Puncture Capsulotomy During Hip Arthroscopy for Femoroacetabular Impingement: Preserving Anatomy and Biomechanics

Abstract

We describe an arthroscopic technique for the treatment of labral pathology and femoroacetabular impingement that provides excellent access to the central and peripheral compartments while preserving the biomechanically crucial components of hip joint stability. The hip capsule and the ligaments within it have been shown to be integral to hip biomechanical stability. Other popular techniques such as interportal and T-capsulotomy inherently damage the capsuloligamentous complex of the hip and can be associated with postoperative gross instability, micro-instability, heterotopic ossification, and seroma. Capsular closure may mitigate some of these effects but has been associated with capsular insufficiency and requires postoperative restrictions that can be prolonged. Our surgical technique focuses on careful portal placement, replacement when necessary, use of a switching stick to maximize peripheral compartment visualization, and joint access in the most minimally invasive manner while avoiding complications associated with extended capsulotomy. The objective of this Technical Note is to describe a technique by which full access to the joint can be obtained while not disrupting the biomechanics of the joint capsule.

Editorial Commentary: Hip Arthroscopy Capsular Approaches: Periportal, Puncture, Interportal, T-Cut…Does It Really Matter?

“…1 As the field has progressed, we have learned many capsular techniques that have improved the visualization needed to technically perform a better osteoplasty, although improved visualization typically means more capsular disruption. 2,3 As a result, we have also encountered complications including microinstability and frank dislocations, hence, substituting one problem for another. 4,5 There is a trade-off involved in the various capsular approaches: the balance between appropriate visualization to adequately perform a complete femoral osteoplasty versus disruption of the capsule, potentially causing iatrogenic hip instability.…”

Use of Bone Marrow Aspirate Concentrate with Acetabular Labral Repair for the Management of Chondrolabral Junction Breakdown

“…Once adequate intra-articular visualization of the lesion is achieved, acetabular labral repair is performed using a chondrolabral junction preservation technique ( Fig 1 , Video 1 ). 9 , 10 , 11 Following labral repair, a central anterior portal is established for the bone marrow aspiration needle. This portal is located superior to the midanterior portal, directly between the anterior and anterolateral portals ( Fig 2 ).…”

“…Following surgery, the patient is discharged on an outpatient basis and managed postoperatively with previously established protocols. 9 , 11

Fig 9 (A) While working through the central anterior portal with saline irrigation turned off, a slotted guide is used to direct the bone marrow biopsy aspiration needle (white asterisk) to the chondrolabral junction (arrow) and labral repair site (labral repair sutures visualized with black asterisk), while viewing through the anterolateral portal. (B) After the syringe containing the megaclot (double asterisk) is attached to the bone marrow aspiration needle (white asterisk), the megaclot is applied to the chondrolabral junction (arrow) and labral repair site (black asterisk) while slight traction is maintained to visualize and (C) adequately coat the chondrolabral junction.

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Periportal Capsulotomy: A Technique for Limited Violation of the Hip Capsule During Arthroscopy for Femoroacetabular Impingement

“…The most common capsular entry technique is the interportal capsulotomy, where the capsule and iliofemoral ligament are incised in line between the anterolateral portal (ALP) and the mid-anterior portal (MAP) or direct anterior portal 3 . Alternatively, some surgeons use a T-capsulotomy, in which the capsule is incised longitudinally in a distal and lateral direction along the anterior femoral head–neck junction starting proximally from the interportal capsulotomy for improved access to large, distal cam lesions 4 . More recently, puncture capsulotomy, using multiple (4-5) small, undilated portals, has been introduced to preserve capsule integrity 4 …”