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

Late post-arthroscopy hip instability. Diagnosis, treatment, and 5-year follow-up: A case report

INTRODUCTION

Hip instability following arthroscopy is a rare complication with a clinical spectrum ranging from gross dislocation (macro-instability) to micro-instability, characterized by pain and limitation for daily activities. Therefore, it should be considered as a potential differential diagnosis in patients experiencing persistent pain after hip arthroscopy.

CASE PRESENTATION

A 41-year-old male presented with a history of anterior hip dislocation and macro-instability symptoms three years post-hip arthroscopy. Magnetic resonance imaging (MRI) revealed a disruption of the anterior hip capsule. The patient initiated physiotherapy and resumed activities, but ten months later, experienced another anterior dislocation. Pain and apprehension during external hip rotation were evident. Three-dimensional computed tomography (CT) indicated irregularities in the anterior and superior margin of the acetabulum, while MRI arthrogram showed a rupture of the anterior capsule and deficiency in the anterior hip ligaments. Open reconstruction of the anterior capsule was performed, resulting in favorable progression over the 5-year follow-up.

DISCUSSION

This case highlights post-arthroscopy hip instability with a delayed presentation, possibly linked to chronic anterior capsule deficiency and inadequate acetabular coverage. Primary capsule repair after hip arthroscopy has proven effective in reducing the occurrence of instability symptoms and reoperations.

CONCLUSIONS

Post-arthroscopic hip instability may manifest immediately after surgery or several years later. Open reconstruction of the anterior capsule emerges as a successful strategy for addressing this complication, demonstrating satisfactory outcomes in a 5-year follow-up.

Cadaveric Biomechanical Evaluation of Capsular Constraint and Microinstability After Hip Capsulotomy and Repair

Background:

It remains unclear if capsular management contributes to iatrogenic instability (microinstability) after hip arthroscopy.

Purpose:

To evaluate changes in torque, stiffness, and femoral head displacement after capsulotomy and repair in a cadaveric model.

Study Design:

Controlled laboratory study.

Methods:

A biomechanical analysis was performed using 10 cadaveric hip specimens. Each specimen was tested under the following conditions: (1) intact, (2) portals, (3) interportal capsulotomy (IPC), (4) IPC repair, (5) T-capsulotomy (T-cap), (6) partial T-cap repair, and (7) T-cap repair. Each capsular state was tested in neutral (0°) and then 30°, 60°, and 90° of flexion, with forces applied to achieve the displacement-controlled baseline limit of external rotation (ER), internal rotation (IR), abduction, and adduction. The resultant end-range torques and displacement were recorded.

Results:

For ER, capsulotomies significantly reduced torque and stiffness at 0°, 30°, and 60° and reduced stiffness at 90°; capsular repairs failed to restore torque and stiffness at 0°; and IPC repair failed to restore stiffness at 30° (P < .05 for all). For IR, capsulotomies significantly reduced torque and stiffness at 0°, 30°, and 60° and reduced stiffness at 90°; and capsular repairs failed to restore torque or stiffness at 0°, 30°, and 60° and failed to restore stiffness at 90° (P < .05 for all). For abduction, IPC significantly decreased torque at 60° and 90° and decreased stiffness at all positions; T-cap reduced torque and stiffness at all positions; IPC repair failed to restore stiffness at 0° and 90°; and T-cap repair failed at 0°, 60°, and 90° (P < .05 for all). For adduction, IPC significantly reduced torque at 0° and reduced stiffness at 0° and 30°; T-cap reduced torque at 0° and 90° and reduced stiffness at all positions; IPC repair failed to restore stiffness at 0° and 90°; and T-cap repair failed at 0°, 60°, and 90° (P < .05 for all). There were no statistically significant femoral head translations observed in any testing configurations.

Conclusion:

Complete capsular repair did not always restore intact kinematics, most notably at 0° and 30°. Despite this, there were no significant joint translations to corroborate concerns of microinstability.

Clinical Relevance:

Caution should be employed when applying rotational torques in lower levels of flexion (0° and 30°).

Anterior Hip Dislocation After Hip Arthroscopy Complicated by Iliopsoas Bursitis

Hip dislocation after hip arthroscopy is an uncommon postoperative complication. We report a case of a 51-year-old woman who underwent right hip arthroscopy and presented with an anterior hip dislocation on postoperative day five. The index surgery involved capsulotomy, cam lesion debridement, and femoroplasty for an anterosuperior labral tear and cam-type femoroacetabular impingement. The patient underwent an uneventful recovery course until eight weeks postoperatively she developed iliopsoas bursitis. Her symptoms were managed conservatively with activity modification and physical rehabilitation. Complete resolution of symptoms was reported by the six-month follow-up visit, and no further dislocations or instability had been reported at 12 months. Anterior hip dislocation is a rare complication following hip arthroscopy and patients may experience persistent iliopsoas bursitis several months following successful reduction.

Is there enough evidence to support hip capsular reconstruction? A systematic review of biomechanical studies

The aim of this study was to review and summarize the available biomechanical data on hip capsular reconstruction to guide clinical decision-making. A literature search was completed in December 2020 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify biomechanical cadaver studies on hip capsular reconstruction, hip capsulectomy or hip capsular defect. The investigated parameters included maximum distraction force, capsular state affecting range of motion (ROM), rotation and translation. Four studies met al. the inclusion–exclusion criteria. The median effective force for resisting maximum distraction for the reconstruction state, capsular defect state and the intact state was 171, 111 and 206 N, respectively. The defect capsule force was significantly lower (P = 0.00438) than the intact capsule force. The reconstruction state had a higher distraction force than that of the capsular defect, but due to heterogeneity, the overall effect size was not statistically significant. The capsular reconstruction state reduced excess motion and the degree of instability compared to the capsular defect state but restored the hip close to its native capsular state in the cadaveric model. When compared to capsulectomy/defect state, hip capsular reconstruction significantly improved the rotational stability and effective force at maximum distraction and minimized translation. However, no conclusions can be made regarding the most effective protocol due to the high heterogeneity between the four studies. Further biomechanical studies are needed to test various types of grafts under the same protocol.

The role of the iliofemoral ligament as a stabilizer of the hip joint

The purpose of this systematic literature review is to analyse the role of the iliofemoral ligament (ILFL) as a hip joint stabilizer in the current literature.

A total of 26 articles were included in the review. The ILFL is the largest hip ligament consisting of two distinct arms and is highly variable, both in its location and overall size, and plays a primary role in hip stability; in the case of hip dislocation, the iliofemoral ligament tear does not heal, resulting in a persistent anterior capsule defect. Clinically, the ILFL is felt to limit external rotation in flexion and both internal and external rotation in extension.

The abduction–hyperextension–external rotation (AB-HEER) test is overall the most accurate test to detect ILFL lesions. Injuries of the ILFL could be iatrogenic or a consequence of traumatic hip instability, and can be accurately studied with magnetic resonance imaging. Different arthroscopic and open techniques have been described in order to preserve the ILFL during surgery and, in case of lesions, several procedures with good to excellent results have been reported in the existing literature.

The current systematic review, focusing only on the ILFL of the hip, summarizes the existing knowledge on anatomy, imaging and function and contributes to the further understanding of the ILFL, confirming its key role in anterior hip stability. Future studies will have to develop clinical tests to evaluate the functionality and stability of the ILFL.

Cite this article: EFORT Open Rev 2021;6:545-555. DOI: 10.1302/2058-5241.6.200112

A Biomechanical Comparison of 2 Hip Capsular Reconstruction Techniques: Iliotibial Band Autograft Versus Achilles Tendon Allograft

BACKGROUND

Several techniques for hip capsular reconstruction have been described to address gross instability or microinstability due to capsular deficiency. However, objective biomechanical data to support their use are lacking.

PURPOSE

To compare the kinematic effect of 2 capsular reconstruction techniques (iliotibial band [ITB] graft and Achilles tendon graft). Kinematic effect encompassed rotational range of motion (ROM) as well as joint translation in the coronal, sagittal, and axial planes.

STUDY DESIGN

Controlled laboratory study.

METHODS

8 paired, fresh-frozen hemi-pelvises (16 hips) were tested on a custom-designed joint motion simulator in the intact state and after capsulectomy. Pairs were randomly allocated to either ITB or Achilles reconstruction and retested. Testing was performed at 0°, 45°, and 90° of flexion. Internal-external rotation (IR-ER) torques and abduction-adduction torques of 3 N·m were applied to the femur via a load cell at each position, and rotational ROM and joint translation in the coronal, sagittal, and axial planes were recorded.

RESULTS

At 45° and 90°, there was a significant effect of the condition of the hip on the total IR-ER (P = .004, effect size [ES] = 0.305; and P < .001, ES = 0.497; respectively). At 45°, mean ± SD total rotation was significantly greater for the capsulectomy (59.7°± 15.9°) state compared with intact (53.3°± 13.2°; P = .007). At 90°, reconstruction significantly decreased total rotation to 49.0°± 18.9° compared with a mean total rotation of 52.8°± 18.7° after capsulectomy (P = .02). No difference was seen in the total abduction-adduction of the hip between conditions. Comparisons of the 2 different reconstruction techniques showed no significant differences in total IR-ER or abduction-adduction ROM or joint translation in the coronal, sagittal, or axial planes. For translation, at both 0° and 45° there was a statistically significant effect of the condition on the medial-lateral translation (P = .033; ES = 0.204). Reconstruction, independent of technique, was successful in significantly decreasing (P = .030; P = .014) the mean medial-lateral translation at 0° and 45° of hip flexion from 5.2 ± 3.8 mm and 5.6 ± 4.0 mm to 2.8 ± 1.9 mm and 3.9 ± 3.2 mm, respectively.

CONCLUSION

The integrity of the native hip capsule played a significant role in rotational stability, where capsulectomy significantly increased rotational ROM. Both ITB and Achilles reconstruction techniques restored normal rotational ROM of the hip at 90° of flexion as well as coronal plane stability at 0° and 45° of hip flexion. No differences were seen between ITB and Achilles reconstruction techniques.

CLINICAL RELEVANCE

Both capsular reconstruction techniques provide comparable joint kinematics, restoring rotation and translation to normal values with the exception of rotational ROM at 45°, which remained significantly greater than the intact state. The most significant results were the rotational stability at 90° of hip flexion and coronal plane stability at 0° and 45° of hip flexion, which were significantly improved compared with the capsulectomy state.

Iatrogenic Hip Instability After Hip Arthroscopy: Is There a Role for Open Capsular Reconstruction?: A Case Report

CASE

A 23-year-old female athlete presented with postoperative hip pain and laxity following 3 arthroscopic hip procedures.

CONCLUSIONS

Open reconstruction of the anterior hip capsule with Achilles allograft can correct arthroscopy-induced hip laxity.

Anterior Capsule Reconstruction of the Native Hip: A Technique Guide

This is a technique guide for open anterior capsule reconstruction in unstable native hips due to Ehlers-Danlos syndrome. Ehlers-Danlos syndrome is a connective tissue disease that predisposes an individual to hypermobility of their soft tissues and recurrent subluxations and dislocations of their joints. This may lead to constant instability, guarding of the hip, and subsequent arthritic changes and poor quality of life. We demonstrate anterior capsule reconstruction of the hip using an Achilles tendon allograft performed through a direct anterior approach to the hip (Heuter's approach). This technique guide outlines in detail the surgical steps required to accomplish this reconstructive procedure. Furthermore, a narrated surgical video is provided that clearly depicts the anticipated result of the increased constrained provided to the hip from the anterior capsule reconstruction using an Achilles tendon allograft.

Orthotopic Transplantation of Achilles Tendon Allograft in Rats: With or without Incorporation of Autologous Mesenchymal Stem Cells

The biology and function of orthotopic transplantation of Achilles tendon allograft are unknown. Particularly, the revitalization of Achilles allograft is a clinical concern. Achilles allografts were harvested from donor rats and stored at -80 °C. Subcutaneous adipose tissue was harvested from the would-be allograft recipient rats for isolation of mesenchymal stem cells (MSCs). MSCs were cultured with growth differentiation factor-5 (GDF-5) and applied onto Achilles allografts on the day of transplantation. After the native Achilles tendon was resected from the left hind limb of the rats, Achilles allograft, with or without autologous MSCs, was implanted and sutured with calf muscles proximally and calcaneus distally. Animal gait was recorded presurgery and postsurgery weekly. The animals were sacrificed at week 4, and the transplanted Achilles allografts were collected for biomechanical testing and histology. The operated limbs had altered gait. By week 4, the paw print intensity, stance time, and duty cycle (percentage of the stance phase in a step cycle) of the reconstructed limbs were mostly recovered to the baselines recorded before surgery. Maximum load of failure was not different between Achilles allografts, with or without MSCs, and the native tendons. The Achilles allograft supplemented with MSCs had higher cellularity than the Achilles allograft without MSCs. Deposition of fine collagen (type III) fibers was active in Achilles allograft, with or without MSCs, but it was more evenly distributed in the allografts that were incubated with MSCs. In conclusion, orthotopically transplanted Achilles allograft healed with host tissues, regained strength, and largely restored Achilles function in 4 wk in rats. It is therefore a viable option for the reconstruction of a large Achilles tendon defect. Supplementation of MSCs improved repopulation of Achilles allograft, but large animal models, with long-term follow up and cell tracking, may be required to fully appreciate the functional benefits of MSCs.

Is there a distinct pattern to the acetabular labrum and articular cartilage damage in the non-dysplastic hip with instability?

PURPOSE

The purpose of this study was to determine whether or not there is a distinct pattern of injury to the acetabular labrum and/or cartilage in the hip with instability without bony dysplasia.

METHODS

Surgical records and intra-operative images of consecutive patients who underwent primary hip arthroscopy for femoroacetabular impingement (FAI) and/or hip instability by the senior author from April 2007 to December 2014 were retrospectively reviewed. Pathological changes were documented and charted on a novel diagram of the acetabulum, and classified into eight patterns corresponding to the lesion's location and size. In patients who had acetabular chondroplasty treatment, the width of the cartilage lesion was recorded.

RESULTS

A total of 953 hips in 886 patients were included, and patients who met our inclusion/exclusion criterion were grouped into an Instability-Only group (45 hips), an Instability-Dysplasia group (12 hips), as well as Pincer-FAI, Cam-FAI, and Combined-FAI groups consisting of 100, 54, and 269 hips, respectively. In the Instability-Only group, 42.2 % of the chondral and labral lesions demonstrated a "Straight-Anterior" pattern, which proportion was statistically significantly different compared with Pincer-FAI (p < 0.000), Cam-FAI (p = 0.0002), and Combined-FAI (p < 0.000) groups. In Instability-Only patients, only 15.6 % of the lesions had an "Anterior to Lateral" pattern, a significantly lower proportion (p < 0.000) compared with the FAI groups. Also 11.1 % of the lesions demonstrated a "Lateral" pattern, which is a significantly greater proportion compared with Pincer-FAI (p < 0.000) and Combined-FAI (p < 0.000) groups. The mean width of the cartilage lesions for the Instability-Only group was 2.9 mm, which was significantly shallower than for the other FAI groups (p < 0.000).

CONCLUSION

A significant predilection of "Straight-Anterior" or "Lateral" location of labral and/or cartilage damage was observed in the hip with instability, while there was shallow width of articular cartilage damage in these patients. These results suggest that there is a distinctive labral and cartilage damage pattern for hips with instability without inherent bony dysplasia.

LEVEL OF EVIDENCE

Diagnostic study, Level IV.