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Hip Arthroscopy: Comparison of the Extracapsular Capsulotomy Technique to the Interportal Technique

February 19, 2016

Contributors: Krista Ellis, MSc; Jennifer Marland, PT; Hugh S West Jr, MD; Russell P Swann, MD; Russell P Swann, MD

BACKGROUND: One of the challenges of hip arthroscopy is accomplishing a safe capsulotomy that allows efficient exposure of the central and peripheral compartments and at the end of the procedure permits secure closure. Two distinctly different capsulotomy approaches can be used to accomplish this task, the interportal capsulotomy (IPC) and the extracapsular capsulotomy (ECC). The IPC is a well-established commonly performed approach that carries some risk of iatrogenic injury to articular cartilage and labrum. The IPC for exposure of the central and peripheral compartments can be challenging, involves use of a 70 degree scope, and may be associated with prolonged traction times. The ECC approach utilizes a longitudinal capsulotomy along the long axis of the femoral neck offering a generous exposure of the hip joint with minimal risk of joint injury and greater surgical convenience in accomplishing the surgical tasks. The ECC approach uses a 30 degree scope and is essentially an arthroscopic version of the open anterior Hueter approach.

PURPOSE: There is a need for evolving techniques in hip arthroscopy that offer improved safety and efficiency. We believe this technique to be reproducible and easy to teach, safely minimizing traction time and iatrogenic injury to the central compartment. The video demonstrating the ECC technique begins contrasting the anatomical difference between the two techniques. The operating room setup with patient positioning for the ECC technique is described as well as pump management recommendations. The portal anatomy and location are shown in relation to anatomic illustrations and fluoroscopic images. Arthroscopy commences with the identification of the reflected head of the rectus, the orienting landmark in the extracapsular space. Without traction, the capsulotomy is made from inferior to superior under direct visualization centered anteriorly along the long axis of the femoral neck. Traction is applied as the central compartment is safely entered under direct visualization. The video shows good visualization of the anatomy, pathology, and where caution should be exercised in the vicinity of the retinacular vessels. Acetabuloplasty and femoral osteochondroplasty are performed but are beyond the time constraints and focus of the video. Capsular closure is accomplished with interrupted suture technique using a needle suture passer for efficient and easy anatomic closure. Subjective outcomes comparing the two techniques are presented.

METHODS: Using IRB (#1040265) approval, we retrospectively compared patient results with the IPC and the ECC performed by one surgeon between 2011 and 2014. Inclusion criteria was treatment of FAI and > 1 year follow up clinically. Exclusion criteria was concomitant surgery for peritrochanteric pain syndrome, psoas release or conversion to total hip arthroplasty (THA). The international hip outcome tool (IHOT-12) was collected preoperatively, and postoperatively at 3 months, 1 year, and 2 years. Welch two sample t-tests were used to evaluate the outcomes of the two groups and P<0.05 was considered significant.

RESULTS: The retrospective study included (N = 195) patients comparing IPC group (N = 65) and ECC group (N = 129) with a mean age of 32 (13-59). There were no differences for age, BMI, or Tegner activity levels between groups. The average IHOT improvement was not different statistically in 1 year IHOT scores; IPC group (69) and ECC group (71), (p = 0.7). Lost to follow up was > 20% at two years therefore statistical inference could not be obtained. However, the following iHOT score were observed; IPC group (N=33, 60) and ECC (N = 30, 72), (p = 0.1). In the IPC group, without capsular closure, three patients had persistent symptoms of instability and two had frank dislocations. All five patients underwent successful revision arthroscopy with capsular plication. For the five patients, the lateral center edge angle was greater than 25 and was not radiographically dysplastic pre and post index arthroscopy. No cases of confirmed instability in the ECC group were found.

CONCLUSIONS: We provide a technical video for another way to access the central compartment of the hip arthroscopically. We believe this to be an easier learning curve and reproducible while minimizing traction times, and iatrogenic injuries. We did not show a difference in clinical outcomes between the two techniques but that unrepaired IPC is a risk for instability postoperatively.

Results for "Hip Preservation"

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