Proximal Anterolateral Accessory Portal Use Improves Peripheral Compartment Access and Capsular Management with T-Capsulotomy

Abstract

One of the primary goals of hip arthroscopy for femoroacetabular impingement (FAI) syndrome is precise removal of pathologic FAI morphology while protecting and restoring the normal soft tissue anatomy. Adequate visualization is a key foundation of precise removal of FAI morphology and varying types of capsulotomies are frequently used to achieve necessary exposure. Anatomic and outcomes studies have influenced an increasing appreciation for repairing these capsulotomies. Thus one of the central technical challenges of hip arthroscopy is achieving both goals of capsule preservation and adequate visualization. Various techniques have been described, including suture-based capsule suspension, portal placement, and T-capsulotomy. The following technique describes how the proximal anterolateral accessory portal can be added to a capsule suspension and T-capsulotomy technique to improve visualization and facilitate repair.

Fig 1

Intra-operative photo with the patient positioned supine demonstrating the approximate locations of the anterolateral (AL), modified anterior (MA), distal anterolateral accessory (DALA), and proximal anterolateral accessory (PALA) portals. This is an image of the left hip the patient in the supine position. The anterior superior iliac spine is circled, and a longitudinal dotted line is drawn toward the patella, approximating the rectus femoris tendon.

Fig 2

Arthroscopic photo viewing from the modified anterior (MA) portal of beaver blade working from the anterolateral (AL) portal and aligned perpendicular to the tensioned capsule just before T capsulotomy is made.

Fig 3

Arthroscopic photo viewing from the modified anterior (MA) portal of peripheral compartment exposure after T-capsulotomy with capsular retention sutures tensioned through anterolateral (AL) and distal anterolateral accessory (DALA) portals. An asterisk (∗) has been added overlying the lateral CAM to highlight the capsular tissue obstructing the view before redirection of sutures through the proximal anterolateral accessory (PALA) portal. This photo shows how the line of pull through the AL portal can bunch this capsular limb and does not consistently retract the capsule away from the femoral neck.

Fig 4

Arthroscopic photo viewing from the modified anterior (MA) portal with loop grasper inserted through the proximal anterolateral accessory (PALA) portal to retrieve the capsular retention suture in the posterior limb of the T capsulotomy. Note the direction from proximal and posterior relative to the capsulotomy.

Fig 5

Arthroscopic photo viewing from the modified anterior (MA) portal of peripheral compartment exposure with capsular retention sutures after the distal lateral capsular (DLC) suture has been retrieved through the proximal anterolateral accessory (PALA) portal. As in Fig 3, an asterisk (∗) has been added overlying the lateral CAM. In this figure, the asterisk highlights the improved visualization of the CAM now that the capsular tissue is no longer obstructing because of the redirection of sutures through the PALA portal.

Fig 6

Schematic demonstrating the orientation of figure-of-eight sutures used for closure of the T capsulotomy. Dashed lines are limbs of the stitch that pass on the deep surface of the capsule.