Editorial Commentary: Restoration of Hip Capsular Tension Is More Important Than Repair Construct Configuration.

The debate regarding optimal capsular management during hip arthroscopy has been evolving for over 20 years. Femoroacetabular impingement emerged in the arthroscopic world in the early 2000s. However, the ability to address osseous deformities and decompress and/or reshape them was limited by the hip capsular structures and small capsulotomies. Some surgeons attempted to arthroscopically manage these deformities with limited capsulotomies, with not surprisingly limited success. Others made larger capsular windows (capsulectomies) to more accurately manage these deformities but potentially left some patients with varying degrees of iatrogenic microinstability or macroinstability. Over time, an increasing awareness of post-arthroscopy instability in the form of case reports, case series, and backroom chatter among the hip arthroscopy thought leaders brought the idea of routine capsular closure to the forefront. Biomechanical studies defined the role of the hip capsular ligaments, the deficits created with various capsulotomies during surgery, and the ability to restore stability after capsular repair. Clinical studies revealed better outcomes and lower revision rates after capsular repair for subtle osseous and soft-tissue instability, revision cases, and athletes compared with unrepaired capsulotomies. Various capsular repair constructs (side-to-side repairs, capsular shifts, and various suture configurations and suture materials) have been proposed, without evidence to support a superior technique or suture material. In the end, capsular management is an evolving art that takes into account various patient-specific factors (i.e., individual activity requirements, soft-tissue and osseous parameters, and intraoperative impressions) with the end goal of achieving a stable, impingement-free joint. There might be various capsular management roads to travel, but the destination remains the same.