Creating and Closing the T-Capsulotomy for Improved Visualization During Arthroscopic Treatment of Femoroacetabular Impingement

Abstract

Treatment of femoroacetabular impingement through an arthroscopic approach has gained widespread popularity in recent years. Although outcomes are generally favorable, one of the most common reasons for failure is incomplete resection of cam lesions of the femoral neck. As a result, the T-capsulotomy has been introduced as a method for improving access to the femoral head-neck junction, which is not always visible through a standard interportal capsulotomy. The T-capsulotomy has the benefits of improving arthroscopic visualization of the femoral neck, reducing overall fluoroscopy exposure for the patient and surgeon, and facilitating capsular plication. We present a reliable and efficient method for creating and repairing the T-capsulotomy. We routinely perform this technique in patients with cam lesions that are too large or too distal to safely visualize and decompress through an interportal capsulotomy.

Fig 1

The anterolateral portal (ALP) is just anterior and proximal to the greater trochanter and is created under fluoroscopic guidance. The midanterior portal (MAP) is created under arthroscopic guidance when viewing from the ALP. The distal anterolateral accessory portal (DALAP) is placed just anterior to the femur and creates a nearly equilateral triangle with the MAP and ALP. The anterior superior iliac spine (ASIS) has been labeled for reference.

Fig 2

(A) When viewing the left hip from the anterolateral portal, the femoral head (FH) can be visualized after the interportal capsulotomy is complete, but the distal extent of the cam lesion is difficult to identify because of the overlying capsule (C). (B, C) Once the T-capsulotomy has been created, the cam lesion is easily identified between the medial limb (ML) and lateral limb (LL) of the capsule (B) before and (C) after osteoplasty.

Fig 3

(A) While viewing from the midanterior portal, the SutureLasso (SL) can be seen penetrating the distal aspect of the lateral limb (LL) of the capsule. The lasso is then advanced toward the medial limb (ML) of the capsule. (B) A sharp tissue-penetrating BirdBeak (BB) suture passer is advanced through the ML and grabs the SutureLasso. This is subsequently retrieved through both capsular limbs and out the distal anterolateral accessory portal. (C) A suture is then shuttled back through both limbs using the SutureLasso. (D) Finally, the knots are tied arthroscopically.