ORIGINAL ARTICLE
Fluoroscopically Guided Hip Capsulotomy: Effective
or Not? A Cadaveric Study
Aric A. Christal, MD, Lisa A. Taitsman, MD, MPH, Robert P. Dunbar, Jr, MD,
James C. Krieg, MD, and Sean E. Nork, MD
Objective: The purpose of this study was to examine the efficacy of
a fluoroscopically guided hip capsulotomy.
Methods: Ten fresh–frozen paired cadaveric hips were injected under
fluoroscopic guidance with saline sufficient to generate an intra-
articular pressure greater than 58 mmHg. The pressure was monitored
continuously using a percutaneous transducer. A limited lateral
approach to the proximal femur was performed by one of two senior
orthopaedic trauma surgeons. Using a scalpel under fluoroscopic
guidance, each surgeon made one attempt at an anterior capsulotomy.
Changes in intra-articular pressure were recorded throughout the
procedure. The specimens were then dissected to measure the extent of
each capsulotomy as well as the distance from the capsulotomy to
nearby neurovascular structures.
Results: A rapid and substantial decrease in intra-articular pressure
was seen in all hips. The mean intra-articular pressure postcapsu-
lotomy was 8.4 mmHg. The capsulotomies averaged 15.1 mm in
length. None of the attempts at capsulotomy lasted longer than 90
seconds. The average distance between capsulotomy and the lateral-
most branch of the femoral nerve was 19.5 mm. The femoral artery
was on average 40.3 mm from the capsulotomy. There was no
correlation between the side on which capsulotomy was performed
and its extent or proximity to neurovascular structures.
Conclusions: Fluoroscopically guided hip capsulotomy through
a small lateral incision appears to be a safe, effective, and expedient
method, which may substantially reduce intra-articular pressure after
minimally displaced femoral neck fractures.
Key Words: femoral neck fracture, capsulotomy, decompression,
avascular necrosis
(J Orthop Trauma 2011;25:214–217)
Accepted for publication May 21, 2010.
From the Department of Orthopaedics and Sports Medicine, University of
Washington, Seattle, WA.
An AO North America Resident Trauma Research Grant was used to fund this
project.
No benefits in any form have been or will be received from a commercial party
related directly or indirectly to the subject of this manuscript.
Reprints: Aric A. Christal, MD, University of Washington, Department of
Orthopaedics and Sports Medicine, Box 356500, 1959 NE Pacific, Seattle,
WA 98195 (e-mail: aric@u.washington.edu).
Copyright Ó 2011 by Lippincott Williams & Wilkins
214 | www.jorthotrauma.com
INTRODUCTION
It is widely accepted that fractures of the femoral neck can
injure fragile retinacular arteries and potentially disrupt blood
flow to the femoral head.1–4 Furthermore, the extent of fracture
displacement appears to correlate with the degree of vascular
damage.1 Swiontkowski noted that early anatomic reduction
and internal fixation of most femoral neck fractures allows
revascularization to take place in an optimized mechanical
environment.5 Other authors have suggested that timely near-
anatomic reduction is associated with a lower incidence of
posttraumatic avascular necrosis involving the femoral head.6–8
Some physicians routinely use a fluoroscopically guided
approach to capsulotomy after operative fixation of femoral
neck fractures. This technique was popularized by Koval and
Zuckerman, who advocate use of a scalpel directed along the
anterior femoral neck under fluoroscopic guidance.9 Although
the authors outline their procedure, they offer no data
regarding the consistency with which a fluoroscopically
guided capsulotomy can be achieved. Presently, there are no
studies examining the efficacy, reliability, or safety of such
a technique in effecting a decompressive hip capsulotomy. We
hypothesized that fluoroscopically guided hip capsulotomy
through a small lateral incision would reliably decrease intra-
articular pressure while maintaining a safe distance from
surrounding neurovascular structures.
MATERIALS AND METHODS
Ten fresh–frozen paired cadaveric hips were used. None
demonstrated radiographic evidence of deformity beyond that
which would be expected from age-related degeneration,
contained implants, or appeared to have been operated on
previously. The cadaveric hips were positioned in a supine
fashion with a towel bump under the operative hip. The
extremity was placed in neutral rotation and extension. Under
fluoroscopic guidance, each hip was injected percutaneously
with a small amount of dilute radiographic contrast dye. Once
proper intracapsular positioning was confirmed, saline was
infused to replicate an intra-articular hematoma. All injections
were performed through an anterior approach. Intracapsular
pressure was observed using an arterial line transducer and
monitor. Beck et al found that on average, 58 mmHg was
necessary to tamponade blood flow to the femoral head.10 As
such, saline was injected until an intracapsular pressure of 58
to 116 mmHg was achieved. The transducer was covered but
left in place to provide a continuous measure of intracapsular
pressure throughout each attempted capsulotomy.
J Orthop Trauma  Volume 25, Number 4, April 2011
J Orthop Trauma  Volume 25, Number 4, April 2011 Fluoroscopically Guided Hip Capsulotomy

One of two senior orthopaedic trauma surgeons (R.P.D.

and J.C.K.) was assigned to each cadaveric hip. A 4- to 8-cm
direct lateral exposure was then performed in each specimen to
simulate the approach used during cannulated screw or sliding
hip screw fixation. Under fluoroscopic guidance, each surgeon
made one attempt at capsulotomy in his assigned specimen by
inserting a scalpel (No. 10 blade) parallel to the anterior cortex
of the femoral neck (Fig. 1). The scalpel was initially oriented
in the coronal plane with its blade directed inferiorly. The
blade was then advanced centrally along the anterior cortex of
the femoral neck using tactile sensation and fluoroscopic
imaging as necessary for guidance. When the leading edge of
the blade was felt to impact the underside of the femoral head,
a posteroanterior fluoroscopic image was obtained to confirm
positioning. The scalpel was then rotated 90° in the sagittal
plane (such that the blade was directed posteriorly toward the
capsule) and withdrawn with pressure applied posteriorly
against the capsule and femoral neck. Each surgeon was FIGURE 2. Capsulotomy identified during dissection. Anterior
allowed a single attempt in each of his assigned specimens and (A), posterior (P), cephalad (Ce) and caudad (Ca).
alternated between left and right hips.
The effect of capsulotomy on intracapsular pressure was RESULTS
assessed through continuous monitoring as described pre- All of the lateral incisions were between 4 and 8 cm in
viously. Pressures were recorded from the time of initial skin length. None of the attempts at capsulotomy lasted longer than
incision until they stabilized after each trial. After capsulotomy 90 seconds. With each attempted capsulotomy, a rapid and
had been attempted in all hips, the specimens were dissected substantial decrease in intra-articular pressure was recorded.
through an extensile anterior (Smith-Petersen) approach.11 The mean intracapsular pressure before each procedure was
Each capsule was carefully inspected for evidence of 83.5 mmHg (range, 58–115 mmHg). The mean intracapsular
capsulotomy (Fig. 2). When identified, the capsular defect pressure postcapsulotomy was 8.4 mmHg (range, 0–40
was measured and recorded. The lateral-most aspects of the mmHg). In nine hips, the final pressure was less than 10
femoral nerve, artery, and vein were then identified in situ. mmHg. In the remaining specimen, the pressure stabilized at
The distance in millimeters between each capsulotomy and its 40 mmHg, but successful capsulotomy was verified through
corresponding neurovascular structures was measured. All direct visualization during subsequent dissection. In the
capsulotomies and measurements were verified independently average hip, capsulotomy resulted in a 90% decrease in
by two investigators (A.A.C. and L.A.T.). intracapsular pressure (Table 1).
On subsequent dissection, full-thickness capsulotomies
were visualized in all hips (Fig. 3). The capsulotomies averaged
15.1 mm in length (range, 3–35 mm). The average distance
between capsulotomy and the lateral-most branch of the femoral
nerve was 19.5 mm (range, 15–30 mm). The femoral artery was
on average 40.3 mm (range, 36–52 mm) from the site of

TABLE 1. Intra-articular Pressures Recorded Before and After

Each Procedure
Starting Postcapsulotomy Decrease in
Pressure Pressure Pressure
Specimen Side Gender (mmHg) (mmHg) (mmHg)
1 R Male 58 7 51
1 L Male 107 10 97
2 R Female 112 7 105
2 L Female 60 0 60
3 R Male 115 0 115
3 L Male 65 0 65
4 R Male 60 40 20
4 L Male 58 8 50
5 R Female 100 2 98
5 L Female 100 10 90
FIGURE 1. Scalpel as it is passed along the anterior aspect of R, right; L, left.
the femoral neck during capsulotomy.

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Christal et al J Orthop Trauma  Volume 25, Number 4, April 2011

Forty-five years ago, Sevitt evaluated the incidence of

avascular necrosis and subsequent revascularization after
femoral neck fracture.2 Using arteriography and histologic
analysis, he identified complete femoral head necrosis in 64%
of 25 specimens at necropsy. When femoral heads exhibiting
partial necrosis were included, that number rose to 84%.
Sevitt’s results were early evidence that femoral neck fractures
disrupt retinacular vessels and may lead to avascular necrosis
of the femoral head. Later work by the same author showed
that vessels within the ligamentum teres are responsible for
little, if any, femoral head perfusion.3 This questioned the
ability of an intact ligamentum teres to prevent femoral head
necrosis in the setting of complete retinacular vessel disruption
or tamponade. More recently, investigators using latex-
injected cadaveric specimens confirmed that femoral head
perfusion stems largely from the medial femoral circumflex
and inferior gluteal arteries.13–15
FIGURE 3. Branches of the femoral nerve identified medial to Although minimally displaced fractures may not disrupt
the capsulotomy. A K-wire is situated along the path of the retinacular vessels, these injuries can still result in avascular
scalpel and traverses the capsulotomy (*). Anterior (A), necrosis of the femoral head. The slightest vascular insult or
posterior (P). intramedullary hemorrhage can lead to the development of an
intracapsular hematoma and increased fluid pressure within the
capsulotomy (Table 2). In each hip, the capsulotomy represented joint.4,10,16–20 Moreover, closed reduction maneuvers commonly
the medial-most extension of soft tissue injury. There was no involve extension and internal rotation of the hip, further
correlation between the side on which capsulotomy was increasing intracapsular pressure.4,16,21 Crawfurd et al examined
performed and its extent or proximity to neurovascular structures. a series of 19 patients with intracapsular femoral neck fractures
using pressure transducers and ultrasonography.17 The average
intra-articular pressure in those patients with nondisplaced or
DISCUSSION minimally displaced fractures was 66.4 mmHg. In contrast,
In a recent study by Kakar et al, 442 physician members Drake et al examined 12 patients with acute femoral neck
of the Orthopaedic Trauma Association and/or AO Interna- fractures using a transducer voltmeter.22 The authors found the
tional were surveyed regarding their treatment of displaced average intra-articular pressure to be only 28 mmHg (range,
femoral neck fractures.12 Of 298 respondents (68%), 69% 0–68 mmHg). They also note that no more than 5 mL of
reported a preference for closed reduction and fixation. hematoma could be aspirated from any hip. These data raised
Interestingly, only 30% of respondents reported routinely concerns regarding the benefits of aspiration or capsulotomy.
decompressing the intracapsular space. Of these, two thirds However, at the time of the study, two patients were found to
preferred capsulotomy over aspiration. These data suggest that have already sustained traumatic capsulotomies, which would
many orthopaedic surgeons believe capsulotomy is unneces- likely result in decreased opening pressure and might explain
sary, ineffective, or risks iatrogenic injury. the low volume of intra-articular hematoma. Furthermore, only
two of the patients were studied less than 10 hours from injury.
Coagulation of the hematoma may have made needle aspiration
TABLE 2. Anatomic Measurements Recorded During difficult and confounded results. More recently, Beck et al used
Dissection Doppler flowmetry to monitor femoral head perfusion in 11
Distance From Distance From patients as saline was injected into the intracapsular space.10 The
Capsulotomy Capsulotomy author reported cessation of pulsatile blood flow to the femoral
Capsulotomy to Femoral to Femoral head at a mean intracapsular pressure of 58 mmHg, well below
Specimen Side Gender Length (mm) Artery (mm) Nerve (mm) the average intra-articular pressure seen in Crawfurd’s series.
1 R Male 5 52 30 Fortunately, intracapsular pressures can be decreased and
1 L Male 3 48 20 perfusion improved with decompression of the intra-articular
2 R Female 35 41 17 space.23 Stromqvist et al used scintimetry to examine femoral
2 L Female 10 39 18 head perfusion in 25 patients with minimally displaced femoral
3 R Male 25 36 15 neck fractures.16 Thirteen (52%) exhibited reduced uptake
3 L Male 15 41 16 before intervention. Of those, nine (69%) showed a marked
4 R Male 23 50 15 increase in uptake immediately after aspiration. Similarly,
4 L Male 12 45 16 Harper et al analyzed intraosseous and intracapsular pressures
5 R Female 8 51 22 in 33 patients with femoral neck fractures.24 Aspiration of the
5 L Female 15 49 26 intracapsular hematoma resulted in a significant decrease in the
R, right; L, left. intraosseous pressure and a substantial increase in pulse
pressure within the femoral head.

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J Orthop Trauma  Volume 25, Number 4, April 2011
These studies make a strong argument for expeditious
capsular decompression in minimally displaced femoral neck
fractures. Although percutaneous aspiration of an intra-
capsular hematoma may reduce intra-articular pressure and
improve femoral head perfusion, the benefits are often
transient. As the hematoma reaccumulates, intracapsular
pressure builds and blood flow to the femoral head is again
compromised. As such, some surgeons choose to perform
a capsulotomy, which is more likely to result in lasting
decompression of the intracapsular space.
In the present study, all specimens showed a rapid and
substantial decrease in intracapsular pressure immediately
after capsulotomy. On average, a 90% decrease in intra-
capsular pressure was seen. In all specimens, the procedure
was performed quickly and with relative ease. As expected, the
femoral nerve was the closest crucial structure to the femoral
neck in each specimen. The average distance between
capsulotomy and the lateral-most branch of the femoral nerve
was 19.5 mm with the shortest interval measuring 15 mm.
Because the blade is advanced along the anterior cortex of the
femoral neck under fluoroscopic guidance, we feel these
measurements represent an acceptable margin. The average
capsulotomy was 15.1 mm in length, but even the smallest
(3 mm) achieved effective decompression.
In conclusion, this study suggests that fluoroscopically
guided hip capsulotomy through a small lateral incision is
a safe, effective, and expedient method by which to substantially
reduce intra-articular pressure and potentially restore femoral
head perfusion after minimally displaced femoral neck
fractures. The technique outlined is straightforward and should
not prove technically difficult for any orthopaedic surgeon.
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