Influence of capsular repair versus unrepaired capsulotomy on 2-year clinical outcomes after arthroscopic hip preservation surgery

A Multicenter Analysis of 3 Decades of Hip Arthroscopy: Evolving Techniques and Growing Patient Volumes From 1988 to 2022

Background

The number of hip arthroscopies performed in the United States has grown significantly over the past several decades, with evolving indications and emerging techniques.

Purposes

To (1) examine the evolution of hip arthroscopy at 3 tertiary referral centers between 1988 and 2022 and (2) quantify trends in patient demographics and procedures performed.

Study Design

Case series; Level of evidence, 4.

Methods

A retrospective analysis was performed of all patients undergoing hip arthroscopy at 3 academic centers between 1988 and 2022. Demographic data were collected using standardized forms and operative notes, and intraoperative images were manually reviewed for each patient to determine the specific procedures performed at the time of the hip arthroscopy. Surgical procedures were plotted over time to evaluate trends. Patients were divided into 3 time periods for comparison: early hip arthroscopy from 1988 to 2008, 2009 (the time of the first labral repair in our cohort) to 2015, and 2016 to 2022.

Results

A total of 3000 patients (age, 35.7 ± 13.8 years; age range, 10-89 years; female sex, 2109 (70.3%); body mass index, 27.4 ± 6.3 kg/m2) underwent arthroscopic hip procedures between 1988 and 2022. The mean number of cases increased from a mean of 3.2 per year in 1988-2008 to 285.9 per year in 2016-2022 (P < .001). Labral treatment at the time of primary hip arthroscopy evolved from 100% debridement and 0% repair in 1988-2008 to 5.0% debridement, 94.0% repair, and 1.0% labral reconstruction in 2016-2022 (P < .001). Cam resection increased from 4.1% in 1988-2008 to 86.9% in 2016-2022 (P < .001). By 2022, 45 out of 325 cases (13.8%) were revisions. The rate of capsular repair at the time of primary hip arthroscopy increased from 0.0% in 1988-2008 up to 81.0% in 2016-2022.

Conclusion

There has been a significant growth of hip arthroscopy volumes as well as a significant transition from use as a tool for diagnosis and labral debridement to procedures restoring native anatomy including labral repair, cam resection, capsular repair, periacetabular osteotomy, and gluteal repair.

Ten-Year Outcomes in Patients Aged 40 Years and Older After Primary Arthroscopic Treatment of Femoroacetabular Impingement With Labral Repair

BACKGROUND

Arthroscopic labral repair has been shown to result in favorable short- and midterm outcomes; however, the durability of outcomes specifically in older patients remains underreported.

PURPOSE

To (1) report prospectively collected hip preservation rates and patient-reported outcome measures (PROMs) at a minimum 10-year follow-up in patients aged ≥40 years after primary hip arthroscopy with labral repair and (2) perform a matched analysis comparing patients aged ≥40 years with patients aged <40 years.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed on all patients who underwent primary hip arthroscopy between February 2008 and December 2011. Patients aged ≥40 years who underwent labral repair were included. Preoperative and minimum 10-year follow-up scores were collected for multiple PROMs. Propensity score matching was utilized to compare these patients with a cohort of patients <40 years.

RESULTS

Of the 113 hips eligible, 91 hips (80.5%) on 85 patients (6 bilateral) had a minimum 10-year follow-up. There were 58 women (68%) and 27 men (32%) with a mean age and body mass index of 47.8 years and 25.8, respectively. The hip preservation rate for patients aged ≥40 years was 78%, with 20 patients requiring arthroplasty during the study period. There was significant improvement in all PROMs from baseline to minimum 10-year follow-up with high rates of achieving the minimal clinically important difference and Patient Acceptable Symptom State clinical outcome thresholds. In total, 69 patients aged ≥40 years were propensity matched to 107 patients <40 years. Patients ≥40 tended to have a lower hip preservation rate (81.2% vs 91.6%; P = .06), while patients in the younger cohort had significantly higher rates of secondary hip arthroscopy (14% vs 3%; P = .02). Improvement in PROMs was comparable between the groups.

CONCLUSION

Patients ≥40 years who underwent primary hip arthroscopy with labral repair demonstrated a hip preservation rate of 78%, significant and durable improvement in PROMs, and high rates of satisfaction at a minimum 10-year follow-up. Matched analysis with patients <40 years revealed comparable improvement in patient-reported outcomes between the 2 groups, with a tendency to a higher level of arthroplasty in patients ≥40 years.

Capsular Repair Versus No Repair After Hip Arthroscopy in Patients Without Dysplasia or Generalized Ligamentous Laxity: A Systematic Review and Meta-analysis

Background

Many recent studies have shown that patients who undergo capsular repair after hip arthroscopy achieve superior clinical outcomes compared with those who do not. However, patients with dysplasia or generalized ligamentous laxity (GLL) were not excluded from most of these studies, which may have affected the outcomes.

Purpose

To determine whether capsular repair influences the outcomes of hip arthroscopy for patients without dysplasia or GLL.

Study Design

Systematic review; Level of evidence, 1.

Methods

Under the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, randomized controlled trials comparing the outcomes of capsulotomy with versus without repair were included, but studies that included patients with dysplasia or GLL were excluded. The study outcomes were patient-reported outcome measures (PROMs) at 6 months and 2 years postoperatively-including the modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), and Hip Outcome Score-Sport-Specific Subscale (HOS-SSS)- and were compared between the repair and no-repair groups. A narrative analysis and meta-analysis were performed to integrate and compare the results of the 2 groups. In the meta-analysis of the outcome measures, studies with significant differences in the preoperative scores between the repair and no-repair groups were excluded because previous studies have shown that these can affect the outcomes.

Results

A total of 761 studies were initially identified, of which 3 were included. Of the 322 included patients, 136 underwent capsular repair, and 186 underwent capsulotomy with no repair. The meta-analysis showed that capsular repair was associated with significantly higher postoperative PROMs: the mHHS at 2 years (P = .03), the HOS-ADL at 6 months (P = .02) and 2 years (P < .0001), and the HOS-SSS at 6 months (P = .02) and 2 years (P = .001).

Conclusion

Capsular repair after hip arthroscopy was associated with superior clinical outcomes when compared with no capsular repair in patients without dysplasia or GLL.

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.

Comparison of Pain Scores and Functional Outcomes of Patients Undergoing Arthroscopic Hip Labral Repair and Concomitant Capsular Repair or Plication Versus No Closure

Background

The need for capsular closure during arthroscopic hip labral repair is debated.

Purpose

To compare pain and functional outcomes in patients undergoing arthroscopic hip labral repair with concomitant repair or plication of the capsule versus no closure.

Study Design

Cohort study.

Methods

Outcomes were compared between patients undergoing arthroscopic hip labral repair with concomitant repair or plication of the capsule versus no closure at up to 2 years postoperatively and with stratification by age and sex. Patients with lateral center-edge angle <20°, a history of instability, a history of prior arthroscopic surgery in the ipsilateral hip, or a history of labral debridement only were excluded. Subanalysis was performed between patients undergoing no capsular closure who were propensity score matched 1:1 with patients undergoing repair or plication based on age, sex, and preoperative Modified Harris Hip Score (MHHS). We compared patients who underwent T-capsulotomy with concomitant capsular closure matched 1:5 with patients who underwent an interportal capsulotomy with concomitant capsular repair based on age, sex, and preoperative MHHS.

Results

Patients undergoing capsular closure (n = 1069), compared with the no-closure group (n = 230), were more often female (68.6% vs 53.0%, respectively; P < .001), were younger (36.4 ± 13.3 vs 47.9 ± 14.7 years; P < .001), and had superior MHHS scores at 2 years postoperatively (85.8 ± 14.5 vs 81.8 ± 18.4, respectively; P = .020). In the matched analysis, no difference was found in outcome measures between patients in the capsular closure group (n = 215) and the no-closure group (n = 215) at any follow-up timepoint. No significant difference was seen between the 2 closure techniques at any follow-up timepoint. Patients with closure of the capsule achieved the minimal clinically important difference (MCID) and the patient acceptable symptom state (PASS) for the 1-year MHHS at a similar rate as those without closure (MCID, 50.3% vs 44.9%, P = .288; PASS, 56.8% vs 51.1%, P = .287, respectively). Patients with T-capsulotomy achieved the MCID and the PASS for the 1-year MHHS at a similar rate compared with those with interportal capsulotomy (MCID, 50.1% vs 44.9%, P = .531; PASS, 65.7% vs 61.2%, P = .518, respectively).

Conclusion

When sex, age, and preoperative MHHS were controlled, capsular closure and no capsular closure after arthroscopic hip labral repair were associated with similar pain and functional outcomes for patients up to 2 years postoperatively.

Capsular Repair, Labral Repair, and Femoroplasty are Increasingly Performed for the Arthroscopic Treatment of Femoroacetabular Impingement Syndrome

PURPOSE

To provide an updated assessment of hip arthroscopy use by using an institutional database that is specific to the treatment of femoroacetabular impingement syndrome (FAIS).

METHODS

All patients undergoing hip arthroscopy for the treatment of FAIS were retrospectively identified between the years 2014 and 2022 via Current Procedural Terminology coding in a multi-institutional, single health system database. A longitudinal analysis was performed to identify trends in the use of arthroscopic techniques including capsular and labral treatment, osteoplasty, and traction set-up.

RESULTS

During the study, 789 arthroscopic hip procedures in 733 patients were analyzed (56 staged bilateral). Between 2016 and 2022, the number of hip arthroscopies performed each year increased by 1,490% (R2 = 0.87, P = .001). Capsular repair (R2 = 0.92, P < .001), labral repair (R2 = 0.75, P = .002), and femoroplasty (R2 = 0.70, P = .004) were performed in an increasing proportion of cases over our study period whereas labral debridement (R2 = -0.84, P < .001) became less used. Postless traction systems were employed in 84% (663/789) of hip arthroscopies overall, were used in at least 70% of hip arthroscopies each year, and did not undergo any significant changes in use (R2 = 0.02, P = .73).

CONCLUSIONS

Capsular repair, labral repair, and femoroplasty were increasingly performed for the arthroscopic treatment of FAIS whereas the use of labral debridement decreased significantly over our study period. Postless traction systems were used in the majority of cases each year.

CLINICAL RELEVANCE

As comparative literature continues to define the safety and efficacy of hip arthroscopy, understanding how novel techniques or procedures are incorporated in clinical practice is important.

Arthroscopic Hip Capsular Repair Improves Patient-Reported Outcome Measures and Is Associated With a Decreased Risk of Revision Surgery and Conversion to Total Hip Arthroplasty

Purpose

To perform a systematic review to assess the effect of capsular repair compared with nonrepair on patient-reported outcome measures (PROMs) and conversion to total hip arthroplasty (THA) after hip arthroscopy in patients with femoroacetabular impingement syndrome.

Methods

We initially searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and PubMed databases, as well as ongoing clinical trials (https://clinicaltrials.gov), on December 15, 2022. The eligibility criteria were randomized controlled trials (Level Ⅰ) and prospective comparative studies (Level II) of patients who underwent capsular repair and nonrepair via hip arthroscopy with a minimum follow-up period of 2 years. We registered this protocol a priori on PROSPERO (identification No. CRD42021239306). We assessed the risk of bias using the Methodological Index for Non-randomized Studies (MINORS) appraisal tool.

Results

This review included 5 studies with a total of 639 patients (270 with capsular repair [average age, 35.4 years; 41% female patients] and 369 with nonrepair [average age, 37.3 years; 38% female patients]). In the included studies, surgical procedures consisting of labral repair and pincer or cam osteoplasty were performed via hip arthroscopy. The modified Harris Hip Score was measured in all the included studies, and the standardized mean difference in PROMs for capsular repair versus nonrepair in the included studies was 0.42 (95% confidence interval [CI], 0.20 to 0.63). A sensitivity analysis of randomized controlled trials achieved consistent results (standardized mean difference in PROMs, 0.31; 95% CI, 0.02 to 0.60). Capsular repair was not associated with a reduction in revision surgery (risk difference, -0.02; 95% CI, -0.06 to 0.03; 26 of 270 patients with capsular repair vs 42 of 369 with nonrepair) but was associated with a reduction in conversion to THA (risk difference, -0.05; 95% CI -0.09 to -0.01; 12 of 270 patients with capsular repair vs 38 of 369 with nonrepair). The average Methodological Index for Non-randomized Studies (MINORS) score in the included studies was 20.

Conclusions

Patients who undergo capsular repair in conjunction with other arthroscopic hip preservation techniques have better PROMs and a lower incidence of THA conversion.

Level of Evidence

Level II, systematic review of Level I and II investigations.

Does capsular repair make a difference in the integrity and thickness of anterior capsule in the setting of borderline hip dysplasia

BACKGROUND

Hip joint capsular ligaments serve a fundamental role in balancing functional mobility and joint stability. However, few studies had focused on postoperative capsule changes in patients with borderline developmental dysplasia of the hip (BDDH).

PURPOSE

To evaluate the integrity and thickness of anterior hip capsular thickness on pre and postoperative MRI in BDDH patients.

STUDY DESIGN

Case series study; Level of evidence III.

METHODS

A retrospective analysis was performed using data from BDDH patients who had arthroscopy between 2016 and 2019. Two groups were created and propensity-score matched based on whether the capsule was sutured. The study group comprised patients who have undergone routine capsule repair between 2018 and 2019. The control group includes BDDH patients with unrepaired capsulotomy between 2016 and 2018. Capsular integrity and thickness were measured on MRI before surgery and at least one year postoperatively. Furthermore, analysis was performed on correlations between the presence of a capsular defect and related factors.

RESULTS

Propensity-score matching yielded 37 hips in the repair group and 37 hips in the non-repair group. There were no significant differences detected in age, sex, and BMI between the two groups. MRI detected capsular defects in 3 hips (8.1%) in the repair group and 10 hips (27.0%) in the non-repair group (p = 0.032). The defect was found to be along the interportal capsulotomy line in all capsular defect cases. Moreover, the postoperative anterior capsule thickness in the study group was significantly thinner compared with preoperative (2.9 ± 0.5 mm vs 3.7 ± 0.6 mm; p < 0.001), and no significant difference was detected in the control group. There were no statistically significant correlations between the presence of a defect capsule and demographic characteristics such as patient age, sex, BMI, preoperative alpha angle, or lateral center-edge angle (LCEA).

CONCLUSION

The majority (91.9%) of the repaired hip capsules in BDDH patients remained closed compared with patients without repair (73.0%). The anterior capsule was significantly thinner in the zone of capsulotomy postoperative compared with preoperative in patients with unrepaired capsules. The presence of a defective capsule does not correlate with demographic factors.

Puncture Capsulotomy Technique for Hip Arthroscopy: Midterm Functional Outcomes

Background

The most common surgical approaches in hip arthroscopy are interportal and T-capsulotomy. However, these methods may introduce capsular instability. Puncture capsulotomy preserves capsuloligamentous integrity by avoiding iatrogenic transection of the iliofemoral capsular ligament.

Purpose

To present minimum 2-year functional outcomes for patients who underwent arthroscopic treatment for acetabular labral tears and concomitant femoroacetabular impingement using the puncture capsulotomy technique.

Study Design

Case series; Level of evidence, 4.

Methods

The authors conducted a retrospective review of prospectively collected data on patients who underwent arthroscopic acetabular labral tear treatment between December 2013 and May 2019. Included were patients aged ≥18 years who underwent hip arthroscopy by a single surgeon and completed a minimum of 2 years of patient-reported outcome measure (PROM) surveys. Intraoperatively, patients underwent hip arthroscopy via puncture capsulotomy to treat labral tears and any concomitant femoroacetabular impingement. Clinical outcome data consisted of PROMs.

Results

A total of 163 hips were included; the mean patient follow-up was 30.4 months (range, 24-60 months; 95% CI, 28.5-32.3 months). Patients had a mean age of 37.9 years (range, 36.1-39.6 years), with a mean body mass index of 25.9 (range, 25.2-26.5). There were significant improvements in mean [95% CI] baseline to final follow-up scores for the 33-Item International Hip Outcome Tool (iHOT-33) (39.6 [36.8-42.4] vs 76.1 [72.7-79.6]), Hip Outcome Score-Activities of Daily Living (70.0 [67.0-73.0] vs 89.3 [87.3-91.3]), modified Harris Hip Score (60.1 [57.9-62.4] vs 84.9 [82.5-87.2]), and Hip Outcome Score-Sports Specific Subscale (41.8 [37.9-45.6] vs 75.7 [71.7-79.7]) (P < .001 for all). Additionally, the mean [95% CI] visual analog scale pain scores were noted to significantly improve throughout the duration of the postoperative period (from 6.3 [5.9-6.7] to 2.2 [1.8-2.6]; P < .001). There were no incidences of infection, avascular necrosis of the femoral head, dislocation/instability, or femoral neck fracture. At the 2-year follow-up, 81.0%, 62.0%, and 58.9% of hips achieved previously published clinically meaningful iHOT-33 thresholds for minimally clinically important difference, Patient Acceptable Symptom Score, and substantial clinical benefit, respectively.

Conclusion

Puncture capsulotomy demonstrated significantly improved functional and clinically meaningful outcomes at a minimum 2-year follow-up, along with a minimal complication rate.

Capsular closure versus unrepaired interportal capsulotomy after hip arthroscopy in patients with femoroacetabular impingement: results of a patient-blinded randomised controlled trial

BACKGROUND

Hip capsular management after hip arthroscopy remains a topic of debate. Most available current literature is of poor quality and are retrospective or cohort studies. As of today, no clear consensus exists on capsular management after hip arthroscopy.

PURPOSE

To evaluate the effect of routine capsular closure versus unrepaired capsulotomy after interportal capsulotomy measured with NRS pain and the Copenhagen Hip and Groin Outcome Score (HAGOS).

MATERIALS AND METHODS

All eligible patients with femoroacetabular impingement who opt for hip arthroscopy (n = 116) were randomly assigned to one of both treatment groups and were operated by a single surgeon. Postoperative pain was measured with the NRS score weekly the first 12 weeks after surgery. The HAGOS questionnaire was measured at 12 and 52 weeks postoperatively.

RESULTS

Baseline characteristics and operation details were comparable between treatment groups. Regarding the NRS pain no significant difference was found between groups at any point the first 12 weeks after surgery (p = 0.67). Both groups significantly improved after surgery (p < 0.001). After 3 months follow-up there were no differences between groups for the HAGOS questionnaire except for the domain sport (p = 0.02) in favour of the control group. After 12 months follow-up there were no differences between both treatment groups on all HAGOS domains (p > 0.05).

CONCLUSIONS

The results of this randomised controlled trial show highest possible evidence that there is no reason for routinely capsular closure after interportal capsulotomy at the end of hip arthroscopy.

TRIAL REGISTRATION

This trial was registered at the CCMO Dutch Trial Register: NL55669.048.15.

Capsule Closure of Periportal Capsulotomy for Hip Arthroscopy

Multiple approaches for management of the hip capsule during hip arthroscopy for femoroacetabular impingement syndrome have been reported. Capsular closure is advocated in the setting of larger capsulotomies, including interportal and T-capsulotomies, to reduce the risk of iatrogenic instability or microinstability of the hip. The periportal capsulotomy technique has been described for conservative management of the capsule that would not necessitate closure. However, hip arthroscopy for patients with ligamentous laxity or joint hypermobility may warrant capsule closure or plication even with use of conservative capsulotomy techniques. We introduce a technique for closure of periportal capsulotomy as a means to repair or plicate the hip capsule in the at-risk hypermobile patient.

Routine Capsular Closure With Hip Arthroscopic Surgery Results in Superior Outcomes: A Systematic Review and Meta-analysis

BACKGROUND

In hip arthroscopic surgery, capsulotomy is performed to improve visualization and allow instrumentation of the joint. Traditionally, the defect has been left unrepaired; however, increasing evidence suggests that this may contribute to persistent pain and iatrogenic capsular instability. Nevertheless, the clinical benefit of performing routine capsular repair remains controversial.

PURPOSE/HYPOTHESIS

We conducted a systematic review and meta-analysis to investigate the effects of routine capsular closure on patient-reported outcomes (PROs), hypothesizing that superior PROs would be observed with routine capsular closure.

STUDY DESIGN

Meta-analysis and systematic review; Level of evidence, 4.

METHODS

A systematic review and meta-analysis was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The terms "hip,""arthroscopy,""capsule,""capsular,""repair," and "closure" were used to query Ovid MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), CINAHL (Cumulative Index to Nursing and Allied Health Literature), SPORTDiscus, and PubMed. Articles with PROs stratified by capsular management were included. Multivariate mixed-effects metaregression models were implemented with study-level random-effects and fixed-effects moderators for capsular closure versus no repair and after controlling for surgical indication and preoperative PROs. The effect of repair on both the postoperative score and the change in scores was evaluated via the Harris Hip Score (HHS)/modified HHS (mHHS), Hip Outcome Score (HOS)-Activities of Daily Living (ADL), and HOS-Sport Specific Subscale (SSS), with a supplemental analysis of additional outcomes.

RESULTS

Of 432 initial articles, 36 were eligible for analysis, with results for 5132 hip arthroscopic procedures. The capsule was repaired in 3427 arthroscopic procedures and unrepaired in 1705. Capsular repair was associated with significantly higher postoperative HHS/mHHS (2.011; SE, 0.743 [95% CI, 0.554-3.467]; P = .007), HOS-ADL (3.635; SE, 0.873 [95% CI, 1.923-5.346]; P < .001), and HOS-SSS (4.137; SE, 1.205 [95% CI, 1.775-6.499]; P < .001) scores as well as significantly superior improvement on the HHS/mHHS (2.571; SE, 0.878 [95% CI, 0.849-4.292]; P = .003), HOS-ADL (3.315; SE, 1.131 [95% CI, 1.099-5.531]; P = .003), and HOS-SSS (3.605; SE, 1.689 [95% CI, 0.295-6.915]; P = .033).

CONCLUSION

This meta-analysis is the largest to date evaluating the effect of capsular closure on PROs and demonstrates significantly higher mean postoperative scores and significantly superior improvement with repair, while controlling for the effects of preoperative score and surgical indication. The true magnitude of the benefit of capsular repair may be clarified by large prospective randomized studies using PRO measures specifically targeted and validated for hip arthroscopic surgery/preservation.

Integrity of the hip capsule measured with magnetic resonance imaging after capsular repair or unrepaired capsulotomy in hip arthroscopy

BACKGROUND

Current literature shows no clear answer on the question how to manage the capsule after hip arthroscopy. Regarding patient reported outcome measures there seems to be no difference between capsular repair or unrepaired capsulotomy.

AIM

To evaluate and compare the integrity of the hip capsule measured on a magnetic resonance imaging (MRI) scan after capsular repair or unrepaired capsulotomy.

METHODS

A case series study was performed; a random sample of patients included in a trial comparing capsular repair vs unrepaired capsulotomy had a postoperative MRI scan. The presence of a capsular defect and gap size were independently evaluated on MRI.

RESULTS

A total of 28 patients (29 hips) were included. Patient demographics were comparable between treatment groups. There were 2 capsular defects in the capsular repair group and 7 capsular defects in the unrepaired capsulotomy group (P = 0.13). In the group of patients with a defect, median gap sizes at the acetabular side were 5.9 mm (range: 2.7-9.0) in the repaired and 8.0 mm (range: 4.5-18.0) in the unrepaired group (P = 0.462). At the muscular side gap sizes were 6.6 mm (range: 4.1-9.0) in the repaired group and 11.5 mm (range: 3.0-18.0) in the unrepaired group (P = 0.857). The calculated Odds ratio (OR) for having a capsular defect with an increasing lateral center-edge (CE) angle was 1.12 (P = 0.06). The OR for having a capsular defect is lower in the group of patients that underwent a labral repair with an OR of 0.1 (P = 0.05).

CONCLUSION

There is no significant difference in capsular defects between capsular repair or unrepaired capsulotomy. Regarding clinical characteristics our case series shows that a larger CE angle increases the likelihood of a capsular defect and the presence of a labral repair decreases the likelihood of a capsular defect.

Capsular Repair During Hip Arthroscopy Demonstrates Restoration of Axial Distraction Resistance in an in Vivo Intraoperative Testing Model

BACKGROUND

Cadaveric models demonstrate that failure of hip capsular repair is dependent on the robustness of the repair construct. In vivo data on capsular repair construct efficacy are limited. We investigated the effect of a figure-of-8 capsular repair on hip distraction resistance relative to native and post-capsulotomy states. We hypothesized that an unrepaired capsulotomy would demonstrate increased axial distraction compared with the native state and that capsular repair would restore distraction resistance to native levels.

METHODS

Patients undergoing primary hip arthroscopy by a single surgeon were prospectively enrolled between March 2020 and June 2020. Prior to any instrumentation, fluoroscopic images of the operative hip were obtained at 12.5-lbs (5.7-kg) traction intervals, up to 100 lbs (45.4 kg). Anterolateral, modified anterior, and distal anterolateral portals were established. Following interportal capsulotomy, labral repair, and osteochondroplasty, fluoroscopic images were reobtained at each traction interval. Capsular repair was performed with use of a figure-of-8 suture configuration. Traction was reapplied and fluoroscopic images were again obtained. Joint distraction distance was measured at each traction interval for all 3 capsular states. Anteroposterior pelvic radiographs were utilized to scale fluoroscopic images to obtain joint space measurements in millimeters.

RESULTS

A total of 31 hips in 31 patients were included. Capsulotomy resulted in significant increases in distraction distance from 25 (11.3 kg) to 100 lbs of traction compared with both native and capsular repair states (all comparisons, p ≤ 0.017). Capsular repair yielded a significantly greater distraction distance compared with the native state at 37.5 lbs (17.0 kg; 5.49 versus 4.98 mm, respectively; p = 0.012) and 50 lbs (22.7 kg; 6.08 versus 5.35 mm; p < 0.001). The mean difference in distraction distance between native and capsular repair states from 25 to 100 lbs of traction was 0.01 mm.

CONCLUSIONS

This in vivo model demonstrates that an unrepaired interportal capsulotomy significantly increases axial distraction distance compared with the native, intact hip capsule. Performing a complete capsular closure reconstitutes resistance to axial distraction intraoperatively. Future research should evaluate the in vivo effects and associated clinical outcomes of other published capsular repair techniques and assess the durability of capsular repairs over time.

Capsular ligaments provide a passive stabilizing force to protect the hip against edge loading

AIMS

In the native hip, the hip capsular ligaments tighten at the limits of range of hip motion and may provide a passive stabilizing force to protect the hip against edge loading. In this study we quantified the stabilizing force vectors generated by capsular ligaments at extreme range of motion (ROM), and examined their ability to prevent edge loading.

METHODS

Torque-rotation curves were obtained from nine cadaveric hips to define the rotational restraint contributions of the capsular ligaments in 36 positions. A ligament model was developed to determine the line-of-action and effective moment arms of the medial/lateral iliofemoral, ischiofemoral, and pubofemoral ligaments in all positions. The functioning ligament forces and stiffness were determined at 5 Nm rotational restraint. In each position, the contribution of engaged capsular ligaments to the joint reaction force was used to evaluate the net force vector generated by the capsule.

RESULTS

The medial and lateral arms of the iliofemoral ligament generated the highest inbound force vector in positions combining extension and adduction providing anterior stability. The ischiofemoral ligament generated the highest inbound force in flexion with adduction and internal rotation (FADIR), reducing the risk of posterior dislocation. In this position the hip joint reaction force moved 0.8° inbound per Nm of internal capsular restraint, preventing edge loading.

CONCLUSION

The capsular ligaments contribute to keep the joint force vector inbound from the edge of the acetabulum at extreme ROM. Preservation and appropriate tensioning of these structures following any type of hip surgery may be crucial to minimizing complications related to joint instability. Cite this article: Bone Joint Res 2021;10(9):594-601.

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 Healing in Interportal and Periportal Capsulotomy Methods of Hip Arthroscopy

Objective

To evaluate the midterm outcomes and the capsular healing in patients who had interportal capsulotomy versus periportal capsulotomy of hip arthroscopy.

Methods

Retrospectively reviewed 33 patients with labral tear received hip arthroscopy, with an average age of 41 (27‐67) years, including 13 cases of Cam deformity and three cases of Pincer deformity. All patients had positive sign of flexion adduction internal rotation or flexion abduction external rotation. With MRI and radiographic (CT, X plain) imageological examination. MRI showed that all patients had labral tear. Radiographic finding (CT, X plain) showed the pathological changes of acetabular and femoral neck osteophyte. One group with 23 patients were treated with periportal capsulotomy. Another group with 10 patients were treated with interportal capsulotomy. All patients did not close the capsule. Clinical outcomes were measured with the Hip Outcome Score Activities of Daily Living (HOS‐ADL) and the modified Harris Hip Score (mHHS), patient satisfaction measured with visual analogue scale (VAS). The healing of the capsule was evaluated by MRI. MRI showed continuous capsular indicated healing, discontinuous capsular indicated unhealing. Postoperatively 6 months, mHHS and HOS‐ADL were obtained. Randomized controlled trials were used in this study for analysis.

Results

All patients were followed up with average time of 9.3 months(3‐29 months). The postoperative symptoms were obviously relieved, the VAS decreased from (4.9 ± 0.6) to (1.2 ± 0.2) after 3 months postoperative. Follow up 6 months post‐operation, patients in the interportal group, the mHHS and HOS‐ADL scores improvement were respectively 69.4 ± 9.3 & 70 ± 8.8 pre‐operation, and 92.5 ± 5.0 & 86.6 ± 5.4 post‐operation (P < 0.05); Patients in the periportal group, the mHHS and HOS‐ADL scores improvement were respectively 69.9 ± 15.8, 68.1 ± 15.0 pre‐operation, and 90.1 ± 9.3 & 86.7 ± 7.9 post‐operation (P < 0.05).The differences were statistically significant. Six months after operation, MRI showed that 23 patients with periportal capsulotomy, the capsule have healed, without other complications. Three of the ten patients with interportal capsulotomy were healed and seven were not.

Conclusion

Interportal and periportal capsulotomy had good outcomes. The technique of periportal capsulotomy had little damage to the joint capsule. Although the capsule did not close, the capsule healed well in postoperative follow‐up. The nonunion rate of the joint capsule was high in the interportal capsulotomy without close the capsule.

Does Capsular Closure Affect Clinical Outcomes in Hip Arthroscopy? A Prospective Randomized Controlled Trial

Background:

There is increasing concern of iatrogenic hip instability after capsulotomy during surgery. Greater emphasis is now being placed on capsular closure during surgery. There are no prospective studies that address whether capsular closure has any effect on outcomes.

Purpose/Hypothesis:

The purpose of this study was to evaluate patient outcomes after interportal capsulotomy repair compared with no repair. We hypothesized that restoration of normal capsular anatomy with interportal repair will achieve clinical outcomes similar to those for no repair.

Study Design:

Randomized controlled trial; Level of evidence, 1.

Methods:

Adult patients with femoral acetabular impingement indicated for hip arthroscopy were randomized into either the capsular repair (CR) or the no repair (NR) groups. All patients underwent standard hip arthroscopy with labral repair with or without CAM/pincer lesion resection. Clinical outcomes were measured via the Hip Outcome Score–Activities of Daily Living (HOS-ADL) subscale, Hip Outcome Score–Sport Specific (HOS-SS) subscale, modified Harris Hip Score (mHHS), visual analog scale for pain, International Hip Outcome Tool, and Veterans RAND 12-Item Health Survey (VR-12).

Results:

A total of 54 patients (56 hips) were included (26 men and 30 women) with a mean age of 33 years. The HOS-ADL score significantly improved at 2 years in both the NR group (from 68.1 ± 20.5 to 88.6 ± 20.0; P < .001) and the CR group (from 59.2 ± 18.8 to 91.7 ± 12.3; P < .001). The HOS-SS score also significantly improved in both the NR group (from 41.1 ± 25.8 to 84.1 ± 21.9; P < .001) and the CR group (from 32.7 ± 23.7 to 77.7 ± 23.0; P < .001). Improvement was noted for all secondary outcome measures; however, there was no significant difference between the groups at any time point. Between 1 and 2 years, the NR group showed significant worsening on the HOS-ADL (–1.21 ± 5.09 vs 4.28 ± 7.91; P = .044), mHHS (1.08 ± 10.04 vs 10.12 ± 11.76; P = .042), and VR-12 Physical (–2.15 ± 5.52 vs 4.49 ± 7.30; P = .014) subsets compared with the CR group.

Conclusion:

There was significant improvement in the VR-12 Physical subscale at 2 years postoperatively in the capsular CR group compared with the NR group. Capsular closure appears to have no detrimental effect on functional outcome scores after hip arthroscopy. We recommend restoration of native anatomy if possible when performing hip arthroscopy.

Capsular Management Techniques and Hip Arthroscopy

There has been an increased emphasis on capsular management during hip arthroscopy in the literature in recent years. The capsule plays a significant role in the hip joint stability and studies have demonstrated that capsular closure can restore the biomechanics of the hip back to the native state. Capsular management also affects functional outcomes with capsular repair resulting in better clinical outcomes in some studies. Management of the capsule has evolved in recent years with more surgeons performing routine capsular closure. Management techniques and degree of capsular closure, however, can be quite variable between surgeons. This review will discuss hip capsular anatomy, the importance of the capsule in hip biomechanics, management of the capsule during arthroscopy, and functional outcomes as it relates to the various capsular closure techniques versus leaving the capsulotomy unrepaired.

A Systematic Approach to Arthroscopic Femoroplasty With Conservative Management of the Hip Capsule

As hip arthroscopy has become increasingly used to treat femoroacetabular impingement, the importance of a complete femoroplasty to properly address cam impingement has been demonstrated. In doing so, different capsulotomy techniques have been described for gaining access to the hip joint as well as the peripheral compartment for cam resection. The periportal capsulotomy technique allows joint access while preserving the structural integrity of the iliofemoral ligament, obviating the need for capsular closure. We present a systematic approach and surgical technique for performing a complete arthroscopic femoroplasty while maintaining conservative hip capsule management through a periportal capsulotomy.

Arthroscopic Correction of Sports-Related Femoroacetabular Impingement in Competitive Athletes: 2-Year Clinical Outcome and Predictors for Achieving Minimal Clinically Important Difference

Background:

A growing body of literature supports surgical intervention for femoroacetabular impingement (FAI) in young, active athletes. However, factors likely to influence results in this cohort are less clearly defined.

Purpose:

To quantify changes in validated patient-reported outcome measures (PROMs) and determine whether differences in baseline athlete demographic characteristics, intraoperative findings, and surgical techniques are associated with achieving improved outcomes and minimal clinically important difference (MCID) after arthroscopic management of sports-related FAI.

Study Design:

Case series; Level of evidence, 4.

Methods:

Data were prospectively collected from competitive athletes who underwent hip arthroscopy between January 2009 and February 2017. Athletes who underwent primary arthroscopic correction of sports-related FAI with labral repair were included providing they had a Tönnis grade ≤1 and a lateral center-edge angle ≥20°, excluding significant articular cartilage injury and lateral rim dysplasia. The modified Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index, University of California Los Angeles activity scale, and 36-Item Short Form Health Survey were used to measure outcomes at the 2-year follow-up. MCID was measured using 3 methods: a mean change method, a distribution-based method, and the percentage of possible improvement (POPI) method. Multivariate regression models were used to assess a number of diagnostic and surgical variables associated with good outcome and achieving MCID at follow-up.

Results:

At 2-year follow-up, statistically significant improvements were observed for all PROMs (P < .001 for all), and 84% of athletes continued to play sport. Higher preoperative PROM scores reduced the likelihood of achieving MCID; however, returning to play was the strongest predictor of reaching MCID in this athletic cohort. Using absolute score change (mean change or distribution method) to calculate MCID was less accurate owing to ceiling effects and dependence on preoperative PROM scores.

Conclusion:

Athletes undergoing arthroscopy for sports-related FAI can expect a successful outcome and continued sports participation at 2 years postoperatively. The majority of athletes will achieve MCID. The POPI method of MCID calculation was more applicable to higher functioning athletic cohorts. Reduced preoperative PROM scores and the ability to return to sport increased the likelihood of achieving MCID in this population.

Achievement of Meaningful Clinical Outcomes Is Unaffected by Capsulotomy Type During Arthroscopic Treatment of Femoroacetabular Impingement Syndrome: Results From the Multicenter Arthroscopic Study of the Hip (MASH) Study Group

BACKGROUND

Capsule management has emerged as an important topic in the field of hip arthroscopy. The 2 most popular techniques are interportal capsulotomy and T-type capsulotomy, but few studies have compared outcomes between these 2 techniques.

PURPOSE

To compare 2-year (±2 months) patient-reported outcomes (PROs) between patients who underwent interportal versus T-type capsulotomy during arthroscopic labral repair for femoroacetabular impingement syndrome (FAIS).

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective review of a large multicenter registry of patients undergoing arthroscopic hip preservation surgery for FAIS was performed. Data from 9 surgeons across 9 sites between January 2014 and February 2018 were included in the study. Baseline demographic data, preoperative PROs, and minimum 2-year postoperative PROs including Hip Outcome Score-Activities of Daily Living (HOS-ADL), HOS-Sports Subscale (HOS-SS), modified Harris Hip Score, and International Hip Outcome Tool-12 (iHOT-12) were recorded. Patients were divided into 2 groups based on whether interportal or T-type capsulotomy was performed according to the senior surgeon's preference and training, and all capsulotomies were then routinely repaired. The 2 groups were matched 1:1 by age, sex, and body mass index (BMI). Achievement of minimal clinically important difference (MCID), Patient Acceptable Symptomatic State (PASS), and substantial clinical benefit (SCB) was compared for the HOS-ADL, HOS-SS, and iHOT-12 between the 2 groups.

RESULTS

The final analysis included 658 of 1483 eligible patients with a mean ± SD age of 32.6 ± 11.6 years and BMI of 24.0 ± 3.7; of these, 329 patients were treated via interportal capsulotomy, and 329 patients were treated via T-type capsulotomy. Female patients comprised 66.3% of the study population. Capsulotomy type was not a predictor of 2-year postoperative PROs on multivariate linear regression analysis when adjusted for covariates. Chi-square analysis showed no statistical difference in achievement of MCID, PASS, and SCB between the interportal and T-type groups for HOS-ADL (80.3%, 75.8%, 52.7% and 77.1%, 71.7%, 53.6%, respectively; P > .01 for all), HOS-SS (83.6%, 72.5%, 51.5% and 81.7%, 68.4%, 49.2%, respectively; P > .01 for all), and iHOT-12 (87.5%, 72.0%, 50.5% and 80.0%, 64.7%, 45.6%, respectively; P > .01 for all).

CONCLUSION

Arthroscopic management of FAIS resulted in significant clinical improvement that was independent of capsulotomy type when the capsulotomy included repair.

Arthroscopic Capsular Management of the Hip: A Comparison of Indications for and Clinical Outcomes of Periportal Versus Interportal Capsulotomy

PURPOSE

To compare the clinical outcomes of periportal capsulotomy versus interportal capsulotomy with closure using a standard clinical algorithm at a minimum of 2 years after hip arthroscopy.

METHODS

A retrospective cohort study of patients treated from July 2015 to October 2017 was conducted to determine the effects of 2 capsular management approaches on clinical outcomes. When patient pathology limited adequate exposure via periportal capsulotomy, an interportal capsulotomy was performed. The capsular management approaches were correlated with the following patient-reported outcomes (PROs) at 2 years: Hip Outcome Score (HOS), 12-item International Hip Outcome Tool, visual analog scale for pain, and patient satisfaction. Preoperative comparisons between the 2 groups were analyzed using t tests or the Fisher exact test, depending on the category of data. Two-tailed independent t tests were performed to evaluate whether preoperative and follow-up outcome scores were significantly different between patients treated with a periportal capsulotomy and those treated with an interportal capsulotomy.

RESULTS

Overall, patients in both groups experienced significant improvements in all PROs on postoperative comparisons at 2-year follow-up (P < .001). The mean changes in the PROs were as follows: HOS-Activities of Daily Living, 24.7 in the periportal group and 23.5 in the interportal group (P = .484); HOS-Sport-Specific Subscale, 30.2 and 31.3, respectively (P = .895); 12-item International Hip Outcome Tool score, 41.9 and 40.2, respectively (P = .564); and visual analog scale pain score, -40.9 mm and -34.5 mm, respectively (P = .791). Additionally, no statistically significant difference in patient satisfaction at 2-year follow-up was found between patients who underwent interportal capsulotomy and those who underwent periportal capsulotomy (P = .604).

CONCLUSIONS

At 2-year follow-up, patients who underwent a periportal capsulotomy reported statistically and clinically significant improvements in PROs and satisfaction with the surgical intervention. This study confirms that the use of a simple clinical algorithm for selection of periportal capsulotomy or interportal capsulotomy with closure results in acceptable management decisions as defined by 2-year PROs.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

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)

Threshold Values for Success After Hip Arthroscopy Using the Patient-Reported Outcomes Measurement Information System Assessment: Determining the Minimum Clinically Important Difference and Patient Acceptable Symptomatic State

BACKGROUND

Threshold values for patient-reported outcome measures, such as the minimum clinically important difference (MCID) and patient acceptable symptomatic state (PASS), are important for relating postoperative outcomes to meaningful functional improvement.

PURPOSE

To determine the PASS and MCID after hip arthroscopy for femoroacetabular impingement using the Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaire.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

A consecutive series of patients undergoing primary hip arthroscopy for femoroacetabular impingement were administered preoperative and minimum 1-year postoperative PROMIS surveys focusing on physical function (PF) and pain interference (PI). External anchor questions for the MCID and PASS were given with the postoperative PROMIS survey. Receiver operator curves were constructed to determine the threshold values for the MCID and PASS. Curves were generated for the study population as well as separate cohorts segregated by median baseline PF or PI scores and preoperative athletic participation. A multivariate post hoc analysis was then constructed to evaluate factors associated with achieving the PASS or MCID.

RESULTS

There were 113 patients (35% male; mean ± SD age, 32.8 ± 12.5 years; body mass index, 25.8 ± 4.8 kg/m²), with 60 (53%) reporting preoperative athletic participation. Survey time averaged 77.5 ± 49.2 seconds. Anchor-based MCID values were 5.1 and 10.9 for the PF and PI domains, respectively. PASS thresholds were 51.8 and 51.9 for the PF and PI, respectively. PASS values were not affected by baseline scores, but athletic patients had a higher PASS threshold than did those not participating in a sport (53.1 vs 44.7). MCID values were affected by preoperative baseline scores but were largely independent of sports participation. A post hoc analysis found that 94 (83%) patients attained the MCID PF while 66 (58%) attained the PASS PF. A multivariate nominal logistic regression found that younger patients (P = .01) and athletic patients (P = .003) were more likely to attain the PASS.

CONCLUSION

The PROMIS survey is an efficient metric to evaluate preoperative disability and postoperative function after primary hip arthroscopy for femoroacetabular impingement. The MCID and PASS provide surgeons with threshold values to help determine PROMIS scores that are clinically meaningful to patients, and they can assist with therapeutic decision making as well as expectation setting.

Hip Arthroscopy in the High-Level Athlete: Does Capsular Closure Make a Difference?

BACKGROUND

Hip arthroscopy has been shown to be effective in athletes who have femoral acetabular impingement and labral tearing. The effect of complete capsular closure versus nonclosure on return to play is unknown.

HYPOTHESIS

Complete capsular closure after hip arthroscopy would lead to a higher rate and faster return to sports in high-level athletes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A nonrandomized retrospective review was performed of high school, collegiate, and professional athletes undergoing hip arthroscopy by a single high-volume hip arthroscopic surgeon. Athletes were divided into those undergoing complete capsular closure (CC group) and non-capsular closure (NC group) after hip arthroscopy. Rate and time to return to play were determined between the 2 groups. Patient-reported outcomes including modified Harris Hip Score (mHHS), Hip Outcome Score Activities of Daily Living (HOS-ADL), and Hip Outcome Score Sport-Specific Subscale (HOS-SSS) were obtained at a minimum of 2 years.

RESULTS

A total of 111 athletes with a minimum 2-year follow-up were included in the study. There were 62 in the CC group and 49 in the NC group. A higher percentage of athletes in the CC group returned to play compared with that in the NC group (90.3% vs 75.5%, respectively; P = .03). The CC group returned to play at a mean ± SD of 4.7 ± 1.9 months compared with 5.8 ± 2.6 months in the NC group (P < .001). Patients in the CC group met the minimal clinically important difference for the mHHS, HOS-ADL, and HOS-SSS patient-reported outcomes at higher percentages: mHHS, 98.3% vs 87.7% for CC vs NC, respectively (P = .02); HOS-ADL, 98.3% vs 87.7% (P = .02); and HOS-SSS, 96.7% vs 89.7% (P = .13). The difference between groups was statistically significant for mHHS and HOS-ADL.

CONCLUSION

Complete capsular closure after hip arthroscopy was associated with faster return to play and a higher rate of return compared with that of nonclosure of the capsule in this sample population of high-level athletes. At a minimum 2-year follow-up, complete capsular closure was associated with significantly higher patient-reported outcomes compared with those of nonclosure in athletes who underwent hip arthroscopy.

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.

Biomechanical Response to Distraction of Hip Capsular Reconstruction With Human Acellular Dermal Patch Graft

PURPOSE

To quantify the biomechanical properties of the hip capsule with human dermal allograft reconstruction to determine whether a dermal patch restored capsular resistance to distraction.

METHODS

Nine cadaveric hip specimens were dissected until capsule and bony structures remained and were then mounted in a testing fixture in neutral flexion and abduction. Four states of the hip capsule were sequentially tested under axial distraction of 5 mm measured with video analysis and with resultant force measurement: (1) intact hip capsule, (2) interportal capsulotomy, (3) capsulectomy to the zona orbicularis, and (4) capsular reconstruction with human dermal allograft using acetabular anchors and capsule-to-patch sutures.

RESULTS

Capsulectomy was different from intact (P = .036), capsulotomy differed from capsulectomy (P = .012), and the repair was statistically significantly different from capsulectomy (P = .042); intact and reconstructed cases were not statistically significantly different. The force required for 5 mm of distraction decreased after interportal capsulotomy by an average of 9% compared with the intact state and further decreased after capsulectomy by 30% compared with the intact state. After capsular reconstruction using dermal allograft, force requirements increased by an average of 36% from the capsulectomy state, only 5% below the intact state.

CONCLUSIONS

Human dermal allograft tissue graft provides restoration of distractive strength for use during hip capsule reconstruction with acetabular anchor fixation and distal soft-tissue fixation after capsulectomy in a cadaveric model.

CLINICAL RELEVANCE

Capsular repair or reconstruction with a dermal patch offers time-zero restoration of function; intact and reconstructed cases showed no difference, and reconstruction restored a capsulectomy to a biomechanical equivalent of the intact case when distraction was applied.

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.

Routine Interportal Capsular Repair Does Not Lead to Superior Clinical Outcome Following Arthroscopic Femoroacetabular Impingement Correction With Labral Repair

PURPOSE

To evaluate the impact of routine capsular repair on clinical outcome in a consecutive series of patients undergoing arthroscopic correction of symptomatic femoroacetabular impingement.

METHODS

Between 2009 and 2015, patients were assigned to 1 of 2 groups based on whether a capsular repair was performed as part of their index hip arthroscopic procedure. Exclusion criteria included previous underlying hip conditions, Tönnis >1, age >45 years, and labrum not repaired. Patients were assessed preoperatively and 2-years postoperatively using patient-reported outcome measures (PROMs), including the modified Harris hip score (mHHS), UCLA activity scale, short form-36, Western Ontario and McMaster Universities Osteoarthritis Index score, and measures of range of hip movements. The incidence of any subsequent revision surgery within 2 years was recorded. Sex and age groups were specifically analyzed.

RESULTS

In total, 966 consecutive cases were included (96.4% follow-up rate): 508 in group A (no repair) and 458 in group B (repair). Average age for all cases was 28.1 ± 7.0 years (14.6-44.9). There were significant improvements in all PROMs following surgery for both groups (P < .001). Statistical significance between groups at 2 years was observed for Short Form-36 (P = .001) and WOMAC (P = .041), greater in group A. Both groups similarly met the minimal clinically important difference (mHHS P = .414 and .605; UCLA, P = .549 and .614; Short Form-36, P = .455 and .079; WOMAC, P = .425 and .750 for distribution and anchor-based methods, respectively). In total, 38 (7.8%) cases group A and 24 (5.4%) cases group B required repeat hip arthroscopy (HA) (P = .148); No (0%) cases in group A and 2 (0.45%) cases in group B required total hip replacement (P = .226). There was significantly lower rate of repeat HA among 25- to 34-year age group (8.6% vs 3.9%, P = .047) where capsular repair was performed. No significant difference in the rate of repeat HA between groups for male (P = .203) or female (P = .603) subjects. Adhesions were more common in the repair group (79.2%, 95% confidence interval [CI] 57.8-92.9 vs 55.3%, CI 38.3-71.4; P = .055), with further capsular repair/plication required more frequently in the unrepaired group (50%, CI 33.4-66.6 vs 25%, CI 10.8-44.3); however, differences between groups were not significant (P = .051). Internal rotation was larger in group A compared with group B at 2 years (36.2 vs 28.1, P = .000). Female patients with capsular repair had reduced PROM scores at 2 years compared with female patients without repair (WOMAC, P = .004, and mHHS, P = .037).

CONCLUSIONS

Arthroscopic correction of femoroacetabular impingement with labral repair results in significant improvements in patient-reported outcomes at 2-years postsurgery, irrespective of whether the capsule is repaired. Routine capsular repair in a consecutive series of patients did not lead to superior outcomes compared with a nonrepaired group; similar proportions of cases in both groups were able to achieve minimal clinically important difference. In female patients, routinely repairing the capsule may lead to statistically inferior clinical outcome at 2-years postsurgery, although this may not be clinically significant. Routine capsular repair, however, may be beneficial in the younger, active patient, where a significant reduction in repeat arthroscopy was observed.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Anatomic Evaluation of the Interportal Capsulotomy Made with the Modified Anterior Portal versus Standard Anterior Portal: Comparable Utility with Decreased Capsule Morbidity

PURPOSE

To identify potential differences in interportal capsulotomy size and cross-sectional area (CSA) using the anterolateral portal (ALP) and either the: (i) standard anterior portal (SAP) or (ii) modified anterior portal (MAP).

MATERIALS AND METHODS

Ten cadaveric hemi pelvis specimens were included. A standard arthroscopic ALP was created. Hips were randomized to SAP (n=5) or MAP (n=5) groups. The spinal needle was placed at the center of the anterior triangle or directly adjacent to the ALP in the SAP and MAP groups, respectively. A capsulotomy was created by inserting the knife through the SAP or MAP. The length and width of each capsulotomy was measured using digital calipers under direct visualization. The CSA and length of the capsulotomy as a percentage of total iliofemoral ligament (IFL) side-to-side width were calculated.

RESULTS

There were no differences in mean cadaveric age, weight or IFL dimensions between the groups. Capsulotomy CSA was significantly larger in the SAP group compared with the MAP group (SAP 2.16±0.64 cm2 vs. MAP 0.65±0.17 cm2, P=0.008). Capsulotomy length as a percentage of total IFL width was significantly longer in the SAP group compared with the MAP group (SAP 74.2±14.1% vs. MAP 32.4±3.7%, P=0.008).

CONCLUSION

The CSA of the capsulotomy and the percentage of the total IFL width disrupted are significantly smaller when the interportal capsulotomy is performed between the ALP and MAP portals, compared to the one created between the ALP and SAP. Surgeons should be aware of this fact when performing hip arthroscopy.

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.

Prospective Randomized Comparison of Capsular Management Techniques During Hip Arthroscopy

BACKGROUND

Capsular management during hip arthroscopy remains controversial. Studies evaluating this topic consist mostly of retrospective comparative reviews of prospectively gathered data on a large series of patients.

PURPOSE/HYPOTHESIS

The purpose was to perform a prospective randomized trial to comparatively assess 3 commonly performed capsular management techniques. It was hypothesized that capsular closure during hip arthroscopy would result in superior outcomes when compared with unclosed capsulotomy management techniques.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

Patients (N = 150) who had hip arthroscopy with labral repairs and femoral osteoplasties performed by the senior author were randomly assigned into 3 groups at the time of their surgery: T-capsulotomy without closure (TC), interportal capsulotomy without closure (IC), and interportal capsulotomy with closure (CC). All patients underwent labral repair and femoral osteoplasty. Patient-reported outcomes were obtained preoperatively and at 3, 6, 12, and 24 months postoperatively. Other outcomes obtained included the need for future hip surgery.

RESULTS

Patient demographics, preoperative patient-reported outcomes, and radiographic measurements were similar among all 3 groups. Revision hip arthroscopy was performed in 5 TC cases, 2 IC cases, and 1 CC case (P = .17). Conversion to hip arthroplasty occurred in 4 patients in the TC group and none in the IC and CC groups (P = .02). The CC group showed higher modified Harris Hip Score (mHHS) and Hip Outcome Score-Activities of Daily Living (HOS-ADL) at the 2-year follow-up when compared with the IC group (P = .003 and P < .001, respectively). When compared with the TC group, the CC group demonstrated superior mHHS (86.2 vs 76), HOS-ADL (85.6 vs 76.8), and HOS-SSS (Hip Outcome Score-Sports-Specific Subscale; 74.4 vs 65.3) at the final 2-year follow-up (P < .001). At the 2-year follow-up, the IC group had a higher mHHS (81.7 vs 76), HOS-ADL (82 vs 76.8), and HOS-SSS (71.4 vs 65.3; P > .001) as compared with the TC group.

CONCLUSION

Patients undergoing complete capsular closure during hip arthroscopy showed improved patient-reported and surgical outcomes when compared with those with unrepaired T-capsulotomy or interportal capsulotomy. These results suggest that repair after capsulotomy may be a favorable arthroscopic capsular management technique.

Physical Activity Following Hip Arthroscopy in Young and Middle-Aged Adults: A Systematic Review

Background

Hip arthroscopy is a common surgical intervention for young and middle-aged adults with hip-related pain and dysfunction, who have high expectations for returning to physical activity following surgery. The purpose of this review was to evaluate the impact of hip arthroscopy on physical activity post-arthroscopy.

Methods

A systematic search of electronic databases was undertaken in identifying studies from January 1st 1990 to December 5th 2019. The search included English language articles reporting physical activity as an outcome following hip arthroscopy in adults aged 18-50 years. Quality assessment, data extraction and synthesis of included studies were undertaken.

Results

Full text articles (n = 234) were assessed for eligibility following screening of titles and abstracts (n = 2086), yielding 120 studies for inclusion. The majority (86%) of the studies were level 4 evidence. One study reported objective activity data. The most frequently occurring patient-reported outcome measure was the Hip Outcome Score-sport-specific subscale (HOS-SS, 84% of studies). Post--arthroscopy improvement was indicated by large effect sizes for patient-reported outcome measures (standard paired difference [95% confidence interval] −1.35[−1.61 to −1.09] at more than 2 years post-arthroscopy); however, the majority of outcome scores for the HOS-SS did not meet the defined level for a patient-acceptable symptom state.

Conclusion

The current level of available information regarding physical activity for post arthroscopy patients is limited in scope. Outcomes have focused on patients’ perceived difficulties with sport-related activities with a paucity of information on the type, quality and quantity of activity undertaken.

Level of Evidence

Level IV, systematic review of Level 2 through to Level 4 studies

Hip Joint Capsular Anatomy, Mechanics, and Surgical Management

➤Hip joint capsular ligaments (iliofemoral, ischiofemoral, and pubofemoral) play a predominant role in functional mobility and joint stability. ➤The zona orbicularis resists joint distraction (during neutral positions), and its aperture mechanism stabilizes the hip from adverse edge-loading (during extreme hip flexion-extension). ➤To preserve joint function and stability, it is important to minimize capsulotomy size and avoid disrupting the zona orbicularis, preserve the femoral head size and neck length, and only repair when or as necessary without altering capsular tensions. ➤It is not fully understood what the role of capsular tightness is in patients who have cam femoroacetabular impingement and if partial capsular release could be beneficial and/or therapeutic. ➤During arthroplasty surgery, a femoral head implant that is nearly equivalent to the native head size with an optimal neck-length offset can optimize capsular tension and decrease dislocation risk where an intact posterior hip capsule plays a critical role in maintaining hip stability.

Outcomes for Surgical Treatment of Femoroacetabular Impingement in Adults

PURPOSE OF REVIEW

To assess the outcomes of modern techniques for arthroscopic surgery in the treatment of femoroacetabular impingement.

RECENT FINDINGS

While initially approached by means of open surgical hip dislocation, recent literature has shown generally good outcomes of arthroscopic treatment for femoroacetabular impingement. Modern advances in hip arthroscopy technique and implants now allow for labral repair or reconstruction when indicated. Arthroscopic treatment of femoroacetabular impingement results in significant improvements in patient pain and function, with low complication rates and high patient satisfaction. A majority of improvements in these patients occur within 1 to 2 years post-operatively. Hip arthroscopy for femoroacetabular impingement yields the best results in patients without significant arthritis or hip dysplasia.

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.

Arthroscopic Treatment of Pigmented Villonodular Synovitis of the Hip Using Puncture Capsulotomy

Pigmented villonodular synovitis (PVNS) is a monoarticular, benign tumor arising from the synovium. Although classically treated with open synovectomy, arthroscopic treatment has demonstrated good clinical outcomes. The arthroscopic management of hip PVNS has been described as technically challenging due to difficulty obtaining the appropriate exposure. The purpose of this technical report is to describe a novel technique that allows for sound excision of PVNS during hip arthroscopy using a puncture capsulotomy. Full visualization throughout the central and peripheral compartments is key to achieving meticulous surgical excision and ablation, with careful attention to the medial and lateral synovial folds and gutters. It is important to avoid chondral injury by using a high outflow rate of irrigation to maintain a constant temperature, to ablate the blood supply of nodular lesions, and to not use a shaver as this may disseminate tumor cells. Multifactorial advancements in hip arthroscopy have permitted adequate visualization and exposure of PVNS lesions, making them amenable to arthroscopic synovectomy. Puncture capsulotomy does not require capsular closure, preserves the iliofemoral ligament, and minimizes exposure of extra-articular structures to the hip joint environment. Recurrence rates are lower in arthroscopic management compared with open management, at 7.7% and 17.8%, respectively.

Midterm Outcomes Following Repair of Capsulotomy Versus Nonrepair in Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement With Labral Repair

PURPOSE

The purpose of this study was to compare the midterm outcomes and conversion to total hip arthroplasty (THA) rate in patients who had repair of the capsulotomy versus nonrepair following arthroscopic hip labral repair and correction of femoroacetabular impingement (FAI).

METHODS

All patients undergoing primary arthroscopic hip labral repair and correction of FAI between 2005 and 2012 were eligible for this study. Exclusion criteria were age < 18 years, lateral center-edge angle < 25°, previous hip procedures, femoral avascular necrosis, radiographic joint space ≤ 2 mm, or microfracture at arthroscopy. Patients who did not have the capsulotomy repaired were matched 1:2 with patients who had the capsulotomy repaired. Patients were matched by age, gender, and intraoperative procedures. The primary outcome score was the Hip Outcome Score Daily Living (HOS-ADL).

RESULTS

Forty-two patients (18 female patients, 24 male patients) without repair of the capsulotomy were matched with 84 patients with repaired capsulotomy. The average age for both groups was 38 ± 15 years. Patients in the nonrepair group were 6.8 (95% confidence interval, 1.2-52) times more likely to undergo THA compared with the repair group. There was no difference in revision rate between the 2 groups. The mean follow-up time was 7.3 ± 2.7 years and 6.4 ± 2.3 years for the nonrepair and repair group, respectively (P = .107). Patients in the repair group had significantly higher HOS-ADL (P = .01) and modified Harris hip score (mHHS; P = .007). The percentage of patients who reached minimum clinically important difference was significantly higher in the repair group for HOS-ADL (P = .002) and HOS-Sport (P = .036) compared with the nonrepair group. However, there was no difference in the percentage of patients who reached minimal important change for the mHHS (P = .060). Following hip arthroscopy, the average alpha angle was 41.6° ± 6° in the nonrepair group and 40.8° ± 3° in the repair group.

CONCLUSIONS

Patients who undergo arthroscopic FAI correction and hip labral repair with repair of the capsulotomy had higher HOS-ADL and mHHS scores at midterm follow-up compared with patients with nonrepair, and the percentage of patients who reached the minimum clinically important difference was significantly higher in the repair group for HOS-ADL and HOS-Sport compared with the nonrepair group. In addition, a lower rate of conversion to THA was seen in the repair group.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Periportal Capsulotomy: Technique and Outcomes for a Limited Capsulotomy During Hip Arthroscopy

PURPOSE

To present the technique and outcomes of a limited periportal capsulotomy without capsular closure for arthroscopic treatment of femoroacetabular impingement (FAI).

METHODS

Retrospective review of a prospectively collected database of patients undergoing primary hip arthroscopy for symptomatic FAI was performed to analyze patients who underwent periportal capsulotomy. Periportal capsulotomy was performed through dilation of the midanterior and anterolateral portals without completion of a full interportal capsulotomy, preserving the iliofemoral ligament. Arthroscopic labral treatment and osteochondroplasty were completed as indicated without necessitating capsular closure. Patient demographics, surgical details, and complications were recorded. Pre- and postoperatively, patients completed the modified Harris Hip Score, Hip Disability and Osteoarthritis Outcome Score (HOOS), 12-item Short-Form survey, and visual analog scale. Postoperative outcome data was analyzed at 1- and 2-year follow-up.

RESULTS

One hundred and forty-two patients treated with the periportal capsulotomy technique were included (mean age, 35.5 ± 11.7; body mass index, 25.4 ± 4.1; 50.7% men). There were no major postoperative complications including hip instability or reoperation. Significant improvements in mean patient-reported outcomes from preoperative scores were seen at the 1- and 2-year follow-ups (modified Harris Hip Score, 18.4 ± 19.1, 21.1 ±17.7, HOOS symptoms, 20.1 ± 21.2, 22.8 ± 23.5, HOOS pain, 23.4 ± 21.2, 27.6 ± 19.3, HOOS activities of daily life, 21.2 ± 20.8, 24.3 ± 21.6, HOOS sport, 32.5 ± 27.0, 36.5 ± 26.9, HOOS quality of life, 37.9 ± 26.7, 46.0 ± 22.8, and 12-item Short-Form survey physical component score, 16.4 ± 15.3, 20.8 ±13.2, respectively). Only the HOOS quality of life demonstrated further improvement from 1- to 2 years postoperatively (P = .043).

CONCLUSIONS

Periportal capsulotomy provides safe and sufficient access to the hip joint for arthroscopic treatment of FAI without necessitating capsular closure. Using this technique, patients showed significant clinical improvement and no postoperative instability at 1 and 2 years after surgery.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Early Outcomes After Arthroscopic Hip Capsular Reconstruction Using Iliotibial Band Allograft Versus Dermal Allograft

PURPOSE

To compare the clinical outcomes between 2 groups of patients who underwent arthroscopic hip capsular reconstruction with the same surgical technique with an iliotibial band (ITB) allograft versus dermal allograft tissue.

METHODS

From March 2013 to October 2015, patients who were 18 years of age or older and who underwent revision arthroscopic hip surgery with capsular reconstruction by the senior author were identified. Patients who were younger than 18 years old, had a lateral center-edge angle <20° or Tonnis osteoarthritis grade 2 or 3, or refused to participate were excluded. Patients were assigned to 2 groups based on whether an ITB (ITB group) or a dermal allograft (dermal group) was used to reconstruct the capsule. The ITB graft was used initially, then the dermal graft was used when it was available. The dimensions were based on the intraoperative measurement of the capsular defect, and the thickness was 3 mm. Other treatments included labral debridement, repair, or reconstruction; treatment of residual femoroacetabular impingement; and treatment of cartilage damage. Clinical outcome scores including the Hip Outcome Score (HOS)-Activity of Daily Living scale (primary outcome measure), modified Harris Hip Score, HOS-Sports scale, SF-12, and Western Ontario & McMaster Universities Osteoarthritis Index were compared between the groups in addition to the failure rate (conversion to total hip arthroplasty, revision hip arthroscopy) and patient satisfaction rate with the outcome (range, 1-10).

RESULTS

Thirty-six patients (9 men and 27 women) met the inclusion criteria. Each group consisted of 18 patients (18 hips) with a mean age of 30.9 ± 9.4 years in the ITB group and a mean age of 29.8 ± 9.4 years in the dermal group (P = .718). There were no differences in patient demographics, physical examination findings, or imaging characteristics. The procedure failed for 8 patients (4 in the ITB group and 4 in the dermal group), and another surgery was required (P = 1.0). Additional surgeries included 3 total hip arthroplasties, 1 periarticular osteotomy, and 4 revision arthroscopies. The mean follow-up time was 25 months (range, 18-38 months) in both groups (P = .881). At follow-up, the HOS-Activity of Daily Living scale, SF-12, modified Harris Hip Score, and HOS-Sports scale measures were significantly higher in the ITB group than in the dermal group (P < .05). A greater percentage of patients reached minimum clinically important difference in the ITB group for Western Ontario & McMaster Universities Osteoarthritis Index and HOS scales with the minimum clinically important difference for HOS-Sports scale being significantly higher in the ITB group (P = .04). Patient satisfaction scores were 8 and 6 in the ITB and dermal groups, respectively.

CONCLUSIONS

At a mean follow-up time of 25 months, hip capsular reconstruction with an ITB allograft results in improved clinical outcomes compared with the dermal allograft. A similar failure rate was noted in both groups, but a greater percentage of patients in the ITB group achieved clinical improvement.

Hip Arthroscopic Management Can Improve Osteitis Pubis and Bone Marrow Edema in Competitive Soccer Players With Femoroacetabular Impingement

BACKGROUND

There is a dearth of knowledge regarding the correlation between femoroacetabular impingement (FAI) and osteitis pubis (OP) among symptomatic soccer players.

PURPOSE

To elucidate whether arthroscopic FAI correction is effective for young competitive soccer players with FAI combined with OP or perisymphyseal pubic bone marrow edema (BME).

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 577 consecutive patients who underwent arthroscopic FAI correction were retrospectively reviewed with a minimum 2-year follow-up. Competitive soccer players who were professional, college, and high school athletes were included. The authors assessed the modified Harris Hip Score and Nonarthritic Hip Score preoperatively and at 6 months, 1 year, and 2 years after surgery. In addition, players were divided into groups according to radiographic evidence of OP and BME (2 groups each). Clinical outcomes, return to play, and radiographic assessments were compared between groups.

RESULTS

Twenty-eight hips met the inclusion criteria. The median modified Harris Hip Score significantly improved after hip arthroscopy (81.4, preoperatively; 95.7 at 6 months, P = .0065; 100 at 1 year, P = .0098; 100 at 2 years, P = .013). The median Nonarthritic Hip Score also significantly improved (75.0, preoperatively; 96.3 at 6 months, P = .015; 98.8 at 1 year, P = .0029; 100 at 2 years, P = .015). Furthermore, 92.0% of players returned to play soccer at the same or higher level of competition at a median 5.5 months (range, 4-15 months); 67.8% had radiological confirmation of OP; and 35.7% had pubic BME. The alpha angle was significantly higher in pubic BME group than the no-pubic BME group (64.8° vs 59.2°, P = .027), although there was no significant difference between the OP and no-OP groups. The prevalence of tenderness of the pubic symphysis significantly decreased preoperatively (32.1%) to postoperatively (3.6%). Magnetic resonance imaging findings confirmed that pubic BME disappeared in all players at a median 11 months (range, 6-36) after initial surgery.

CONCLUSIONS

Arthroscopic management for FAI provides favorable clinical outcomes, a high rate of return to sports, and, when present, resolution of pubic BME among competitive soccer players.

Hip Joint Torsional Loading Before and After Cam Femoroacetabular Impingement Surgery

BACKGROUND

Surgical management of cam femoroacetabular impingement (FAI) aims to preserve the native hip and restore joint function, although it is unclear how the capsulotomy, cam deformity, and capsular repair influence joint mechanics to balance functional mobility.

PURPOSE

To examine the contributions of the capsule and cam deformity to hip joint mechanics. Using in vitro, cadaveric methods, we examined the individual effects of the surgical capsulotomy, cam resection, and capsular repair on passive range of motion and resistance of applied torque.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Twelve cadaveric hips with cam deformities were skeletonized to the capsule and mounted onto a robotic testing platform. The robot positioned each intact hip in multiple testing positions: (1) extension, (2) neutral 0°, (3) flexion 30°, (4) flexion 90°, (5) flexion-adduction and internal rotation (FADIR), and (6) flexion-abduction and external rotation. Then the robot performed applicable internal and external rotations, recording the neutral path of motion until a 5-N·m of torque was reached in each rotational direction. Each hip then underwent a series of surgical stages (T-capsulotomy, cam resection, capsular repair) and was retested to reach 5 N·m of internal and external torque again after each stage. During the capsulotomy and cam resection stages, the initial intact hip's recorded path of motion was replayed to measure changes in resisted torque.

RESULTS

Regarding changes in motion, external rotation increased substantially after capsulotomies, but internal rotation only further increased at flexion 90° (change +32%, P = .001, d = 0.58) and FADIR (change +33%, P < .001, d = 0.51) after cam resections. Capsular repair provided marginal restraint for internal rotation but restrained the external rotation compared with the capsulotomy stage. Regarding changes in torque, both internal and external torque resistance decreased after capsulotomy. Compared with the capsulotomy stage, cam resection further reduced internal torque resistance during flexion 90° (change -45%, P < .001, d = 0.98) and FADIR (change -37%, P = .003, d = 1.0), where the cam deformity accounted for 21% of the intact hip's torsional resistance in flexion 90° and 27% in FADIR.

CONCLUSION

Although the capsule played a predominant role in joint constraint, the cam deformity provided 21% to 27% of the intact hip's resistance to torsional load in flexion and internal rotation. Resecting the cam deformity would remove this loading on the chondrolabral junction.

CLINICAL RELEVANCE

These findings are the first to quantify the contribution of the cam deformity to resisting hip joint torsional loads and thus quantify the reduced loading on the chondrolabral complex that can be achieved after cam resection.

Periportal Capsulotomy: A Technique for Limited Violation of the Hip Capsule During Arthroscopy for Femoroacetabular Impingement

Hip arthroscopy has become the standard treatment for symptomatic femoroacetabular impingement as patients have shown good outcomes and high satisfaction with this intervention. However, capsular management to gain access for intra-articular procedures remains greatly debated. Capsular closure is advocated particularly in the setting of interportal or T-capsulotomy to avoid complications of instability or nonhealing capsule. We introduce a technique for capsular management through a limited periportal capsulotomy during arthroscopic treatment of femoroacetabular impingement. In using dilation of the anterolateral and mid-anterior portals without completion of a full interportal capsulotomy, the stabilizing iliofemoral ligament is preserved. We have found that periportal capsulotomy provides safe and sufficient access to the hip joint without necessitating capsular closure.