Complete Capsular Repair Using a Knotless Barbed Suture With a Mini-direct Lateral Approach for Total Hip Arthroplasty: A Technique Note and Feasibility Study

In total hip arthroplasty (THA), processing of the hip joint capsule by capsulotomy and its repair or resection (capsulectomy) is an important step in the surgical procedure. Although there might be no clinical difference in postoperative 1-year outcomes among major THA approaches,1 several previous studies have reported advances in capsular repair using the posterior approach to achieve a lower rate of dislocation.2,3 Preserving capsules may also contribute to reducing intraoperative blood loss.4 In contrast, a recent randomized controlled trial showed no difference in dislocation rates between capsular repair and nonrepair when using a direct anterior approach.5,6

Although such previous trials for capsular repair have been reported, the technical definition of “capsular repair” is different for each report. Specifically, there have been no detailed technical descriptions of complete repair of ligament attachment to the original femoral site using a direct lateral approach. The recent development of suture devices contributes to the convenient and durable fixation of soft tissue. Particularly, the knotless barbed suture has been recognized as a useful suture material also in total joint arthroplasty.7 Our hypothesis is that complete capsular repair is well feasible as a routine technique by taking notice of several pearls and pitfalls and using knotless barbed sutures.

In this technical report, we present detailed technical pearls and pitfalls for the complete repair of the capsular ligament using a knotless barbed suture with a mini-direct lateral approach and then revealed the feasibility of this technique for consecutive case series.

MATERIALS AND METHODS

A total of 45 consecutive cases that underwent mini-direct lateral approach THA with complete capsular repair between March 2021 and December 2021 were included. As a historical control group, we reviewed 169 cases that underwent mini-direct lateral approach THA with partial capsulectomy without repair (partial resection) between April 2019 and February 2021. The institutional review board has approved this retrospective observational study. Inclusion criteria were for all cases that need primary THA due to osteoarthritis or osteonecrosis. The exclusion criteria were osteoarthritis with Crowe type 4. Operative time, bleeding, days starting independent gait with T-cane, and days of hospitalization were investigated for both 2 groups. The major intraoperative and postoperative complications within 1 month after surgery including fracture, great vessel injury, surgical site infection, deep infection, symptomatic venous thromboembolism, and dislocation were also evaluated.

Surgical techniques: See video file (link), Supplemental Digital Content 1 (https://links.lww.com/TIO/A50).

Surgical Approach to the Joint Capsule

This technique is based on a modified mini-incision direct lateral approach through the lateral decubitus position.8 A ∼7 cm skin incision was made distally along the femoral axis starting 1.5 cm proximal to the tip of the greater trochanter. The fascia incision was 2 cm longer than the skin incision at the proximal and distal ends. At this point, the entire gluteus medius from the anterior to posterior edges was exposed. The anterior one-third of the gluteus medius was split to expose the gluteus minimus. The whole gluteus minimus was thus identified, and its femoral side attachment was marked by Pyoktanin blue (Fig. 1A). The gluteus minimus was detached en bloc from the marked side, with particular attention to preserving the margin used to seam the femoral side. The whole lateral side of the capsular ligament was then exposed (Fig. 1B). It is important to expose the proximal, posterior, and anterior sides as much as possible.

F1FIGURE 1:

Incision line on the Gmin and capsular ligament. The margin used to seam the Gmin is drawn by a Pyoktanin blue pen (A), then the Gmin is separated to the proximal side on the capsule layer (iliofemoral ligament). The entire lateral side of the capsule is then exposed, and a T-shaped line is drawn for the cut by a Pyoktanin blue pen (B). The margin used to seam the capsule on the femoral side is adequately preserved around the basal femoral neck (arrow). An indicates anterior; C, capsule; D, distal; Gmed, gluteus medius; Gmin, gluteus minimus; GT, greater trochanter tip; Po, posterior; Pr, proximal.

Capsulotomy

A T-shaped capsulotomy was performed as shown in Figure 2A. Before capsulotomy, it is important to draw a T-shaped cut line with Pyoktanin blue (Fig. 1B) to ease the identification of the sutured side during the subsequent capsular repair. The margin to be seamed at the femoral side of the capsular ligament must be preserved intact with a width of ∼1 cm. Capsulotomy was performed to the acetabular edge to allow identification of the labrum. Retractors were inserted at the recess between the capsule and the acetabular labrum to expose the entire hip joint (Fig. 2B).

F2FIGURE 2:

Capsulotomy and exposure of the femoral head. A T-shaped capsulotomy is performed (A) to expose the femoral head (B). A retractor is placed in the recess between the capsule and acetabular labrum (arrow), which is clearly exposed. An indicates anterior; D, distal; F, femoral head; Po, posterior; Pr, proximal.

The remaining steps from dislocation to implantation are similar to standard THA procedures using the direct lateral approach. It is essential to preserve the capsule and its femoral attachment site during the preparation of both the acetabular and femoral sides.

Repair of the Capsular Ligament and Abductor Muscle

We used STRATAFIX Symmetric PDS Plus #1 (ETHICON Inc.) as a knotless tissue control device for repairing the capsular ligament and gluteus minimus. First, we repaired the horizontal anterior-posterior cut by continuous suture, then the vertical proximal-distal cut with the same suture (Fig. 3A). After complete closure of the capsular ligament, the gluteus minimus was repaired, again with the continuous suture (Fig. 3B). Finally, the gluteus medius was repaired by a transfixion suture. Upon closure of the fascia lata, skin closure was completed. We do not usually place a drain tube.

F3FIGURE 3:

Capsular and Gmin repair using continuous barbed suture. A continuous suture using STRATAFIX Symmetric PDS Plus #1 is used to repair the horizontal capsule cut between the anterior and posterior segments, followed by matless suture of the vertical capsule cut between the proximal and distal segments (femoral side) (A). Subsequently, the Gmin is repaired by the same continuous mattress suture technique (B). An indicates anterior; D, distal; Po, posterior; Pr, proximal; RC, repaired capsule; RGmin, repaired gluteus minimus.

POSTOPERATIVE REHABILITATION

On postoperative day 1, the patient was transferred to a wheelchair, after which full-weight bearing and active straight leg raising were allowed as soon as possible. Upon achieving self-reliant walking and climbing stairs with the support of a T-cane, the patient was usually allowed to discharge after 10 days postoperatively.

RESULTS

In 45 cases, the complete capsular repair was successfully achieved in 42 cases (93.3%). Table 1 shows demographic data of 42 cases that succeeded in complete capsular repair. There are no significant differences between groups. The average operative time was 106±20 minutes in the capsular repair group and 102±25 minutes in the partial resection group. The average intraoperative bleeding was 369±241 mL in the capsular repair group and 371±259 mL in the partial resection group. The average number of days starting independent gait with T-cane was 5.7±2.1 days in the capsular repair group and 5.8±2.4 days in the partial resection group. The average hospitalization was 15.2±3.4 days in the capsular repair group and 16.0±3.9 days in the partial resection group. There were no statistical differences in these parameters between the 2 groups. There were no major complications either intra or postoperatively in the capsular repair group. In 3 impossible complete capsular repair cases, 1 case needed capsular resection due to a severely calcified capsule and 2 cases received partial repair of the capsule because of insufficient margin used to seem at the femoral attachment.

TABLE 1 - Demographic Data of Patients Succeeded Complete Capsular Repair and Control Group Succeeded Complete Capsular Repair, N=42 Control Group With Partial Capsular Resection, N=169 P M/F 10/32 41/128 1.00 Average age 67±12 66.7±11.4 0.72 BMI (kg/m2) 24.6±4.3 24.5±4.7 0.52 Primary diagnosis 0.298  OA 38 152  ON 4 17 Operative time (min) 106±20 102±25 0.269 Blood loss (mL) 369±241 371±259 0.929 Starting independent gait with T-cane (d) 5.7±2.1 5.8±2.4 0.664 Hospitalization (d) 15.2±3.4 16.0±3.9 0.277

BMI indicates body mass index; OA, osteoarthritis; ON, osteonecrosis.


DISCUSSION

In this surgical technique report, we presented detailed procedures, pearls and pitfalls (Table 2), for complete capsular repair through a direct lateral approach using a knotless barbed suture. As a result, it was possible to achieve complete capsular repair in 93.3% of cases. Thus, we showed the feasibility of complete capsular repair using a knotless tissue control device during THA with a mini-direct lateral approach.

TABLE 2 - Pearls and Pitfalls of the Surgical Technique Pearls Pitfalls Preserving the margin used to seam the insertion of the capsular ligament on the femoral side Impossible to completely repair the capsule without enough margin used to seam the femoral side Using STRATAFIX Symmetric PDS Plus as a continuous knotless barbed suture both for the capsular ligament and gluteus minimus Difficult to preserve a capsule with severe hypertrophy or calcification Controlling limb position with flexion and slight internal rotation during capsular reattachment on the femoral side Difficult to reattach the capsule on the femoral side in cases that require limb extension of >2 cm

In previous comparative studies, capsular repair has been achieved using posterior,9–13 superior,14 anterolateral,15 and direct anterior approaches.5,6,16 In several of these procedures, repair between the proximal part of the capsule and the femoral side was completed through drill holes.9,11,12 In recent reports of capsular repair using the direct anterior approach, either the capsule along the intertrochanteric line was repaired5 or capsulotomy for the repair of the superior aspect of the vertical limb was not possible.6 Thus, complete repair of the capsule after THA was not straightforward, particularly reattachment onto the original femoral side. Our procedure for the complete repair of the capsular ligament through a direct lateral approach using continuous barbed suture is the first to describe a reproducible routine technique that does not require a screw hole for ligament fixation.

The greatest advantage of this procedure is the restoration of the stability of the hip joint after THA, particularly against torsional stress.17 Even before repairing the capsule, stability is preserved because much of the capsular ligament, particularly the iliofemoral ligament, is not resected. This might result in deficient acetabular exposure, and therefore it is essential to effectively use the retractor by inserting it into the recess between the acetabular labrum and the capsule to provide good visualization of the acetabulum. Nevertheless, it may be difficult to maintain adequate visualization of the acetabulum in cases with severe hypertrophic or calcified capsules.

An important technical advance reported here is the use of STRATAFIX, a kind of barbed suture, for repairing the capsule. Because the tensile force of a single ligature is high given the strength of capsular tissue, there is a high probability of a “cheese cut” caused by each knot at the repair site. Actually, we recognized that it was difficult to perform the complete capsular repair by standard suture technique due to cheese cuts at each suture knot site. In this regard, a knotless continuous barbed suture facilitates gradual plication, thus avoiding the concentration of tensile force that causes a cheese cut. Another important technical point is careful preservation of the margin used to seam the insertion of the capsular ligament on the femoral side and avoid inadvertent resection, particularly during the femoral neck cut. During reattachment of the capsule on the femoral side, it is important to maintain the limb in a favorable position during side-by-side closure of the reattachment site, typically allowing flexion of around 30 degrees with slight internal rotation. Nevertheless, it is still difficult to reattach the capsule on the femoral side in cases where limb elongation of >2 cm is required.

In conclusion, we introduce a surgical technique of complete capsular repair through a mini-direct lateral approach for THA using a knotless barbed suture, and then demonstrated its feasibility as a routine technique. Future comparative studies are required to demonstrate the clinical advantages of this technique.

REFERENCES 1. Bircher JB, Kamath AF, Piuzzi NS, et al. No clinically meaningful difference in 1-year patient-reported outcomes among major approaches for primary total hip arthroplasty. HIP Int. 2021;32:1120700021992013. 2. Kwon MS, Kuskowski M, Mulhall KJ, et al. Does surgical approach affect total hip arthroplasty dislocation rates? Clin Orthop Relat Res. 2006;447:34–38. 3. Sun X, Zhu X, Zeng Y, et al. The effect of posterior capsule repair in total hip arthroplasty: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2020;21:263. 4. Schneeberger AG, Schulz RF, Ganz R. Blood loss in total hip arthroplasty. Arch Orthop Trauma Surg. 1997;117:47–49. 5. Vandeputte FJ, Vanbiervliet J, Sarac C, et al. Capsular resection versus capsular repair in direct anterior approach for total hip arthroplasty: a randomized controlled trial. Bone Joint J. 2021;103-B:321–328. 6. Schwartz AM, Goel RK, Sweeney AP, et al. Capsular management in direct anterior total hip arthroplasty: a randomized, single-blind, controlled trial. J Arthroplasty. 2021;36:2836–2842. 7. Han Y, Yang W, Pan J, et al. The efficacy and safety of knotless barbed sutures in total joint arthroplasty: a meta-analysis of randomized-controlled trials. Arch Orthop Trauma Surg. 2018;138:1335–1345. 8. Inaba Y, Kobayashi N, Yukizawa Y, et al. Little clinical advantage of modified Watson-Jones approach over modified mini-incision direct lateral approach in primary total hip arthroplasty. J Arthroplasty. 2011;26:1117–1122. 9. Pellicci PM, Bostrom M, Poss R. Posterior approach to total hip replacement using enhanced posterior soft tissue repair. Clin Orthop Relat Res. 1998;355:224–228. 10. Chiu FY, Chen CM, Chung TY, et al. The effect of posterior capsulorrhaphy in primary total hip arthroplasty. a prospective randomized study. J Arthroplasty. 2000;15:194–199. 11. White RE, Forness TJ, Allman JK, et al. Effect of posterior capsular repair on early dislocation in primary total hip replacement. Clin Orthop Relat Res. 2001;393:163–167. 12. Tarasevicius S, Robertsson O, Wingstrand H. Posterior soft tissue repair in total hip arthroplasty: a randomized controlled trial. Orthopedics. 2010;33:871. 13. Edipoglu, E. Durability of transosseous repair of posterior soft tissues after primary total hip arthroplasty: a prospective randomized controlled trial. Arch Orthop Trauma Surg. 2021. Epub ahead of print August 2021. doi:10.1007/s00402-021-04118-1. 14. Capuano N, Grillo G, Carbone F, et al. Total hip arthroplasty performed with a tissue-preserving technique using superior capsulotomy. Int Orthop. 2018;42:281–287. 15. Lu Y, Wu Z, Tang X, et al. Effect of articular capsule repair on postoperative dislocation after primary total hip replacement by the anterolateral approach. J Int Med Res. 2019;47:4787–4797. 16. McLawhorn AS, Christ AB, Morgenstern R, et al. Prospective evaluation of the posterior tissue envelope and anterior capsule after anterior total hip arthroplasty. J Arthroplasty. 2020;35:767–773. 17. van Arkel RJ, Ng KCG, Muirhead-Allwood SK, et al. Capsular ligament function after total hip arthroplasty. J Bone Joint Surg Am. 2018;100:e94.

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