about deficient capsule, which is becoming a more and more difficult problem to a special intervention patient. So where I find a deficient capsule in our patient, usually it's medially with the psoas ears and laterally with the minimuses. And that can be a source of big disability for the patient. So why would we see this? Sometimes it could be traumatic, sometimes it could be iatrogenic. Unfortunately, sometimes to get exposure, people will debris the capsule and they don't have enough tissue to close it. So they leave the capsule open, hoping it's going to close by itself. Sometimes it will have actually some tissue that will grow, but it's not functional tissue. So for us, and sometimes adhesion actually can cause some problem with the capsule as well. So there's many reasons why the capsule fail. And as was discussed earlier, the capsule has a role in stability. And again, we have to define micro-instability a little better. But if you have a deficient labrum, eventually you'll have your psoas, the systemic stabilizer is going to help with stability, but also you'll stretch ilioformal ligament. So there's a lot of implication with having a deficient ilioformal ligament that can augment or cause more instability to an already unstable situation. So what are the treatment option when you have a deficient capsule? You can try to close it primarily. It's very difficult to do, especially if you don't have enough tissue, it's a large defect. You can have tried sometime with small defect to do it considerably with biologics. We had some success in a few patient when it's a small hole, and protecting them with appropriate protection, it works. But now we've moved to more reconstruction and in a few instances, we do augmentation. So why do we do this? Well, if you look at that picture there at the top, you can see the psoas standing herniating through the defect, and that can be very painful. So I look at it almost like a hernia. Also it has a structural significance, especially at the ilioformal ligament anteriorly where it provides stability. So closing the capsule or reconstructing will provide more stability. But truly also an intact capsule will help maintain your seminal fluid in the joint. So there's a lot of mechanical and biological issue why you should close a capsule. And we know now from a cadafric study that if you have a good capsule reconstruction in the lab, we can restore some destructive stability for the hip joint. So that's not that uncommon. Like I said, adhesions. You can look on the picture. If you have adhesion connecting the labrum, you have a hole where the psoas is. And sometimes you have patients who have a psoas tendon that doesn't heal after tendonitis. And then what you'll see, you'll see that they'll have a communicating burst or sometimes a defect in the capsule. So this is a patient who has a large defect medially. So we measure the defect. We do that without traction. And usually our graph will be between 5 to centimeter wide to 3 to 4 centimeter from proximal to distal. We use, I like to use IT banalograph. And we like to have the thickness to be about 3 to 4 millimeters. And when you prepare your graph, you have to make sure it's very, the suture line are very stable because the way to deliver it for us, we just place the anchor proximally and we deliver it without a cannula. So sometimes if it stays stuck in the soft tissue, you want to make sure that you're able to maintain the integrity. So the preparation of the graph is very important. I use more absorbable sutures. What you're seeing there in the corner is just for the anastomosis with the host capsule. We make some loop there. Now I switch that to absorbable sutures. So I was saying it's so large that it's very hard to deliver it through cannula. But we start proximally. Usually I place the most manual anchor first. And sometimes that anchor, you have to be careful because there's not a lot of bone stock there. This is after I deliver the graph. It's like delivering a carpet. You unfold it. Then you can see distally there, I grab the host capsule and then you just do an anastomosis. This is the proximal anastomosis. And you want to make sure it's more like an oblique placement because it's very hard to do it perfectly lined up proximal to distal. So I put it slightly oblique because of the bony purchase. It's very hard sometimes to place the anchor manually. So you have to be, like I said, I use a curved anchor system or a smaller anchor system. And then what we do is we just use graspers and we just do the anastomosis. So now, I used to use a suture relay. Now with the new development of new instrumentation, it's much easier. You can do it in one step. Start proximal to distal, then medial to lateral. Usually we use seven to eight suture distally and two to three anchors proximally. And it can be challenging because it's like building a ship in a bottle. You don't have a lot of room to maneuver. You have to do it step by step. After I deliver the capsule, I use a cannula. And again, you got to maneuver the leg, flexion to extension, intonation, exonotation. Sometimes I'll use a flexible device to deliver my sutures where I want to, especially medially. And then usually we have, this is after the anastomosis. And then I'll cycle it, flexion to extension, to make sure that it's not under too much tension. The first patient we did with this technique was actually a baseball, major league baseball player, who had the previous surgery, had the capsular defect, couldn't stabilize his leg when he was pitching, and after the procedure went back to pitch. This is a second look capsular construction for capsular deficiency. In the center is just a labrum, but this patient had adhesion. So if you look at the inferior pictures, you can see the capsule has remodeled, the graft has remodeled, very stable, and it's very functional tissue. So the pearl I would say for me, I started initially doing this with dermal allograft. Now I switched to IT band allograft. We have better results with those. And make sure you have distally these suture loops that will help you make your anastomosis. And again, it's very tight space, so you have to take your time and make sure you place your camera properly, so you visualize, especially medially, you visualize your anastomosis properly, and you make sure it's solid, and then cycle it after the treatment. So this is just comparing capsular reconstruction with IT band versus dermal allograft. We had better results with the IT band allograft. Mid-term results, we had 39 patients. This is a difficult group of patients. Most of these patients had two plus or one surgery before we went to them. We had six of them that converted to total HIP after 2.1 years, four revisions. So the three-year survivorship was 86%, and mean survival of 5.7 years. So a difficult group of patient, the patient had good reported outcome scores, and good solution for a difficult group of patient. So to keep in mind, a capsule is important for the health of our joint. And when you do your primary HIP, make sure your capsulotomy is appropriate. You can do a T or parallel, whatever you need, or just extend your portals. Be aware that that can cause problems down the line. The group I just showed, these were complex patients. But now more we learn about it, and clinically, these patients do really well. When you see them in follow-up, they'll tell you when they sit down, they have minimal discomfort even early on post-op. So it's a very rewarding procedure, actually, the capsular reconstruction. And the results are encouraging mid-term. We just need more longer term, and I think we'll develop a better technique to make it easier to do. So in conclusion, I think the capsule is very important to maintain. And if you have the defect, be aware when you see this patient, persistent pain after primary scopes, that this patient might have defect. And on the MRI, I didn't show MRI imaging, but you can see clearly that it's very easy to pick up the defect, especially if you look from a ligament level. So thank you very much.

hip capsule

iliofemoral ligament

capsulotomy

capsule closure

capsular reconstruction