Disclosure Consultant: Smith & Nephew Stock: Johnson & - - PowerPoint PPT Presentation

Orthopaedic Summit 2017: Evolving Techniques

Las Vegas, Nevada USA Allston J. Stubbs, M.D., M.B.A.

Medical Director Hip Arthroscopy & Associate Professor Department of Orthopaedic Surgery December 5-9, 2017

Are You Kidding! Never Close the Capsule

Disclosure

• Consultant: Smith & Nephew
• Stock: Johnson & Johnson
• Research Support: Bauerfeind
• Department-Division Support: Smith & Nephew, DePuy-Mitek, Arthex
• Boards/Committees: AAOS, ABOS, AOSSM, ISHA, AANA, MASH, ISAKOS, Journal
• f Hip Preservation Surgery

Aren’t we tired of this debate?

• Didn’t exist until surgical techniques converted

an arthroscopic procedure into an “open” one . . .

• School of thought that opened the capsule had

to return to the podium to remind (demand) one to close it

• Let’s get back to doing arthroscopic surgery!

Risks with capsular sutures

• Reaction to nonabsorbable suture  SYNOVITIS
• Over-tightening of joint  STIFFNESS
• Iatrogenic trauma to chondral surfaces  OA
• Heterotopic ossification of capsule  HO
• Increased case time  FLUID EXTRAVASATION
• Incarceration of anatomy (IP, rectus mm, glut mm)  PAIN
• Hemarthrosis/Effusion vessel tamponade  AVN

Ask yourself 3 questions

• 1. What kind of surgeon are you?
• 2. What is hip instability?
• 3. What are you actually doing to the capsule?

Do benefits outweigh risks?

First Question

Are you an arthroscopic surgeon or are you an

• pen surgeon?

There is a difference!

Options for Scope “Access”

• Capsulotomy: I, T, Inverted-T, H
• Capsulectomy
• Mini-Open

Typical Goal: Replicate the open approach

Is that wise?

T-Capsulotomy with Closure

MRA PreScope MRA PostScope

Iatrogenic Capsule Deficiency Despite Closure

MRI Arthrogram

s/p capsulectomy

BAD IDEA

What type of surgeon?

Arthroscopic

• Small holes
• Camera eye
• Micro instruments
• Deliver anatomy

Open

• Large holes
• Human eye
• Macro instruments
• Expose anatomy

Orthopaedic principle: do not close puncture wounds

Primum Non Nocere

Arthroscopy “Keyhole” joint preserving surgery

Do you really want a hip endoscopy?!

Iatrogenic Capsular Compromise

• Fluid Extravasation
• Instrument Scissoring
• Ligament Sectioning
• Instability: Micro & Macro

PAIN?

2017 Special Equipment

• Portal placement guides
• Flexible RF devices
• Curved shavers/burs/guides
• Dynamic tables
• Percutaneous drill guides

Capsule Sparing Surgical Strategy

• Portal dilation
• Percutaneous instrument placement
• Curved instrumentation
• Smaller diameter instrumentation

• Synovial >> Capsular Sectioning
• Pathology delivery
• Avoid “fixed fulcrum” devices
• Avoid “connecting the dots” and making “T”
• Avoid capsulectomy

Capsule Sparing Surgical Strategy

Capsulotomy Changes Fulcrum

Skin Capsule PRE POST

Let’s Not Connect the Dots

Skin Capsule Intraportal Capsulotomy Scissoring & Extravasation & Scarring

Second Question

Do you believe that the native hip is inherently a stable joint or an unstable joint?

There is a difference!

arthrohealth.com.au

Let’s accept Hip Instability Exists

• Rotational
• Atraumatic vsTraumatic
• Bone > Soft Tissue
• Tx: PT  Surgery

Can we learn from the shoulder?

• Shoulder is less constrained joint than hip (ie, more prone

to instability)

• Shoulder arthroscopy is common
• Routine portal closure in shoulder arthroscopy is

uncommon

• Capsulorrhaphy and Rotator interval closure in select

shoulder patients

Hip Joint Restraints

• Primary

– Bony congruency – Ligaments

• Secondary

– Labrum – Ligamentum teres – Capsule and zona orbicularis – Muscle tendon units

Intricate system that is only partially understood

Hip Instability

Iatrogenic

• Associated with compromise of normal dynamic and static stabilizers of the hip

– Excessive acetabular resection (pseudoretroversion) – Capsulotomy/Capsulectomy – Ligamentum teres resection – Zona orbicularis transection

• Postoperative trauma (early)

Traumatic

• Associated with frank dislocation / subluxation

Atraumatic

• Association with labral tears, acetabular deficiency states, attritional FAI
• Evidence of generalized ligamentous laxity

– Ehlers-Danlos syndrome – Down syndrome – Idiopathic – DDH

Will capsular closure adequately address these etiologies?

Third Question

Are you performing a capsular closure or are you performing a capsulorrhaphy?

There is a difference!

Mmmm . . .

What’s the difference?

Capsular closure

• Anatomic side to side

approximation

• May leave gaps
• Tenuous around

anterosuperior region

• Volume preserving

Capsulorrhaphy

• Non-anatomic capsular

shift

• Pants-Over Vest concept
• Volume reducing

Classic “T” Closure

Frank R et al. AJSM 2014

Capsulorrhaphy

Domb et al Arthroscopy 2013

Pathologic Conditions

• Bone defect/deficiency
• Capsular laxity/deficiency
• Ligament laxity/deficiency
• Ligamentum teres deficiency

What to do . . .

Leave alone

• Portal based hip

arthroscopy

• Arthritic changes
• Adequate bony congruency
• Chondrolabral preservation

Capsulorrhaphy

• Symptomatic collagen

laxity

• Acetabular dysplasia and

soft tissue compromise

Summary

• Stay arthroscopic!

– Strategic portal placement, dilation, minimal capsulotomy allow adequate access and treatment

• Respect static & dynamic hip stabilizers

– Know reportable complications of capsular compromise to avoid iatrogenic contributions

• Strategic capsulorrhaphy

– Recognize at risk instability patients

Cool Future Hip Meetings

Melbourne October 2018 www.isha.net

Cancun May 2019 www.isakos.org