Sequential Suture Passage With Delayed Tying for Capsular Closure in Hip Arthroscopy

Figures

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  Fig 1. Patient preparation and positioning. In preparation for hip arthroscopy, the operative extremity (right) is prepared and draped in the standard sterile fashion. The patient is positioned supine on a postless traction table (Guardian; Stryker, Greenwood Village, CO). The patient is placed in approximately 3° of Trendelenburg positioning. Both lower extremities are secured into traction boots. Countertraction is applied to the operative extremity. A C-arm is draped in the standard sterile fashion and moved into position to assist with portal placement.

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  Fig 2. Portal placement. In preparation for hip arthroscopy, the operative extremity (right) is prepared and draped in the standard sterile fashion. Fluoroscopy is used to localize the hip joint, and the standard hip arthroscopy portals—anterolateral (AL), modified midanterior (MMAP), and distal accessory anterolateral (DALA)—are identified and precisely marked with a surgical marker. Proper portal placement is critical to allow for efficient instrument management in addressing pathology.

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  Fig 3. Leaflet exposure. This is the left hip in the supine position viewed with a 70° arthroscope from the modified midanterior portal showing the interportal capsulotomy. To begin closure of the interportal capsulotomy, a radiofrequency ablation device from the anterolateral portal is used to debride pericapsular fat, particularly from the acetabular leaflet, to ensure clear visualization of the leaflets for suture placement. Acetabular leaflet (AL), femoral leaflet (FL), and femoral head (FH).

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  Fig 4. Suture placement. This is the left hip in the supine position viewed with a 70° arthroscope in the modified midanterior portal showing the interportal capsulotomy. The 70° Slingshot suture shuttling device (Stryker Sports Medicine) is used in the anterolateral portal (supine- left hip) to pass the second blue-white suture in the acetabular leaflet (AL) and retrieved through the femoral leaflet (FL). The senior author alternates suture colors, typically starting with black-white (the most medial suture, which was passed previously). This process repeats, alternating colors, until watertight closure is achieved, typically using three sutures.

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  Fig 5. Suture management. This is the left hip in the supine position viewed with a 70° arthroscope in the modified mid-anterior portal showing the interportal capsulotomy. To begin closing the capsulotomy, the blue-white sutures which were placed last in the series of interrupted sutures from medial to lateral is tied first. This blue-white suture is tied via the working cannula which is in the anterolateral portal (supine-left hip). Note the previously passed black-white suture more medial and outside of the cannula to avoid tangling during tying. The sutures are tied from lateral to medial, completing the closure of the acetabular leaflet (AL) and femoral leaflet (FL).

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  Fig 6. Completed capsular closure. This is the left hip in the supine position viewed with a 70-degree arthroscope in the modified mid-anterior portal showing a fully plicated interportal capsulotomy. The interportal closure is performed with a Slingshot suture shuttling device (Stryker Sports Medicine) in the anterolateral portal to shuttle sutures with alternating colors in the acetabular leaflet and retrieved through the femoral leaflet. These sutures are left untied until the final, most lateral suture is placed. The sutures are sequentially tied and cut from lateral to medial.