Conceptual evolution in arthroscopic capsulotomy techniques and capsular management strategies for the hip

Table 1 Comparison of different hip arthroscopic capsulotomy techniques and their biomechanical impacts

Technique	Approach	Incision direction and relationship to iliofemoral ligament	Impact on iliofemoral ligament	Evidence level	Ref.
Interportal transverse capsulotomy	Inside-out	Transverse, perpendicular to fibers	Reported to disrupt the iliofemoral ligament; increased external rotation laxity	Category 1 and 3	[22,24,25,27]
T-capsulotomy	Inside-out	Transverse + longitudinal	Divides the ligament into four portions; considered to cause substantial disruption of restraint	Categories 3 and 4	[21,27,28,69,70]
Limited puncture capsulotomy	Inside-out (modified)	Limited longitudinal through hollow exchange rod	Reduces area of capsular injury, with a limited longitudinal incision	Category 1	[31]
Skip capsulotomy	Inside-out (modified)	Multiple short, non-communicating incisions	Designed to avoid transverse transection of iliofemoral ligament; continuity of fibers is preserved	Categories 4 and 6	[32,33]
Outside-in longitudinal capsulotomy	Outside-in	Longitudinal, parallel to iliofemoral ligament fibers	Minimizes transverse ligament injury; designed to preserve the fiber continuity	Categories 1, 4, and 5	[44,45,48,53,64]

Table 2 Capsular closure necessity and suturing difficulty across different capsulotomy techniques

Technique	Disruption of capsular continuity	Closure strategy	Suturing difficulty	Rationale	Evidence level	Ref.
Periportal capsulotomy	Minimal (portal expansion only, no interconnection)	Generally not required	Relatively low	Low traction demand; minimal iatrogenic injury; limited to diagnostic or simple loose body removal	Category 4	[67,68]
Interportal transverse capsulotomy	Substantial capsular disruption	Recommended	Relatively high	Ligament considered severely disrupted; closure generally recommended to restore biomechanical stability	Category 3	[24,25,27,29]
T-capsulotomy	More extensive capsular disruption involving transverse and longitudinal limbs	Recommended	Relatively high	Substantial ligament disruption; both limbs generally require closure	Categories 3 and 4	[21,24,27,28]
Limited puncture capsulotomy	Moderate (reduced incision area via hollow exchange rod)	Generally recommended	Relatively moderate	Reduced capsular disruption; closure still recommended	Category 1	[31]
Skip capsulotomy	Localized (multiple short, non-communicating incisions)	Case-by-case	Relatively low	Ligament continuity largely preserved; suturing technically undemanding when performed	Categories 4 and 6	[32,33]
Outside-in longitudinal capsulotomy	Linear longitudinal incision, parallel to iliofemoral ligament fibers	Suggested based on expert consensus	Relatively low	Designed to avoid transverse transection; facilitates edge-to-edge closure	Categories 1, 4, and 5	[44,45,48,53,64]