Dr. Andrea Spiker:
Welcome, everyone, to the Arthroscopy Association's Arthroscopy Journal Podcast. I'm Dr. Andrea Spiker from the University of Wisconsin, and today I'm joined by Dr. Mario Hevesi, who is an assistant professor of orthopedic surgery at the Mayo Clinic in Rochester, Minnesota with a clinical focus on open and arthroscopic hip preservation. Dr. Hevesi was the senior author of the article, “Arthroscopic Hip Capsular Reconstruction: A Step-by-Step Guide with Rectus Overlay,” which was published in the June 2024 edition of the Arthroscopy Techniques Journal. Dr. Hevesi's co-authors were Fabien Meta, Sean Clark, and Aaron Krych.
Welcome, Dr. Hevesi, and thanks so much for joining us.
Dr. Mario Hevesi:
Thanks so much for having me.
Dr. Andrea Spiker:
Mario, thanks so much again for joining us on the Arthroscopy Podcast. Can you begin by telling us more about yourself and your practice?
Dr. Mario Hevesi:
Yeah, thanks for having me. I'm an orthopedic surgeon at the Mayo Clinic and my focus is on both open arthroscopic hip surgery and hip preservation, and I have a specialist focus on labral repair reconstruction, but also capsular management, especially as capsular management, and then the solution for evolving capsular issues, particularly in the revision setting has evolved over time with hip arthroscopy.
Dr. Andrea Spiker:
Well, that's perfect because the topic of conversation today is on this techniques paper that you recently published. Tell us a little bit about how the topic of this techniques paper came about. What situations were you encountering that resulted in the innovations that you were describing in your technique?
Dr. Mario Hevesi:
Great question. Well, something that drew me into hip arthroscopy is the fact that it's continuously evolving, and we have a recently published paper actually that talks about the Mayo Clinic's past three-decade experience, and it's amazing to think that we started off with hip arthroscopy as a diagnostic tool. We were taking a look but not able to really repair much in terms of labrum, certainly not capsule. Then our forefathers used to do capsulotomies, although oftentimes they ended up being capsulectomies, and that was limited by the techniques that were available, the instrumentation that was available. Now, with the advent of increasing use of hip arthroscopy, we see them being performed in high volumes all around the country, and then as a tertiary referral center, I'm seeing quite a few referrals for revision hip arthroscopy, which we get an arthrogram and we see either a small capsular defect, or at times, a large capsule defect that's worrisome for the fact that we might not be able to repair it in a primary manner.
Dr. Andrea Spiker:
You mentioned arthrograms. I do the same. I find that very helpful in the revision setting, especially if you're looking for capsule issues where you get that bloom of the dye extravasating from the capsule. Are you using arthrograms in your primary hips or is that just a revision situation?
Dr. Mario Hevesi:
Just for revisions, we have some good data from our radiology colleagues that a 3 Tesla MRI done without any contrast is equivalent to a 1.5 Tesla arthrogram. Because of that, we have 3 Tesla imaging at our practice and we've switched to 3 Tesla standard MRI for hips, if we're doing that in a primary setting. But as you mentioned, anyone that's getting a revision, I'm getting an arthrogram because it's amazing to be able to both look on that fluoroscopically-guided arthrogram, and oftentimes, you can see that bloom, you can follow it up the iliopsoas sheath at times or out laterally. And then truly on those axials and on those coronals on your MRI, you can really quantify how well was this capsule closed. And if there's a defect, sometimes we can actually even form a 3D reconstruction with our anatomic modeling unit and see exactly how that defect looks.
Dr. Andrea Spiker:
I agree, and I do the same with a primary need of hip. I'll just get the non-contrast, no arthrogram MRI. So as long as it's on a 3 Tesla, I agree with that. So let's talk through your technique step-by-step. Do you know when you go into a case whether you'll be performing this capsular reconstruction technique with the rectus overlay or is this something that you're deciding intraoperatively? And can you just take us through your technique description from the beginning to the end?
Dr. Mario Hevesi:
Yes. So the technique and the decision-making certainly start in clinic. In general, capsule reconstruction is going to be indicated for a revision hip arthroscopy case. This is going to be a patient that's potentially complaining of instability. They particularly dislike hip hyperextension, external rotation. They have an iliofemoral bounce, so they have more external rotation when they're lying flat on the effected side than the other side. And if you externally rotate their foot, it doesn't bounce back quite as much as the other side. Again, showing that you have a lack of that anterior capsular constraint. Usually, that gives me a pretty good index of suspicion that going into our case this is something that is at least concerning for a need for hip capsule reconstruction, particularly after reviewing the MRI. If that defect is bigger than one to two centimeters, I'm certainly getting it grafted and being prepared to do a capsule reconstruction.
And then I counsel my patients that if they have a small defect, we'll do a revision closure or a revision capsulorrhaphy, but probably about 90% of that decision-making has already happened prior to the time of surgery. And then intraoperatively, I'll lyse any adhesions around the capsule itself and once those adhesions are lysed, I think the true test is to see if you can mobilize that capsule and get it back to that proximal leaflet, if the proximal leaflet even exists, on acetabular cuff, and if not, then the decision is clear. It's time for a capsule reconstruction. So that's what relates to the decision-making itself. In terms of the step-by-step technique, these patients generally distract easily. They don't have a capsular constraint. We access them through their existing inner portal, or I should say their existing capsular defect. And then the early part of the case is spent reestablishing our planes, being able to isolate what they have left of their native capsule.
I think that whenever we can use native tissue, that's ideal. Usually, that's all their distal capsule. Oftentimes, these patients have quite a deficiency proximally and proximally-medially. After that, I'll proceed with any central compartment work, labral repair. I've done this in conjunction with labral reconstruction as well. We clear off RM. And then really when it's time for the capsule reconstruction, the main steps are obtaining suture anchor fixation proximal along the acetabular rim, and we'll start at the anterior inferior iliac spine and work our ways laterally. I use hand tied anchors for this. And then, once I've placed those anchors and I'm done with my central compartment work, I'll let down traction. We'll, again, look at what the mobility of that distal capsule leaflet is, we'll measure arthroscopically the defect that we're working with, and then we'll establish a tangle-free suture cord. Or I always tell our residents, our fellows, "This is the time that this procedure is the most like a superior capsule reconstruction in the shoulder and certainly suture management is key."
And once we've assessed the size of our defect, we've placed our initial anchors. Usually, I'll use double loaded anchors so that, as we describe in the technique, we can do that rectus overlay. We can pass one set of sutures from each anchor, particularly medially where that indirect head of that rectus tendon is quite robust, through that rectus tendon so that we can do a vest over pants configuration. We will then shuttle down a dermal allograft that's approximately one centimeter wider in both length and width than our measured defect. And then we'll initially tie this to our proximal row of anchors and then individually around the intact capsule as we look medially, laterally, and then distally.
Dr. Andrea Spiker:
That's a great description and I encourage all the listeners to watch the techniques video. I think you do a really nice job of showing how this is done. I think you mentioned that you put your suture anchors for the capsule reconstruction about five to 10 millimeters proximal to the labrum. Are you doing this under direct visualization of the joint? Are you doing this under fluoroscopy? How do you place those proximal anchors?
Dr. Mario Hevesi:
Great question. I do this under direct visualization of the joint. Usually, these are your safer anchors to place, particularly if you're using your DALA portal as you're drilling for them. As one extends laterally, particularly if you have a large defect in that medial lateral direction, I do use an adjunct fluoroscopy to ensure that the drill trajectory is going superior to the acetabular tectum, particularly as it becomes more challenging to view directly beyond the 12 o'clock position.
Dr. Andrea Spiker:
Okay. So you are doing these anchors while you're still in traction, is that correct?
Dr. Mario Hevesi:
I am, yes. And that way I can have a direct visualization of the chondral surface and completely ensure that these anchors are extraarticular.
Dr. Andrea Spiker:
Okay. Great. And so you mentioned mobilizing that capsule, how often are you getting into the joint? You have a graft in the operating room in case you need it. How frequently do you find that you don't actually need to do the reconstruction and that you can instead do a repair of the native capsule?
Dr. Mario Hevesi:
In settings where I think that we'll be using a capsule reconstruction, so settings that I would say with a defect bigger than one by two centimeters, I would say that one in 10 times do you get such good mobility that you feel that you can, A, get a good repair, but also a tension-free repair in the sense that, that patient will be able to achieve full hip extension and you're not worried about creating a hip contracture or the first time the patient stands up straight tearing those sutures out. Certainly, if you do feel like you get good mobility, we will do a complex capsular closure. Then I switch to a figure of eight sutures and suture tapes for that. And I think that we can really advance capsule quite well.
But I would say that any defect particularly greater than one by two centimeters, there's at least a 90% chance that we're going to be using that graft. Because, again, we want to have a relatively tension free closure understanding that patients will develop pericapsular scarring after we do their capsule reconstruction as well.
Dr. Andrea Spiker:
Great. And one question I wanted to ask you, Mario, integrating that indirect head of the rectus into that vest over pants repair, do you think that, that can in some instances cause irritability or over tightening of the joint? How are you addressing that to make sure that, that rectus isn't over tightened in this technique?
Dr. Mario Hevesi:
Yeah, the indirect head of the rectus I think is powerful because it is a distinct entity as you look medially along the hip capsule, but then it blends into the hip capsule as you look laterally by the time you reach about the 12 o'clock position. And so it is relatively immobile in the sense of suturing into it. People have described it as a technique for using it as a proximal cuff when there is no proximal cuff of capsule. I think that it's both robust but well anchored and non-mobile. I do think that final tensioning your repair, whether that's a repair or reconstruction, particularly as it relates to the inner portal in hip extension, can be very helpful for this so that you know that you haven't captured the hip, you haven't sutured together the inner portal or sutured your capsular graft in at 50 degrees of hip flexion and suddenly when you extend it's too tight.
And then I think it's key that you develop the plane between any remnant of capsule and that indirect head of the rectus so you can truly visualize the indirect head of rectus and be assured that you're using that indirect head as it reflects laterally rather than the direct head of the rectus or some other structure which might be more mobile and more prone towards having a symptomatic tether for those patients.
Dr. Andrea Spiker:
Okay, excellent. So the topic of this paper addressing the hip capsule is really quite timely. And you mentioned this earlier, more and more we're realizing how important this capsule is and the role it plays in the success of our hip arthroscopies. So can you take us through how you approach the hip capsule specifically when you're meeting a patient who's undergoing a primary hip arthroscopy and then also those patients who have the need for a revision of hip arthroscopy but may not necessarily fall into a capsule reconstruction group?
Dr. Mario Hevesi:
Definitely. I think that capsular management is probably one of the most important things in hip arthroscopy and really to fail to prepare for your capsular closure when you're initially making your capsulotomy is to prepare to fail when it's time to close it. And so really capsular closure begins at the time of initial access. And so we try to make sure that our anterior lateral portal at our initial instrumentation with our needle is close to the femoral head and far away from the labrum, which we all do in order to prevent any iatrogenic damage. But more so when we're developing that mid-anterior modified anterior portal, we're ensuring that we have at least five millimeter, if not centimeter proximal cuff of capsule so that we have good robust tissue to suture to at the time of closure. And I really do think that it is key and oftentimes the place that I see that these large capsular defects are formed are people that are too close to the rim and suddenly they're out of any tissue to suture to because there's always more capsular tissue as one goes distally.
So I think that that's a large component of it. I think minimalizing the size of our inter portal capsulotomy is really important. Shane Nho’s group has some really good information on it. He was a great mentor to me in terms of the biomechanical constraints of particularly those longitudinal fibers that are cut at the time of your inner portal capsulotomy. And so if we can keep this to 15 to 20 millimeters at maximum, I think that, that can be very powerful for maintaining capsule restraints and also having a minimal inner portal capsulotomy to close. To that point, I do a T-capsulotomy in essentially all of my primary hip arthroscopies understanding that being able to cut in line with the fibers of the capsule as you do that vertical limb of your T, you're being more capsule preserving definitely in a biomechanical standpoint and using that minimal sized inner portal and minimal sized T-capsulotomy that you need to see, which can definitely be augmented by suspension sutures.
In terms of subsequent management suspension, I think it's also really important that oftentimes there's the temptation to use the shaver, the ablate feature, or radio frequency wand when we're preparing our capsule or to better visualize after a capsulotomy. And the further away we can stay from turning that capsulotomy into a capsulectomy, the better off we are at the end of the case. Finally, in terms of revisions, oftentimes I think that we are lucky in terms of accessing or falling into that inner portal capsulotomy, especially if there's a defect upon initial instrumentation from the anterolateral portal. And then if I can see their previous inner portal capsulotomy, then I will place my mid-anterior portal in the previous inner portal capsulotomy so I'm not creating parallel defects to any existing defects. And I think that can be really powerful for closing capsule, especially when combined with taking down any adhesions in the pericapsular space, particularly superior or more superficial to the capsule as well.
Dr. Andrea Spiker:
Those are excellent tips, and I agree with you, I think over time my approach to the capsule has changed and I'm doing many of the things that you discussed, keeping that inner portal as far lateral as possible, as small as possible. And you mentioned this earlier, but that very anterior medial capsule is relatively flimsy. And so I think if we can avoid just getting into it in the first place, we're really doing the patient a service. So I agree with all of your comments. How are you closing? Are you using absorbable or non-absorbable sutures?
Dr. Mario Hevesi:
So in general, I will use partially absorbable sutures. I find that those hybrid sutures that are partially absorbable but do have a permanent component are nice to know that you'll be decreasing at least some portion of your knot bulk. I have switched to closing essentially exclusively with figure of eight sutures. I find that it's nicer for re-approximating tissue. You can really have a nice capsulorrhaphy in that way rather than simple interrupted sutures. And again, I think that being able to decrease our knot burden superficial to the capsule is likely helpful in terms of decreasing scar. I will usually end up using two, perhaps three figure of eight sutures in the vertical limb of my T and then one figure of eight on either side when I'm closing my inner portal capsulotomy.
For patients with large defects, or we've all encountered that patient that has the very, very thin flimsy capsule, oftentimes in the setting of hyperlaxity, Ehlers-Danlos, these are the patients that are easy to distract, I'll have a low index to convert over to using suture tape because I think that the strength of that suture within the tissue is much better and you can similarly have a much stronger capsulorraphy with those suture tapes.
Dr. Andrea Spiker:
Yeah, that's great. I also have been starting to use more and more figure of eights, and it's been very surprising how much more of a robust closure you can get than with a simple. And I agree with you, I think I have concerns with all absorbable sutures because I worry that they will dissolve before the capsule actually completely heals. And unfortunately, I've seen a number of revisions where the prior surgeon had used a completely absorbable simple suture repair with not that many sutures. So all things to keep in mind.
Dr. Mario Hevesi:
Yeah, definitely real considerations. I always found that all absorbable suture, if you tie your knot too tight, you'll tear your suture, which I find worrisome that our patients who are going to put their full body weight on it. We would like a more robust or stronger suture for that as well. The only positive with the all absorbable sutures, of course, is if you're revising then there's no knot stacks to remove. But I would much rather have knots that stay and a capsular closure that stays.
Dr. Andrea Spiker:
Agreed. So this technique that you just talked us through, how frequently are you actually finding that you have to use this? So when you think about your practice as a whole, how common is this specific technique in your entire patient population?
Dr. Mario Hevesi:
As a tertiary referral center, we see a lot of revisions. So this technique, I wouldn't say is completely uncommon. That being said, we perform this technique a couple of times a year truly for those very large defects that are not amenable to primary closure. I do believe that native tissue, particularly for the classic young hip arthroscopy population, we're treating a lot of 20-year-olds, teenagers, and 30-year-olds. If we can get their capsule to have a good primary closure, then I'd much rather do a complex closure. I'd much rather place many figure of eight sutures, but have a good tension-free construct than use a reconstructive technique. That being said, certainly a few times a year we'll have patients come in with large defects where clearly primary closure is out of the question. I think that this a really powerful technique for that, and thus far we've had good results.
Dr. Andrea Spiker:
Excellent. Yeah. Now, you teach trainees in your institution, residents and fellows, and what have you found to be the most effective teaching methodology for your trainees as you're teaching them how to address the capsule, be it capsulotomy, capsule closure, these reconstructive techniques? What would you say has been the most effective teaching method?
Dr. Mario Hevesi:
Great question. I think that this is a thing that is at the forefront for a lot of trainees and teachers alike. Most of us feel that it's relatively easy to teach a trainee to retrieve a suture, pass a suture through a labrum, but when it comes to passing through capsule, passing through capsule without tangling and having good visualization, that's much more challenging. To that point, we actually just finished building a hip arthroscopic simulator that has 3D printed T-capsulotomies. And so our trainees actually are able to use an arthroscope, a 70 degree arthroscope, and practice closing their capsule. And we actually have a painted femoral head that shows scuffs, if you plunge too deep. And so I think that being able to log many repetitions on that is particularly helpful for trainees. And it's nice that they can always actually lift up the artificial skin and do it directly. They can do it through the arthroscope.
And as anything, practice makes perfect, but really capsular management is what allows you to get a good visualization at the time of your initial capsulotomy. It allows you to improve your visualization with suspension. And at the end of the case, I think many trainees in particular dread capsular closure simply because it's seen as something that's technically challenging. But with hopefully some good mentorship, but definitely repetitions, be that in the lab or with a simulator or under close guidance of an attending, I think it's something that attendees can pick up very quickly and say that, "I feel much more comfortable doing a good capsulotomy knowing that closure is not going to be an issue in the end."
Dr. Andrea Spiker:
I agree. And I would also agree this is probably one of the hardest parts of the hip arthroscopy, so really emphasizing the importance of practicing for our trainees is definitely the way to go. Now, you described this relatively novel technique in this arthroscopy techniques paper. So what research do you think we need to determine the best approach for this reconstruction technique and others when it comes to the capsule?
Dr. Mario Hevesi:
So I think that prospective research obviously is better than retrospective research, and we've been following all of our patients that we've done capsule reconstructions on in a prospective manner, seeing what activities they're getting back to doing strength testing and similar, and now at one to two years out from the time of their surgery. And I think that's really important that as clinicians but also as academicians that are trying to come up with novel ways to solve current problems, we need to be very sensitive to what the outcomes are of our proposed solutions. I think the best approach to fixing capsular defects is to not create them in the first place. And to that point, good training for our trainees and our colleagues is really helpful in terms of good capsular management and trying to prevent the formation of at least these large defects, understanding that some capsules will dehisce, but they tend to be amenable to revision closure.
And I really do think that recently there's a great editorial by Chris Larson about the fact that hip arthroscopies are rapidly advancing, and one of the most important things is that we continue to publish our techniques but also publish our outcomes. Certainly, if someone else has other interesting and innovative ways to fix this, it's best to be able to disseminate that amongst other surgeons. And we need to share our outcomes in the sense that, when we first started down this journey at Mayo Clinic, there were two technique articles out there on various ways of managing capsular defects but no outcome studies. And I think that, that highlights the fact that this is an exciting new chapter in terms of how we're optimizing hip arthroscopy, particularly revision arthroscopy, but certainly there's lots of work to be done in terms of not just proving that this is technically feasible, but proving mid to long-term results of it as well.
Dr. Andrea Spiker:
Yeah, that's a fantastic summary. And so I think that leads to my final question today. What are some of the challenges with the hip capsule that we still need to address going forward, and where are the areas that we can really focus on in the future?
Dr. Mario Hevesi:
I think our understanding of the hip capsule, particularly as a dynamic structure, is just beginning. We know that there's the ilio capsularis there in terms of muscles that insert upon capsule itself and are probably modulating how that capsule moves. Our results has some interesting data on capsule impingement, and certainly that's something that's new and being thought of. And then when we're closing capsule, whether we try do a side-to-side closure or for a capsular tightening, I think that there's a lot to be discussed still about, what is the ideal amount of capsular tension and capsular volume to provide a patient, particularly if that patient has undergone a large camera section and so then the volume of their femoral neck is different?
And so to that point, the capsule is a dynamic structure. Clearly, it relaxes and it tightens as one goes through a range of motion. You have an interesting article out there regarding dealing with capsular contractures and being able to truly dial in the nature of our capsular repair, our capsular closure, our capsular tension, I think is going to be something that hopefully in the future plays just as important a role in our hip arthroscopy as does our labral repair and in our suction seal.
Dr. Andrea Spiker:
Excellent. Yeah, and I would add to that, talking about it on podcasts such as this one are also very helpful to our future improvements in capsule management. So thank you again for joining us.
Dr. Mario Hevesi:
Definitely. Thanks so much for having me, Andrea.
Dr. Andrea Spiker:
Dr. Hevesi's arthroscopy techniques article titled “Arthroscopic Hip Capsular Reconstruction: A Step-by-Step Guide with Rectus Overlay” can be found online at www.arthroscopytechniques.org. This concludes our episode of the Arthroscopy Journal Podcast. Thank you so much for joining us. The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal.
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