Capsular management during hip arthroscopy: from femoroacetabular impingement to instability

Advances in the ability to treat various soft-tissue and osseous pathologic conditions of the hip arthroscopically have been predicated on an improved exposure of the pathology of the central, peripheral, and peritrochanteric compartments. The management of the capsule is critical and must allow for an improved exposure without compromising stability and kinematics of the hip. Described approaches have included capsulectomy, limited capsulotomy, extensile capsulotomy, capsular plication, and capsular shift. The selected approach must consider various factors, including symptomatic complaints, underlying hyperlaxity, specific mechanical pathology, and surgical expertise. Universally using a single technique without consideration of the complex mechanical and anatomic factors unique to each patient may result in incomplete treatment of the pathoanatomy or iatrogenic instability. This article reviews the anatomy of the hip capsule and provide a diagnosis-based consideration of capsular management during hip arthroscopy. The senior author's preferred techniques are also presented.