The Role of Comprehensive Capsular Management in Hip Arthroscopy for the Treatment of Femoroacetabular Impingement Syndrome

Abstract

Advances in the understanding of femoroacetabular impingement syndrome and advancements in hip arthroscopic techniques, including chondrolabral preservation and labral repair, have led to improvements in success rates, functional outcomes, and return to sports over the past several years. This improvement in outcomes also is attributed to the increased awareness of performing capsular closure after addressing intra-articular hip pathology, to preserve the biomechanical properties of the hip. A number of biomechanical studies have demonstrated that the iliofemoral ligament is a critical component of hip biomechanics, providing stability and limiting joint translation, distraction, and rotation within the normal range of hip motion. The interportal and T-capsulotomy are the most commonly used methods for accessing intra-articular pathology; both techniques require transection of the iliofemoral ligament perpendicular to its fibers, which may lead to micro- and macroinstability if left unrepaired at the end of the procedure. Several clinical studies have been published in the recent literature demonstrating that patients who undergo hip arthroscopy for femoroacetabular impingement syndrome and have an unrepaired capsule have lower functional outcome scores, achievement of meaningful outcomes, success rates, as well as greater failure rates and reported pain when compared with patients who have complete capsular closure. Capsular plication of the vertical T-limb and closure of the interporal limb via plication have been reported to improved outcomes. Degree of plication is dependent on dynamic, intraoperative assessment of hip range of motion. The senior author recommends reflecting of the medial and lateral leaflets after T-capsulotomy with polyethylene sutures to provide better exposure of the peripheral compartment, which can be used for closure. The remainder of the closure is performed with a suture-passing device and approximately 2 to 3 interrupted stitches per limb.