Capsule Closure of Periportal Capsulotomy for Hip Arthroscopy

No Differences in Clinical Outcomes Between Hip Arthroscopy With Versus Without Capsular Closure in Patients With Cam- or Mixed-Type Femoroacetabular Impingement: A Randomized Controlled Trial

PURPOSE

To compare 2-year clinical outcomes of primary hip arthroscopy with versus without capsular closure after interportal capsulotomy in patients with cam- or mixed-type femoroacetabular impingement (FAI).

METHODS

Patients with cam- or mixed-type FAI undergoing primary hip arthroscopy with interportal capsulotomy were prospectively enrolled in this randomized controlled trial (RCT) and allocated into either capsular closure or no capsular closure groups. Patients were blinded to group allocation. Clinical outcomes were assessed preoperatively and at 2-year follow-up using the 12-item International Hip Outcome Tool (iHOT-12), modified Harris Hip Score (mHHS), and 6 subsections of the Copenhagen Hip and Groin Outcome Score (HAGOS). Complications and reoperations were noted.

RESULTS

Eighty-four patients (100 hips) were enrolled, 49 hips in the capsular closure group and 51 in the no capsular closure group, with no significant differences in age (28.5 ± 7.5 vs 30.4 ± 8.4, P = .261), body mass index (23.5 ± 3.0 vs 23.4 ± 1.9, P = .665), and sex distribution (female: 10.2% vs 13.7%, P = .760). Four patients were lost to follow-up (2.0% vs 5.9%, P = .618) and 6 had reoperations (6.1% vs 5.9%, P = 1.000), which left 45 hips per group for clinical assessment. There were no significant differences between groups in the net change of iHOT-12 (28.3 ± 19.6 vs 32.5 ± 22.7, P = .388), mHHS (7.6 ± 13.1 vs 7.5 ± 10.2, P = .954), and subsections of HAGOS (P > .05). Complication rates were also similar between groups (P > .05).

CONCLUSIONS

The present RCT compared primary hip arthroscopy with versus without capsular closure after interportal capsulotomy in a male-dominated, non-dysplastic, non-arthritic cohort with cam- or mixed-type FAI and found no significant differences in patient-reported clinical outcomes, complication rates, or reoperation rates.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Capsular Management During Hip Arthroscopy

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.

Hypermobile Patients With Femoroacetabular Impingement Syndrome Can Be Effectively Treated Utilizing Hip Arthroscopy With Periportal Capsulotomy Closure: A Matched Cohort Analysis Compared to Patients Without Joint Hypermobility

PURPOSE

To assess the 2-year outcomes of arthroscopic treatment with periportal capsulotomy closure for femoroacetabular impingement syndrome (FAIS) in patients with generalized ligamentous laxity (GLL).

METHODS

A retrospective analysis was performed from a prospectively collected database of FAIS patients undergoing hip arthroscopy. FAIS patients with GLL were identified as having Beighton score ≥4. FAIS patients with GLL were treated with arthroscopic labral repair, osteochondroplasty, via periportal capsulotomy with subsequent capsular closure. These patients were matched by age, sex, and body mass index (BMI) with a cohort of FAIS patients without GLL who underwent the same procedure via periportal capsulotomy without capsular closure. Preoperatively, and 2 years postoperatively, patients completed patient-reported outcomes (PRO) scores, including the Hip Disability and Osteoarthritis Outcome Score (HOOS), 12-item Short-Form survey (SF-12) and the visual analog scale (VAS).

RESULTS

Forty patients (5 male, 35 female) with FAIS and GLL were included (age: 29.7 ± 9.0; BMI: 23.3 ± 4.1). FAIS patients with GLL demonstrated similar significant PRO score improvements compared to a matched cohort of FAIS patients without GLL at 2 years after surgery (VAS Pain: (-)2.5 ± 3.0, (-)2.7 ± 2.7; SF-12 PCS: 17.7 ± 14.2, 16.7 ± 15.0; HOOS-Symptoms: 26.3 ± 24.0, 20.6 ± 18.1; HOOS-Pain: 29.8 ± 20.4, 24.4 ± 9.0; HOOS-ADL: 24.9 ± 18.4, 22.0 ± 19.9; HOOS-Sports: 43.6 ± 26.1, 33.1 ± 29.8; and HOOS-QOL: 44.2 ± 27.6, 41.7 ± 27.1, respectively). Both cohorts achieved minimal clinically important differences (MCID) for each HOOS subscore at equivalent high rates (70-88%).

CONCLUSIONS

Patients with GLL in the setting of FAIS can be effectively treated with arthroscopy via periportal capsulotomy and capsular closure. These patients demonstrate significant improvements in PRO scores at 2 years, similar to normal laxity FAIS patients undergoing arthroscopic treatment via periportal capsulotomy without capsular closure.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Editorial Commentary: Interportal Capsulotomy for Hip Arthroscopy in Patients With Borderline Hip Dysplasia May Result in Inferior Outcomes: Periportal Capsulotomy May Reduce Hip Capsular Damage

Management of the hip capsule remains an ongoing discussion in the field of hip arthroscopy. Interportal and T-capsulotomies remain the most common approaches to gain access to the hip during surgery, and biomechanical and clinical research supports repair of these types of capsulotomies. Less is known, however, about the quality of the tissue that heals at these repair sites during the postoperative period, particularly in the setting of patients with borderline hip dysplasia. The capsular tissue provides important joint stability to these patients, and disruption to the capsule can result in significant functional impairments. There is also an association between borderline hip dysplasia and joint hypermobility, which increases the risk of insufficient healing after capsular repair. Patients with borderline hip dysplasia show poor capsular healing after arthroscopy followed by interportal hip capsule repair, and incomplete healing results in inferior patient-reported outcomes. Periportal capsulotomy may limit capsular violation and improve outcomes.

Knotless Implant for Arthroscopic Hip Capsule Closure

The hip joint capsule plays a significant role in maintaining hip stability, including translation and rotation. Hip capsular closure or plication has been shown to increase stability of the joint following capsulotomy in hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS) and/or associated labral tears. This technique article describes a knotless method of closing the hip capsule.

Arthroscopic Capsular Suture-Lifting Technique for Treating Femoroacetabular Impingement Patients With a High Risk of Postoperative Anterior Instability

With the increasing popularity of hip arthroscopy, postoperative iatrogenic instability due to bony and soft-tissue issues has been noted by more orthopaedic surgeons. Although there is a low risk of serious complications in patients with normal hip joint development even without suturing of the joint capsule, for patients with a preoperative high risk of anterior instability-including those with excessive anteversion of the acetabulum or femur, borderline dysplasia of the hip, and hip arthroscopic revision surgery with an anterior defect of the joint capsule-capsulotomy without repair will result in postoperative anterior instability of the hip joint and related symptoms. Capsular suturing techniques that provide anterior stabilization will be of great help for these high-risk patients and reduce the possibility of postoperative anterior instability. In this Technical Note, we introduce the arthroscopic capsular suture-lifting technique for treating femoroacetabular impingement (FAI) patients with a high risk of postoperative hip instability. In the past 2 years, the capsular suture-lifting technique has been used to treat FAI patients with borderline dysplasia of the hip and excessive femoral neck anteversion, and clinical results have shown that the suture-lifting technique provides a reliable and effective solution for FAI patients with a high risk of postoperative anterior hip instability.