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Contemporary Hip Capsular Management and Closure Using a Suture Passing Device

Before comprehensive correction of femoroacetabular impingement syndrome, capsular management must be thoughtfully considered to ensure both adequate visualization for bony resection and prevention of iatrogenic microinstability. A number of biomechanical and clinical studies have shown the importance of performing comprehensive capsular closure to restore native hip biomechanical kinematics. The purpose of this Technical Note is to describe the technique of using a suture passing device for capsular plication by a fellowship-trained hip arthroscopist at a large-volume academic center.

Abstract: Before comprehensive correction of femoroacetabular impingement syndrome, capsular management must be thoughtfully considered to ensure both adequate visualization for bony resection and prevention of iatrogenic microinstability. A number of biomechanical and clinical studies have shown the importance of performing comprehensive capsular closure to restore native hip biomechanical kinematics. The purpose of this Technical Note is to describe the technique of using a suture passing device for capsular plication by a fellowship-trained hip arthroscopist at a largevolume academic center. P erioperative capsular management during hip arthroscopy is critical to maintaining hip stability. A number of clinical and biomechanical studies have shown that not closing the capsule after capsulotomy can result in microinstability, iatrogenic macroscopic instability, and inferior postsurgical patient-reported outcomes. [1][2][3][4][5] Furthermore, others have shown that complete capsular repair leads to restoration of hip biomechanical properties back to the native intact hip, in addition to superior clinical outcomes. [6][7][8][9] As evidence on the benefit of capsular closure continues to grow, surgeons have cautioned against leaving the capsule unrepaired after hip arthroscopy with capsulotomy. 2 However, despite mounting evidence on the importance of capsular management, many surgeons continue to leave the capsule unrepaired at the conclusion of the case. This may be reflective of the high technical demands of this portion of the procedure, which requires a thorough understanding of the capsular anatomy and arthroscopic techniques. For this reason, we present this Technical Note detailing the senior author's (S.J.N.) routine capsular plication technique using a suture passing device performed by a fellowship-trained hip arthroscopist at a large-volume academic center.

Operative Indications
Capsulotomies have become a routine procedure in hip arthroscopy that provide improved intraoperative visualization of pathology in both the central and peripheral compartments of the hip joint. The risk of postoperative complications and inferior function because of improper capsular management has led to a growing majority of hip arthroscopists incorporating capsular closure after hip arthroscopy, particularly capsular plication in patients with a patulous capsule. 8,10 Although continued debate exists as to the superiority of capsular closure over plication, our current practice uses capsular plication for all patients undergoing hip arthroscopy for femoroacetabular impingement, with the exception of those patients with capsular defects or insufficiency requiring reconstruction.

Patient Positioning
The patient is placed supine on a traction table, and general anesthesia is induced for complete muscle relaxation. The patient is then positioned on the table with a well-padded perineal post and boots. The pelvis is slightly translated toward the contralateral, nonoperative hip, and gentle distraction is applied across the operative limb. The operative limb is then placed in 20 of abduction and 20 of flexion, and manual distraction is applied. Gentle oscillations are used as the limb is slowly extended and adducted to obtain distraction up to 10 mm. The optimal position for the hip during this procedure is neutral adduction, extension of the extremity parallel to the floor, and internal rotation of 45 for maximal femoral neck length.

Arthroscopic Technique and Interportal Capsulotomy
After sterile preparation and patient draping, the anterior superior iliac spine is marked, and a vertical line is extended down the thigh toward the center of the patella. The greater trochanter is then outlined (Fig  1). The anterolateral (AL) portal is first established under fluoroscopic visualization, penetrating the capsule at the 12 o'clock position. Standard cannulation allows for intra-articular visualization with a 70 arthroscope (Stryker Endoscopy, San Jose, CA). Under    direct visualization, the anterior portal is then created at the 2 o'clock position to minimize the size of the interportal capsulotomy. The arthroscope is switched to the anterior portal to view the position of the AL portal and ensure that it is adequate. A standard interportal capsulotomy is performed w8 mm from the acetabulum using an arthroscopic scalpel (Samurai Blade; Stryker Sports Medicine) (Fig 2). The camera is then switched back to the AL portal, and the capsulotomy is completed around the area of chondrolabral injury (2 to 4 cm in length). A diagnostic arthroscopy is performed to evaluate the status of the labrum and any concomitant intra-articular pathology. Indicated procedures are then completed based on the intraoperative evaluation in the central compartment, including but not limited to acetabuloplasty, labral tear repair and or reconstruction, and microfracturing.

Vertical T-limb Capsulotomy and Capsular Plication
After completion of the procedures in the central compartment, traction is released, and the hip is typically flexed to 20 to access the peripheral compartment. Via the anterior portal, the arthroscope is placed into the peripheral compartment, and a T-capsulotomy is performed between the 12 and 2 o'clock positions to the intertrochanteric line (Fig 3). The suture passing device (SlingShot Suture Manager; Stryker, Greenwood Village, CO) is used to reflect the capsule using no. 2 high-molecular-weight polyethylene sutures in the medial leaflet of the iliofemoral ligament (IFL) and another in the lateral leaflet of the IFL. The medial stitch is retrieved out of the distal anterolateral accessory (DALA) portal and tensioned with a hemostat against the skin (Fig 4). The lateral stitch is retrieved out of the AL portal and tensioned with a hemostat against the skin. With the capsule reflected, osteochondroplasty of the CAM deformity is performed with excellent visualization of the peripheral compartment. A combination of intra-operative fluoroscopy and dynamic hip examination confirms comprehensive correction of the CAM deformity from the lateral synovial folds to the medial synovial folds (Fig 5).
Once the arthroscopic procedure is complete, a complete capsular closure is performed to ensure normal biomechanical properties of the IFL. While viewing from the anterior portal, an 8.5 Â 110-mm plastic cannula is placed in the DALA portal, and an 8.5 Â 90mm plastic cannula is placed in the AL portal. The previously placed suspension stitches are unclamped and used to repair the interportal capsulotomy. For the medial stitch, a looped retriever via the DALA portal is used to loosen the stitch and place it next to the medial aspect of the acetabular leaflet. The suture passing device is passed through the acetabular leaflet of the IFL, and filaments from the suture passing device are advanced to retrieve the suture (Fig 6). For the lateral stitch, a looped retriever via the AL portal is used to loosen the stitch and place it next to the lateral aspect of the acetabular leaflet. The suture passing device is passed through the acetabular leaflet of the IFL, and filaments from the suture passing device are advanced to retrieve the suture. To pass the middle stitch, a loaded suture passing device passes the suture from the middle of the acetabular leaflet. The unloaded suture passing device is passed through the apex of the Tcapsulotomy to retrieve the suture. All 3 stitches are retrieved and left united until after the vertical aspect of  the T-capsulotomy is closed. Because it is more difficult to pass stitches in the interportal cut after the vertical aspect is closed, the authors recommend passing these stitches but not tying until after the vertical capsulotomy is closed.
The vertical T-limb of the T-capsulotomy is closed first, beginning at the base of the IFL using a suture passing device loaded with a no. 2 high-molecularweight polyethylene suture. While viewing from the anterior portal, the suture passing device loaded with suture is inserted through the cannula in the DALA portal, and a full-thickness pass is made through the medial limb of the T-capsulotomy (Fig 7). The unloaded suture passing device is then reinserted through the DALA portal, and a full-thickness pass is made through the lateral limb of the vertical portion at the base of the T-capsulotomy. If capsular plication is desired, wider bites from the capsulotomy can be taken to reduce capsular volume. The suture passing device then retrieves the suture passed through the medial leaflet (Fig 8). A standard arthroscopic knot is tied under direct visualization and cut. These steps are repeated, and 2 more sutures are passed in the vertical portion of the Tcapsulotomy. Depending on the size of the incision and integrity of the capsule, the vertical T-limb is typically closed with 2 to 4 sutures. The interportal limb of the T-capsulotomy is repaired next. Of note, the process described here and shown in the video is for a right hip. For procedures involving the left hip, the shuttling suture device is inserted in through the AL portal.

Interportal Capsular Closure
The stitches that were previously passed for the interportal capsulotomy can be unclamped and tied sequentially. Beginning with the lateral stitch, a looped retriever can be used to pull the sutures through the cannula in the AL portal. If these stitches are difficult to identify in the extra-articular space, a knot pusher can be placed over these stitches to be more easily visualized. A standard arthroscopic knot is then tied under direct visualization. The hip can now be placed in neutral extension, and the remaining stitches can be tied to allow for neutral tension of the anterior capsule. The middle and medial stitches can be retrieved and tied sequentially (Fig 9). With the capsule completely repaired, the femoral head articular cartilage should no longer be visible.

Postoperative Rehabilitation
Rehabilitation is started on postoperative day 1 for all patients as previously described. 8 Patients go through a  4-phase rehabilitation protocol that lasts an average of 16 to 18 weeks. Rehabilitation phase 1 prioritizes joint protection and soft tissue mobilization techniques. Our preference is to use a night splint and hip orthosis (Hip Rebound Brace, Ossur, Foothill Ranch, CA) for the first month after surgery to protect the capsular repair. Early circumduction is recommended but excessive extension and external rotation should be avoided for the first couple weeks. Phase 2 focuses on normal gait maintenance, full range of motion restoration, improvement of neuromuscular control, and maintenance of pelvic and core stability. Phase 3 incorporates single leg squats and strengthening, soft tissue and joint mobilization, and cardiovascular fitness. Phase 4 emphasizes return to preinjury level of sports participation. Patients are cleared to return to sports if they are able to participate in sports without pain, have full dynamic functional control, and pass all return-to-sports tests.

Discussion
This Technical Note describes a method of capsular closure and plication using a suture management device. We recognize that capsular management is technically challenging and therefore provided a visual guide for orthopaedic specialists less experienced in hip arthroscopy and capsular closure. The benefits of using the suture shuttling device for capsular closure are many. First, the suture is passed and retrieved easily using the same device, requiring less surgical equipment in the surgical field. Second, the suture can be visibly passed from 1 leaflet to the other, ensuring adequate purchase for capsular closure via plication or approximation of the leaflets. Finally, slingshot suture management prevents iatrogenic chondral damage when passing the suture blindly from 1 leaflet to another as with other arthroscopic capsular closure devices.
Capsular management strategies must be considered before comprehensive correction of any intraarticular hip pathology that balances adequate visualization and the opportunity for complete closure. To prevent hip macro-and microinstability, it is critical to understand the structure and function of the iliofemoral ligament. Complete anatomic repair of the iliofemoral ligament restores the biomechanical characteristics of the capsule, including axial strain, translation, and rotation. 5,7,11 More recent biomechanical studies have shown that proper capsular plication of T-capsulotomy leads to a quantifiable decrease in intra-articular volume. 9 Clinically, complete capsular closure has shown improved patient-reported outcomes and increased survivorship compared with partial closure. Frank et al. 8 reported superior sportspecific outcomes in the complete versus partial closure group. Furthermore, there was a 13% revision rate in the partial closure group, with none seen in their counterparts.
The advantages and disadvantages of our capsular plication technique are listed in Table 1. Plication of the capsulotomy after hip arthroscopy can help maintain the stability of the joint, preventing iatrogenic subluxation, dislocation, and microinstability. 12 The disadvantages include increased surgical time, potential to damage the acetabular surface, and increased technical demand. Furthermore, there is significant debate about capsular closure in cases of stiff hips and radiographic signs of arthritic changes. 13 Nonetheless, the growing evidence of benefits for capsular closure in the majority of patient populations has led to improved methods and   HIP CAPSULAR MANAGEMENT AND CLOSURE USING A SUTURE PASSING DEVICE e951 dissemination of techniques such as this for assisting current and future orthopaedic surgeons in improving their hip arthroscopy outcomes. Pearls and pitfalls of capsular repair are described in Table 2.
In conclusion, capsular management and capsular plication techniques described in this article provide a step-by-step process to ensure that both emerging and established hip arthroscopists are able to perform the challenging procedure. Growing evidence has shown that capsular closure leads to decreased complications and restores the biomechanical properties of the hip to its native intact state.