Available online 20 January 2024, 151067

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The hip joint is a ball and socket joint supported by static and dynamic stabilizers. The hip capsule and its constituent ligaments provide support during weight-bearing activities. Hip arthroscopy requires capsulotomy for visualization and instrumentation and a thorough understanding of the anatomy and biomechanics of the hip capsule allows surgeons to select the appropriate capsulotomy technique for each procedure. This chapter described capsular access techniques including periportal, interportal, and T-capsulotomy, as well as puncture and extracapsular access techniques. Capsular closure techniques are reviewed and outcomes after varying capsular management techniques are summarized.

Section snippetsHip Capsule Anatomy

The hip joint is a ball and socket diarthrodial joint with freedom of motion in the coronal and sagittal planes as well as along the longitudinal axis. The osseous articulation and the surrounding fibrocartilaginous labrum provide a layer of inherent stability during weight bearing and load transfer from the axial skeleton.1,2

The hip joint is supported by a collaboration between static and dynamic stabilizers. Static stabilizers include the osseous, chondrolabral, and ligamentous structures.

Hip Capsule Biomechanics

Hip mobility requires approximately 45 degrees of coronal plane motion and tolerance of at least one-third of body weight during a stationary double-leg stance; ambulation increases the joint reactive forces generated by the periarticular musculature to six times body weight.12 The hip capsule contributes to maintenance of hip stability in the presence of these increased physical demands.

Anatomic studies of hip capsule tautness and laxity throughout the range of motion reveal that the

Hip Capsulotomy Techniques

The capsular ligamentous structures and the thick pericapsular soft tissue can limit manipulation of arthroscopic devices within the joint, requiring capsulotomy to perform effective arthroscopic interventions.19

Three main techniques for capsulotomy and intra-articular access have been described in the hip arthroscopy literature: interportal capsulotomy, T-capsulotomy, and peri-portal capsulotomy. (Figure 5) Arthroscopic access to the hip joint as described by Dienst and colleagues uses an

Effects of capsulotomy on hip biomechanics

Interportal capsulotomy increases external rotation in neutral flexion by a mean of 4.5 degrees, while T capsulotomy increases external rotation in neutral flexion by a mean of 7.9 degrees.30 In a biomechanical study, a 4 cm interportal capsulotomy increases rotational range of motion about a transverse plane by an average of 7%, and a 6 cm interportal capsulotomy increases range of motion by an average of 13%. These changes return to the baseline range of motion upon capsular repair.31 The

Capsular repair techniques

Nine of 82 studies included in a systematic review of the capsular management literature described the authors’ preferred capsular closure techniques.22 (Figure 6) Specialized capsular closure devices are also available from multiple orthopaedic device vendors to assist in passing suture through capsule leaflets.22,34 The use of both nonabsorbable sutures and absorbable sutures has been described.27,34,35

In the setting of generalized joint hypermobility, when capsulotomy is necessary for

Outcomes after capsular management

A retrospective review of patients undergoing periportal capsulotomy without capsular closure demonstrated continued improvement of patient-reported outcome measures (specifically the Hip Disability and Osteoarthritis Outcome score) at 2 years following surgery.40 A retrospective cohort study of patients undergoing periportal capsulotomies without closure and interportal capsulotomies with closure demonstrated no statistically significant differences in patient-reported outcome measures. The

Conclusions

Choosing the appropriate capsular management option requires a thorough understanding of native hip capsule anatomy and biomechanics as well as the structural effects of hip pathophysiology. A multitude of capsular access strategies with acceptable outcomes are described in the literature. The hip arthroscopist adept with these techniques can be assured they have the tools to appropriately treat a variety of hip pathologies.

Disclosures

SS: No disclosures

BGL: Arthrex Consultant, Royalties, Educational Grant Funding, Research Grant Funding

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