Thank you guys for coming. Really excited to be here. Thanks, Ivan, for putting this together. So I'll be speaking on my algorithm for capsular management. So we'll start with a case just to kind of illustrate the importance of hip instability. This is a case of a woman that I saw probably about a year ago. She was a 35-year-old lady. She had a hip arthroscopy about six months ago. And I think in taking her history, I think she said that after surgery, she was actually much worse than what she was beforehand. And she said that she was actually doing okay, like, in terms of her regular pain. And then she says about five months after surgery, she was in the shower. She just tried to get out of the bathtub, and she actually dislocated her hip. So she had to get the ambulance to take her to the hospital. They closed and reduced her. And since then, when I saw her in the office, she was actually having pretty significant pain. On crutches and her brace. And she was pretty miserable at that point. So I think one of the things that we noticed on exam is that she was very guarded. She was very apprehensive. She had loss of range of motion in all directions. She had pain with Faber and Fader, and she had anterior apprehension as well. And she also had pain with straight leg raising. So these are the x-rays that she had in the emergency department. Obviously, she dislocated her hip. It was closed and reduced. And when we saw her, she had an MRI, which showed that she had a pretty significant capsular defect. So on the coronal view, you can see the capsule just kind of stops right here. And then on the axial view, you can see how the capsule is blunted in kind of a large open space. And basically, she was in a brace and crutches at this point. So I'll go back to this case at the end of the talk and talk about what we did for it. So I think this is why the capsule is important, because I think while macro instability or hip dislocation events are pretty rare, they can happen. I think most of us have probably seen it in our careers at some point. We may not have recognized it in some cases when the symptoms are pretty subtle. So in other cases, when you don't have like a macro dislocation event, sometimes these patients may demonstrate like micro instability or just very subtle subluxation of their hip that they really have a hard time describing. So we published a paper looking at patients who underwent revision surgery and found that there's actually a high percent of them that actually had capsular insufficiency defects or just kind of scarring of the capsule. So I think it's one of these cases like when you look inside arthroscopically, I think it becomes much more apparent when you look inside because you'll see how the tissue is much more disorganized than what you would expect. In the literature itself, there's 11 cases of instability, either macro or full-on dislocation events. But I think they're much, much less reported than what's actually out there. The concept of instability I think is pretty simple. This is a video that Jorge Chala put together. But when you make a capsulotomy and you don't repair it, you can see that not only do you have more rotation, translation, but you also have a lot of strain that can occur as well. And when you fix it, you can see how you restore the biomechanics back to its native state. This is a video from Steve Aoki just showing when he went in on some revision cases with just two fingers on the distraction table, he's able to very easily distract the joint. When he goes back in, he sees that there's a large capsular defect. He sews it back up. And then upon time zero at the same setting of surgery, he's able to do that distraction type maneuvers again. This is going to be a challenge, huh? Okay. So anyway, so he's able to keep it stable thereafter. So in terms of repairing or not repairing, not only will you prevent instability events, but I think you'll also decrease the amount of conversion to hip replacement. Mark Philippon's paper showed that when he didn't repair the capsule, he had almost a seven-time increased incidence of total hip replacement, and I think that other authors have found that as well. So in terms of the anatomy, I think it's obviously always good to be familiar with the anatomy. The iliofemoral ligament is the one that's most commonly violated. The strongest ligament in the body really helps to restrain the hip in extension and external rotation. And the origin of this, you can see when you're making your interportal capsulotomy, really starts to violate that iliofemoral ligament as well as portions of the ischiofemoral, depending on where the location of your interportal capsulotomy is. The three most popular capsulotomy types are the periportal, interportal, and T-capsulotomy. I think they're all based on surgeon preferences. The other thing about the anatomy that you want to keep in mind is that the capsule is thickest at that two o'clock position, and so just be cognizant if you are going around the two o'clock position that you especially want to think about repairing it in those cases. Some surgeons ask me, like, how do you repair the capsule or how do you manage the capsule? And I always start by saying the most important aspect of that is where you start your capsulotomy and how big you make it and just kind of your process in terms of doing that. This is some nice video that Jorge put together in terms of the interportal capsulotomy. Depending on how large you make it, it'll kind of help facilitate your visualization. If you're doing a T-cut, I usually limit it to about two centimeters or so. But if you're only doing interportal, you want to make it much larger so you can see everything and access everything as easily as you can. This is what you can see with a two-centimeter interportal. Obviously it's limited. If you start to go down and make a little bit of a T-extension, this is what you see with what we call a half or a mini T. Obviously in order to see the whole peripheral compartment, you have to flex and rotate it with either the half T or the interportal cut. And then with a larger T with traction stitches, you can see that everything is much more visible in the peripheral compartment. So keep that in mind as you're going through your capsulotomy options as far as what you want to see and how much you're going to have to manipulate the hip in order to get to where you need to go. So obviously the larger the capsulotomy, the more you'll be able to see. And that obviously affects the biomechanics as well. Mark Philippon's group has done some elegant biplanar floral studies just showing that as you start to section the capsule and the labrum, you start to increase the amount of translation that occurs. But he also shows that when you repair it, you're able to restore the biomechanics back down to its normal intact state. This is a nice study that came out of the Vail group as well, just showing that when you section the capsule, you're increasing the amount of rotation by about 15 degrees or so. And then also when you do this rotational biomechanical testing, that the number of sutures does help to restrain the capsule. And we've done biomechanical studies too, showing that the larger the capsulotomy, the more strain that increases the amount of strain of the iliofemoral ligament as well. So this is just a technique of what I would call like a mini T. And so here you can see that when we've made our capsulotomy about two centimeters or so and we make a small vertical extension, really that entire surface area probably fits my cannula. My cannula is probably about 8.5 millimeters. So here I have my camera in the modified interior portal. I'm working through that distal accessory. Sorry. Ooh. It's going to be a challenge, yeah? Okay. So yeah. So here's a look kind of on face. So you've got your traction stitches. We got the camera in that modified interior portal. We're working through the anterolateral portal. We'll use a capsule repair device. This is called a slingshot device where we'll go ahead and pass our high-strength sutures through the iliofemoral ligament. And I like to pass and then I'll tie kind of sequentially, kind of as we go. See if I can go, maybe this, maybe it didn't like that video. So this is, if you're doing an interportal capsulotomy, which I do as well. So I'll use either depending on what we're dealing with here. But in this case, we've got our camera through the anterolateral portal. We've got, we're working through our modified interior portal. And here we'll go ahead and place serial stitches and we'll kind of, we'll try to snap them as we go. And so we'll pass all of our stitches first and then we'll kind of tie at the end. This takes a little bit more suture management involved. So here we're just kind of passing sequentially. And as you get pretty familiar with these capsule repair devices, I think this becomes, you know, fairly, fairly routine. I think the most challenging part is just kind of managing capsule, capsular stitches and kind of getting them out of the way. And so I think sometimes if you, if you tie a few of them, it can't help rather than kind of leaving all of them at the end. Some people will use like different colored sutures. You could use like suture tape. There are different options to kind of help you see. And if you alternate it, it just helps along the way. I think this one we actually kind of tied as we went. But as you get to the last couple of stitches, you're, you really start to kind of back yourself out. You don't have as much space. But I think the benefit of doing it this way is that you'll, you won't have to manage the sutures as much. This is kind of a full inter portal capsulotomy about probably about four centimeters or so and just placing probably about six stitches in it to close the capsule in its entirety. So what we find is that in general, I say that the larger the capsulotomy, the more stitches you want to place. My kind of algorithm is I want to place about one stitch for every centimeter of capsulotomy that I make, whether it's an inter portal or a T cut. So going back to that initial case, this is kind of the case that we'll kind of go through today. So this was that 35 year old woman. She had a hip scope about six months ago when she saw me again, she dislocated, she was in a brace and she was in pretty significant pain and stability as well. But at this point we said, hey, you should probably think about getting this thing revised. This is the MRI. And so this is kind of what we saw when we got in there. So again, right hip, you can see pretty significant labral insufficiency, cartilage seemed to be intact. She had a radial split right there. And so upon seeing this, you can see that she basically retore her labrum. She kind of went through whatever scar tissue that was remaining. And so given the insufficiency of the labral tissue, basically we decided that we should do an augmentation. In this situation, we try to use as much native tissue as we can just to help facilitate some sort of biologic environment. Here we're just sizing the graft and then we're making the graft on the back table. My preference is to use a tibialis anterior allograft. We'll place all of our stitches first and then we'll kind of shuttle it through as we go. So here we're also placing these tape stitches we're using for the capsule at the end of the case. So I think we kind of prepared that, you know, given the amount of capsule insufficiency that we'd have to have some sort of anchor proximally to allow for repair of the capsule. And so we just kind of put that to the side and we're passing our labral. Yeah, we've been struggling with this all. Yeah, so here we're passing the labral graft. And I think Mark is going to go through a lot of his pearls as far as labral augmentation and reconstruction. Here you can see our tibialis anterior graft. And it can be challenging, especially if you've got larger graft sizes. And so you just want to be careful with your suture management and so forth. Here you can see we've got the native tissue beneath it. You've got your graft on top of it. And that addresses the labral side of things. You want to just keep going. So now we're addressing the capsule. So you can see there are stitches. The tape, again, is on the proximal side of the attachment, the iliofemoral ligament. We're actually passing the stitches through the ostabular side and the femoral side first. This is a video, it's okay. And given the size of the defect, we went ahead and used a dermal allograft to help kind of patch the defect up. And so we used the stitches from the proximal part of the suture anchor and we kind of sized the sutures themselves. We created the graft and now we're shuttling the graft. So you can see on the proximal cannula, we're kind of pulling the graft into the joint. And that will kind of, using what Mike Elman calls a kite technique, kind of reduce the graft into the joint. And now we're kind of suturing down or tying down the distal extent of it. And this will basically, I think with just the sutures themselves, we had a little bit of a defect and so this will help to augment that and give us not only structural support but also biologic scaffold. So this is kind of the final look. You can see as you rotate the joint how the capsule is able to rotate and extend and flex with the joint as well. So the evidence for a capsule repair I think is growing. I think that myself and other authors have shown significant improvement in terms of patient report outcomes as well as a higher proportion of MCID achievement and lower complications. So we've done a series of studies looking at comparisons between patients who have had capsule repairs and those who haven't and found that those who repair the capsule do really well. And even patients with hypermobility, you can see that their outcomes will be much more predictable and similar to those that don't have hypermobility. So in conclusion, I think we want to understand the biomechanical role of the iliofemoral ligament and that obviously starts with knowing and being familiar with the anatomy. Obviously know what kind of capsulotomy you're using, whether interportal or T-capsulotomy and how it affects both translation, rotation, and strain. Repairing does restore the native biomechanics of the joint and I think it's really important. Again, I like to use that one centimeter rule. For every centimeter of capsulotomy, you want to place at least one stitch to help repair. And clinical outcomes favors capsular closure over not repairing the capsule. I think you increase your patient report outcomes and you also decrease your complications, instability as well as conversion to hip replacement. And it's a very common cause of failed hip arthroscopy as well. Thank you.

capsular management

hip arthroscopy

capsular defect

capsular insufficiency

capsulotomy