But we're gonna talk about capsular management at the hip today. And then if there's any questions that come up, of course, as we said earlier, we'll collect them. But if there's something that's really grabbing your attention on a slide or something, be sure to stop me and we can of course discuss everything. So first of all, in terms of the hip capsule, we know that it's formed by three main ligaments. The iliofemoral ligament, which is also called the Y ligament of Bigelow is the strongest ligament of the body and some sources will quote 770 pounds of tensile force to disrupt it. So it's a major stabilizer in terms of anterior stability of the hip. And then the other two ligaments, the ischial femoral ligament and the pupal femoral ligament make up the rest of the hip capsule. Now, why is the hip capsule so important that you guys have been seeing a lot of literature on this from the hip arthroscopist? Well, it is very important for hip joint stability. So the hip joint is stabilized by the capsule as well as the bony anatomy, as well as the labrum and the negative suction seal within the hip itself. The problem with any disruption to this capsule, which a lot of times can be iatrogenic is that it can cause post-op instability as well as micro instability. And things that can cause this would include surgically iatrogenic excessive capsulotomy or capsulectomy without repairing the capsule, over resection of the bone during arthroscopy for FAI, labral debridement versus repair can sometimes decrease that or it could cause you to lose that suction seal. And then over distraction of the hip as well can lead to injuries. So going on from here, let's see. So I know Dr. Safran has already given you guys the talk on micro instability. So you've heard from the expert, but I referenced this article all the time in terms of him describing clinical symptoms of micro instability, as well as imaging findings for it. So there's some really great exams that he posts about this. Micro instability is a newer topic that Dr. Safran has really brought to our attention. But before some of his articles on this, most of the time we probably were not recognizing this very well. And anytime people had capsular problems, we thought it was all due to post-surgery iatrogenic causes. But there is definitely symptoms of micro instability, even without having had previous hip arthroscopy before. So some of the clinical signs I like to use that he pointed out, anterior apprehension, abduction, external rotation, and then axial distraction. So these are some of the things that I typically test for in terms of micro instability in the clinic. And then in terms of clinical symptoms, we haven't seen a lot of this, but we just looked at some of our cohorts recently at UCSF, and we just did some minor revisions on this paper for JOR. And we found that when we quantitatively image the capsule, the thicker the anterior volume of the, sorry, the thicker the volume of the anterior capsule, the higher the correlation with patient pain symptoms in the setting of FAI. So this is something we're gonna try to study a little bit more on in terms of the morphology of the hip capsule and how that could be related to patient's symptoms. And then, so I approach the capsule management, there's a few things when we're doing, when we're paying attention to the capsule surgically. First thing is that when you're doing a hip arthroscopy, you wanna minimize trauma during hip distraction. And then number two, oops, sorry about this. And then number two, when you're planning for your hip arthroscopy, you wanna plan your hip joint entry and your capsulotomy before the surgery. So based on what kind of the anatomy the patient has, whether it's like a coxa profunda, you might wanna think about where you wanna enter with your portals versus someone with the valgus femoral neck shaft angle. So based on those, you're gonna wanna plan on where you come in through the hip and how you're gonna approach the capsule too based on their pathology. And then you definitely wanna protect the capsule during your peripheral compartment work. This is an area where when you're doing your thermoplasty, you can really eat up the capsule with your burr or you might shave off too much of it if you're not protecting it. So we'll talk a little bit more about that. And then lastly, at the end of your case, you wanna evaluate whether you need to close the capsule or not. So this will depend a lot on what you've done during the case and the status of the capsule at the end of it, as well as what type of capsulotomy you've performed. So in terms of hip distraction, okay, so there's different ways of getting distraction on your hip during hip arthroscopy. So on a picture on the left here, this is a HANA table. So people can do hip arthroscopy through the HANA table, but what you don't wanna do is have a small post like what it's shown in this diagram. So then a newer attachment, this is from Smith and Nephew where they have a larger peroneal post greater than 20 centimeters in diameter that decreases your risk of pubertental nerve injury. And that definitely takes a lot of the pressure off the peroneal area. And then there's also, and there's also this new post free hip distractor from Stryker that you're using a Trendelenburg force to kind of get the patient's body weight to stabilize it. And then also using the apparatus to distract the hip through this. So this is something that we have tested it, but I haven't used a lot of it yet. Sorry, I saw a question here. Is capsule thickening reactive or do you think that it's part of the pathology? Yeah, so that's a great question. I do think it's probably a part of the innate morphology in terms of the capsule thickening in patients. There have been some other studies looking at development at the hip as related to the capsule in the pediatric population. So I do think it's part of the maturation process. And then in terms of getting the distraction, going back, I like to really deliberately use the air arthrogram to our advantage. So not just venting the capsule, but actually injecting air into the joint to force off that negative suction seal really makes distraction a lot easier. And then you're putting a lot less force through the peroneal area. So what we do here is we'll prep and drape and everything is sterilized. And then we'll go into the hip capsule away from the actual articular weight-bearing surface and away from the labrum. So you're in a safe spot inside of the capsule. And then we'll inject like 20 cc's of air, positive pressure into the joint. And just with that, you get this much distraction without any fine traction. I just put the knee in a little bit of tension, gross traction wise, but we're not pulling hard on it at all, just taking the slack out of the leg. And then just with injecting air, you can really get quite a bit of distraction in the capsule. And then diagram C here, this is just with 10 turns of fine traction on the hip distractor. So that's really very minimal force and you've got plenty of room in there for your hip arthroscopy. And then we'll redirect the needle back into the joint in the safe area. So when we looked at our patients with this, we did 30 patients without air arthrogram and then 30 patients with air arthrogram in terms of getting into the hip. The patients without air arthrogram, we just basically put a lot of gross traction on them and then a lot of fine traction, 20, 30, 40 turns until the hip actually distracted versus the technique I just described. And we saw that for the patients where we use the air arthrogram in the recovery room, they had a lot less pain in terms of both maximum, minimum and mean pain scores. And of course, because of that, they need a lot less opioids in the recovery room. So using this technique, we do think that there's less trauma during hip arthroscopy from it. And it has helped with being able to get distraction. Sometimes you can have a really tight hip, but then once you get the air arthrogram in there, everything opens up quite well. And then after you get good distractions, I aim for like something like 1.5 to two centimeters of joint distraction. The trocar that you get in with the hip is typically five millimeters. So then you wanna make sure you have enough room in there. And then some people will really make sure you distract a lot like three or four centimeters. I typically try to do a little bit less of that just because I don't wanna stretch out any of the connective tissue because even though you may not actually tear anything, you could loosen some of the properties of it. No evidence for that right now, just kind of personal feelings about that. And then in terms of the portals, we'll use the anterolateral portal as well as the mid-anterior portal to start our case. So we'll go in through the anterolateral portal like you saw on the fluoroscopy view. And then when you're in there, you wanna make sure you've got a good visualization of your hip joint. You've got the femoral head on the right and then the labrum on the left. And you wanna see that triangular space there of your capsule and the anterior part. And then you can put your second portal in there with a direct visualization. And then of course, using guide wires and then watching each of your next instruments come in with the next portal to make sure you're safe and not injuring any of the other structures. So visualizing safe entry is important. And then after that, the fun part begins where you kind of decide on how you wanna open up the capsule and what kind of capsulotomy you wanna do. So mainly there's four common types of capsulotomy procedures that surgeons will use during hip arthroscopy. The most common one by far is the interportal capsulotomy. And then the T-capsulotomy is also quite common depending on where you train. So if you're at Rush or HSS or Duke, your attendings will typically use that. Puncture capsulotomy is also used. And then periportal capsulotomy is something that's been described a little bit more recently. So going into each of these, interportal capsulotomy, you've got your two portals, you've got the anterior lateral one and then the mid anterior or direct anterior one. And then you basically just cut and then connect the two. And then you've got this space here to maneuver around with all of your instruments. So classic interportal capsulotomy, when we do it, we'll try to do it with a knife to preserve the tissues. So I'm looking through the anterior lateral portal and I've got my knife in the mid anterior portal and then I'm cutting towards my anterior lateral portal and then I switch portals. So now I'm viewing through the mid anterior portal and the knife's through the anterior lateral portal and then I'm cutting away from and then towards your other portal. And then you'll switch back and it's a pretty thick capsule. So there's always some remnants hanging on on this very peripheral part. So you wanna make sure you cut that across and you see the full range there all the way across so that there's nothing in your way. And then for a T-capsulotomy, so you've got the diagram here of the interportal and then basically you just extend that longitudinally along the anterior neck. So I don't do this personally, so I don't have any video of it, but you can imagine it's not too much trouble once you've got that interportal opened up, you just basically put your knife and then bring it down distally across the neck there. And then sometimes you can do this later on in the case, you don't need the interportal at the beginning of the case when you're doing your intraarticular work, but it's definitely used for the femoroplasty part. So maybe a lot of surgeons after they'll come off traction and then extend that. And then you can also make an accessory dala portal to do that and then that way it's right in line with your portal, it makes it easier to do. But the reason surgeons do this is that it definitely opens up the hip joint, especially the peripheral compartment, it makes it wide open and it makes it very easy to visualize the CAM lesion. So when you're doing your femoroplasty, so this is a view of it, this is viewing from the anterolateral portal and then the knife is coming in through the dala portal and then that's just basically cutting straight down and then you can see all the way down, if you really wanted to go all the way to the trochanter, you can, but it makes it very easy to do femoroplasty and definitely no arguments about that part. The other capsulotomy that's been described as the puncture capsulotomy, Scott Martin described this where you're using various portals. So you've got a proximal portal, the dean's portal, you've got the anterior portal, mid-anterior and anterolateral and then also the posterolateral portal. So instead of dilating each of these, you're using various multiple portals within the capsule to preserve the iliofemoral ligament without cutting into it. And then this doesn't necessitate capsule closure. And then correct me if I'm wrong, but I think Dr. Safran uses a similar technique to this. So then you're using multiple portals, but these are aimed in various directions to make sure you can do all the work you need to do. If you're gonna do some of your femoroplasty work, you're gonna need one from the proximal aiming a little bit more distal. And then you've got the various portals for your cannulas as well as for labral repair. And the main thing is you're just putting portals in there without cutting across the ligament. And then we described a couple of years ago as something called the periportal capsulotomy. So here we're using two portals for this. It's a little bit like the puncture capsulotomy and a little bit like the inner portal, but not quite either way. So we're using the two major portals. And what we do is we dilate around each of our portals. The mid-anterior one is the working portal. Usually we'll put a disposable cannula in there that's about eight millimeters. So you'll wanna dilate that to at least one centimeter. So you've got some room there. And then the anterolateral one, you just need a little bit of room to move around with your camera to be able to see posterior and anterior. So you can dilate that a couple of millimeters from the five millimeter cannula to make sure you can see everything. And then we also wanna preserve the iliofemoral ligament. So instead of cutting all the way across it, like you would do for an inner portal capsulotomy, you wanna preserve center between the two portals where your iliofemoral ligament is sitting. And then you dilate enough just so you have enough working room to do your work. So this is how we typically do it. We're looking from the anterolateral portal again through the mid-anterior. So we'll put our RF device in there. I typically will do this with an RF just because it'll shrink back the tissues around the capsule a little bit. Whereas if you just kind of cut it with a knife, then you've got all this kind of synovium that kind of falls in and there's not quite as much room. So you can see we've got wiggle room with our cannula, and then we switch portals. We're looking through the mid-anterior back towards the anterolateral, and we're dilating that portal up a little bit. And then you can kind of undermine the portal a little bit, especially there's synovitis there. And then you just make sure you have enough room to maneuver with your cannula. And then after you've done the capsulotomy, you wanna make sure you've preserved the iliofemoral ligaments. So we're just showing the view there, both anteriorly that's well-preserved, and then here in between the two portals that's preserved as well. And then with that, you've got plenty of room to do your intraticular work. And then we looked at our outcomes using this technique. So we did 140 patients using the FAIR-E portal without closing any of these, and they all had good improvements and no major post-op instability afterwards, so no revisions or anything like that in this cohort. So then that brings us to, you've made your capsulotomy, you've decided on what you wanna do, you've done everything intraticularly, what do you wanna do with the capsule at the end of the case? So is capsule closure necessary? So it depends definitely on your capsulotomy. So if you're doing a puncture capsulotomy, no, you definitely don't need to close that. If you're doing periportal capsulotomy, for the most part, you don't need to close that. And then T-capsulotomy, yes, you definitely need to close that. There's no argument about leaving a T-capsule open. That's very dangerous for dislocations. And then the more controversial one is an interportal capsulotomy, which the consensus is yes, for the most part, but there's definitely studies out there that argue against having to close every interportal capsulotomy. So we'll talk a little bit about that. So, but first, in terms of the periportal capsulotomy, so the cohort that I presented with 142 patients, those are all very kind of strict indications for doing this technique. So no patients with borderline dysplasia, no ligamentous laxity, no Bain scores greater than four. So for those patients, we're very comfortable not closing the capsules for a periportal, but for any patients that I do surgery on now that have maybe a little bit higher Bain score, like a six, or if they have borderline dysplasia, I will definitely close. Even if I do a periportal, I'll definitely close those up. And it's not too hard to close. You just put a simple stitch across each of your portals. So here, this is, when we close those up, I'm looking through the anterolateral portal. I just put one simple stitch through the mid-anterior and I'm still in the joint, so I can watch it come in and make sure I'm not getting the labrum or anything. And then as you tie it down, you're watching from the inside, you can see that mid-anterior portal kind of closed down the space. And then the next one, the anterolateral portal, you'll need to scoot your camera out into the peripheral compartment and then close that from the outside in. And then you can see that knot at the very top there once you close that. So we do close it, especially for the patients where I'm worried about micro instability after a case. In terms of the T-capsule, they've shown that closing the T-capsule all the way is definitely much better than even a partial one. So I don't think anyone opens up a full T and just leaves it like that. So some people will close the vertical limb of it and then leave the inner portal limb without closing that, but they've shown at Rush that closing it fully is much better than just leaving part of it closed. So for T-capsulotomy, for the most part, if you're gonna make this large cut, you're gonna wanna put at least two or three stitches in the vertical limb because that's the part that's most troublesome. And then you're also gonna wanna close the inner portal at least with a stitch on either side. So in this diagram, you can see what the hip looks like when the capsule is completely filleted open with the full T-cut. You can see all the way down the neck, they've done a nice femoroplasty here, but then you wanna definitely make sure you close that tightly. So here they're passing suture to close the vertical limb and then they close the horizontal limb to fully make sure that. Now, you can't get this view without really clearing off all the kind of bursa muscle, some muscle and fat over the capsule. So the surgeons that do really good peripheral capsular work really are able to expose it very well because if you can't see the capsule, you're not gonna be able to close it very well. I think that's some of the difficulty with some of the capsule closure techniques. And then coming back to the inner portal capsulotomy being the most common type of capsulotomy. There's a lot of people that do it very different ways in terms of how they treat it with closure. Biomechanically, if you leave an interportal capsule open, it's definitely not the same function as an intact iliofemoral ligament because that interportal cut comes right across the Y part where the two limbs come together of the iliofemoral ligament. And then you've got one side from the gluteus medius pulling it superiorly. And then you've got the iliocapsularis and iliopsoas sometimes pulling it anteriorly and distally. So you've got different forces of pull really keeping that capsulotomy unstable. And then biomechanically, just creating that in the lab, the force of distraction for a hip is much lower than compared to an intact capsule. So biomechanically, no doubt about the weakness of an interportal. But some people will argue that interportal capsulotomies do heal. So this paper from Omer Maydan out of Colorado showed that they did a interportal cut in 30 patients and then they randomized them to closure versus no closure at the end of the case and did MRI follow-up for up to six months. And at six months, both groups showed contiguous healed capsules on their MRIs, but this study didn't have any clinical outcomes. So we're not sure if there's any of those patients that have micro instability or any pain because they didn't have capsule closure. But their MRI images are pretty interesting. At six weeks, you can see this one, they cut the capsule, didn't close it. It wasn't really healing, maybe some scar tissue in there. And then in this one, by six months, you can see the cut before surgery. And by six months, that had kind of healed back together. So that's an interesting imaging analysis that came out a couple of years ago looking at healing of the capsule. And then in terms of clinical outcomes, this study just came out in January of this year out of Ireland. And they looked at almost a thousand patients and about half of them, they did capsule repair on, another half of them, they didn't do repair on. And they looked at PROs at two years and it was similar between the two groups. And they also saw a sub analysis where their female patients that they closed the capsule on actually did worse than their female patients where they didn't close the capsule, which is a little counterintuitive because typically we think of our female patients having a little bit more ligamentous laxity and they're the ones who usually are a little bit more cognizant about closing the capsule on. This other study from Ben Dome had two year and five year follow up on his patients. And he did 65 patients where he closed the interportal capsule up and then 65 where he didn't close them up. And at two years, their outcomes were pretty similar, but then at five years, his outcomes show that the repair group had less improvement compared to the repair group. Even though both groups did still prove the ones that he closed the capsule on did a little bit better in terms of meeting MCID criteria at five years. So clinical outcomes may be a little bit harder to parse out the differences between these techniques, but definitely biomechanically, it's been shown that leaving it open is a lot weaker. So I think by and large, most people do prefer to close interportal capsulotomy. And that's relatively straightforward in terms of doing that, where you could put two or three stitches depending on how wide your capsule is. Steve Aoki is doing some interesting configurations where he's doing like a figure of eight across these to make sure that it's really airtight. But I think you can close it any number of ways. In terms of how we manage this, if we do make it interportal capsulotomy, we typically do this in the setting where we're planning on to actually try to placate the capsule a little bit. So typically I'll do the periportal, but if there's a patient that may have a little bit of ligamentous laxity, where I'm thinking I wanna make sure their capsule is really tight afterwards, we'll do a full interportal cut and then placate it afterwards. And when we do that, we make the capsulotomy with a knife instead of an RF because you don't wanna shrink the edges back of your capsule. You wanna maintain as much healthy tissue as you can for direct repair. And then we'll use suspension sutures on the proximal aspect of the capsule to lift that off away from the labrum, away from the acetabulum. So when you're doing your labral work and any acetabuloplasty work, you don't eat up the capsule with your instruments or damage it. And then you definitely wanna also preserve the capsule and be very cognizant of where it is during your femoroplasty as well. And then lastly, I like to close it with absorbable sutures. I have seen a couple of patients come in where they had a capsule closure using like non-absorbable high tensile suture, like fiber wire or something like that, where they felt those knots kind of right underneath their iliopsoas. So I personally prefer absorbable suture for closing the capsule. So this is how we would do that. So first we've made our interportal cut just like it was shown earlier with our knife and you see the nice clean edges. And then before we do anything else, what we'll do is I'll tag the proximal capsule right away while it's wide open for us. So using our passing device, grabbing that, and then I've got a medial limb there and I'll put another one attraction stitch in a little bit more superiorly, and then I'll retrieve that. And then basically I'll have these sutures outside of the skin, outside of the portal, and you can basically just clip them with the hemostat close to the skin. So that way you've got tension on your capsule here and you're lifting it up away from the labrum, which is below it. So then now you can see here, we've got plenty of room for our acetabuloplasty underneath the proximal capsule. And this capsule is all thick and nicely preserved by getting it out of the way without battering it up too much. And then once you're done with the acetabuloplasty, you can go on to do your labral repair. There's plenty of room there with the capsule out of the way to put your anchor in and then pass your anchor around the labrum to do your repair. And then after you've repaired it, you can take the tractions off. So you don't really need the medial traction stitches now, but I usually just leave them in there. But, and then if you have problems with the distal capsule, you can actually put traction stitches in distally too to really open that area up. Most of the time you can just kind of move it out of the way with your cannula and protect it as you're doing your femoroplasty. And then at the end, you're gonna wanna close that. So you can just put in your, so if your traction stitches are in a good place, you could basically just use those. So that's what I'm doing here. I basically will now take my passer, go through the distal limb, which is a lot more mobile. So you could bring that up all the way to where you need to go and then grab that original stitch that you previously tagged the proximal capsule with. And then you can tie that down one at a time. And then here, we're going to the other limb here, putting our passer right through the distal part and then grabbing the more superior traction stitch. And then tying that down. And then you can make sure, you can see it from the outside looking in. So make sure you can't see any part of the joint and you're seeing just capsule right across your previous capsulotomy there. So then, so that's it for the lecture part. I wanna go on to a case for you guys. So if there's any questions, feel free to chime in or from any of the other faculty, if you guys wanna chime in on the case as well, happy to hear your thoughts on this. So let me see here. So we've got one question here. Okay, so do you have any tips and tricks when ready to close the capsule? The edges are very tight and you're concerned that the moment the patient slightly extends their leg, they will break their suture. Yeah, so you should close. So I basically will close the capsule in neutral. So I don't try to flex the hip too much when I close it because I wanna make sure I don't over tighten it. I don't over tighten them. I've seen patients come in where they've had closures where some surgeons will close it at 10 degrees of flexion and it's just too tight and the patient will feel that for at least the first few weeks. Eventually it kind of softens up and loosens up but they'll have a lot of inhibition of extension if you close it too tight. So first I close it in neutral and then your capsule should be mobile. So it shouldn't be closed where it's so tight where you think that as soon as they're gonna extend, they're gonna pop their stitch. Usually if you're not taking too big of a bite, you shouldn't over constrain them. So when you're putting your passer in, you wanna put it close to the edges of where your casulotomy is. So you're not taking a huge bite unless you're deliberately trying to placate the capsule. But yeah, so for this case, this is a 34 year old recreational ice hockey player who had an outside hip arthroscopy surgery in Texas four months ago and then he moved to the Bay Area. And he said that he's been continuing to have groin pain for the last four months after his hip arthroscopy. He said, at first his post-op course was pretty uneventful. He was on crutches for two weeks and then advanced to weight bearing. And then he did continue to have a fair amount of pain over the first three months, but he thought that was kind of regular for his recovery. But then he started to do a little bit more aggressive physical therapy around the three month mark, trying to get his range of motion a little bit better and then trying to increase his activities, walking tolerance and some gym activities. And then that's when it started to really hurt him, but his wounds have been fine, no drainage, no fevers. He's a normal person, non-smoker, no social problems or anything like that. And then when we examined him, we found that the operative side was the right side. He had a little bit of decreased flexion there, guarding a little bit from pain with max flexion. Extension was okay on either side in terms of range of motion. Internal rotation was a little bit limited as well. And he actually had a little bit more external rotation on his post-op side compared to his contralateral side. And then when we looked at his strength testing, a little bit weak with extension on the right side, but otherwise pretty normal for that. He did still have a positive fader test, but negative favor and negative log roll. And then he definitely had quite a few of these signs for instability, including the anterior apprehension tests, as well as abduction and external rotation tests. And then the prone external rotation test was positive. So then we're able to get his x-rays. So these are his x-rays post-surgery. And we also got his op report, and it said that he had a femoroplasty with labral repair. Interportal capsulotomy was described without closure. And then these are his post-op x-rays, which look fine for the most part. We don't have the pre-op x-rays, but I mean, no major glaring problems, maybe a little bit of distal residual camp and nothing bad there. I think that's pretty typical. On the AP view there, maybe a little bit on this area. And then we got a new MRI for him. So this is four months after surgery from his previous hip arthroscopy. And what we see here is, this is a non-contrast MRI. So this is all just joint fluid here. And you see this large capsule defect right here on the superior lateral aspect. So you can see the capsule right here, and you can see basically this big defect between this end of the capsule to that end of the capsule, where it's supposed to be connected. And then you scroll anterior a little bit, you see some proximal limb of that capsule, and then a little bit of a distal limb, but a large defect here. You can see his previous femoroplasty right there as well. And then when we look at a couple other cuts, the anterior, sorry, the axial cut doesn't look too bad. So the anterior capsule, inferior anterior capsule looks like it's probably okay here. Maybe they didn't extend that inner portal quite that far anterior, which is fine. And then same with this view on the sagittal cut here. So a little bit more inferior and medial, the capsule looks fine. So it looks like that defect is more superior and lateral. So maybe pull some of our faculty, like what would you guys think about a patient like this, or how to approach this case in terms of a revision, or should we wait a little bit longer, let it see if he can heal? Do any other diagnostic tests? I unmuted a couple of our faculty, Mark, Dr. Workman, and also Winston, if you guys wanna chime in. Nice job, Alan. Nice talk. So this post-op MRI is how far out now from his surgery? About four months now. Yeah, so I mean, I've seen some capsules heal upwards of that. The problem with Omar Maydan's study that you showed was it was a non-contrast MRIs, and I have seen people that have MRIs, if they don't just catch it quite right, they'll miss the defect, if you will. So an MR arthrogram is probably more helpful, but your patient here has an effusion, and so you don't need to do an arthrogram. But I have seen some that have healed at six months. I actually saw one that healed at one year. They weren't very symptomatic. They rehabbed him some more, and they can actually heal. But if he's symptomatic, and as you showed, he had all three instability signs positive. We found that if you had all three instability signs positive, you had a greater than 95% likelihood of having laxity in the OR, which would be consistent with the instability. So if he was really symptomatic, after you've really rehabbed him, got good strength, and it's been beyond six months, I'd go in there with the expectation to close it. It looks, based on what you showed, you probably can get it closed primarily. If there was any concern, you could have something like a Regenitin patch to put over it if you felt like the tissue was of poor quality, or you could potentially get an allograft of sorts to do a capsular reconstruction if it really was unsalvageable. But from what this looks like, this looks like you could probably get an arthroscopic primary repair, and I found that it can dramatically make patients feel a whole lot better. But the key is leaving, and again, you had talked about whether or not you should always repair or not always repair the capsule. I don't think that it's an all or none phenomenon. There's certainly your stiffer patients to begin with may not really have a problem, and I learned that by spending a lot of time early on with Jim Glick and Tom Sampson where they were doing big capsulotomies and capsulectomies, and they never really had problems with patients with instability. But you get some of your ligamentously looser individuals, and you do a capsulotomy and leave them be, I think that some of those people can have instability or persistent symptoms, and I think you need to close them. So it's not, in my mind, an all or none phenomenon, but you get back to this case. If he's really symptomatic, you can go back and close him, but otherwise I'd send him to some rehab. I'm a little concerned when I look at that, the second of the two, those are done, that's the same MRI you guys got, just different cuts, right? Yes, yes. Yeah, so I'm a little concerned that he's dysplastic. What was the center edge angle? So when we looked at his X-ray here, let me see here. So, yeah, so. That actually doesn't look that bad, but his MRI looks a little concerning, but the MRI looks a little bit borderline dysplastic to me. Right, yeah, on that cut, I agree. I mean, on this cut on the right, definitely does look a little bit dysplastic on that one. It didn't show up so much on the X-ray. They didn't do any acetabuloplasty work based on the MRI, on the op report, so. I mean, yeah, I definitely agree with your comments on that, especially if we are worried that he has some borderline dysplasia. Definitely, in those patients, I would wanna be a little bit more aggressive about closing the capsule and tightening him up. And so we discussed that with him, the options, and he said, you know, he's pretty active. He wanted to get back to hockey, so pretty high. Well, not high level, but recreationally, but that is a somewhat contact sport, even for like the low-level people, I think. So we wanted to make sure he had a stable hip from this. So we did decide to go in there to repair it. And because it's at four months, we thought the tissue would be amenable to repair. So just like you described, you can close it up or you can even try to placate it a little bit if the tissue is a little bit loose and beat up. And then just like you described, if there is any problems with the capsule integrity itself, you could do a capsule reconstruction with like a dermal allograft or the regentin patch that people are using both in the shoulder and in the hip nowadays. So we discussed this, but because we're gonna get in there relatively acutely four months after surgery, we said there was probably low likelihood that we would need like a reconstruction. So this is what we saw when we got in there. So right away, you can see there's a large capsular defect here. Some frayed edges, didn't really heal much or anything. You can see the repair underneath it. So first thing we do is just kind of tag the proximal end because I was worried about the proximal end being really kind of thin and not holding stitches. So I wanna make sure that part was amenable to repair. And there is some scar tissue intermixed with that in there, but it does look like it held the stitches pretty well. So then we just went inside, just to make sure everything looked good in the joint, maybe touch up the thermoplasty a little bit, nothing major there. And then we wanna make sure that the distal limb wasn't retracted too much and that we could close it without having too much stress on our repair. So we wanna make sure that distal limb is mobile. And it is, it was, and there's all the scar tissue around it. So then we just basically put in the stitches on the distal side and coming across three simple repair stitches. The first couple are in here and then putting in the third one here and then closing that up altogether. And it came together pretty nicely. So I was happy with that without having to do any, reconstruction or allograft supplement to it. And then post-operatively, he's now six months out and he felt a lot better afterwards and he's back to hockey at this stage. So those are my references. I think we still have some time, but there's questions for discussion from the fellows. From Winston. Yes, I'm back. While you're out playing with your kids, do you have some comments? So, today's actually my birthday. They were singing happy birthday to me as you guys are about to ask me that question. So, I have to be careful. Wait, wait, hold on. Let's sing them happy birthday. Come on. We got to. Three, two, one. Happy birthday to you. Mute them. Mute them. Happy birthday to you. Mute. Happy birthday dear Winston. Happy birthday to you. Happy birthday dear Winston. Happy birthday to you. to you. Thank you very much guys. But I have a lot of thoughts about that and first off that was a great case and I think I probably would have done probably the same thing you did. I find that if you if it's a capsular problem like that one was and you repair them they have a remarkable recovery just like yours did even though I thought the FEI work was pretty good. I agree it has a little residual stuff down there on the thermal neck but when you see a big capsular hole like that and they still have groin pain for me it's really instability until proven otherwise and so I would agree with it's hard to know when to MRI them that's the thing and and all the fellows out there are going into practice you'll have patients like this four or five six months out who are still kind of struggling and when do you MRI them and what do you expect to find the MRI I guess is the question and so when you hit a home run like that it kind of reassures you that you're doing the right thing but there will be some that that might heal on their own and it might get better on their own when you pull the trigger and I don't have the answer for that and maybe that's why Marcus didn't cut the capsule because he didn't have to worry about that in his practice but we all see it that's for sure yeah I guess I would comment that if that proximal limb is pretty sometimes you get into the proximal limb it's pretty attenuated you don't really have a whole lot there and so sometimes I'll throw a suture anchor in the subspine region or even two to give me just a second point of fixation otherwise you're relying on your stitch just to hold that proximal capsule and you don't feel that great about it when you when you close after you after you close you don't really feel that great about that how that's going to hold over time so I just put that out there as a possibility yeah yeah I mean great point yeah I mean that up when you when people make their capsulotomy is really close to the labrum into the acetabulum that tissue isn't very mobile and it's really hard to um get a good bite and that it's more likely to rip out I think in that in that scenario so you're you're exactly right the key is is following the anatomy of of the capsular insertions which was interesting when we submitted our anatomy of the of the um ligaments themselves the one that showed that where you if you join the anterior and anterolateral portals or do the interportal capsulotomy you're cutting the iliofemoral ligament which is the whole problem when we tried to do one with just the insertions none of the journals would accept it because they said there's no no value um in understanding that I was like wait till we start to do the labor do capsular reconstructions you'll see if you'll start to see the value but it was kind of a it took like two three years to finally get it to get it accepted to a journalist um because of that but but you're exactly right uh Winston I I've um that proximal stuff is is tough and the patients are good I don't know when the right time is you know because they do heal and like I said I've I've had one case of a soccer player that had a defect at six months and had um and had no defect at one year it was healed at one year so and and both were MR arthrograms so both were clear so yeah do you routinely if somebody has pain after is so um it seems like Alan you don't necessarily routinely get um an MR arthrogram because your patient had an infusion but um Winston are you getting MR arthrograms on anybody's looking at with post-op pain or you are you just looking at um a straight MR? MR arthrogram you know I think there's a lot of value in the arthrogram I mean I Berman always tell me that the you know that the arthrogram can kind of conceal things but I think in the case of a post-operative fit it reveals things it reveals that capsule or feels I mean there's two things a capsule can do one they can have a defect in it or two it can be really patulous and really kind of like you know when it healed it might have healed in the lengthened position so I just want to see what that capsular um integrity is when I so I usually get an MRI arthrogram and a radiologist before that too here so and also you can put a little bit of lidocaine in there with your arthrogram sometimes and give you a little sense of to make sure it's the hip joint causing the trouble. What Alan are so do you do much arthrogram with it or not? So if they're a little farther out I would this person was like four months so I thought it was relatively acute so I didn't feel like I needed to do contrast in there but definitely people that are coming in like six months plus I would definitely do an arthrogram for them. Yeah and what I do with my arthrogram is I use instead of gadolinium I use rapivacaine and to see if it relieves their pain to confirm the pain is intra-articular or not and because sometimes the gadolinium can upset their hip in and of itself. So are you using anesthetic uh Winston I'm do you sit right? Yeah I'll use some marketing you know like you said a lot of cane. So I use rapivacaine for one reason only. Connie Chu? Basically medical legal right? Yeah I know your partner Connie wrote the paper on that so. Yeah I do it not because of Connie I do it because of the lawyers who read Connie's paper. So I would warn the fellows out there that um if you're gonna order a post-operative MRI you got to be able to help the patient interpret it because the radiology reads gonna open up a bunch of can of worms and so I usually go into that saying I'm looking for some specific things on the MRI um just so they know that you know the signal in the labrum whatever else they might find might be an expected finding as well because post-operative MRIs never look perfect even in a perfect scenario. Actually I tell them up front I said we're going to get an MRI I guarantee you there your labrum is going to look abnormal because they did a labral repair it'll always look abnormal for the rest of your life so rule that I try to get that stuff out up front so that they don't freak out. Yeah preemptive counseling can be very helpful as opposed to when you get the MRI and there's a read on the labrum and you feel like you're kind of you're trying to like I don't know so I'm trying to be preemptive as possible for those. Yeah I agree and I think they're um we're trying to look at some studies looking at the accuracy of post-op MRIs for the hip um and it's just the reads are all over the place like even like in uh inter uh greater um classifications between radiologists this is very very inaccurate. I thought they're in New York and and Hollis Potter's reading it then you don't need an art that's right she picks it all yeah she'll tell you what you got yeah yeah so so Alan so then you're doing your your when you do your periportal capsulotomy how often do you convert to making a bigger capsulotomy as far or do you always just do a T when you're going in the peripheral compartment or what? So yeah great question so probably uh one out of like every 20 cases I'll actually need to complete the inner portal cut and and then just close it afterwards and the hard part is the thermoplasty part if you're trying to do it through uh your small uh capsule preserving holes that sometimes if you have a really large or distal cam you can't reach down there very well so then sometimes I will just go ahead and connect the two portals and then close that up afterwards. Winston are you doing inner portals T's what are you doing? I do inner portals about 80 percent of the time and I'll do a T on the on the really big cams and the distal cams um so if I do inner portal sorry Mark I think about you when I cut that that ligament. So here how far down do you go on your how far down do you go on your T? Just to the very edge of the zona I don't ever go through the zona. And Alan do you go through the zona? I never do a T so I just try to get there with the inner portal yeah if I need to. Hey Latul undo undo Will Workman for a sec too. Who are there what are the faculty on here? Yeah I think he was unmuted um there he goes. I was just waiting for Mark to stop talking. Wow wait he's on my topic here man that's for me I'm gonna I'm gonna throw a great question out in a second but you throw do you do T or technical portal what do you do? Well Alan thanks that was that was a wonderful talk and I picked up some tips from you. I'm I'm a you know I'm a community guy I do uh inner portal and um I rarely close the capsule and you know just as a teaching point I think that case you showed to me looked really dramatic I mean it it uh I mean it I I kind of questioned uh you know before you showed us your repair whether that was sort of an over resection of the capsule because that looked like a really big defect and I don't think a lot of them show up that way at least you know because I have occasion to go and do MRIs on my patient six months out if they haven't gone to Mark already for their capsular closure and I never uh you know I never see them like that so I'm not sure that that I mean in my in my experience that's not a real common scenario and I mean just it sort of jumps out there like yeah this thing needs to be closed yeah I agree yeah that's probably the biggest one I've seen in my practice so that's why I wanted to show it but typically yeah yeah I do the same for the fellows like that's that's probably not how they're going to typically typically present but um but yeah so I inner portal and again I think my patient population this came up like last week the week before I think minor tend to be a little bit older athletes and they're not quite I don't have the you know the borderline dysplastic you know micro instability ones as much unless I'm making them into those and Mark's got to fix them but they've done pretty well that hasn't really been the issue I think and I and I do I try to be really careful with and I do the inner portal and I just kind of clean up the edges and I can pretty much get pretty far down on even a big cam and then I kind of leave it I have been burned a couple times I feel like when I've closed the capsule and they've gotten a little bit stiff okay so here I'm going to ask a question of we're going to get the tool our moderator back on here for a second which is going to be thrown back to you guys so the tool you do multi-leg knees right yes you do isolated PCL reconstructions I do is it easier to do an isolated PCL reconstruction with the AC or is it easier to do PC reconstruction when the ACL is in the way or not in the way not in the way right so do you cut the ACL to do a piece every construction because it's easier and then so the ACL back up and hope it's going to function normally no sir so does it make any sense to cut the iliofemoral ligament and or the zone orbicularis to be able to do a camera section just to sew it up later and figure it's going to function normally you lost me but I would say no would you do an interportal capsulotomy cutting the iliofemoral ligament so that you can do a hip scope and then sew it back up and expect that the iliofemoral ligament is going to function normally um I question whether it's going to happen you know it's a thick ligament I'm just saying Winston I'm just saying I hear what you're saying only time I scope hips is on call if I get a septic hip really yeah I can't get I can't get any of my partners to scope a hip yeah well I learned how to get a scope in a hip as a fellow but that was before Jim Rosnick came back to the Cleveland Clinic so um that's about and that back in those days all they were doing was burning and eating the labrum so uh I can get in the joint that's all I need to do so so Mark when you do the puncture capsulotomy do you ever have to extend or anything for to get to your distal cams you know uh so I don't I don't do what I end up doing is for my central compartment I do what you call a puncture capsulotomy I don't I used to actually enlarge the capsulotomy initially probably for about four or five years but I don't do that anymore because with the three portals I can get to anywhere I want in the central compartment with the instrumentation that we now have that being said for the peripheral compartment to do my camera section I go on what I call the rotator interval of the hip so what what what Anil Ranawat yesterday told me was a different interportal capsulotomy which is to say I'm not going between the anterolateral and anterior portals because that's the iliofemoral ligament but if you go between the anterolateral and posterolateral portals you're in a part of the capsule that has no ligament because the post lateral portals by the ischiofemoral ligament so I go in that in that zone that doesn't have any ligaments and I and I so I enter the peripheral compartment from straight lateral not going through not damaging the ligaments and then while I'm doing my camera section I'll have my fellow or you know lift the leg and rotate the leg around for me to get as distal as I need as proximal as I need as medial as I need and I can do that without without cutting cutting the ligaments themselves okay great great looks like we have a question from uh Alexander Brown here any rehab changes when doing a capsule repair yeah so I'll throw it to you guys I uh I mean for that patient that had that big capsulotomy that I repaired I kept him on crutches for like four weeks which is a little bit longer I typically do two weeks of crutches uh but I don't know if you guys change your protocol uh for for your capsules I don't normally brace but when I have a capsule repair that's my target I'll brace them that's one thing I'll change otherwise it's pretty much the same you almost said that like you're the most interesting man in the world I don't normally break but when I do no what I would say my routine hip scopes I don't brace but when there's a capsule or a situation that I'm worried about I'll brace them to kind of slow them down a little bit and help it heal I think so I brace labral repairs and I brace uh capsular plications um capsular closures and I do that for two weeks um and I brace my labral reconstructions a little bit longer um but uh and my capsule reconstruction is a little bit longer but um because that's a non-native tissue that I'm trying to get to heal but but my I worry about stiffness so I don't want to brace them too long and with the bracing I let them flex to 90 and I let them get to a regular extension not hyper extension so yeah Alan do you uh do you ever come up with like a patch or a graft or something just to augment your capsular repair I haven't I haven't done that so I mean I haven't had we haven't had a lot of people or in my practice that have had really bad capsular defects I mean you know Dr. Safran and uh and Paolo Alto is conservative with the capsule I'm pretty conservative with my capsule work so we don't have a lot of people doing t-cuts in the bay area at least so I haven't seen a lot of people that have had that that much problems where I've needed to do that you know you know it's interesting Mark and this might be interesting studying of itself to follow the lineage of hip arthroscopy where people have trained and where their capsular management situations are because you know the entire Brian Kelly line is the t-cutters you know Shane Ngo and and Chad Mather and those folks you had the Philippon interportal guys you have the Safran Prairie portal the Thomas Byrd interportal so it's kind of interesting to watch the lineage of how people trained and it's kind of see where they developed their practice because I you know I started off I watched Tom Byrd and Tom Sampson and they you know didn't make um interportals actually when I watched Tom Byrd he didn't make an interportal capsulotomy but that was back in 2005 or something like that 2003 somewhere in that area um so he wasn't making an interportal at that time um but you know unfortunately you know I trained Rosnick and you know he's an interportal guy I mean obviously I didn't I didn't teach him well enough but uh or he went and I learned to do it right but and so he made an interportal so but you're right I mean you know when when Alan was saying you know Rush New York and Duke I mean that's all from the Brian Kelly lineage right so right but there is a I think there's a trend toward making it smaller that's for sure and so maybe by the time we're done with this we'll go back to being all period portal guys so um but I think we're just getting better so you know when I was a bird even eight years ago we were doing pretty large capsulotomies and then this I mean we would we would resect some capsule and not really close very many nationally has changed your last eight years so I don't know I don't know the answer but you know the capsule is not being messed with um I think that's a big source of post-operative problems yeah and around 2001 I saw uh some video from Tom Sampson and they were with him and Jim Glick and they were very aggressive about resecting capsule and I remember when I went and visited Mark Philippon around 2007 he's making the you know his interportal um but now you know people are repairing so that's you know I think that's a good thing um that that's a that's a step in the right direction now if I can get to people to not cut then I think I'll be even in in a better way I don't think it's going to happen though but you know you should watch the fellows when you make that t-cut their eyes just open up wide like oh my god I can see and every time I talk to Razek and he tells me that he's making interportal I feel it I feel a few more cardiac cells going away awesome guys good discussion yeah Alan thanks so much appreciate it um as as uh Latul had mentioned um this is going to be on the AOSSM uh learning management system and um and so also tomorrow Mark Philippon is not going to be able to talk but he's going to be talking the following week um I sent out a schedule to the fellowship programs of the um of the changes there's just a couple of uh schedule changes just because we set this all up eight weeks ago when nobody knew what was going to happen with the pandemic and we still don't know what's happening but some people are working and some are not and whatnot so but uh Alan thank you for your time I appreciate it Latul thank you for pinch hitting while I was having computer issues and all uh as always um appreciate everybody's contribution Will Winston thank you you all have a good day thanks so much thanks thanks Alan thank you Latul hit end meeting okay yes thank you got it

capsular management

hip surgeries

hip capsule

ligaments

capsule disruption

micro instability

capsulotomy procedures

capsule closure

hip instability