Capsular closure does not affect development of heterotopic ossification after hip arthroscopy

Capsule closure has better hip function than non-closure in hip arthroscopy for femoracetabular impingement: A systematic review and meta-analysis

Background

The impact of capsular closure vs non-closure in hip arthroscopy for femoracetabular impingement (FAI) was assessed by a meta-analysis.

Methods

With the most recent search update occurring in August 2022, relevant studies were found by searching the Pubmed and EMBASE databases. A collection of studies was made that conducted hip arthroscopy for FAI. Review Manager 5.3 was used to carry out the meta-analysis. The dichotomous and continuous factors were compared using the odds ratios (OR) and mean differences (MD). A fixed-effect or random-effect model was chosen, depending on the degree of heterogeneity (I2). Forest plots were used to assess the results. A significance level of P < 0.05 was applied to the statistical analysis.

Results

Ultimately, 15 studies were incorporated into the meta-analysis. The surgery time was longer for the capsular closure group (CC group) compared to the non-closure (NC group) group. (P < 0.001, SMD = 8.59, 95%CI [7.40, 9.77], I2 = 32 %). Following hip arthroscopy, the CC group's mHHS was superior to that of the NC group (P = 0.001, MD = 2.05, 95%CI [0.83, 3.27], I2 = 42 %), HOS-ADL (P < 0.001, MD = 4.29, 95%CI [3.08, 5.50], I2 = 0 %). The capsular closure group had a reduced rate of postoperative complications (P = 0.001, OR = 0.21, 95%CI [0.08, 0.54], I2 = 0 %) and conversion to THA (P = 0.01, OR = 0.42, 95%CI [0.21, 0.83], I2 = 0 %) following hip arthroscopy than the non-closure group. The revision rate, VAS, and postoperative HOS-SSS did not significantly differ between these two groups (P＞0.05).

Conclusion

The current meta-analysis found that the closed group had a lower complication rate and considerably greater mHHS and HOS-ADL following surgery compared to the non-closed capsule group. Whether this is related to the continuous progress of biomechanical and clinical research techniques deserves our attention.

Level of evidence

Level IV, systematic review of Level I through Level III studies.

Heterotopic Ossification in Hip Arthroscopy

Introduction  Hip arthroscopy is a rising surgical technique due to the increase in hip diseases, especially femoroacetabular impingement. One of the several complications related to such procedures is heterotopic ossifications (HO). The aim of this study is to describe the prevalence of HO after hip arthroscopy in a series of patients with femoroacetabular impingement and to compare its preoperative and intraoperative variables with a matched control group of patients without HO. Methods  All patients who underwent hip arthroscopy for femoroacetabular impingement between 2010 and 2017 with a minimum follow-up of 2 years were included in this analysis. Radiographic examinations were recorded to select cases with HO. A case-control analysis was performed comparing preoperative and intraoperative variables between cases with HO and a matched control group without HO. Results  A total of 700 cases were included in the analysis. HO was found in 15 (2.14%) of subjects. Cases with HO showed more severe cartilage injuries, less cam morphology ratio, and a higher proportion of partial labrectomies than the control group. No significant differences were observed in preoperative hip pain or function between groups. Conclusions  The prevalence of HO after hip arthroscopy in subjects with femoroacetabular impingement was 2.14%. Cases with HO had more severe cartilage injuries, lower ratio of cam morphology, and higher proportion of partial labrectomies than the control cases without HO. Level of Evidence  Level III.

Incidence of heterotopic ossification following hip arthroscopy is low: considerations for routine prophylaxis

PURPOSE

This scoping review aims to map and summarise the available literature on heterotopic ossification (HO) following hip arthroscopy, with particular focus on incidence, distribution as per Brooker classification, efficacy of prophylactic measures and factors that may influence the likelihood of production of HO.

METHODS

A computer-based search was performed on PubMed, Embase, Emcare, Cinahl, ISI web of science and Scopus using the terms 'heterotopic ossification' and 'hip arthroscopy'. Articles reporting heterotopic ossification following hip arthroscopy for any condition were included after two-stage title/abstract and full-text screening.

RESULTS

Of the 663 articles retrieved, 45 studies were included. The proportion of patients with HO ranged from 0 to 44%. The majority of the cases were either Brooker grade I or II. Of the six studies investigating the effect of NSAID prophylaxis, five reported a significantly lower incidence of heterotopic ossification associated with its use. Weak evidence suggests that an outside-in arthroscopic approach, no capsular closure, male sex and mixed cam and pincer resection may be associated with an increased risk of HO.

CONCLUSION

Although there is a large variation in rates of HO following hip arthroscopy in the current literature, the majority of studies report a low incidence. Evidence exists advocating the administration of post-operative NSAIDs to reduce the incidence of HO following hip arthroscopy. This, combined with the low risk of complications, means there is a favourable risk-benefit ratio for prophylactic NSAID used in HA. Future research should work to identify patient clinical and demographic factors which may increase the risk of development of HO, allowing clinicians to risk stratify and select only specific patients who would benefit from receiving NSAID prophylaxis.

Heterotopic Ossification After Arthroscopic Procedures: A Scoping Review of the Literature

Background:

Heterotopic ossification (HO) is the formation of bone in soft tissue resultant from inflammatory processes. Lesion formation after arthroscopic procedures is an uncommon but challenging complication. Optimal prophylaxis and management strategies have not been clearly defined.

Purpose:

To present a scoping review of the pathophysiology, risk factors, diagnostic modalities, prophylaxis recommendations, and current treatment practices concerning HO after arthroscopic management of orthopaedic injuries.

Study Design:

Scoping review; Level of evidence, 4.

Methods:

A scoping review via a PubMed search was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The search strategy was based on the terms “heterotopic ossification” AND “arthroscopy.” The clinical outcomes review included studies on the arthroscopic management of orthopaedic injuries in which the primary subject matter or a secondary outcome was the development of HO. An analysis of the pathophysiology, diagnostic modalities, and management options was reported.

Results:

A total of 43 studies (33,065 patients) reported on HO after hip arthroscopy, while 21 (83 patients) collectively reported on HO after arthroscopic procedures to the shoulder, elbow, knee, or ankle; however, management techniques were not standardized. Identified risk factors for HO included male sex and mixed impingement pathology, while intraoperative capsular management was not suggested as a contributing factor. Diagnosis of ossification foci was performed using radiography and computed tomography. The rate of HO after hip arthroscopy procedures approached 46% without prophylaxis, and administration of nonsteroidal anti-inflammatory drugs (NSAIDs) decreased occurrence rates to 4% but carries associated risks. External beam radiation has not been exclusively studied for use after arthroscopic procedures.

Conclusion:

HO is a known complication after arthroscopic management of orthopaedic injuries. NSAID prophylaxis has been demonstrated to be effective after hip arthroscopy procedures. Patients with persistent symptoms and mature lesions may be indicated for surgical excision, although variability is present in patient-reported outcome scores postoperatively.

Capsular Repair May Improve Outcomes in Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement: A Systematic Review of Comparative Outcome Studies

PURPOSE

To review the existing literature in order to determine the effect of hip capsule repair on outcomes after hip arthroscopy for femoroacetabular impingement syndrome.

METHODS

This study used Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to find articles by using PubMed and Embase. Included studies were Level I through III studies that focused on patient outcomes as a function of hip capsular treatments: capsulotomy repair, partial repair, plication, and unrepaired capsulotomies. The Methodological Index for Non-randomized Studies was used for quality assessment of clinical outcome studies. After applying inclusion and exclusion criteria, a total of 16 comparative outcome studies evaluating 2,996 hips were included; they evaluated the following capsular management techniques: complete repair (n = 1,112, 37.1%), partial repair (n = 32, 1.1%), plication (n = 223, 7.4%), and unrepaired capsulotomy (n = 1629, 54.4%).

RESULTS

Of the 16 studies, 13 included patient-reported outcome scores (PROs), 3 included imaging outcomes data, and 2 reported on reoperation. Of the studies, 10 directly compared patient-reported outcomes between a capsular repair group and an unrepaired group. Of the 10 studies that directly compared PROs between a group with unrepaired capsulotomy and a group with capsular repair, 8 studies demonstrated statistically significantly better PROs in the repaired group compared to the unrepaired group, and 2 studies found no difference between the groups. Reoperation rates demonstrated mixed results between groups, and no difference was found in regard to imaging outcomes.

CONCLUSIONS

Midterm outcome studies suggest that capsular repair is safe and effective in patients without arthritis who are undergoing hip arthroscopy, and it may result in superior PROs compared with those found after unrepaired capsulotomy. Studies consistently demonstrate similar or superior outcomes in cohorts after capsular repair compared to unrepaired capsulotomy, and no studies reported superior results in unrepaired capsulotomy patients.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through Level III studies.

Capsular management in the arthroscopic treatment of the femoro-acetabular impingement in athletes: our experience

Background and aim of the work:

In the last decade, thanks to the improvement of the surgical techniques, arthroscopic treatment of hip diseases has significantly spread and evolved and currently it represents the gold standard for the treatment of femoral-acetabular impingement. In the recent years, the function of the joint capsule (and therefore the results of an arthroscopic capsulotomy) has been better understood, opening a heated debate. The Literature is still torn about a proper capsular management and the need for a capsular suture, but latest studies are more oriented to its execution at the end of the surgical procedure. According to these recent studies, the joint capsule performs an essential function on primary stability, so a conservative capsulotomy and its final closure are therefore reccomended to restore the native anatomy and physiology. Although capsular management remains a controversial topic, in recent years we have developed a new conservative capsulotomy technique associated with a final capsular suture. The aim of the present retrospective study is to assess the influence of different capsulotomy techniques and a possible capsular suture role on the patient’s functional outcome in a cohort of patients with femoral-acetabular impingement arthroscopically treated.

Hypothesis:

Our hypothesis is that a conservative “longitudinal” capsulotomy with a proper capsular suture positively influences the patient’s functional outcome in athletes.

Methods:

36 patients (competitive athletes) treated with hip arthroscopy for femoral-acetabular impingement have been retrospectively enrolled at the Orthopaedic Clinic of Academic Hospital of Udine during a period of two years (2016-2018); collected data have been analyzed and compared with a retrospective model. Patients have been divided into three equivalent groups, 12 without a suitable capsular management (T-Capsulotomy technique), 12 performing a Longitudinal Capsulotomy but without a final suture and 12 treated with a conservative Longitudinal Capsulotomy and a capsular suture. Patient’s post-operative functional outcome has been analysed using the modified Harris Hip Score (mHHS), the Hip Outcome Score-Activity of Daily Living (HOS-ADL) and the Hip Outcome Score-Sport Scale (HOS-SS). Return to sport.

Results:

In our series there was no statistically significant difference in functional scores, however longitudinal capsulotomy seems to be associated with a higher percentage of return to sports activity (91,6% vs 75%).

Conclusions:

The new longitudinal shape capsulotomy technique and a capsular suture with a single side-to-side stitch at the end of the procedure in athletes can positively influence the patient’s functional outcome. (www.actabiomedica.it)

Approach to the Patient With Failed Hip Arthroscopy for Labral Tears and Femoroacetabular Impingement

There has been an exponential increase in the diagnosis and treatment of patients with femoroacetabular impingement, leading to a rise in the number of hip arthroscopies done annually. Despite reliable pain relief and functional improvements after hip arthroscopy in properly indicated patients, and due to these increased numbers, there is a growing number of patients who have persistent pain after surgery. The etiology of these continued symptoms is multifactorial, and clinicians must have a fundamental understanding of these causes to properly diagnose and manage these patients. Factors contributing to failure after surgery include those related to the patient, the surgeon, and the postoperative physical therapy. This review highlights common causes of failure, including those related to residual bony deformity as well as capsular deficiency, and provides a framework for diagnosis and treatment of these patients.

Effect of Capsular Closure on Outcomes of Hip Arthroscopy for Femoracetabular Impingement: A Systematic Review and Meta-analysis

Objective

To evaluate the effect of hip arthroscopy with or without capsular closure in femoracetabular impingement (FAI) by meta‐analysis.

Methods

Pertinent studies were identified by searching Pubmed, EMBASE databases with the last search update on 16 February 2020. Studies that reported hip arthroscopy for FAI were collected. Meta‐analysis was performed by the use of Review Manager 5.3 software. The odds ratios (OR) and mean differences (MD) were used to compare dichotomous and continuous variables. Additionally, the I² was used to assess heterogeneity among studies, and the fixed‐effects model or the random‐effects model was selected for the quantitative analysis. Outcomes were evaluated by forest plots. For statistical analysis, P < 0.05 was considered significant.

Results

There was no significant difference among the preoperative mHHS (MD = –2.66，95% CI [−7.25, 1.92], I² = 80%, P = 0.25), preoperative (MD = ‐4.94, 95% CI [−11.56, 1.67], I² = 50%, P = 0.14) and postoperative HOS‐SSS (MD = ‐1.00, 95% CI [−6.98, 4.98], I² = 66%, P = 0.74), patient satisfaction (MD = 0.03, 95% CI [−0.25, 0.31], I² = 19%, P = 0.84; OR = 0.94, 95% CI [0.59, 1.50], I² = 0%, P = 0.78), complications (OR = 1.23, 95%CI [0.56, 2.67], I² = 0%, P = 0.61), revisions (OR = 1.77, 95% CI [0.87, 3.60], I² = 36%, P = 0.11), and surgery time (SMD = –0.38, 95% CI [−1.16, 0.40], I² = 92%, P = 0.34) between the capsule closure group and the non‐closure group. For the comparison of postoperative mHHS (MD = –2.66, 95% CI [−7.25, 1.92], I² = 80%, P = 0.25) and HOS‐ADL (MD = ‐4.20, 95% CI [−5.75, −2.65], I² = 24%, P < 0.00001), the score of the non‐closure group was significantly better than that of the closure group.

Conclusions

Remain capsule unclosed after hip arthroscopy for FAI may, to some extent, has a better postoperative functional score than the non‐closure treatment.

Capsular closure after hip arthroscopy: our experience

BACKGROUND AND AIM OF THE WORK

In the last decade, arthroscopic treatment of hip diseases has significantly spread and evolved and currently it represents the gold standard for the treatment of femoral- acetabular impingement. In the recent years, the function of the joint capsule (and therefore the results of an arthroscopic capsulotomy) has been hugely developed, opening a heated debate. The Literature is still torn about the need for a capsular suture, but more recent studies are more oriented in its execution at the end of the surgical procedure. According to these recent studies, the joint capsule performs an essential function of primary stability, and its closure is therefore necessary to restore the native anatomy and physiology. Nevertheless, capsular management remains a controversial topic. This is a retrospective study with the aim of assessing the influence of capsular suture on the patient's functional outcome in a cohort of patients with femoral-acetabular impingement arthroscopically treated.

HYPOTHESIS

Our hypothesis is that an adequate capsular suture positively influences the patient's functional outcome.

METHODS AND RESULTS

50 patients treated with hip arthroscopy for femoral-acetabular impingement have been retrospectively enrolled at the Orthopaedic Clinic of Academic Hospital of Udine during a period of two-years (2017-2018); collected data have been analysed and compared with a retrospective model. Patients have been divided into two equivalent groups, 25 treated with capsular suture, 25 without performing the suture. Patient's post-operative functional outcome has been analysed using the modified Harris Hip Score (mHHS), the Non-Arthritic Hip Score (NAHS) and the Hip Outcome Score-Sport Scale (HOS-SS). The functional outcome in patients where capsular sutures were performed was better than in non-sutured patients, in all three analysed scales.

CONCLUSIONS

Capsular suture with a single side-to-side stitch at the end of the procedure can positively influence the patient's functional outcome.

Repaired or unrepaired capsulotomy after hip arthroscopy: a systematic review and meta-analysis of comparative studies

PURPOSE

To conduct a systematic review and meta-analysis comparing the surgical techniques, clinical outcomes, rates of revision and conversion to arthroplasty and complications between a repaired and unrepaired capsulotomy after hip arthroscopy.

METHODS

A search of the PubMed, Embase and Google Scholar databases was performed to identify comparative articles published prior to 10 July 2019 that reported the capsule management strategy and clinical outcomes after hip arthroscopy. A narrative analysis and meta-analysis were performed to integrate and compare the results of the 2 groups.

RESULTS

12 comparative studies (n = 1185 hips) with an average (methodological index for non-randomized studies) MINORS score of 17.45 ± 2.02 were identified for analysis, of which 5 were included in the meta-analysis. The pre- to postoperative improvements in the modified Harris Hip Score (mHHS), Hip Outcome Score-Sport-Specific Subscale (HOS-SS), and Hip Outcome Score-Activities of Daily Living (HOS-ADL) revealed no significant differences between the repaired and unrepaired groups (p = 0.40, 0.26 and 0.61, respectively). The risk ratio of the revision rate for the 2 groups was 0.66 (p = 0.21). Evaluation of the MRI scans and the rate of heterotopic ossification also showed no significant differences. The most preferred capsulotomy techniques were interportal and T-shape. No postoperative hip instability was reported in any of the 12 studies.

CONCLUSION

The currently published evidence is still not strong enough to confirm the superiority of repairing the capsule after hip arthroscopy; hence, routine repair of the capsule during surgery cannot be suggested.

Femoroacetabular impingement treatment using the arthroscopic extracapsular outside-in approach: Does capsular suture affect functional outcome?

BACKGROUND

Over the last decades, the arthroscopic treatment of hip pathology has highly grown thanks to the evolution of surgical techniques and instrumentation development. An alternative approach consisting in making a first outside-in longitudinal capsulotomy was described by Laude at the end of the 2000s and is experiencing significant development in France. The clinical results of this technique have rarely been reported and in particular the influence of the repair of the capsule is unknown. Therefore we performed a retrospective case control study aiming to asses: (1) the clinical outcomes and complication rates of the outside-in extracapsular approach for the treatment of FemoroAcetabular Impingement (FAI) and (2) the effect of capsular closure on the functional outcome.

HYPOTHESIS

We hypothesize that the outside-in extracapsular approach is a safe and efficient technique and the capsular closure at the end of the procedure positively affects the functional outcome.

METHODS

A retrospective study was conducted on prospectively collected data of a consecutive series of hip arthroscopies performed for surgical treatment of FAI using the outside-in extracapsular approach. Any complications during follow-up were identified and recorded. Linear regression models were used to estimate the influence of capsular closure on the functional outcome. Functional outcome was assessed using modified Harris Hip Score (mHHS) and Non-arthritic Hip Score (NAHS).

RESULTS

Sixty-four hips in 57 patients operated by a single surgeon between October 2013 and December 2016 were analyzed at the time of final follow-up of 34.17 months (range 24 to 53). As the surgical technique evolved over time, a side-to-side capsular closure was performed at the end of the procedure for 25 hips and the capsule was left open for the remaining 39 patients. Functional outcome measurements showed an improvement from the preoperative to the last follow-up: 63.5±11.0 to 88.1±11.2 for mHHS, 63.1±13.8 to 86.4±13.4 for NAHS. Capsular closure leads to a significantly improved clinical outcome: gain in mHHS: 25.8±2.3 vs. 20.6±1.9 (p≤0.044), gain in NAHS: 26.1±2.5 vs. 19.6±2.1, (p=0.023). No major complications occurred. One case of postoperative tensor fascia latae atrophy was documented in the group "capsule left open".

CONCLUSION

Hip arthroscopy in the management of FAI with an extraarticular starting point (outside-in) is a safe technique with functional results and postoperative morbidity comparable to previously reported techniques. Side-to-side capsular closure at the end of the procedure might positively affect the final functional outcome.

LEVELS OF EVIDENCE

III, case control retrospective study.

Incidence and location of heterotopic ossification following hip arthroscopy

Background

We investigated the incidence and location of heterotopic ossification (HO) following hip arthroscopy.

Methods

This retrospective study enrolled 327 patients who underwent hip arthroscopy from January 2010 to December 2015. From this cohort, we extracted an HO group with simple radiographs or three-dimensional computed tomography (3D CT). Findings consistent with HO were classified according to the Brooker classification aided with 3D CT for the location of HO. The indication for revision arthroscopic excision of HO was painful, functional impairment of the hip. Patient clinical outcomes were assessed pre- and postoperatively, with modified Harris Hip Scores (mHHS), a visual analogue scale (VAS) for pain, and the Hip Outcome Score-Activity of Daily Living (HOS-ADL) and Sport Specific Subscales (HOS-SSS).

Results

In all, 14 (4.28%) of the 327 patients had confirmed HO radiographically. The mean follow-up was 39 months. In 13 patients, HO formed in the central area of the arthroscopic portals or capsulotomy. Ten patients had Brooker Grade 1 and four had Grade 2. At the last follow-up, 12 asymptomatic patients had significant (P < 0.001) improvements in all clinical outcome scores (mHHS, pain VAS, HOS-ADL, and HOS-SSS). Two patients developed symptoms sufficient to require revision hip arthroscopy for HO excision. After revision hip arthroscopy, both symptomatic patients had improved significantly in all clinical outcomes at the final follow-up.

Conclusions

HO is a minor complication of hip arthroscopy, but sometimes induces severe pain and functional impairment. Usually, HO forms in the arthroscopic portal or capsulotomy area.

How capsular management strategies impact outcomes: A systematic review and meta-analysis of comparative studies

Purpose

To objectively evaluate the effect different management strategies have on the following post-surgical outcomes.

Methods

The PubMed, Embase and Cochrane Library databases were reviewed for articles published between January 1st, 2000 to September 18, 2019 that reported on studies comparing techniques for handling the capsule during hip arthroscopy. After applying the inclusion and exclusion criteria, our final analysis included 10 studies. In total, these articles included 1556 hips. The following capsular management strategies were implemented: complete repair (n = 444; 28.53%), partial repair (n = 32; 2.06%), plication (n = 223; 14.33%) and release/no-repair (n = 857; 55.08%). A meta-analysis was performed on outcomes presented in three or more studies using sufficient pooled statistical analysis data.

Results

Our meta-analysis demonstrated an improvement in the HOS-SS with capsular repair without being statistically significant (95%CI [-6.71, 8.21], p = 0.06). However, a significant improvement in the mHHS was detected with capsular repair (95%CI [-1.37, 9.39], p = 0.03). Of the Four studies evaluating HOS-ADL, two reported improved outcomes with capsular repair (p < 0.05 for both) while the other two reported no significant difference. While mixed results were demonstrated for reoperation rates, no difference was found across capsular management strategies regarding radiological outcomes, NAHS (all p-values >0.05) pain (p > 0.05), flexion (p > 0.05), and patient satisfaction (p > 0.05).

Conclusion

Capsular repair has the potential to improve patient reported outcomes after hip arthroscopy. While there was no consensus in literature, studies consistently reported similar or superior outcomes in the capsular repair cohorts compared to capsular release. Further randomized controlled studies need to be conducted for better evaluation of outcomes.

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.

Surgical Treatment for FAI: Arthroscopic and Open Techniques for Osteoplasty

PURPOSE OF REVIEW

To review the relevant literature and techniques regarding arthroscopic and open treatment of femoroacetabular impingement (FAI). To discuss both the senior authors' preferred method of arthroscopic and open treatment of FAI.

RECENT FINDINGS

Routine treatment of FAI has moved away from open techniques and is more focused arthroscopic methods. Arthroscopic treatment of FAI has more recently focused on differing techniques of hip access and capsular management. Open techniques still have a role in FAI, but indications for open management are focused on cases with more severe pathology. While arthroscopic techniques have shown better outcomes in the short term and higher return to play, it is not without risk and is a procedure with a steep learning curve. In cases of complex joint pathology, such as FAI coupled with dysplasia or Legg-Calve-Perthes, arthroscopy may be not indicated and an open approach preferred. We outline various techniques for both arthroscopic and open treatment of FAI and their outcomes when possible.

Heterotopic Ossification in Hip Arthroscopy: an Updated Review

PURPOSE OF REVIEW

Heterotopic ossification (HO) in hip arthroscopy is a common post-operative complication. This review was undertaken to provide an update (2014 present) on the current literature regarding HO in hip arthroscopy.

RECENT FINDINGS

Risk factors for HO post-hip arthroscopy include male gender, mixed impingement, picture, and the size of CAM resection. HO prophylaxis with NSAIDs has been proven to decrease the rate of HO post-hip arthroscopy; however, there is inherent risk to long-standing NSAIDs therapy. HO post-hip arthroscopy is not uncommon as a radiological finding, but symptomatic HO post-hip arthroscopy requiring revision surgery is a rare event, at < 1%. The outcomes for revision surgery for HO excision have fair outcomes. The hip arthroscopist should stratify their patients based on known risk factors, and determine whether NSAIDs prophylaxis is warranted.

Puncture Capsulotomy During Hip Arthroscopy for Femoroacetabular Impingement: Preserving Anatomy and Biomechanics

We describe an arthroscopic technique for the treatment of labral pathology and femoroacetabular impingement that provides excellent access to the central and peripheral compartments while preserving the biomechanically crucial components of hip joint stability. The hip capsule and the ligaments within it have been shown to be integral to hip biomechanical stability. Other popular techniques such as interportal and T-capsulotomy inherently damage the capsuloligamentous complex of the hip and can be associated with postoperative gross instability, micro-instability, heterotopic ossification, and seroma. Capsular closure may mitigate some of these effects but has been associated with capsular insufficiency and requires postoperative restrictions that can be prolonged. Our surgical technique focuses on careful portal placement, replacement when necessary, use of a switching stick to maximize peripheral compartment visualization, and joint access in the most minimally invasive manner while avoiding complications associated with extended capsulotomy. The objective of this Technical Note is to describe a technique by which full access to the joint can be obtained while not disrupting the biomechanics of the joint capsule.

Hip Arthroscopy in Patients Age 40 or Older: A Systematic Review

PURPOSE

To (1) report clinical outcomes, complication rates, and total hip arthroplasty (THA) conversion rates for patients age 40 or older who underwent hip arthroscopy, and (2) report any age-related predictors of outcome identified in the literature.

METHODS

MEDLINE, EMBASE, and PubMed were searched for relevant studies and pertinent data were abstracted from eligible studies. No meta-analysis was performed because of heterogeneity amongst studies.

RESULTS

Seventeen studies were included in this review comprising 16,327 patients, including 9,954 patients age 40 or older. All studies reported statistically significant improvements in outcomes after hip arthroscopy for femoral osteochondroplasty, labral repair, or unspecified indications. In patients 40 or older who underwent labral debridement, these improvements were not clinically significant. Obesity and osteoarthritic changes predicted poorer outcomes. Only 1 of 3 studies directly comparing the 2 groups found that patients 40 or older had a significantly less improvement in a standardized hip outcome score than patients under 40 after hip arthroscopy, but all found that patients 40 or older had significantly higher rates of THA conversion. The rate of conversion to THA was 18.1% for patients 40 or older, 23.1% for patients over 50, and 25.2% for patients over 60 with a mean of 25.0 months to THA.

CONCLUSIONS

Indications for hip arthroscopy including femoral osteochondroplasty and labral repair resulted in clinically significant improvements in patients 40 or older in most research studies examined in this review, whereas labral debridement did not produce clinically significant improvements postoperatively in the same studies. In these studies, the rate of conversion to THA is higher than in patients under 40 and increases with each decade of life, with many individual studies showing a significant increase in the rate of THA conversion. Hip arthroscopy may be suitable for some patients 40 or older, but patient selection is key and patients should be informed of the higher risk of conversion to THA.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

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.

Intraoperative and Early Postoperative Complications After Hip Arthroscopic Surgery: A Prospective Multicenter Trial Utilizing a Validated Grading Scheme

BACKGROUND

There is limited literature looking at comprehensive complication rates after arthroscopic hip procedures.

PURPOSE

To prospectively report complication rates for a consecutive series of hips undergoing arthroscopic procedures.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Over a 29-month period, 1615 consecutive hips in patients with a mean age of 30.5 years underwent arthroscopic hip procedures at 4 institutions. The diagnosis, demographic information, and procedures were recorded, and a validated grading classification for complications of hip joint surgery was utilized prospectively. The cohort with complications was observed postoperatively for a mean of 36.7 months (range, 24-54 months).

RESULTS

There were 1487 primary hip arthroscopic procedures and 128 revision hip arthroscopic procedures. Arthroscopic femoroacetabular impingement correction was performed in 1505 hips (93.2%), and 1273 hips (78.8%) underwent a labral repair procedure. The most common event was postoperative lateral femoral cutaneous (LFC) nerve disturbance (16.5%), which persisted beyond 6 months in only 1.6%. The incidence of iatrogenic chondral injuries was 1.2%, iatrogenic labral punctures was 0.9%, superficial portal infections was 1.1%, sensory deficits about the foot was 0.8%, deep venous thrombosis was 0.1%, pulmonary embolism was 0.1%, perineal numbness (pudendal nerve) was 1.4%, heterotopic ossification was 0.8%, and femoral neck stress fractures was 0.1%. There was no iatrogenic instability, avascular necrosis, or extra-abdominal fluid extravasation identified in this cohort. The overall complication rate, not including temporary LFC periportal and thigh numbness (sequela), was 8.3% (134 hips). Overall, a grade 1 complication was seen in 7.2% (117 hips), grade 2 in 0.6% (10 hips), grade 3 in 0.4% (6 hips), and grade 4 in 0.1% (1 hip). There was a significantly higher rate of complications for longer surgical time and traction time (P < .01) and for female patients as compared with male patients (P = .017). Most notably, traction time longer than 60 minutes was associated with a significantly increased complication rate (P < .001). Hips with pudendal nerve neurapraxia had longer traction times than those without (61.5 vs 43.8 minutes, respectively; P < .001). No differences were found between primary versus revision cases (P = .123) or between labral repair versus debridement (P = .209), and body mass index had no effect on the complication rate (P = .103).

CONCLUSION

The overall complication rate after hip arthroscopic surgery at tertiary hip centers was 8.3%, with higher rates reported for longer traction times (>60 minutes) and for female patients. Compared with surgical hip dislocation using the same classification system, the overall rate of complications was similar, but the rate of higher grade complications was lower for arthroscopic hip procedures.

Capsulotomy Size Affects Hip Joint Kinematic Stability

PURPOSE

To evaluate the effect of capsulotomy size and subsequent repair on the biomechanical stability of hip joint kinematics through external rotation of a cadaveric hip in neutral flexion.

METHODS

Eight fresh-frozen cadaveric hip specimens were used in this study. Each hip was tested under torsional loads of 6 N·m applied by a servohydraulic frame and transmitted by a pulley system. The test conditions were (1) neutral flexion with the capsule intact, (2) neutral flexion with a 4-cm interportal capsulotomy, (3) neutral flexion with a 6-cm capsulotomy, and (4) neutral flexion with capsulotomy repair. Soft tissue was retained during all interventions. Measures indicating joint kinematics (range of motion [ROM], hysteresis area [HA], and neutral zone [NZ]) were obtained for each condition.

RESULTS

For all hip specimens, the average ROM, HA, and NZ were calculated relative to the intact capsular state (100%) and expressed in terms of percentage (± SD). The findings for ROM were as follows: intact, 100%; 4 cm, 107.42% ± 5.69%; 6 cm, 113.40% ± 7.92%; and repair, 99.78% ± 3.77%. The findings for HA were as follows: intact, 100%; 4 cm, 108.30% ± 9.30%; 6 cm, 115.30% ± 13.92%; and repair, 99.47% ± 4.12%. The findings for NZ were as follows: intact, 100%; 4 cm, 139.61% ± 62.35%; 6 cm, 169.25% ± 78.19%; and repair, 132.03% ± 64.38%. Statistically significant differences in ROM existed between the intact and 4-cm conditions (P = .039), the intact and 6-cm conditions (P < .0001), the 4-cm and repair conditions (P = .033), and the 6-cm and repair conditions (P < .0001). There was no statistically significant difference between the intact and repair conditions (P > .99) or between the 4- and 6-cm conditions (P = .126).

CONCLUSIONS

Under laboratory-based conditions, larger-sized capsulotomies were accompanied by increases in all 3 measures of joint mobility: ROM, HA, and NZ at time zero. Complete capsular closure effectively restored these measures when compared with the intact condition.

CLINICAL RELEVANCE

Cadaveric models consisting of the hip joint with surrounding soft tissue were used under laboratory testing conditions to investigate potential iatrogenic joint instability resulting from expansive capsulotomies, showing that complete capsular closure leads to reconstitution of original joint stability properties at time zero.

Creating and Closing the T-Capsulotomy for Improved Visualization During Arthroscopic Treatment of Femoroacetabular Impingement

Treatment of femoroacetabular impingement through an arthroscopic approach has gained widespread popularity in recent years. Although outcomes are generally favorable, one of the most common reasons for failure is incomplete resection of cam lesions of the femoral neck. As a result, the T-capsulotomy has been introduced as a method for improving access to the femoral head-neck junction, which is not always visible through a standard interportal capsulotomy. The T-capsulotomy has the benefits of improving arthroscopic visualization of the femoral neck, reducing overall fluoroscopy exposure for the patient and surgeon, and facilitating capsular plication. We present a reliable and efficient method for creating and repairing the T-capsulotomy. We routinely perform this technique in patients with cam lesions that are too large or too distal to safely visualize and decompress through an interportal capsulotomy.

Heterotopic ossification after hip arthroscopy

Heterotopic ossification (HO) after hip arthroscopy is the abnormal formation of mature lamellar bone within extra skeletal soft tissues. HO may lead to pain, impaired range of motion and possibly revision surgery. There has been a substantial amount of recent research on the pathophysiology, prophylaxis and treatment of HO associated with open and arthroscopic hip surgery. This article reviews the literature on the aforementioned topics with a focus on their application in hip arthroscopy.