Capsulotomy First: A Novel Concept for Hip Arthroscopy Mathieu Thaunat, M.D., Colin G. Murphy, M.D., Romain Chatellard, M.D., Bertrand Sonnery-Cottet, M.D., Nicolas Graveleau, M.D., Alain Meyer, M.D., Frédéric Laude, M.D.  Arthroscopy Techniques  Volume 3, Issue 5, Pages e599-e603 (October 2014) DOI: 10.1016/j.eats.2014.06.016 Copyright © 2014 Arthroscopy Association of North America Terms and Conditions

Fig 1 Patient position and portal placement. (A) The patient is placed supine on a surgical table, and the feet are well padded and placed into traction boots. (B) The first portal is located 2 cm anterior and distal to the superior tip of the greater trochanter (GT). A 4-mm blunt trocar is introduced and directed medially underneath the tensor fascia lata and anteriorly to the gluteus minimus muscle in the direction of the anterior iliac spine (AIS). (C, D) The instrumental portal is then created medially to the tensor fascia lata and is located at least 2 inches from the first portal to triangulate more easily. Arthroscopy Techniques 2014 3, e599-e603DOI: (10.1016/j.eats.2014.06.016) Copyright © 2014 Arthroscopy Association of North America Terms and Conditions

Fig 2 Outside-in capsulotomy technique. (A) The anterior surface of the femoral neck, underneath the tensor fascia lata (TFL), is the only area of the capsule where there is no muscle insertion. (B) Instead, a precapsular fatty tissue is seen, which can be easily debrided to show the white fibers of the capsule between the gluteus medius muscle (GM) and the iliocapsularis muscle (ICM). (C) The capsular incision is performed along the neck of the femur and, only if necessary, is extended over the labrum and then along the acetabular rim so as to expose the area from the base of the femoral neck to the supra-acetabular ilium. Arthroscopy Techniques 2014 3, e599-e603DOI: (10.1016/j.eats.2014.06.016) Copyright © 2014 Arthroscopy Association of North America Terms and Conditions

Fig 3 Arthroscopic views of outside-in capsulotomy technique. (A) After the anterior aspect of the capsule (C) has been identified (white structure), the precapsular fatty tissue (PCF) is removed with an electrode. (B) The capsular incision is performed along the neck of the femur. (C) Labral fibers (L) are perpendicular to those of the capsule, which is pearly white and easily identifiable. (D) A simple debulking of the capsule with the shaver along the acetabular rim provides sufficient exposure, and a T-shaped capsulotomy is usually not necessary. (E) The longitudinal capsulotomy allows exposure of the area from the base of the femoral head (FH) to the supra-acetabular ilium. (F) Anatomic side-to-side reduction of the capsule can be obtained with an automated suture passer. Arthroscopy Techniques 2014 3, e599-e603DOI: (10.1016/j.eats.2014.06.016) Copyright © 2014 Arthroscopy Association of North America Terms and Conditions