AANA Lab Course 907-Arthroscopic/Open Strategies - Hip Preservation-Capsular Management in Hip Preservation-Misty Suri, MD

Capsular Management in Hip Preservation-Misty Suri, MD

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This presentation by Drs. Misty Suri and Brian Wissel discusses capsular management strategies in hip preservation, focusing on arthroscopic and open techniques. Diagnosing hip instability is challenging, with no definitive preoperative tests; five physical tests (log roll, anterior and posterior apprehension, prone external rotation, abduction-extension-external rotation) are used, but idiopathic microinstability lacks a clear diagnostic marker.<br /><br />Capsulotomy, necessary for surgical exposure, can be performed as interportal or T/H types, driven by surgeon preference and case specifics. The hip capsule anatomy includes three external ligaments—iliofemoral (Y-ligament of Bigelow), ischiofemoral, and pubofemoral—and one internal ligament, the zona orbicularis. The portals used during arthroscopy pierce the iliofemoral ligament at specific locations, with various interportal capsulotomy approaches described.<br /><br />Biomechanically, studies show that sectioning the iliofemoral ligament increases external rotation and anterior translation. Interportal capsulotomy does not significantly increase external rotation, but T-capsulotomy does. Capsular closure decisions vary: some surgeons always close, some never do, and most decide case-by-case.<br /><br />Evidence suggests not closing the capsule can lead to instability in some patients, while others tolerate it well, especially if stiffness is a concern. Partial closure is less favored due to higher revision rates and worse outcomes compared to complete closure. Full capsular repair restores hip stability to near-native levels and is increasingly the standard in femoroacetabular impingement (FAI) surgery.<br /><br />Capsular plication is recommended for patients with ligamentous laxity or mild dysplasia to improve satisfaction without compromising motion. Overall, capsular management should be individualized based on patient factors such as preoperative laxity, instability, stiffness, and intraoperative findings, while respecting the complex anatomy and biomechanics of the hip joint to optimize outcomes.

Keywords

hip preservation

capsular management

arthroscopic hip surgery

hip instability diagnosis

capsulotomy techniques

iliofemoral ligament

capsular closure

hip biomechanics

femoroacetabular impingement

capsular plication