Arthroscopic Hip Capsule Reconstruction for Anterior Hip Capsule Insufficiency in the Revision Setting

Abstract

Iatrogenic hip instability is increasingly recognized as a cause of persistent pain and disability after hip arthroscopy. Many authors currently advocate capsular repair to reduce postoperative instability. However, anatomic deficiencies in the anterosuperior capsule can prevent a functional capsular repair, particularly in the revision setting. Capsular reconstruction has been shown to restore biomechanical stabilization in cadaveric models and improve shortterm patient outcomes in patients with primary hip arthroscopy failure. Arthroscopic hip capsular reconstruction is technically challenging, largely owing to complex suture management and difficulties with graft placement and sizing. This article describes the capsular reconstruction technique, detailing the technical aspects of anterosuperior capsular defect identification; capsular preparation; suture management; and dermal allograft sizing, preparation, and positioning.

Arthroscopic Capsular Suture-Lifting Technique for Treating Femoroacetabular Impingement Patients With a High Risk of Postoperative Anterior Instability

“…Additionally, although postoperative instability of the hip joint can be caused by multiple factors, the most common of these factors—iatrogenic factors—can be avoided by strict control of surgical indications, improvements in surgical techniques, and appropriate management of the joint capsule for high-risk patients. 19 , 20 , 21 , 22 , 23 Our capsular suture-lifting technique restores the integrity of the anterior capsule of the hip joint, improves the tension of the anterior soft tissue, and prevents postoperative anterior instability in high-risk patients. Over the past 2 years, we have applied this surgical technique for the treatment of FAI patients with a high risk of postoperative hip instability, including BDDH and excessive femoral or acetabular anteversion ( Table 1 ); Figure 3 shows healing and the morphology of the lifted joint capsule 1 year after surgery.…”

Hip Capsular Reconstruction With Indirect Head of the Rectus Femoris Tendon

“… 27 has echoed those ex vivo biomechanical findings, showing postoperative improvement in clinical outcomes after hip capsular reconstruction at 2-year follow up. A wide array of graft and technical approaches have been described as options for reconstruction, including the use of dermal allograft 17 , 19 , 28 iliotibial band allograft, 29 , 30 Achilles allograft, 31 and bioinductive collagen implants, 32 among others.…”

“… 6 A positive dial test also has been found to correlate with capsular insufficiency. 18 , 19 Preoperative radiographs must include a classic anteroposterior view with center-edge angle measured, as well as a 45° Dunn view with alpha angle measured to detect features compatible of remaining femoroacetabular impingement. 6 , 20 In addition, a magnetic resonance imaging (MRI) study will often reveal substantial extravasation of fluid indicative of capsular insufficiency ( Fig 1 ).…”

Magnetic Resonance Arthrogram Improves Visualization of Hip Capsular Defects in Patients Undergoing Previous Hip Arthroscopy

“…These findings are significant given evolving options for surgical management in the hip instability patient population. 15 , 16 , 17 , 18 …”