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Metz AK, Lewis DC, Froerer DL, Featherall J, Rosenthal RM, Khalil AZ, Aoki SK. Dysplastic Hips Have Decreased Iliofemoral Ligament Thickness on Coronal Sequences in Magnetic Resonance Imaging: A Matched Cohort Analysis. Arthroscopy 2024:S0749-8063(24)00417-1. [PMID: 38944323 DOI: 10.1016/j.arthro.2024.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 05/18/2024] [Accepted: 05/30/2024] [Indexed: 07/01/2024]
Abstract
PURPOSE To characterize hip capsule thickness on advanced imaging in patients with and without hip dysplasia and to also evaluate differences in capsular thickness between borderline and true dysplastic patients. METHODS Patients evaluated by the senior author for concerns of hip pathology from June 2020 to June 2021 were queried and images reviewed to determine dysplasia status by lateral center edge angle (LCEA) ≤ 25 degrees. A group of non-dysplastic patients was identified and matched for age, sex, and body mass index (BMI). Hip capsular thickness was quantified using MRI. A sub-analysis was conducted to compare true dysplastic patients (LCEA < 20°) to borderline dysplastic patients (LCEAs between 20 - 25°). Analysis included independent samples t-tests, Chi-square tests, and multivariable regression. RESULTS Eighty total patients were included, with a mean age of 31.8 ± 11.7 years, a mean BMI of 26.6 ± 6.5 points, and 70% (56) female patients. Dysplastic patients had a mean LCEA of 19.8 ± 4.3 degrees. Dysplastic individuals had decreased capsular thickness compared to their non-dysplastic controls (2.75 ± 0.96 vs 3.52 ± 1.22 mm, p = 0.003). Multivariable regression showed decreased capsular thickness associated with decreased LCEAs (β = 2.804, R = 0.432, p<0.001) and dysplasia (β = -0.709, R2 = 0.056, p = 0.004). Results of a sub-analysis of the dysplastic group examining differences between accepted definitions of borderline dysplasia and true dysplasia showed no significant differences in capsular thickness between the two groups (p = 0.379). CONCLUSIONS Patients with hip dysplasia were found to have thinner iliofemoral ligaments in the coronal plane on magnetic resonance imaging on magnetic resonance imaging. Further investigation is needed to evaluate any potential implications with hip instability given the thinner hip capsule demonstrated in this study.
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Affiliation(s)
- Allan K Metz
- University of Utah, Department of Orthopaedic Surgery, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Daniel C Lewis
- University of Utah, Department of Orthopaedic Surgery, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Devin L Froerer
- University of Utah, Department of Orthopaedic Surgery, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Joseph Featherall
- University of Utah, Department of Orthopaedic Surgery, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Reece M Rosenthal
- University of Utah, Department of Orthopaedic Surgery, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Ameen Z Khalil
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Stephen K Aoki
- University of Utah, Department of Orthopaedic Surgery, 590 Wakara Way, Salt Lake City, UT 84108, USA.
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Arshad Z, Marway P, Shoman H, Ubong S, Hussain A, Khanduja V. Hip Arthroscopy in Patients With Generalized Joint Hypermobility Yields Successful Outcomes: A Systematic Review. Arthroscopy 2024; 40:1658-1669. [PMID: 37952744 DOI: 10.1016/j.arthro.2023.10.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 10/19/2023] [Accepted: 10/25/2023] [Indexed: 11/14/2023]
Abstract
PURPOSE To evaluate the outcomes of hip arthroscopy in patients with generalized joint hypermobility (GJH). METHODS A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses. An electronic record search was performed in PubMed, Web of Science, Cochrane Library, and Embase. A 2-stage title/abstract and full-text screening was performed using the following inclusion criteria: (1) observational studies, cohort studies, and randomized controlled trials; (2) describing more than 5 patients with a mean age over 18 years and GJH; (3) undergoing arthroscopy of the hip; (4) reporting patient-reported outcome measures (PROMs), return to sport, or complications/reoperations; and (5) published in English. RESULTS Of the 517 articles identified, 10 studies meeting all selection criteria were included. Included studies report significant improvements in a range of different functional and pain-based PROMs. Most patients (25.0%-97.0%) in each study achieved a clinically important improvement postoperatively in at least 1 PROM. No complications were described in any of the 4 studies reporting this metric. One study each found an association between GJH and an increased risk of postoperative deep gluteal syndrome and iliopsoas tendinitis. The rate of revision arthroscopy ranged from 0% to 11.4%, and only 2 patients in a single study of 11 hips required conversion to total hip arthroplasty. No statistically significant differences were reported between patients with and without GJH with respect to any of the described outcomes. CONCLUSIONS Patients with GJH may achieve good outcomes following hip arthroscopy with respect to PROMs, perioperative complications, reoperation, and return to sport. With effective labral repair and capsular closure, outcomes achieved in patients with GJH are comparable to those reported in patients without hypermobility. LEVEL OF EVIDENCE Level IV, systematic review of level III to IV studies.
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Affiliation(s)
- Zaki Arshad
- University Hospitals Leicester NHS Trust, Leicester, England
| | | | - Haitham Shoman
- Department of Experimental Surgery, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Sonia Ubong
- Department of Surgery, University of Cambridge, Cambridge, England
| | - Ali Hussain
- East Kent Hospitals University NHS Foundation Trust, Kent, England
| | - Vikas Khanduja
- Young Adult Hip Service, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England.
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Froerer DL, Khalil AZ, Metz AK, Rosenthal RM, Featherall J, Maak TG, Aoki SK. Magnetic Resonance Imaging and Magnetic Resonance Arthrography Are Both Reliable and Similar When Measuring Hip Capsule Thickness in Patients With Femoroacetabular Impingement Syndrome. Arthrosc Sports Med Rehabil 2024; 6:100874. [PMID: 38328530 PMCID: PMC10847024 DOI: 10.1016/j.asmr.2023.100874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 12/19/2023] [Indexed: 02/09/2024] Open
Abstract
Purpose To propose an accurate method of measuring hip capsular thickness in patients with femoroacetabular impingement syndrome and to compare the reliability of these measurements between magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA). Methods A previously established database of patients with femoroacetabular impingement syndrome (FAIS) was used to identify candidates with preoperative MRI or MRA from November 2018 to June 2021. Two reviewers independently examined preoperative imaging for 85 patients. Capsular thickness was measured in 12 standardized locations. Intraclass correlation coefficients (ICCs) were calculated using an absolute-agreement, 2-way random-effects model. Using the same method, 30 patients were randomly selected for repeat measurements by 1 reviewer following a washout period. Ten additional patients with preoperative MRI and MRA of the same hip were identified to compare measurements between modalities using paired samples t test. Results ICCs for measurements on MRIs and MRAs using these proposed measurements to compare inter-rater reliability were 0.981 and 0.985. ICCs calculated using measurements by a single reviewer following a washout period for intrarater reliability were 0.998 and 0.991. When comparing MRI and MRA measurements in the same patient, t test for all pooled measurements found no difference between modality (P = .283), and breakdown of measurements by quadrant found no difference in measurements (P > .05), with the exception of the inferior aspect of the capsule on coronal sequences (P = .023). Conclusions In patients with FAIS, both MRI and MRA have excellent reliability for quantifying hip capsular thickness. A difference in capsular thickness was found only when comparing MRI and MRA on inferior coronal aspects of the hip capsule, indicating interchangeability of these imaging modalities when measuring the clinically important aspects of the hip capsule. Level of Evidence Level IV, diagnostic case series.
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Affiliation(s)
- Devin L. Froerer
- School of Medicine, University of Utah, Salt Lake City, Utah, U.S.A
| | - Ameen Z. Khalil
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, U.S.A
| | - Allan K. Metz
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, U.S.A
| | - Reece M. Rosenthal
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, U.S.A
| | - Joseph Featherall
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, U.S.A
| | - Travis G. Maak
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, U.S.A
| | - Stephen K. Aoki
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, U.S.A
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Ohlsen SM, Metz AK, Froerer DL, Mortensen AJ, Smith TR, Featherall J, Rosenthal RM, Aoki SK. Relationship Between Hip Capsular Thickness and Instability After Previous Hip Arthroscopic Surgery: A Matched-Cohort Analysis. Orthop J Sports Med 2024; 12:23259671241231763. [PMID: 38449694 PMCID: PMC10916485 DOI: 10.1177/23259671241231763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 08/29/2023] [Indexed: 03/08/2024] Open
Abstract
Background Thinner anterior hip capsules are associated with hip laxity, but there is little known about the impact of capsular thickness on the development of instability after primary hip arthroscopic surgery. Purpose To investigate the relationship between hip capsular thickness as measured on preoperative magnetic resonance imaging (MRI) and the development of hip instability after hip arthroscopic surgery for femoroacetabular impingement. Study Design Case-control study; Level of evidence, 3. Methods We reviewed revision hip arthroscopic procedures performed between January 1, 2019, and May 1, 2021, at a single institution. Inclusion criteria were preoperative MRI/magnetic resonance arthrography, completion of the study traction protocol, and asymmetric distraction between the hips of ≥3 mm on examination under anesthesia. A comparison group of patients treated for femoroacetabular impingement with primary hip arthroscopic surgery who did not develop capsular instability were matched 1:1 to the patients with instability. Superolateral hip capsular thickness was measured on MRI before index surgery. Analysis was conducted using independent-samples t tests and multivariable linear regression. Results A total of 44 patients were included, with 22 patients each in the instability and no-instability groups. The mean capsular thickness was lower in the patients with hip instability than in those without (1.9 ± 0.6 vs 3.4 ± 1.1 mm, respectively; P < .001). Decreased capsular thickness was significantly associated with hips with instability versus no-instability (β = -1.468 [95% CI, -2.049 to -0.887]; P < .001). Conclusion Thinner preoperative hip capsules in the region of the iliofemoral ligament were seen in patients who subsequently underwent revision arthroscopic surgery for hip instability compared to patients who underwent primary hip arthroscopic surgery without subsequent revision. Patients at a higher risk for the development of postoperative hip instability had a superolateral hip capsular thickness of <2 mm.
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Affiliation(s)
| | - Allan K. Metz
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| | - Devin L. Froerer
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | | | - Tyler R. Smith
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Joseph Featherall
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| | - Reece M. Rosenthal
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| | - Stephen K. Aoki
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
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Harris JD. Editorial Commentary: Femoral Version and Capsular Thickness Analysis in Hip Preservation Surgery-Surgical Indications Are as Important as Surgical Technique. Arthroscopy 2024; 40:78-80. [PMID: 38123275 DOI: 10.1016/j.arthro.2023.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 07/02/2023] [Accepted: 07/04/2023] [Indexed: 12/23/2023]
Abstract
Optimal treatment of patients with femoroacetabular impingement syndrome requires both thoughtful decision-making and skillful operative technique. Traditional evidence-based literature and routine clinical practice overemphasize the role of the alpha angle on the femoral side and lateral center edge angle on the acetabular side. Femoral and acetabular version are critical values that influence outcomes and warrant measurement and consideration. Without version analysis, an uniformed, possibly poor, decision may be made. The literature and clinical practice also place dichotomous emphasis on labral (torn/intact) and capsular (torn/intact) integrity, with minimal appreciation of the morphological details of both. Not all capsules are created equal. "Normal" capsule thickness is a nebulous concept, with thinner anterior capsules more prone to anterior instability. Intuitively, it biomechanically stands to reason that excessive femoral anteversion (and excessive anterior cranial and central acetabular version) would place additional stress on the anterior capsule. Excessive femoral anteversion is associated with a thinner anterior capsule. Whether the latter is a reactive process (implies causation) or simply 2 concordant metrics (only correlation) has yet to be determined. In patients with nonarthritic hip pain, comprehensive quantitative consideration of both femoral and acetabular version and capsular thickness determines the optimal hip preservation procedure. Surgical indications are as important as surgical technique.
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Hartwell MJ, Moulton SG, Zhang AL. Capsular Management During Hip Arthroscopy. Curr Rev Musculoskelet Med 2023; 16:607-615. [PMID: 37436651 PMCID: PMC10733234 DOI: 10.1007/s12178-023-09855-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE OF REVIEW Hip arthroscopy is widely used for the management of intra-articular pathology and there has been growing interest in strategies for management of the hip capsule during surgery. The hip capsule is an essential structure that provides stability to the joint and it is necessarily violated during procedures that address intra-articular pathology. This article reviews different approaches to capsular management during hip arthroscopy including anatomical considerations for capsulotomy, techniques, clinical outcomes, and the role of routine capsular repair. This article also reviews the concept of hip microinstability and its potential impact on capsular management options as well as iatrogenic complications that can occur as a result of poor capsular management. RECENT FINDINGS Current research highlights the key functional role of the hip capsule and the importance of preserving its anatomy during surgery. Capsulotomies that involve less tissue violation (periportal and puncture-type approaches) do not appear to require routine capsular repair to achieve good outcomes. Many studies have investigated the role of capsular repair following more extensive capsulotomy types (interportal and T-type), with most authors reporting superior outcomes with routine capsular repair. Strategies for capsular management during hip arthroscopy range from conservative capsulotomy techniques aimed to minimize capsular violation to more extensive capsulotomies with routine capsule closure, all of which have good short- to mid-term outcomes. There is a growing trend towards decreasing iatrogenic capsular tissue injury when possible and fully repairing the capsule when larger capsulotomies are utilized. Future research may reveal that patients with microinstability may require a more specific approach to capsular management.
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Affiliation(s)
- Matthew J Hartwell
- Department of Orthopaedic Surgery, University of California-San Francisco, 1500 Owens Street, Box 3004, San Francisco, CA, 94158, USA
| | - Samuel G Moulton
- Department of Orthopaedic Surgery, University of California-San Francisco, 1500 Owens Street, Box 3004, San Francisco, CA, 94158, USA
| | - Alan L Zhang
- Department of Orthopaedic Surgery, University of California-San Francisco, 1500 Owens Street, Box 3004, San Francisco, CA, 94158, USA.
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Devitt BM, Harrington CÍ. Editorial Commentary: Patients With Thin Hip Capsules, Capsular Redundancy, Capsular Defects, Hypermobility, Dysplasia, and Female Patients Are at Increased Risk of Hip Instability. Arthroscopy 2022; 38:3141-3142. [PMID: 36462779 DOI: 10.1016/j.arthro.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 06/10/2022] [Indexed: 12/05/2022]
Abstract
Patients with thin hip capsules, capsular redundancy, capsular defects, hypermobility, dysplasia, and female patients are at increased risk of hip instability. As our understanding of the factors that contribute to hip instability has increased, so too has our ability to identify "at-risk" patients, in whom we should avoid surgery or perform capsular repair or plication following hip arthroscopy to achieve optimal results. We must tailor our surgical planning accord to gender, bony morphology, capsular volume, and properties of the tissue.
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