Gross Instability After Hip Arthroscopy: An Analysis of Case Reports Evaluating Surgical and Patient Factors

Contemporary Hip Capsular Management and Closure Using a Suture Passing Device

Before comprehensive correction of femoroacetabular impingement syndrome, capsular management must be thoughtfully considered to ensure both adequate visualization for bony resection and prevention of iatrogenic microinstability. A number of biomechanical and clinical studies have shown the importance of performing comprehensive capsular closure to restore native hip biomechanical kinematics. The purpose of this Technical Note is to describe the technique of using a suture passing device for capsular plication by a fellowship-trained hip arthroscopist at a large-volume academic center.

Does capsular closure influence patient-reported outcomes in hip arthroscopy for femoroacetabular impingement and labral tear?

Capsulotomy is necessary to facilitate instrument manoeuvrability within the joint capsule in many arthroscopic hip surgical procedures. In cases where a clear indication for capsular closure does not exist, surgeon's preference and experience often determines capsular management. The purpose of this study was to assess the influence of capsular closure on clinical outcome scores and satisfaction in patients who underwent hip arthroscopy surgery for femoroacetabular impingement (FAI) and labral tear. Data were prospectively collected and retrospectively analysed for hip arthroscopy surgeries with a minimum 2 years follow-up. Patients with developmental dysplasia of the hip, previous back or hip surgeries, and degenerative changes to this hip and secondary gains were excluded. Demographic data, intraoperative findings and patient-reported outcome scores were recorded, including the Modified Harris Hip Score (MHHS) and Hip Outcome Score (HOS). A total of 29 and 35 patients were included in the non-closure and closure groups, respectively. The mean follow-up time was over 3 years for both groups. The mean pre-operative and post-operative HOS scores and MHHS scores did not significantly differ between groups (pre-operative HOS: 65.6 and 66.3, P = 0.898; post-operative HOS: 85.4 and 87.2, P = 0.718; pre-operative MHHS: 63.2 and 58.4, P = 0.223; post-operative MHHS: 85.7 and 88.7, P = 0.510). Overall patient satisfaction did not differ significantly between groups (non-closure 86.3%, closure group 88.6%; P = 0.672). Capsular closure did not significantly influence satisfaction or clinical outcome scores in patients who underwent arthroscopic hip surgery for FAI or labral tear.

Acetabular Retroversion Is a Risk Factor for Less Optimal Outcome After Femoroacetabular Impingement Surgery

BACKGROUND

Patients with acetabular retroversion are at risk of labral tear and hip pain. It is unknown whether femoroacetabular osteoplasty (FAO) without reverse periacetabular osteotomy can be used in these patients. This study evaluated the outcome of mini-open FAO in patients with acetabular retroversion and compared that to patients without acetabular retroversion.

METHODS

Fifty-one patients (29 male, 22 female) with acetabular retroversion who had undergone FAO between 2007 and 2015 were identified. The minimum 2-year clinical and radiological outcome was compared with 550 patients without dysplasia or retroversion who underwent FAO by the same surgeon. The preoperative and postoperative alpha angle, center-edge angle, Tonnis grade, joint space, and presence of labral tear and chondral lesion were determined.

RESULTS

The mean age in the retroversion cohort was 27.4 ± 9.5 years compared to 34.5 ± 11.2 years in the control. The mean follow-up was 4.8 ± 1.5 years for retroversion and 4.1 ± 1.2 years for the control. The mean preoperative Short-Form 36 Health Survey and modified Harris hip score were not different between the cohorts. At the latest follow-up, the mean modified Harris hip score and Short-Form 36 Health Survey were significantly lower in the retroversion group (75.4 and 76.5) compared to the control (83.4 and 85.6). There was a higher percentage of failure among retroversion patients (13.7%) compared to the control (2.5%).

CONCLUSION

Acetabular retroversion resulting in femoroacetabular impingent may be treated by FAO, but the outcome appears to be less optimal compared to patients with femoroacetabular impingent and no evidence of dysplasia and acetabular retroversion. Hip preservation surgeons should be aware of this anatomic variation and possible inferior treatment results after FAO in these patients.

A T-capsulotomy provides increased hip joint visualization compared with an extended interportal capsulotomy

The purpose of this study was to compare the cross-sectional area (CSA) of joint visualization between extended interportal and T-capsulotomies. Twenty fresh-frozen cadaveric hips were dissected to their capsuloligamentous complexes and fixed in a custom apparatus in neutral hip position. Ten hips underwent sequential interportal capsulotomies at lengths of 2, 4, 6, and 8 cm. Ten hips underwent sequential T-capsulotomies starting from a 4 cm interportal capsulotomy, creating a 2 cm T-capsulotomy (Half-T), and finally a 4 cm T-capsulotomy (Full-T). Following each sequential capsule change in both groups, a high-resolution digital photograph was taken to measure the visualized intra-articular cross-sectional area (CSA). Independent t-test was used to compare CSA interportal and T-capsulotomy groups. Analysis demonstrated a statistically significant increase in CSA visualization with each sequential increase in interportal capsulotomy length up to 6 cm (2cm: 0.6 ± 0.2 cm²; 4cm: 2.1 ± 0.5 cm² (p<0.001); 6cm: 3.6 ± 1.0 cm² (p=0.001)), and no difference at 8cm (4.2 ± 1.2 cm² (p=0.20)). For the T-capsulotomy group the average CSA visualization significantly increased from 3.2 ± 0.9 cm2 for the Half-T to 7.1 ± 1.0 cm² for the Full-T (p<0.001). The Half-T CSA visualization was not statistically different from the 6 cm capsulotomy (p=0.4) and the 8cm capsulotomy (p=0.05). The Full-T had significantly superior CSA visualization area as compared to the 6 cm and 8 cm interportal capsulotomies (p<0.001 for both). In conclusion, T-capsulotomy resulted in improved cross-sectional area of joint visualization compared to an extended (8cm) interportal capsulotomy in a cadaveric model. Surgeons must weigh the benefits of greater visualization from T-capsulotomy that may help to avoid residual FAI while ensuring to completely repair the capsulotomy to avoid iatrogenic instability.

Comparable patient-reported outcomes in females with or without joint hypermobility after hip arthroscopy and capsular plication for femoroacetabular impingement syndrome

Hip arthroscopy is widely utilized to treat femoroacetabular impingement syndrome (FAIS). In order to evaluate the postoperative clinical and functional outcomes at 2-year follow up in patients with and without benign joint hypermobility syndrome following hip arthroscopy with capsular plication for FAIS, consecutive female patients with generalized ligamentous laxity undergoing primary hip arthroscopy with complete T-capsulotomy closure via plication for FAIS were prospectively identified. Patients were matched in a 4:1 ratio based on Beighton-Horan joint mobility index (BHJMI) then classified into no generalized joint laxity (NGJL, Score<4) or generalized joint laxity cohort (GJL, Score=4). Patient and surgical-related factors were analyzed using univariate and paired analysis with statistical significance set at a = 0.05. A total of 125 female patients were included in the study: 25 generalized joint laxity (GJL) patients and 100 matched to age, sex and BMI (NGJL cohort). The results demonstrated that there were no significant differences between demographics, preoperative range of motion, or radiographic analysis on univariate analysis. There was no statistical difference in postoperative range of motion between groups, though both groups demonstrated significant increases in postoperative flexion and postoperative internal rotation following hip arthroscopy. Paired analysis demonstrated no significant difference in HOS-SS, HOS-ADL, mHHS or VAS-pain, while GJL patients reported significantly greater patient satisfaction score at 2-years follow-up (p=0.007). In summary, hip arthroscopy with capsular plication is a highly effective treatment for FAIS in patients with and without generalized joint laxity. In our analysis, patients with and without generalized joint laxity demonstrated statistically similar and significant improvement in outcomes.

Capsular plication in the non-deformity hip: impact on post-operative joint stability

Purpose and hypothesis

The aim of this study was to evaluate the hip joint range of motion after different capsular plication. The study hypothesis proposed that capsular plication after hip arthroscopy may reduce hip external rotation and thus prevent the hip joint instability created by arthroscopic capsulotomies.

Methods

Six fresh frozen human cadavers were studied in the intact state (5 males, 1 females) for a total of 12 non-deformity hips tested. They were fixed to the operating room table using a custom-made apparatus. Three Steinman pins were inserted, the first into ASIS, a parallel pin into the distal femur proximal to inter-epicondylar axis and the third pin into the lateral epicondyle. Simulation of arthroscopic capsulotomies was done progressively with simulation of three capsular plication techniques. The first plication technique consisted of a primary plication shift of the antero-lateral capsule. The distal-medial arm of the iliofemoral ligament was shifted toward the proximal-lateral arm. The second plication technique consisted in adding a longitudinal arm to the capsulotomy, between the lateral arm and the medial arm of the iliofemoral ligament, to create a T-shaped capsulotomy. The resulting two triangular capsular flaps were overlaid onto each other by approximately 5 mm, plicated fully and tighly sutured in a double-breast manner. The third plication technique, called redrapping, consisted in excising the inferior capsular triangular flap (previously made in the second technique), and suturing the latero-anterior superior capsular flap to the medial arm of the iliofemoral ligament, superimposing the capsular edges for closure. External rotation of the hip at 0°, 15° and 30° of flexion were obtained after the capsulotomy and each capsular plication technique to quantify the increase in hip stability after plication. Data were assessed using a two-way repeated measure analysis of variance (ANOVAs) and Student’s T-test when necessary to determine if the change in external rotation was significantly different.

Results

After capsulotomy, external rotation averaged 26.3°, 29.1° and 31.1° at 0°, 15° and 30° of flexion. With the primary plication shift, external rotation averaged 24.9°, 30.3° and 34.0°. With the two-triangle technique, external rotation averaged 26.1°, 31.9° and 33.3°. With the re-draping technique, external rotation averaged 25.8°, 30.9° and 32.0°. A significant relationship was found between «Plication Technique» and «Angle of flexion» factors for the measured angle of external rotation (P = 0.04).

A decomposition of the interaction showed that external rotation decreased at 0° of hip flexion and increased as the hip flexion angle increased. The only significant difference found corresponded to the two triangles technique at 15° flexion (mean difference compared to the non-repaired state = 2.8° ± 3.8° or 8.8% increase in external rotation; P = 0.03).

Conclusions

Different techniques of capsular plication result in a non-significant increase in hip external rotation when compared to unrepaired capsulotomies. Therefore, special attention should be paid at the time of capsular plication, which could be disadvantageous when done overzealously aiming to increase postoperative stability.

Mild or Borderline Hip Dysplasia: Are We Characterizing Hips With a Lateral Center-Edge Angle Between 18° and 25° Appropriately?

BACKGROUND

Controversy surrounds the classification and treatment of hips with a lateral center-edge angle (LCEA) between 18° and 25°. It remains undetermined as to whether periacetabular osteotomy (PAO) or arthroscopic surgery is best used to treat this patient population.

HYPOTHESIS

Patients with hip pain and mild or borderline acetabular dysplasia defined by an LCEA between 18° and 25° have different features of acetabular and femoral morphology, as determined by other relevant radiographic measures assessing the anterior and posterior acetabular walls, anterior coverage of the femoral head by the acetabulum, and femoral head and neck junction sphericity.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A retrospective review of patients who had an LCEA between 18° and 25° undergoing hip preservation between January 2010 and December 2015 with either PAO or hip arthroscopic surgery was performed. Anteroposterior, Dunn lateral, and false profile radiographs were used to measure the LCEA, Tönnis angle, anterior center-edge angle (ACEA), anterior wall index (AWI) and posterior wall index (PWI), femoral epiphyseal acetabular roof (FEAR) index and posterior to anterior wall index, and alpha angle and femoral neck-shaft angle. An agglomerative hierarchical clustering analysis was then performed on the continuous radiographic variables to identify different subtypes of hip pathomorphology among the study cohort. There were sex-specific trends in hip morphology. Therefore, we proceeded to perform separate cluster analyses for each sex. Multivariate logistic regression was used to identify radiographic parameters for distinguishing between female patients who underwent hip arthroscopic surgery versus PAO.

RESULTS

Ninety-eight patients with hip pain and an LCEA between 18° and 25° underwent surgery in the study period, 77 (78%) were female, and 81 (82%) had complete radiographs for cluster analyses. The mean age was 22.6 years. Hip arthroscopic surgery was performed in 40 (41%) patients, and PAO was performed in 58 (59%) patients. The ACEA (45%), FEAR index (34%), and AWI (30%) were the most commonly abnormal radiographic parameters among all patients. In female patients, the ACEA (55%), FEAR index (42%), and AWI (34%) were the most commonly abnormal radiographic parameters. In male patients, the PWI (48%) was the most common radiographic abnormality. For female patients, 3 clusters representing different patterns of hip morphology were identified: acetabular deficiency with cam morphology, lateral acetabular deficiency, and anterolateral acetabular deficiency. For male patients, 3 clusters were also identified: posterolateral acetabular deficiency with global cam morphology, posterolateral acetabular deficiency with focal cam morphology, and lateral acetabular deficiency without cam morphology. The ACEA (odds ratio [OR], 47.7 [95% CI, 9.6-237.6]; P < .001) and AWI (OR, 3.9 [95% CI, 1.0-15.0]; P = .049) were identified as independent factors predicting which procedure was performed in female patients.

CONCLUSION

A comprehensive evaluation of radiographic parameters in patients with an LCEA between 18° and 25° identified sex-specific trends in hip morphology and showed a large proportion of dysplastic features among these patients. An isolated assessment of the LCEA is an oversimplistic approach that may jeopardize appropriate classification and may provide insufficient data to guide the treatment of hips with additional features of dysplasia and instability.

Effects of Capsular Reconstruction With an Iliotibial Band Allograft on Distractive Stability of the Hip Joint: A Biomechanical Study

BACKGROUND

The capsular ligaments and the labral suction seal cooperatively manage distractive stability of the hip. Capsular reconstruction using an iliotibial band (ITB) allograft aims to address capsular insufficiency and iatrogenic instability. However, the extent to which this procedure may restore hip distractive stability after a capsular defect is unknown.

PURPOSE

To evaluate the biomechanical effects of capsular reconstruction on distractive stability of the hip joint.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eight fresh-frozen cadaveric hip specimens were dissected to the level of the capsule and axially distracted in 3 testing states: intact capsule, partial capsular defect, and capsular reconstruction with an ITB allograft. Each femur was compressed with 500 N of force and then distracted 6 mm relative to the neutral position at 0.5 mm/s. Distractive force was continuously recorded, and the first peak delineating 2 phases of hip distractive stability in the force-displacement curve was analyzed.

RESULTS

The median force at maximum distraction in the capsular reconstruction state (156 N) was significantly greater than that in the capsular defect state (89 N; P = .036) but not significantly different from that in the intact state (218 N; P = .054). Median values for distractive force at first peak (60 N, 72 N, and 61 N, respectively; P = .607), distraction at first peak (2.3 mm, 2.3 mm, and 2.5 mm, respectively; P = .846), and percentage decrease in distractive force (35%, 78%, and 63%, respectively; P = .072) after the first peak were not significantly different between the intact, defect, and reconstruction states.

CONCLUSION

Capsular reconstruction with an ITB allograft significantly increased the force required to distract the hip compared with a capsular defect in a cadaveric model. To our knowledge, this is the first study to report an initial peak distractive force and to propose 2 distinct phases of hip distractive stability.

CLINICAL RELEVANCE

The consequences of a capsular defect on distractive stability of the hip may be underappreciated among the orthopaedic community; with that said, capsular reconstruction using an ITB allograft provided significantly increased distractive stability and should be considered an effective treatment option for patients with symptomatic capsular deficiency.

Arthroscopic Iliopsoas Fractional Lengthening

Background

Iliopsoas fractional lengthening (IFL) is performed on patients with symptomatic internal snapping. This condition is defined as painful and sometimes audible snapping of the iliopsoas (IP) tendon over the femoral head or iliopectineal line. Arthroscopic IFL is performed if the snapping is unresponsive to conservative treatment^1,2.

Description

Hip arthroscopy is performed with the patient in the supine position on a traction table. The portals used to access the joint capsule include standard anterolateral, mid-anterior, and distal anterolateral accessory (DALA) portals³. With a 70° arthroscope, diagnostic arthroscopy is conducted to assess the quality of labral tissue, acetabular and femoral cartilage surfaces, and the ligamentum teres. When indicated, supplementary procedures, such as acetabuloplasty, labral repair, or labral reconstruction⁴, are performed prior to IFL. With traction still applied, IFL is then performed from the central compartment at the level of the joint line. Exposure of the IP tendon is achieved with the use of a curved blade to extend the capsulotomy medially over the 3 o'clock position (right hip). Once the tendon can be appropriately visualized, a progressive and complete transverse cut is made in the tendinous portion, taking care to avoid the muscular portion. During this process, the anterolateral and mid-anterior portals serve as visualization and working portals, respectively⁵.

Alternatives

Prior to arthroscopic IFL for painful internal snapping, nonsurgical options^6,7 may include (1) physical therapy programs, (2) activity modification, (3) nonsteroidal anti-inflammatory drugs (NSAIDs), or (4) ultrasound-guided cortisone injections.

Previous failed hip arthroscopy negatively impacts early patient-reported outcomes of the periacetabular osteotomy: an ANCHOR Matched Cohort Study

Surgical treatment of hip dysplasia by arthroscopic procedures remains controversial. The aim of this study was to compare outcomes of periacetabular osteotomy (PAO) after failed hip arthroscopy to a matched-control group without previous arthroscopy. Fifty-two patients who underwent PAO after failed hip arthroscopy were matched to two subjects without arthroscopy based on age, sex, BMI and radiographic severity. Pre- and post-operative patient self-reported outcomes and radiographic parameters were compared at minimum 1-year follow-up. Prior to PAO the failed hip arthroscopy group exhibited lower modified Harris hip scores (mHHS; 57 versus 62; P = 0.04), WOMAC (59.9 versus 66.3; P = 0.08), UCLA activity (5 versus 7; P = 0.001) and SF12 physical scores (34 versus 40; P = 0.001) compared with the non-arthroscopy group. At minimum 1-year follow-up, the failed hip arthroscopy group had lower mHHS (78 versus 87; P = 0.003); worse WOMAC (84.1 versus 90.8; P = 0.02) and SF-12 physical component (46 versus 50; P = 0.02) with similar UCLA (7 versus 8; P = 0.21) compared with the non-arthroscopy group. No differences were detected regarding radiographic parameters or in patient-reported outcomes from preoperative to follow up. PAO achieved the desired radiographic correction and significant improvement in pain and function after a failed previous hip arthroscopy, however, the patient-reported outcomes were inferior to those of PAO without previous failed arthroscopy.

Editorial Commentary: Caveat Flexor-To Release or Not to Release the Iliopsoas, That Is the Question

In nonarthritic patients with femoroacetabular impingement syndrome, borderline dysplasia, and symptomatic iliopsoas snapping, arthroscopic iliopsoas fractional lengthening carries a significant risk of postarthroscopic instability. The iliopsoas is a dynamic stabilizer of the anterior hip. Thus, although statistically significant and clinically important improvements in hip function have the potential to be achieved with iliopsoas fractional lengthening, surgeons must be supremely confident in their ability to perform a secure capsular plication, labral preservation (not debridement), comprehensive cam correction, avoidance of intra-abdominal fluid extravasation, release of all iliopsoas tendon bands (if bifid or trifid), and ensure that femoral version is normal or low, neck-shaft angle is not excessively valgus, the dysplasia magnitude is no more than mild, and that there is no excessive soft tissue hypermobility. If these goals can be met, then excellent outcomes can be achieved. If not, then an iliopsoas fractional lengthening should not be performed.

Anatomic Predictors of Sagittal Hip and Pelvic Motions in Patients With a Cam Deformity

BACKGROUND

As there is a high prevalence of patients with cam deformities and no ongoing hip dysfunction, understanding the biomechanical factors predicting the onset of symptoms and degenerative changes is critical. One such variable is how the spinopelvic parameters may influence hip and pelvic sagittal mobility. Hypothesis/Purpose: Pelvic incidence may predict sagittal hip and pelvic motions during walking and squatting. The purpose was to determine which anatomic characteristics were associated with symptoms and how they influenced functional hip and pelvic ranges of motion (ROMs) during walking and squatting.

STUDY DESIGN

Controlled laboratory study.

METHODS

Fifty-seven participants underwent computed tomography and were designated either symptomatic (n = 19, cam deformity with pain), asymptomatic (n = 19, cam deformity with no pain), or control (n = 19, no cam deformity or pain). Multiple femoral (cam deformity, neck angle, torsion), acetabular (version, coverage), and spinopelvic (pelvic tilt, sacral slope, pelvic incidence) parameters were measured from each participant's imaging data, and sagittal hip and pelvic ROMs during walking and squatting were recorded using a motion capture system.

RESULTS

Symptomatic participants had large cam deformities, smaller femoral neck-shaft angles, and larger pelvic incidence angles compared with the asymptomatic and control participants. Discriminant function analyses confirmed that radial 1:30 alpha angle (λ₁ = 0.386), femoral neck-shaft angle (λ₂ = 0.262), and pelvic incidence (λ₃ = 0.213) ( P < .001) were the best anatomic parameters to classify participants with their groups. Entering these 3 parameters into a hierarchical linear regression, significant regressions were achieved for hip ROM only when pelvic incidence was included for walking ( R² = 0.20, P = .01) and squatting ( R² = 0.14, P = .04). A higher pelvic incidence decreased walking hip ROM ( r = -0.402, P = .004). Although symptomatic participants indicated a trend of reduced squatting hip and pelvic ROMs, there were no significant regressions with the anatomic parameters.

CONCLUSION

A cam deformity alone may not indicate early clinical signs or decreased ROM. Not only was pelvic incidence a significant parameter to classify the participants, but it was also an important parameter to predict functional ROM. Symptomatic patients with a higher pelvic incidence may experience limited sagittal hip mobility.

CLINICAL RELEVANCE

Patients with symptomatic femoroacetabular impingement showed a higher pelvic incidence and, combined with a cam deformity and varus neck, can perhaps alter the musculature of their iliopsoas, contributing to a reduced sagittal ROM. With an early and accurate clinical diagnosis, athletes could benefit from a muscle training strategy to protect their hips.

Clinical outcomes following arthroscopic treatment of femoro-acetabular impingement using a minimal traction approach and an initial capsulotomy. Minimum two year follow-up

PURPOSE

Although the arthroscopic management of femoroacetabular impingement (FAI) is increasing, severe complications have been reported due to traction. We developed an arthroscopic technique based on an initial capsulotomy and a minimal traction approach. The main purpose of this study was to analyze the clinical outcomes of FAI treatment using this technique after at least two years of follow-up.

METHODS

Forty-seven consecutive patients underwent surgery for FAI. There were two initial portals: a proximal anterolateral portal and a distal anterior instrumental portal. An anterior working space was created and a T-shaped incision was made in the anterior capsule to relieve joint distraction. Short traction (less than 20 mn) made it possible to approach the central compartment. Acetabuloplasty was performed in the presence of pincer impingement. Traction was then released. A head-neck femoral osteochondroplasty was performed in case of bump impingement. All patients underwent a mean 3.3 ± one years of follow-up based on two self-administered questionnaires: the Harris hip score and the QOL Oxford score. None of the patients were lost to follow-up.

RESULTS

There were three complications: two ossifications and one case of injury to the femoral cutaneous nerve with good clinical outcomes at the final follow-up. Five patients (10%) underwent surgical revision after a mean 1.4 years of follow-up: three total hip arthroplasties, one peri-acetabular osteotomy, and one repeat arthroscopic hip debridement. The Harris score increased significantly from 60 ± 10 to 86 ± 15 (p < 0.0001) and the Oxford score improved from 34 ± 15 to 50 ± 11. Only 25% of patients had a "forgotten hip" at the final follow-up.

CONCLUSION

Our clinical results were comparable to previously reported outcomes with other surgical techniques for the management of FAI. However, it should also be noted that despite these good clinical outcomes, the percentage of patients with a "forgotten hip" is low, and patients should be informed of this.

Patient-Reported Outcomes of Capsular Repair Versus Capsulotomy in Patients Undergoing Hip Arthroscopy: Minimum 5-Year Follow-up-A Matched Comparison Study

PURPOSE

To elucidate whether capsular closure during hip arthroscopy affected patient outcomes over midterm follow-up.

METHODS

Between 2008 and 2011, data were prospectively collected and retrospectively reviewed on patients who underwent hip arthroscopy. Patients were then matched for age, gender, worker's compensation, body mass index, and acetabular coverage. The inclusion criteria were capsular repair or unrepaired capsulotomy, lateral-center edge angle ≥18°, and minimum 5-year follow-up. The exclusion criteria were previous hip surgery or conditions and Tönnis grade >1. Patient-reported outcome scores (PROs) included modified Harris hip score (mHHS), nonarthritic hip score, hip outcome score sport-specific subscale, and visual analog score for pain, which were collected preoperatively, at 3 months, and annually thereafter. Minimal clinical important difference (MCID) and patient acceptable symptomatic state (PASS) for both groups were analyzed. Patient satisfaction was noted as well as any complications, secondary surgery, and conversion to arthroplasty.

RESULTS

Minimum 5-year follow-up was available for 82.5% (287 of 348) hips that met the inclusion criteria and were eligible for matching. Ultimately, 65 patients who underwent capsular repair could be matched in a 1:1 ratio to 65 patients with release. Both groups had significant improvements in all mean PROs. The repair group had significant improvement of mean PROs, visual analog score, and patient satisfaction at both 2-year and minimum 5-year follow-up. The unrepaired group had a significant decrease in mHHS (P = .001) and patient satisfaction (P = .01) between 2- and 5-year follow-up. Despite decreasing mHHS in the repair group between 2- and 5-year follow-up, both groups met the MCID and PASS criteria with no significant difference between them. More patients in the release group required conversion to hip arthroplasty (18.5% vs 10.8%). Subgroup analysis considering various perioperative factors confirmed this trend. Rate of revision arthroscopy was the same in both groups (15.4%). Complication rate was low (4.6% vs 6.4%) in both groups.

CONCLUSIONS

Patients undergoing hip arthroscopy and who have minimal or no arthritis have significant short-term improvement, whether the capsule is closed or left unrepaired. However, at midterm follow-up, patients who had unrepaired capsules had deterioration in mHHS as well as a higher rate of conversion to arthroplasty, even when controlling for various perioperative variables. Despite this, patients in both groups met the MCID and PASS criteria. This study suggests that routine capsular closure may lead to more consistently durable outcome in patients undergoing hip arthroscopy, but also that individual patient pathology may dictate capsular management.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Hip Arthroscopic Surgery for Femoroacetabular Impingement With Capsular Management: Factors Associated With Achieving Clinically Significant Outcomes

BACKGROUND

There has been increasing interest in defining clinically meaningful outcomes in patient reported outcomes following orthopaedic surgery. Little is known about the factors associated with clinically meaningful outcomes after hip arthroscopy for femoroacetabular impingement.

STUDY DESIGN

Case-control study; Level of evidence, 3.

PURPOSE

To report on a large, prospectively collected consecutive series of patients who underwent comprehensive arthroscopic treatment of femoroacetabular impingement (FAI) and capsular management with greater than 2-year follow-up. The objectives were to determine (1) what percentage of patients achieve clinically significant outcomes after hip arthroscopic surgery for FAI as determined by the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) and (2) what factors are associated with achieving the MCID and PASS.

METHODS

Data from an institutional repository of consecutive patients undergoing primary hip arthroscopic surgery with routine capsular closure for FAI that had failed nonsurgical management between January 2012 and January 2014 were prospectively collected and analyzed. Of 474 patients during the enrollment period, 386 (81.4%) patients were available for a minimum 2-year follow-up. Demographics, radiographic measurements, intraoperative characteristics, and patient-reported outcome scores were collected. The primary outcome measure was achieving published thresholds for the MCID and PASS for the Hip Outcome Score (HOS)-Activities of Daily Living (ADL) in patients with FAI. The HOS-Sport-Specific Subscale (SSS), complications, and reoperations were secondary outcome measures. Multivariate regression analyses were conducted to identify factors associated with achieving the MCID and PASS.

RESULTS

At a minimum of 2-year follow-up, the patients had statistically significant improvements in all patient-reported outcomes (HOS-ADL, HOS-SSS, and modified Harris Hip Score [mHHS]; P < .001 for all), with a 1.2% rate of revision hip arthroscopic surgery and 1.7% rate of conversion to total hip arthroplasty. The MCID was achieved by 78.8% of patients for the HOS-ADL, and the PASS was achieved by 62.5% for the HOS-ADL. Younger age ( P = .008), Tönnis grade 0 ( P = .022), and lower preoperative HOS-ADL score ( P < .001) were associated with successfully achieving the MCID for the HOS-ADL. Younger age ( P < .001), larger medial joint space width ( P = .028), and higher preoperative HOS-ADL score ( P < .001) were associated with achieving the PASS for the HOS-ADL. Younger age ( P < .001), lower body mass index ( P = .006), non-workers' compensation status ( P = .020), and lower preoperative HOS-SSS score ( P < .001) were associated with achieving the MCID for the HOS-SSS. Younger age ( P = .001), Tönnis grade 0 ( P = .014), running ( P = .008), and higher preoperative HOS-SSS score ( P < .001) were associated with achieving the PASS for the HOS-SSS. Overall, 49.4% of patients achieved all 4 clinically significant outcomes: both the MCID and PASS for the HOS-ADL and HOS-SSS.

CONCLUSION

The majority of patients undergoing hip arthroscopic surgery with routine capsular closure for FAI experienced clinically significant outcomes that met the MCID or PASS criteria, with low rates of revision and conversion to total hip arthroplasty. Factors associated with these successful outcomes on multivariate analyses included younger age with a normal joint space. Patients with lower preoperative HOS scores were more likely to achieve the MCID, whereas patients with higher preoperative HOS scores were more likely to achieve the PASS.

Refractory pain following hip arthroscopy: evaluation and management

With increased knowledge and understanding of hip pathology, hip arthroscopy is rapidly becoming a popular treatment option for young patients with hip pain. Despite improved clinical and radiographic outcomes with arthroscopic treatment, some patients may have ongoing pain and less than satisfactory outcomes. While the reasons leading to failed hip arthroscopy are multifactorial, patient selection, surgical technique and rehabilitation all play a role. Patients with failed hip arthroscopy should undergo a thorough history and physical examination, as well as indicated imaging. A treatment plan should then be developed based on pertinent findings from the workup and in conjunction with the patient. Depending on the etiology of failed hip arthroscopy, management may be nonsurgical or surgical, which may include revision arthroscopic or open surgery, periacetabular osteotomy or joint arthroplasty. Revision surgery may be appropriate in settings including, but not limited to, incompletely treated femoroacetabular impingement, postoperative adhesions, heterotopic ossification, instability, hip dysplasia or advanced degeneration.

Should the Capsule Be Repaired or Plicated After Hip Arthroscopy for Labral Tears Associated With Femoroacetabular Impingement or Instability? A Systematic Review

PURPOSE

To critically evaluate the existing literature on hip capsule biomechanics, clinical evidence of instability, and outcomes of capsular management to answer the following question: Should the capsule be repaired or plicated after hip arthroscopy for labral tears associated with femoroacetabular impingement or instability?

METHODS

We used PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines to find articles using PubMed and Embase. Included studies were Level I through V studies and focused on hip capsule biomechanics, postarthroscopic instability, and clinical outcomes. Articles were excluded if they discussed treatment of the hip capsule during arthroplasty, dislocations without a history of arthroscopy, and pre-existing conditions. The Methodological Index for Non-randomized Studies (MINORS) was used for quality assessment of clinical outcome studies.

RESULTS

A total of 34 articles were included: 15 biomechanical studies, 9 instability case reports, and 10 outcome studies. There is consensus from biomechanical studies that the capsule is an important stabilizer of the hip and repairing it provides better stability than when unrepaired. Case reports of instability have raised concerns about capsular management during the index procedure to decrease the complications associated with this problem. Furthermore, outcome studies suggest that there may be an advantage of capsular closure versus capsulotomy during hip arthroscopy for nonarthritic patients.

CONCLUSIONS

Short-term outcome studies suggest that capsular closure is safe and effective in nonarthritic patients undergoing hip arthroscopic procedures and may yield superior outcomes compared with unrepaired capsulotomy. Moreover, biomechanical evidence strongly supports the role of capsular repair in maintaining stability of the hip. In patients with stiffness or inflammatory hip disorders, a release may be appropriate. In patients who have signs and symptoms of instability, there is existing evidence that capsular plication may be associated with significant improvement in patient-reported outcomes. Although the multiple procedures performed in combination with capsular treatment present confounding variables, current evidence appears to support routine capsular closure in most cases and to support capsular plication in cases of instability or borderline dysplasia.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II through IV studies.

Female Sex Is a Risk Factor for Failure of Hip Arthroscopy Performed for Acetabular Retroversion

BACKGROUND

The success of hip surgery in treating acetabular retroversion depends on the severity of the structural deformity and on selecting the correct patient for open or arthroscopic procedures.

PURPOSE

To compare a group of patients with retroverted hips treated successfully with hip arthroscopy with a group of patients with retroverted hips that failed arthroscopic surgery, with special emphasis on (1) patient characteristics, (2) perioperative radiographic parameters, (3) intraoperative findings and concomitant procedures, and (4) patient sex.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

We retrospectively reviewed the charts of 47 adult patients (47 hips) with acetabular retroversion who had undergone hip arthroscopy. Retroversion was based on the presence of an ischial spine sign in addition to either a crossover or posterior wall sign on a well-positioned anteroposterior pelvic radiograph. A total of 24 hips (50%) (16 females, 8 males; mean patient age, 31 years) had failed arthroscopy, defined as modified Harris Hip Score (mHHS) <80 or need for subsequent procedure. Twenty-three hips (8 females, 15 males; mean patient age, 29 years) were considered successful, defined as having no subsequent procedures and an mHHS >80 at the time of most recent follow-up. Perioperative variables, radiographic characteristics, and intraoperative findings were compared between the groups, in addition to a subgroup analysis based on sex.

RESULTS

The mean follow-up for successful hips was 30 months (SD, 11 months), with a mean mHHS of 95. In the failure group, 6 patients required subsequent procedures (4 anteverting periacetabular osteotomies and 2 total hip arthroplasties). The mean overall time to failure was 21 months, and the mean time to a second procedure was 24 months (total hip arthroplasty, 29.5 months; periacetabular osteotomy, 21.2 months); 18 hips failed on the basis of a low mHHS (mean, 65; range, 27-79) at last follow-up. Factors significantly different between the success and failure groups included patient sex, with males being more likely than females to have a successful outcome (P < .02), as well as undergoing femoral osteoplasty (P < .02). Intraoperative variables that were associated with worse outcome included isolated labral debridement (P < .002). In a subgroup analysis, males were more likely than their female counterparts to have a successful outcome with both isolated cam and combined cam-pincer resection (P < .05). Level of crossover correction on postoperative radiographs had no correlation with outcome.

CONCLUSION

Acetabular retroversion remains a challenging pathoanatomy to treat arthroscopically. If hip arthroscopy is to be considered in select cases, we recommend labral preservation when possible. Male patients with correction of cam deformities did well, while females with significant retroversion appeared to be at greater risk for failure of arthroscopic treatment.

Iatrogenic Hip Instability Treated With Periacetabular Osteotomy

Hip dislocation following hip arthroscopy is a devastating complication. Previous reports of arthroscopy-related iatrogenic instability have focused on strategies aimed at restoring the stabilizing effects of the hip joint capsuloligamentous complex. Less has been written about treatment options for patients in whom deficient acetabular coverage of the femoral head is implicated in the functionally unstable hip joint. Given this relative paucity of information, an optimal treatment approach has yet to be elucidated for these patients. Periacetabular osteotomy has been described as a treatment for iatrogenic hip instability related to surgical hip dislocation; however, to our knowledge, this is the first case of a patient with hip arthroscopy-related iatrogenic instability manifesting as recurrent, frank dislocations treated with periacetabular osteotomy.

Foot Progression Angle Walking Test: A Dynamic Diagnostic Assessment for Femoroacetabular Impingement and Hip Instability

BACKGROUND

Determining an accurate clinical diagnosis for nonarthritic hip pain may be challenging, as symptoms related to femoroacetabular impingement (FAI) or hip instability can be difficult to elucidate with current testing methods. In addition, commonly utilized physical examination maneuvers are static and do not include a dynamic or weightbearing assessment to reproduce activity-related symptoms. Therefore, implementing a dynamic assessment for FAI and hip instability could help to improve diagnostic accuracy for routine clinical examinations of patients with nonarthritic hip pain.

PURPOSE

To assess the efficacy of a novel diagnostic foot progression angle walking (FPAW) test for identifying hip pathology related to FAI or hip instability.

STUDY DESIGN

Prospective cohort study; Level of evidence, 3.

METHODS

This prospective study included 199 consecutive patients who were evaluated for unilateral hip pain and who underwent FPAW testing along with standard physical examination testing. Demographic data, including age, sex and hip laterality, were collected from each patient. FPAW testing was performed with directed internal and external foot progression angles from their baseline measurements, with a positive test reproducing pain and/or discomfort. Comparisons were then made with flexion adduction internal rotation (FADIR) and flexion abduction external rotation (FABER) tests as the designated diagnostic standard examinations for FAI and hip instability, respectively. Sensitivity and specificity, along with the McNemar chi-square test for group comparison, were used to generate summary statistics. In addition, areas under the combined receiver operating characteristic curves (AUC) of test performance were calculated for both FPAW and the designated standard examination tests (FADIR, FABER). Radiographic imaging was used subsequently to confirm the diagnosis.

RESULTS

The average age of the study cohort was 35.4 ± 11.8 years, with 114 patients being female (57%). Positive internal FPAW testing demonstrated 61% sensitivity and 56% specificity for an FAI diagnosis, compared with the 96% sensitivity and 11% specificity seen with FADIR testing. Internal FPAW was less sensitive, yet more specific compared with FADIR (P < .001). Combined testing had improved accuracy (AUC = 0.58; P < .05) compared with FADIR (AUC = 0.52; P = .21) or FPAW (AUC = 0.57; P = .057) alone. Positive external FPAW revealed 67% sensitivity and 70% specificity for hip instability, while FABER testing was 54% sensitive and 90% specific. External FPAW was significantly more specific but had similar sensitivity to FABER. Combined testing had greater accuracy (AUC = 0.77) compared with FABER (AUC = 0.70) or FPAW (AUC = 0.67) alone (P < .001).

CONCLUSION

The FPAW examination can be used as an adjunct examination to assist and improve the accuracy of the clinical diagnosis for FAI and hip instability.

Anterior hip capsuloligamentous reconstruction with Achilles allograft following gross hip instability post-arthroscopy

The increasing use of hip arthroscopy has led to further development in our understanding of hip anatomy and potential post-operative complications. Iatrogenic gross hip instability following hip arthroscopy is a concerning complication described in recent orthopaedic literature. Post-arthroscopy hip instability is thought to be multifactorial, related to a variety of patient, surgical and post-operative factors. Given its infrequency, there is scarcity of literature describing appropriate surgical management and operative technique for addressing this instability. This study reports a case of gross hip instability following hip arthroscopy, describing a novel technique of management through anterior hip capsuloligamentous reconstruction with Achilles tendon allograft. Level of evidence V, Case Study.

Hip arthroscopic capsulotomy techniques and capsular management strategies: a systematic review

PURPOSE

Hip arthroscopy is increasingly used to address hip joint pathology. Iatrogenic instability has been reported as a potential complication, leading to the evaluation of various capsular management strategies. The purpose of this review was to (1) report the techniques used for capsulotomy in hip arthroscopy, (2) understand techniques and indications for capsular closure, and (3) report outcomes based on capsular management strategy.

METHODS

MEDLINE, EMBASE, and PubMed were searched and screened in duplicate for relevant studies. Data regarding patient demographics, indications, surgical technique, rehabilitation strategies, and complication rates were obtained. Study quality was assessed in duplicate using the Methodological Index for Non-Randomized Studies (MINORS) Criteria.

RESULTS

Eighty-two studies of primarily level IV evidence (80 %) and of fair quality involving 4504 patients with a mean age of 35 years old (range 1.2-82 years) were included. Fifty percent of patients were male. Mean follow-up was 24.9 months (range 5 days to 13 years). Of 68 studies reporting capsulotomy technique (only 7 % of all otherwise eligible studies), 55 % performed an interportal capsulotomy while 24 % performed a T-capsulotomy. Of 36 studies reporting capsular management strategy post-arthroscopy, 22 % did not repair the capsulotomy, 6 % routinely performed partial repair, and 50 % performed complete repair. Of three studies (206 patients) directly comparing capsular management strategies, only one study found a statistically significant difference between complete and partial repair on the Hip Outcome Score-Sport Specific Subscale, though this difference was less than the minimal clinically important difference (83.6 versus 87.3). The total rate of reported post-operative dislocation, instability, or instability was 0.3 % (5 patients).

CONCLUSIONS

Technical details regarding capsulotomy and capsular management post-hip arthroscopy are not consistently reported in the literature. Capsulotomies are most often performed using an interportal technique, and more recent studies report routine closure. Overall, post-operative instability is rare and there is no consistent trend for capsular management strategy. Given current evidence, there is little basis on which to establish the relationship between surgical technique and post-operative instability or long-term consequences (e.g., kinematic changes). Thus, while capsular closure/plication may be suitable for specific populations (i.e., dysplasia or laxity), evidence-based indications for capsular repair remain unclear.

LEVEL OF EVIDENCE

Level IV, systematic review of level I-IV Studies.

Hip instability: a review of hip dysplasia and other contributing factors

BACKGROUND

Hip instability has classically been associated with developmental dysplasia of the hip (DDH) in newborns and children. However, numerous factors may contribute to hip instability in children, adolescents, and adults.

PURPOSE

This review aims to concisely present the literature on hip instability in patients of all ages in order to guide health care professionals in the appropriate diagnosis and treatment of the various disorders which may contribute to an unstable hip.

METHODS

We reviewed the literature on the diagnosis and surgical management of hip dysplasia and other causes of hip instability.

CONCLUSIONS

Multiple intra- and extra-articular variables may contribute to hip instability, including acetabular bony coverage, femoral torsion, femoroacetabular impingement, and soft tissue laxity. Physical examination and advanced imaging studies are essential to accurately diagnose the pathology contributing to a patient's unstable hip. Conservative management, including activity modification and physical therapy, may be used as a first-line treatment in patients with intra-articular hip pathology. Patients who continue to experience symptoms of pain or instability should proceed with arthroscopic or open surgical treatment aimed at correcting the underlying pathology.

LEVEL OF EVIDENCE

V.

Editorial Commentary: Iatrogenic Instability of the Hip: A Perfect Storm

Iatrogenic instability of the hip is likely a perfect storm with enough factors coming together just wrong to create the problem. Capsular neglect is but one potential component. Instability is also just one of a myriad of problems that can be encountered following hip arthroscopy that ranges on a spectrum from too loose to too stiff with numerous reasons in between for incomplete pain relief and residual dysfunction. Proper capsular management does not always mean capsular repair.