Hip capsule is 1 cm thick with the Iliofemoral ligament being the strongest ligament in the human body. Routine capsular repair restores anatomy and stabilizes the hip joint.
Open hip surgery
There are multiple ways to open the capsule with open surgery. ‘T’ and ‘H’ capsulotomy are common in open cases. ‘Z’ shaped capsulotomy is commonly used for safe surgical dislocation. Capsular repair is routine, but a tight repair can compromise femoral head circulation, especially after surgical dislocation and extended retinacular flap elevation. The capsule is left open or a small part excised after drainage of septic arthritis.
Hip arthroscopy is difficult because of the joint’s deep location, strong muscles, and a very thick capsule. Considerable force is required to penetrate the capsule with blunt instruments initially and it is not easy to find the initial hole for instrument exchange even with cannulas and switching sticks. Capsulotomy to enlarge the portal sites makes instrument passage easier. Capsulotomy can increase hip instability especially with acetabular dysplasia contraindicating a wide capsulotomy, relatively contraindicating arthroscopy altogether, and indicating capsular repair and postoperative bracing in these cases.
Periportal capsulotomy is enlargement of the portal sites. This capsulotomy does not destabilize hip, but also does not make extensive procedures easy.
Interportal capsulotomy releases the capsule parallel to the labral margin between the two common portals from 12 o’clock to 3 o’clock positions. It gives adequate exposure for acetabular work, but needs traction sutures to see more laterally on the neck.
T- capsulotomy adds a longitudinal limb along the neck axis to the interportal capsulotomy. It usually divides the Zona orbicularis along the fat plane between Iliocapsularis and Gluteus minimus muscles and shows the neck adequately. Traction sutures can be placed for wider exposure and to protect the flaps from damage during shaving and burring.
Capsulectomy in a limited fashion increases exposure, but precludes capsular repair.
Capsulorraphy seems to give better results compared to not repairing the capsule. Complete repair is shown to be better than partial repair. Both absorbable and non-absorbable sutures have been used successfully in various suture configurations. Some surgeons feel that disruption of the capsular repair is a common cause of postoperative pain and recommend repairing the capsule again or reconstructing the defect with thick dermal allograft.
Dr. Prasad Gourineni does a single portal for evaluating the cartilage in acetabular dysplasia. I repair the capsule selectively in borderline dysplastics when I do not do much rim trimming. With adequate rim trimming, the medial attachment of the capsule to the acetabulum is disrupted and adequate repair is not feasible. Most often I do medial capsulectomy when I do rim trimming leaving nothing to repair. I do interportal capsulotomy usually and add a T cut if I can’t see enough of the neck. My patients do not seem to complain much when I did not do a capsular repair after open or arthroscopic surgery.
T- capsulotomy of distracted right hip with retraction sutures in the capsular flaps that can be sutured back anatomically.