The “Chopsticks” Method: A Technique for Capsular Retraction During Hip Arthroscopy Utilizing Switching Sticks

Abstract

Background:

Hip arthroscopy has become an effective method for treating several symptomatic disorders of the hip, which includes femoroacetabular impingement (FAI). Capsulotomy is often necessary for visualization of hip pathology; however, this presents multiple challenges in both capsular management intraoperatively and final capsule closure. Current techniques include use of capsular suspension sutures to provide adequate views of the central and peripheral compartments. We present an atraumatic technique that may be used in conjunction with suspension sutures to decrease the need for excessive capsular debridement, additional personnel, and risk of injury for adequate visualization.

Indications:

Indications for using the “chopsticks” method for capsular retraction include patients with FAI who require osteochondroplasty or debridement of pathology within the peripheral compartment during hip arthroscopy.

Technique Description:

The patient is positioned supine with post-free traction applied. An anterolateral portal is established, followed by a modified mid-anterior portal under direct visualization. An interportal cut is performed for better visualization and access. A diagnostic arthroscopy of the central compartment is performed, and pathology is addressed as needed, including labral repair, subspine decompression or pincer resection, and chondroplasty. Traction is subsequently released, and if needed for visualization, a T-capsulotomy is performed to separate the medial and lateral limbs of the iliofemoral ligament with the knee and hip under slight flexion. Two switching sticks are inserted in the anterolateral portal. With the camera in the modified mid-anterior portal, 1 switching stick is placed intracapsular laterally (between the femoral neck and capsule) while the other is placed intracapsular medially (between the femoral neck and capsule) to retract the capsule and allow for osteochondroplasty. Complete capsular closure is performed following adequate cam decompression and removal of debris.

Results:

Careful retraction of the capsule intraoperatively decreases the need for excessive capsular debridement and retains adequate tissue for repair of the capsule at the end of the procedure. Numerous cadaveric and clinical studies have shown the importance of capsular closure in optimizing post-operative outcomes and, similarly, the importance of decreasing iatrogenic injury to the capsule intraoperatively. This also decreases the need of additional personnel in the operating room as capsular suspension sutures can require an assistant to hold traction to improve visualization or, in other cases, an assitant must flex/extend/internally and externally rotate the leg in order to achieve adequate visualization of the femoral head-neck junction.

Discussion:

The “chopsticks” method of capsular retraction presents a technically straightforward, economic approach to capsular retraction and allows for better visualization of cam deformities for resection.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

We present our technique of the “chopsticks” method, a technique for capsular retraction during hip arthroscopy using switching sticks.

Here are our disclosures, none of which are relevant to this presentation.

Here is a brief overview of the organization of this talk.

Background

The treatment of hip pathology has advanced significantly over the past 100 years. From percutaneous procedures to treat intracapsular neck fractures ¹⁰ to Burman’s first use of arthroscopy to visualize the hip joint ⁹ and Ganz’s description of the periacetabular osteotomy for the treatment of hip dysplasia, ⁵ hip arthroscopy has become a common procedure for treating a wide variety of hip injuries.

Hip preservation is a rapidly growing field in orthopaedics and continues to increase in popularity as understanding of its applications continues to improve.

Studies have shown that hip arthroscopy demonstrates successful clinical outcomes in hip disorders.^2,4,7,8 As understanding of hip arthroscopy grows, many current studies have examined various techniques to preserve native hip biomechanics.

Capsulotomy improves visualization during arthroscopy; however, inadequate exposure can lead to poor cam or pincer resection and ultimately to revision hip arthroscopy.^3,4,6,11 Aggressive retraction of the capsule or inadequate retraction can lead to capsule damage during resection, and capsular retraction can be limited by multiple factors.

We present a healthy 18-year-old man with 6 months of right hip pain unresponsive to conservative measures.

His physical examination is pertinent for a positive subspine impingement sign as well as a positive FADIR (flexion, adduction, internal rotation).

His preoperative imaging shows adequate acetabular coverage on both the anteroposterior pelvis and false profile views.

The 45° Dunn lateral view is used to assess the α angle, which in this patient is measured to be 86°. A complete summary of his preoperative measurements is shown here.

Sagittal magnetic resonance imaging confirms a labral tear with further evidence of adjacent articular cartilage wear along the acetabulum.

Based on the patient’s history and imaging, our surgical plan consisted of a right hip arthroscopy with labral repair, acetabular rim decompression, femoroplasty, and capsule repair.

Technique Description

The patient was taken to the operating room. The authors prefer to use post-free traction, and the setup is shown here for a right hip arthroscopy. The C-arm is positioned perpendicular to the patient for the duration of the case.

An anterolateral portal is established under fluoroscopic guidance, followed by a modified mid-anterior portal under direct visualization. For better visualization and access, a small intraportal cut is made using an arthroscopic knife.

Arthroscopic examination demonstrates a labral tear between the 11- and 3-o’clock position as well as grade 2, grade 3, and some areas of grade 4 transition zone chondromalacia, consistent with a predominantly cam pattern of impingement in the setting of femoral retroversion.

A labral repair was performed in the central compartment as well as an abrasion chondroplasty of the focal area of grade 4 chondromalacia. The hip was then taken off traction.

We then enter the peripheral compartment with the shaver in the DALA portal. Seen here is the interportal capsulotomy. The switching stick is placed in the anterolateral portal, allowing us to retract the gluteus muscle to better visualize the peripheral compartment.

We decide whether to retract the distal capsule with suspension sutures versus a T-capsulotomy on the amount of excursion we can achieve, once again using the switching stick. If there is adequate excursion of the capsule, we may consider the use of suspension sutures, as seen on the left. However, if we feel we are unable to visualize the cam lesion, we will move forward with a T-capsulotomy, as seen on the right.

Due to inadequate excursion of the capsule in this patient and the large cam lesion, the decision was made to proceed with a small T-capsulotomy. Pertinent landmarks for the T-capsulotomy are the iliocapsularis muscle medially and gluteus insertion laterally. The small T-capsulotomy is performed at the mid-aspect at the interportal cut and extends along the femoral neck until adequate visualization is achieved. The smallest possible T-capsulotomy is used, taking care to keep the zona orbicularis intact.

This is an example from a different patient of the use of suspension sutures when adequate excursion of the capsule is seen on examination and a T-capsulotomy is not made. Two traction sutures are placed into the femoral side of the interportal capsulotomy after traction is released and the hip is flexed. The medial suture is placed through the DALA portal, and the lateral suture is placed through the anterolateral portal, both using a slingshot device. A hemostat is placed on the sutures, and retraction is provided by an assistant. This capsular retraction provides excellent visualization of the cam lesion. Here a switching stick can be used to assist with capsular retraction.

For adequate retraction of the hip capsule in the setting of a small T-capsulotomy, a switching stick is placed through the anterolateral portal and parked on the lateral side of the femoral neck. A second switching stick is placed through the same portal and on the medial side of the femoral neck. We now have 2 switching sticks retracting the capsule for improved visualization of the cam lesion.

The borders of the cam lesion are defined using a radiofrequency ablation device. Switching sticks may be used at this juncture for assessing the medial and lateral extents of the cam lesion as well as protecting the capsule throughout this step.

Switching sticks may also be used to retract the capsule to identify relevant anatomy important during cam resection. In this case, the femoral circumflex vessels are identified for protection throughout the duration of the case.

Here we have the 2 switching sticks through the anterolateral portal. One stick is located medially over the femoral neck, and the other is lateral, holding the medial and lateral limbs of the capsule out of the way to adequately resect the cam lesion without capsular injury. The burr is then used through the DALA portal for cam resection.

To obtain fluoroscopy to evaluate resection progress, the arthroscopic instruments, including the switching sticks, can be pulled away from the joint and positioned in line with the leg to move them out of the path of imaging.

To access the lateral extent of the cam, the 2 switching sticks can be placed along the lateral limb of the capsule, between the capsule and the femoral neck. To access the anterior/medial cam, the switching sticks can be brought over the medial femoral neck and downward pressure is applied. The assistant can then hold the switching sticks, allowing the surgeon to resect the medial extent of the cam lesion, again without damaging the overlying capsule, which is protected by the switching sticks. The switching sticks can then be brought laterally to resect the lateral extent of the cam. An assistant is not required for this portion of the technique.

As seen by this fluoroscopic image, a small portion of the proximal cam remains in the superolateral quadrant at the head neck junction. This can be difficult to access with the hip in flexion.

The leg is extended to bring the more proximal portion of the cam into view. The switching sticks remain in the anterolateral portal. The 2 switching sticks are then placed along the inferior aspect of the femoral neck laterally, allowing for adequate retraction of the lateral limb of the capsule and resection of the residual cam lesion.

A shaver may be used to access hard-to-reach areas of the superolateral cam lesion with the 2 switching sticks between the capsule and the lateral neck.

The burr may also be moved from the DALA portal to the anterolateral portal for access to the more proximal cam lesion.

Fluoroscopy is used to evaluate the cam resection.

A dynamic flexion examination can be performed intraoperatively to assess for further femoroacetabular impingement. The hip is flexed to 90° and internally and externally rotated to assess for residual impingement. The switching sticks are used intraoperatively through the anterolateral portal to retract the capsule and allow for better visualization.

We then turn our attention to capsule closure. A slingshot device is used, through a cannula in the anterolateral portal, for placement of a minimum of 3 simple interrupted tape sutures to close the T-limb portion of the capsule. The interportal capsulotomy is then closed with a minimum of 2 to 3 simple interrupted tape sutures. These sutures are passed with the hip in flexion, then tied with the hip in extension.

Discussion

The authors always close the hip capsule after hip arthroscopy. Many studies have highlighted the importance of capsule closure following hip arthroscopy.^1,3,4,6,11 As 1 example, Boos et al. ¹ analyzed 294 patients with a 12-year follow-up after primary hip arthroscopy. Looking at total hip arthroplasty as an end point, they found the survivorship was 79% with capsulotomy alone compared to 97% for those who underwent capsular repair.

The patient is 20% body weight weightbearing for 2 to 3 weeks after surgery, with physical therapy starting within a day or two of surgery. Our full rehabilitation protocol can be seen here.

Here are our references.

Thank you.