PMC6501439_01
Pre-operative log-roll test. (A) Operative side (right) and (B) non-operative side (left). The log-roll test for evaluating joint instability is positive on the right side.
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The dial test and log-roll test for evaluating joint instability were positive only on the right side (Fig. 1).
Pre-operative AP supine pelvic radiograph of the patient. The lateral-center-edge angles (right/left) were 18 /40 , and acetabular inclination (right/left) was 14 /-1 . The radiograph showed no osteoarthritic changes at the right hip joint. For the left hip joint, slight joint space narrowing was observed.
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She underwent radiographic evaluation of the right hip with a supine anteroposterior (AP) pelvic radiographs (Fig. 2), 45  Dunn view, and false-profile view.
MRA of the right hip. Coronal (A) and axial (B) T2*-weighted images. There was no leakage of the contrast agent from the joint. (A) showed adhesion between the labrum and the capsule (arrows); the capsule became thin. (B) showed adhesion between the capsule and the site where cam osteochondroplasty was performed (asterisks).
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Magnetic resonance arthrography (MRA) revealed adhesions between the labrum and joint capsule, joint capsule, and cam osteochondroplasty site (Fig. 3).
Arthroscopic findings. (A) Severe adhesion between the anterosuperior labrum and joint capsule (arrow). (B) After adhesion release with a radiofrequency probe. (C) The suture anchor is inserted into the capsular footprint of the acetabular margin. (D) An Accu-Pass Suture Shuttle (Smith & Nephew, Andover, MA) is inserted from the MAP and passed through the distal joint capsule. (E) The looped thread from the Accu-Pass Suture Shuttle is grasped using a grasper inserted from the PMAP. (F) The joint capsule is repaired with a horizontal mattress suture for each anchor (four stitches). A, acetabulum; C(A), capsule (acetabular side); C(D), capsule (distal side); L, labrum; FH, femoral head; MAP, mid-anterior portal; PMAP, proximal mid-anterior portal; RC, repaired capsule.
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Arthroscopy revealed severe adhesions between the labrum and joint capsule, joint capsule, and cam osteochondroplasty site (Fig. 4A). We completely released the adhesion using a radiofrequency probe (VAPR: Johnson & Johnson, Raynum, MA) (Fig. 4B). Subsequently, we inserted 2.3-mm suture anchors (Osteoraptors, Smith & Nephew) into the joint capsular insertional footprint of the acetabular margin (Figs 4C and 5C). An Accu-Pass Suture Shuttle (Smith & Nephew) was inserted from the MAP and passed through the distal joint capsule (Fig. 4D). The looped thread from the Accu-Pass Suture Shuttle was grasped using a grasper inserted from the PMAP (Fig. 4E). This suture relay technique was repeated for a total of eight times (Fig. 5C), and the joint capsule was repaired with a horizontal mattress suture for each anchor (four stitches) (Figs 4F and 5D).
Procedure illustration of capsular repair using proximal advancement. (A) Inter-portal capsulotomy between ALP and MAP. The proximal joint capsule was fragile. (B) The proximal joint capsule was removed. (C) The four suture anchors were inserted into the capsular footprint of the acetabular margin. The anchor thread penetrated the distal joint capsule through its looped thread. This suture relay technique was repeated for a total of eight times. (D) The joint capsule is repaired with a horizontal mattress suture for each anchor (four stitches). ALP, anterolateral portal; MAP, mid-anterior portal.
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We attempted joint capsular plication, but the procedure could not be performed because of acetabular side joint capsule fragility (Fig. 5A). The proximal joint capsule was removed (Fig. 5B), and minimal acetabular rim decortication (<1 mm) was performed using a motorized round burr (Smith & Nephew, Andover, MA) under fluoroscopic guidance. Subsequently, we inserted 2.3-mm suture anchors (Osteoraptors, Smith & Nephew) into the joint capsular insertional footprint of the acetabular margin (Figs 4C and 5C). This suture relay technique was repeated for a total of eight times (Fig. 5C), and the joint capsule was repaired with a horizontal mattress suture for each anchor (four stitches) (Figs 4F and 5D).