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Vidal Leão R, Fernandes Batista Pereira R, Omena Martins R, Sayuri Yamachira V, Tokechi Amaral D, Ejnisman L, de Paula Correa MF, Partezani Helito PV. Imaging evaluation of hip capsule disorders: a comprehensive review. Skeletal Radiol 2024:10.1007/s00256-024-04766-5. [PMID: 39096373 DOI: 10.1007/s00256-024-04766-5] [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: 06/13/2024] [Revised: 07/20/2024] [Accepted: 07/22/2024] [Indexed: 08/05/2024]
Abstract
The hip capsule and capsular ligaments play crucial roles in providing hip stability and mobility. Their role in hip pathologies is being increasingly recognized, underscoring the need for thorough imaging evaluation, which is better performed through MRI-arthrography. Various diseases affect the hip capsule directly or indirectly. Improper mechanical loading, as seen in conditions such as femoroacetabular impingement or chondrolabral pathology, can induce capsule thickening, whereas thinning and laxity of the capsule are characteristics of microinstability. Inflammatory conditions, including adhesive capsulitis of the hip, crystal deposition disease, polymyalgia rheumatica, and infections, also lead to capsular changes. Traumatic events, particularly posterior hip dislocations, cause capsule ligament disruption and may lead to hip macroinstability. Friction syndromes can lead to capsular edema due to impingement of the adjacent capsule. Hip arthroscopy can result in various postoperative findings ranging from fibrotic adhesions to focal or extensive capsule discontinuation. Although the significance of hip capsule thickness and morphology in the pathogenesis of hip diseases remains unclear, radiologists must recognize capsule alterations on imaging evaluation. These insights can aid clinicians in accurately diagnosing and effectively managing patients with hip conditions.
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Affiliation(s)
- Renata Vidal Leão
- Musculoskeletal Division, University of Iowa Hospitals and Clinics, Iowa, IA, USA.
| | | | - Raul Omena Martins
- Radiology Department, Hospital Sírio-Libanês, R Adma Jafet, São Paulo, 101, Brazil
| | | | | | - Leandro Ejnisman
- Institute of Orthopaedics and Traumatology, Av. Albert Einstein, 627/701, Morumbi, São Paulo, Brazil
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Hoffer AJ, Beel W, Ng KG, Degen RM. The Contribution of Soft Tissue and Bony Stabilizers to the Hip Suction Seal: A Systematic Review of Biomechanical Studies. Am J Sports Med 2024; 52:2657-2666. [PMID: 38318815 PMCID: PMC11344966 DOI: 10.1177/03635465231208193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 08/30/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Previous biomechanical studies have identified capsular closure, labral repair or reconstruction, and osteochondroplasty as important surgical interventions to improve hip stability. PURPOSE To investigate the outcome metrics used to quantify hip stability and assess and measure the relative contributions of the labrum, capsule, and bone to hip stability through a quantitative analysis. STUDY DESIGN Systematic review and meta-analysis; Level of evidence, 4. METHODS PubMed and Embase databases were searched using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included studies evaluated cadaveric hip biomechanics related to capsular, labral, and bony management during hip arthroscopy. Studies were assessed for distraction force and distance, fluid measures, and contact forces used to quantify the suction seal. Exclusion criteria included open surgery, arthroplasty, reorientation osteotomy, or traumatic dislocation. RESULTS A total of 33 biomechanical studies comprising 322 hips that evaluated 1 or more of the following were included: distraction force or distance (24 studies), fluid measures (10 studies), and contact forces (6 studies). Compared with a capsulotomy or capsulectomy, capsular repair or reconstruction demonstrated greater resistance to distraction (standardized mean difference [SMD], 1.13; 95% CI, 0.46-1.80; P = .0009). Compared with a labral tear, a labral repair or reconstruction demonstrated less resistance to distraction (SMD, -0.67; 95% CI, -1.25 to -0.09; P = .02). Compared with a labral debridement, repair or reconstruction demonstrated greater resistance to distraction (SMD, 1.74; 95% CI, 1.23 to 2.26; P < .00001). No quantitative analysis was feasible from studies evaluating the effect of osseous resection due to the heterogeneity in methodology and outcome metrics assessed. CONCLUSION Most biomechanical evidence supports capsulotomy repair or reconstruction to improve hip distractive stability at the end of hip arthroscopic surgery. While the repair of a torn labrum does not improve distractive resistance, it is superior to labral debridement in most biomechanical studies.
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Affiliation(s)
- Alexander J. Hoffer
- Department of Surgery, The University of Western Ontario, London, Ontario, Canada
- Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada
| | - Wouter Beel
- Department of Surgery, The University of Western Ontario, London, Ontario, Canada
- Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada
| | - K.C. Geoffrey Ng
- Department of Surgery, The University of Western Ontario, London, Ontario, Canada
- Department of Medical Biophysics, The University of Western Ontario, London, Ontario, Canada
- Department of Medical Imaging, The University of Western Ontario, London, Ontario, Canada
- Robarts Research Institute, The University of Western Ontario, London, Ontario, Canada
| | - Ryan M. Degen
- Department of Surgery, The University of Western Ontario, London, Ontario, Canada
- Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada
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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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Kaplan DJ. Editorial Commentary: Protected Physical Therapy and Rehabilitation Is Essential After Hip Capsule and Labral Repair. Arthroscopy 2024:S0749-8063(24)00412-2. [PMID: 38866375 DOI: 10.1016/j.arthro.2024.06.006] [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: 06/04/2024] [Accepted: 06/05/2024] [Indexed: 06/14/2024]
Abstract
Hip arthroscopy is an effective procedure with rapidly improving techniques and implants. Routine labral and capsular repair are broadly agreed upon as standard of care in most cases, which is now supported by long-term outcome studies. A crucial component of patient postoperative success is physical therapy. While accelerated programs are appealing, biomechanical studies have consistently demonstrated decreased stability at time zero after hip arthroscopy, particularly labral repairs. Therefore, although we want to help our patients get back to their lives as soon as possible, it remains our responsibility to protect their hip in the early postoperative period. If, in ideal laboratory conditions, we cannot restore stability to an intact state, then we must presuppose that the suction seal improves as the capsule, and more importantly, the labrum, heals after surgical manipulation. This means we are not able to rely solely on the strength of our repair, and there is a distinct period where the repaired hip is particularly vulnerable. Most hip arthroscopy protocols use a protective period, ranging from 4 to 8 weeks, during which there is an emphasis on passive range of motion only, with a strict moratorium on "pushing beyond pain."
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Hoffer AJ, St George SA, Lanting BA, Degen RM, Ng KCG. Hip Labral and Capsular Repair Are Unable to Restore Distractive Stability in a Biomechanical Model. Arthroscopy 2024:S0749-8063(24)00306-2. [PMID: 38697324 DOI: 10.1016/j.arthro.2024.04.011] [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: 01/25/2024] [Revised: 03/22/2024] [Accepted: 04/07/2024] [Indexed: 05/04/2024]
Abstract
PURPOSE To evaluate the change in hip distractive stability after a capsulotomy, labral tear, and simultaneous repair of both the capsule and the labrum in a biomechanical model. METHODS Ten fresh-frozen human cadaveric hips were analyzed using a materials testing system to measure the distractive force and distance required to disrupt the hip suction seal under the following conditions: (1) native intact capsule and labrum, (2) 2- or 4-cm interportal capsulotomy (IPC), (3) labral tear, (4) T extension, (5) labral repair, (6) T extension repair, and (7) IPC repair. Each specimen was retested at 0° of flexion, 45° of flexion, and 45° of flexion with 15° of internal rotation. RESULTS A significantly higher distractive force was required to rupture the suction seal in the intact condition compared with IPC (P = .012; 95% confidence interval [CI], 4.9-42.4); IPC and labral tear (P = .002; 95% CI, 11.3-49.4); IPC, labral tear, and T extension (P = .001; 95% CI, 13.9-51.5); IPC, labral repair, and T extension (P < .001; 95% CI, 20.8-49.7); IPC, labral repair, and T extension repair (P = .002; 95% CI, 12.5-52.4); and IPC repair, labral repair, and T extension repair (P = .01; 95% CI, 5.8-46.1). The IPC condition required a higher distractive force in isolation than when combined with a labral tear (P = .14; 95% CI, 1.2-12.0), T extension (P = .005; 95% CI, 2.8-15.3), or labral repair (P = .002; 95% CI, 4.4-18.8). CONCLUSIONS The distractive resistance of an intact hip capsule and labrum was not restored once the soft tissues were violated, despite labral repair with a loop technique and capsular repair with interrupted figure-of-8 sutures. CLINICAL RELEVANCE Time-zero complete capsular repair with concomitant labral repair may not be adequate to restore distractive hip stability after hip arthroscopy, reinforcing the use of postoperative precautions in the early postoperative period.
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Affiliation(s)
| | | | - Brent A Lanting
- Department of Surgery, Western University, London, Ontario, Canada
| | - Ryan M Degen
- Department of Surgery, Western University, London, Ontario, Canada; Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada
| | - K C Geoffrey Ng
- Department of Surgery, Western University, London, Ontario, Canada; Department of Medical Biophysics, Western University, London, Ontario, Canada; Department of Medical Imaging, Western University, London, Ontario, Canada; Robarts Research Institute, Western University, London, Ontario, Canada.
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Fırat A, Veizi E, Koutserimpas C, Alkan H, Şahin A, Güven Ş, Erdoğan Y. Extended Interportal Capsulotomy for Hip Arthroscopy, a Single-Center Clinical Experience. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:738. [PMID: 38792921 PMCID: PMC11123463 DOI: 10.3390/medicina60050738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 05/26/2024]
Abstract
Background and Objectives: The number of hip arthroscopy procedures is on the rise worldwide, and awareness regarding proper management of the hip capsule has increased. No capsulotomy shape is agreed upon as a standard approach, with literature supporting both isolated interportal and T-shaped capsulotomies. The aim of this retrospective cohort study is to report the clinical results of a standardized extended interportal capsulotomy (EIPC) during hip arthroscopy. Materials and Methods: Patients operated on between 2017 and 2020 with a hip arthroscopy were eligible. The inclusion criteria were ages 18-60 years, failed non-operative treatment, and at least a 2-year follow-up. Exclusion criteria were bilateral femoroacetabular impingement syndrome (FAS) cases or labral lesions, ipsilateral knee injury, history of ipsilateral hip surgery, and significant spine lesions. Data regarding demographic characteristics such as age, gender, operation date, BMI, but also Beighton score, presence of postoperative pudendal nerve damage, and revision for any reason were gathered from patients' records. All patients were evaluated preoperatively with a visual analog scale (VAS), the Hip Disability and Osteoarthritis Outcome Score (HOOS), and the modified Harris Hip Score (mHHS). Results: Of the 97 patients operated on with a hip arthroscopy between the defined dates, only 90 patients were included. The mean age was 37.9 ± 9.8, and 58.9% of patients were male. The most frequent surgical indication was an isolated FAS lesion (73.3%), followed by FAS associated with a labral tear (12.2%), an isolated labrum tear (10.0%), synovitis (3.3%), and a loose body (1.1%). The mean follow-up for the study cohort was 39.3 months. The majority of the patients had uneventful surgeries (76.7%), while there were three cases of sciatic nerve neuropraxia and 12 cases of pudendal nerve neuropraxia. Two patients underwent revision surgery during the study period. Comparison between preoperative and postoperative clinical scores showed a significant improvement with a final mHHS mean value of 67.7 ± 18.2, an HOOS value of 74.1 ± 13.2, and a low VAS score of 1.3 ± 1.2. Conclusions: A hip arthroscopy procedure with a standardized and unrepaired, extended interportal capsulotomy is a safe procedure with satisfactory mid-term results and high overall patient satisfaction. At a minimum of 2 years and a mean of 39.2 months, patients showed improved clinical scores and a low revision rate.
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Affiliation(s)
- Ahmet Fırat
- Department of Orthopedics and Traumatology, Ankara City Hospital, Ankara 06000, Turkey; (A.F.); (H.A.); (A.Ş.); (Ş.G.); (Y.E.)
| | - Enejd Veizi
- Department of Orthopedics and Traumatology, Ankara City Hospital, Ankara 06000, Turkey; (A.F.); (H.A.); (A.Ş.); (Ş.G.); (Y.E.)
| | - Christos Koutserimpas
- Department of Anatomy, School of Medicine, Faculty of Health Sciences, National and Kapodistrian University of Athens, 75 Mikras Asias Str., Goudi, 11527 Athens, Greece
| | - Hilmi Alkan
- Department of Orthopedics and Traumatology, Ankara City Hospital, Ankara 06000, Turkey; (A.F.); (H.A.); (A.Ş.); (Ş.G.); (Y.E.)
| | - Ali Şahin
- Department of Orthopedics and Traumatology, Ankara City Hospital, Ankara 06000, Turkey; (A.F.); (H.A.); (A.Ş.); (Ş.G.); (Y.E.)
| | - Şahan Güven
- Department of Orthopedics and Traumatology, Ankara City Hospital, Ankara 06000, Turkey; (A.F.); (H.A.); (A.Ş.); (Ş.G.); (Y.E.)
| | - Yasin Erdoğan
- Department of Orthopedics and Traumatology, Ankara City Hospital, Ankara 06000, Turkey; (A.F.); (H.A.); (A.Ş.); (Ş.G.); (Y.E.)
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Dasari SP, Kasson LB, Condon JJ, Mameri ES, Kerzner B, Khan ZA, Jackson GR, Gursoy S, Sivasundaram L, Hevesi M, Chahla J. Systematic Review and Meta-analysis of Studies Comparing Complete Capsular Closure Against Unrepaired Hip Capsules During Hip Arthroscopy. Orthop J Sports Med 2023; 11:23259671231197435. [PMID: 37868216 PMCID: PMC10585995 DOI: 10.1177/23259671231197435] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 04/26/2023] [Indexed: 10/24/2023] Open
Abstract
Background While the biomechanical importance of the hip capsule is well described, there remains controversy over the necessity of routine capsular closure after hip arthroscopy. Purpose To perform a meta-analysis of clinical studies to compare pooled outcomes of complete hip capsular closure cohorts against unrepaired hip capsule cohorts. Study Design Systematic review; Level of evidence, 3. Methods The Cochrane Database of Systematic Reviews, Cochrane Register of Controlled Trials, PubMed, MEDLINE, Web of Science, CINAHL/EBSCO, and Scopus were queried in February 2022 for studies that directly compared clinical outcomes for hip arthroscopy patients treated with either complete capsular closure or an unrepaired capsule. Outcomes assessed were incidence of revision hip arthroscopy, incidence of subsequent conversion to total hip arthroplasty (THA), and improvement from baseline in modified Harris Hip Score (mHHS), Hip Outcome Score (HOS) activities of daily living (ADL), HOS sports specific (SS) subscale, Copenhagen Hip and Groin Outcome Score (HAGOS) ADL, and HAGOS SS subscale. A pooled weighted mean difference (WMD) was used to compare changes in mHHS. A pooled standardized mean difference (SMD) was used to compare changes in the ADL and SS outcomes. A pooled risk ratio (RR) was used to compare the probability of revision hip arthroscopy and conversion to THA based on capsular management. For pooled outcomes where heterogeneity was regarded as potentially unimportant, a fixed-effects model was implemented. For pooled outcomes with considerable heterogeneity, a random-effects model was implemented. Results Of the 1896 records identified in our search, 11 studies (1897 patients) were included. A significantly higher improvement in mHHS (WMD, -3.72; 95% CI, -4.95 to -2.50; P < .00001) and ADL outcomes (SMD, -0.30; 95% CI, -0.54 to -0.07; P = .01) were seen after complete capsular closure. There was a significantly lower probability of subsequent revision hip arthroscopy (RR, 1.67; 95% CI, 1.14 to 2.45; P = .008) and conversion to THA (RR, 2.01; 95% CI, 1.06 to 3.79; P = .03) after complete capsular repair. There was no difference in SS outcomes (SMD, -0.02; 95% CI, -0.16 to 0.13; P = .81) between the 2 groups. Conclusion This meta-analysis demonstrated that routine complete capsular closure after hip arthroscopy led to superior clinical outcomes relative to unrepaired hip capsules.
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Affiliation(s)
- Suhas P. Dasari
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Luke B. Kasson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Joshua J. Condon
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Enzo S. Mameri
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Benjamin Kerzner
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Zeeshan A. Khan
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Garrett R. Jackson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Safa Gursoy
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Mario Hevesi
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Jorge Chahla
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
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Yang F, Huang HJ, Zhang X, Wang JQ. Does capsular repair make a difference in the integrity and thickness of anterior capsule in the setting of borderline hip dysplasia. BMC Musculoskelet Disord 2023; 24:187. [PMID: 36915070 PMCID: PMC10009957 DOI: 10.1186/s12891-023-06307-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 03/09/2023] [Indexed: 03/16/2023] Open
Abstract
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.
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Affiliation(s)
- Fan Yang
- Department of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Haidian District, 49 North Garden Rd, 100191, Beijing, P. R. China
| | - Hong-Jie Huang
- Department of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Haidian District, 49 North Garden Rd, 100191, Beijing, P. R. China
| | - Xin Zhang
- Department of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Haidian District, 49 North Garden Rd, 100191, Beijing, P. R. China.
| | - Jian-Quan Wang
- Department of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Haidian District, 49 North Garden Rd, 100191, Beijing, P. R. China.
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Yang F, Zhang X, Xu Y, Huang H, Wang J. Patients With Unhealed or Partially Healed Anterior Capsules After Hip Arthroscopy for Borderline Developmental Dysplasia of the Hips Have Inferior Patient-Reported Outcome Measures. Arthroscopy 2023; 39:1454-1461. [PMID: 36736444 DOI: 10.1016/j.arthro.2023.01.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/23/2022] [Accepted: 01/10/2023] [Indexed: 02/05/2023]
Abstract
PURPOSE To evaluate the changes in anterior hip capsular thickness on pre- and postoperative magnetic resonance imaging (MRI) and their associated clinical outcomes in patients with borderline developmental dysplasia of the hip (BDDH). METHODS A minimum 2-year follow-up retrospective analysis was performed using data from symptomatic patients with BDDH who underwent hip arthroscopy with routine capsular closure between 2018 and 2020. An available postoperative hip MRI was a prerequisite for study inclusion. Capsular thickness at the capsulotomy zone was measured on MRI. An analysis of the correlations between anterior capsular thickness differences and demographic factors (including age, sex, body mass index, laterality, preoperative alpha angle and lateral center-edge angle, cartilage lesion grade, follow-up time, and capsule management) was performed. Patients with unhealed or partially healed capsules (study group) were propensity-score matched 1:1 to patients with completely healed capsules based on age, sex, body mass index, and follow-up time. Comparisons and analyses of the following parameters were completed for both groups: patient-reported outcomes (Hip Outcome Score-Activities of Daily Living [HOS-ADL], Hip Outcome Score-Sports-Specific Subscale [HOS-SSS], International Hip Outcome Tool 12-component form [iHOT-12], and modified Harris Hip Score), visual analog scale scores, radiographic measures, performed procedures, and complications. RESULTS Data were compiled for 59 patients' hips after patient selection. The majority of the repaired hip capsules remained closed (93.2%) at a minimum 2-year follow-up. Propensity-score matching was applied to distribute 25 subjects in the study group and 25 in the control group. The anterior capsule was significantly thinner postoperation in the study group (3.0 ± 1.2 mm vs 4.1 ± 0.6 mm; P < .001). Compared with the control group, patients in the study group had significantly inferior postoperative HOS-ADL (75.1 vs 83.5, P = .007), HOS-SSS (64.5 vs 77.1, P = .005), and iHOT-12 scores (56.1 vs 70.2, P = .006). In addition, patients in the study group were significantly less likely to achieve the minimum clinically important difference for the HOS-ADL score (52% vs 80%, P = .037) score and patient acceptable symptomatic state for the HOS-ADL score (32% vs 60%, P = .047). CONCLUSIONS The majority of the repaired hip capsules in patients with BDDH remained closed but not all capsules completely healed at a minimum 2-year follow-up. Patients with an unhealed or partially healed capsule had inferior HOS-ADL, HOS-SSS, and iHOT-12 scores and were less likely to achieve the minimum clinically important difference and patient acceptable symptomatic state for the HOS-ADL score. LEVEL OF EVIDENCE III, retrospective comparative prognostic study.
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Affiliation(s)
- Fan Yang
- Department of Sports Medicine, Peking University Third Hospital. Institute of Sports Medicine of Peking University. Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Xin Zhang
- Department of Sports Medicine, Peking University Third Hospital. Institute of Sports Medicine of Peking University. Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Yan Xu
- Department of Sports Medicine, Peking University Third Hospital. Institute of Sports Medicine of Peking University. Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Hongjie Huang
- Department of Sports Medicine, Peking University Third Hospital. Institute of Sports Medicine of Peking University. Beijing Key Laboratory of Sports Injuries, Beijing, China.
| | - Jianquan Wang
- Department of Sports Medicine, Peking University Third Hospital. Institute of Sports Medicine of Peking University. Beijing Key Laboratory of Sports Injuries, Beijing, China
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Metz AK, Featherall J, Froerer DL, Mortensen AJ, Tomasevich KM, Aoki SK. Female Patients and Decreased Hip Capsular Thickness on Magnetic Resonance Imaging Associated With Increased Axial Distraction Distance on Examination Under Anesthesia: An In Vivo Study. Arthroscopy 2022; 38:3133-3140. [PMID: 35550416 DOI: 10.1016/j.arthro.2022.04.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 04/14/2022] [Accepted: 04/19/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate the relation of hip capsular thickness as measured on preoperative magnetic resonance imaging (MRI) and intraoperative hip joint axial distraction distance on an examination under anesthesia. METHODS A retrospective review of primary arthroscopic hip procedures performed between November 2018 and June 2021 was conducted. The inclusion criteria included a diagnosis of femoroacetabular impingement syndrome and preoperative radiographic imaging and MRI. Fluoroscopic images were obtained at 0 lb and 100 lb of axial traction force. Total distraction distance was calculated by comparing the initial joint space with the total joint space at 100 lb. Hip capsular thickness was measured on MRI. Analysis was conducted using multiple linear regression, independent-samples t tests, and Mann-Whitney U tests. RESULTS Eighty patients were included. Bivariable regression showed an association between an increased distraction distance and female sex (β = 4.303, R = 0.561, P < .001), as well as decreased anterior axial (β = -1.291, R = 0.365, P < .001) and superior coronal (β = -1.433, R = 0.501, P < .001) capsular thickness. Multivariable regression (R = 0.645) showed an association between an increased distraction distance and female sex (β = 3.175, P < .001), as well as decreased superior coronal capsular thickness (β = -0.764, P = .022). Independent-samples t tests showed that female patients had significantly decreased superior coronal capsular thickness (2.92 ± 1.14 mm vs 3.99 ± 1.15 mm, P < .001). CONCLUSIONS Female sex and decreased hip capsular thickness in the superior aspect of the coronal plane on magnetic resonance scans were found to be predictors of increased hip joint axial distraction distance on examination under anesthesia prior to hip arthroscopy, with anterior axial capsular thickness being a moderate predictor. Poor predictors of distraction distance were posterior axial and inferior coronal capsular thickness, age, body mass index, and lateral center-edge angle. Female patients were also found to have thinner hip capsules in the superior region, which may explain the association between female patients and increased distraction. These findings further characterize the relation between capsular thickness and hip laxity. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Allan K Metz
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, U.S.A
| | - Joseph Featherall
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, U.S.A
| | - Devin L Froerer
- School of Medicine, University of Utah, Salt Lake City, Utah, U.S.A
| | | | - Kelly M Tomasevich
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, U.S.A
| | - Stephen K Aoki
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, U.S.A..
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11
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Maldonado DR, Banffy MB, Huang D, Nelson TJ, Kanjiya S, Yalamanchili D, Metzger MF. Comparable Torque to Failure Using the Simple Stich Versus the Figure-of-Eight Configuration for Hip Capsular Closure Following an Interportal Capsulotomy: A Cadaveric Study. Arthroscopy 2022; 38:3143-3148. [PMID: 35750245 DOI: 10.1016/j.arthro.2022.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 04/23/2022] [Accepted: 05/31/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To measure and compare the torque to failure and stiffness of the capsular repair construct consisting of four-suture simple stitches to a two-figure of eight stitches repair construct in external rotation following an interportal capsulotomy. METHODS Six pairs of fresh-frozen cadaveric hemipelves were divided into two capsular repair groups. All hips underwent a 40-mm interportal capsulotomy from the 12 o'clock position to the 3 o'clock position. Capsular closure was performed using either the two stitches in a figure of eight or with four simple stitches. Afterward, each hemipelvis was securely fixed to the frame of a mechanical testing system with the hip in 10° of extension and externally rotated to failure. Significance was set at P < .05. RESULTS The average failure torque was 86.2 ± 18.9 N·m and 81.5 ± 8.9 N·m (P = .57) for the two stitches in a figure of eight and the four simple stitches, respectively. Failure stiffness was also not statistically different between groups and both capsular closure techniques failed at similar degrees of rotation (P = .65). CONCLUSION Hip capsular repair using either the four simple stitch or two-figure of eight configurations following interportal capsulotomy demonstrated comparable failure torques and similar stiffness in a cadaveric model. CLINICAL RELEVANCE Adequate and comprehensive capsular management in hip arthroscopy is critical. Capsular repair following capsulotomy in femoroacetabular impingement surgery has been associated with higher patient-reported outcomes when compared to capsulotomy without repair. Therefore, determining which capsular closure construct provides the higher failure torque is important.
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Affiliation(s)
- David R Maldonado
- Cedars-Sinai, Kerlan-Jobe Institute, Los Angeles, California, U.S.A..
| | - Michael B Banffy
- Cedars-Sinai, Kerlan-Jobe Institute, Los Angeles, California, U.S.A
| | - Dave Huang
- Cedars-Sinai Orthopaedic Biomechanics Laboratory, Los Angeles, California, U.S.A
| | - Trevor J Nelson
- Cedars-Sinai Orthopaedic Biomechanics Laboratory, Los Angeles, California, U.S.A
| | - Shrey Kanjiya
- Cedars-Sinai, Kerlan-Jobe Institute, Los Angeles, California, U.S.A
| | | | - Melodie F Metzger
- Cedars-Sinai Orthopaedic Biomechanics Laboratory, Los Angeles, California, U.S.A.; Cedars-Sinai, Department of Orthopaedic Surgery, Los Angeles, California, U.S.A
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12
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Cong S, Pan J, Huang G, Xie D, Zeng C. The Modified Longitudinal Capsulotomy by Outside-In Approach in Hip Arthroscopy for Femoroplasty and Acetabular Labrum Repair-A Cohort Study. J Clin Med 2022; 11:jcm11154548. [PMID: 35956163 PMCID: PMC9369754 DOI: 10.3390/jcm11154548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/24/2022] [Accepted: 07/26/2022] [Indexed: 02/04/2023] Open
Abstract
Hip arthroscopy is difficult to perform due to the limited arthroscopic view. To solve this problem, the capsulotomy is an important technique. However, the existing capsulotomy approaches were not perfect in the surgical practice. Thus, this study aimed to propose a modified longitudinal capsulotomy by outside-in approach and demonstrate its feasibility and efficacy in arthroscopic femoroplasty and acetabular labrum repair. A retrospective cohort study was performed and twenty-two postoperative patients who underwent hip arthroscopy in our hospital from January 2019 to December 2021 were involved in this study. The patients (14 females and 8 males) had a mean age of 38.26 ± 12.82 years old. All patients were diagnosed cam deformity and labrum tear in the operation and underwent arthroscopic femoroplasty and labrum repair by the modified longitudinal capsulotomy. The mean follow-up time was 10.4 months with a range of 6−12 months. There were no major complications, including infection, neurapraxias, hip instability or revision in any patients. The average mHHS were 74.4 ± 15.2, 78.2 ± 13.7 and 85.7 ± 14.5 in 3 months, 6 months and 12 months after surgery, respectively, which were all better than that before surgery (44.9 ± 8.6) (p < 0.05). The average VAS were 2.8 ± 1.2, 1.5 ± 0.6 and 1.2 ± 0.7 in 3 months, 6 months and 12 months after surgery, respectively, which were all lower than that before surgery (5.5 ± 2.0) (p < 0.05). The modified longitudinal capsulotomy by outside-in approach is proved to be a safe and feasible method for hip arthroscopy considering to the feasibility, efficacy and security. The arthroscopic femoroplasty and labrum repair can be performed conveniently by this approach and the patient reported outcomes after surgery were better that before surgery in short-term follow-up. This new method is promising and suggested to be widely used clinically.
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13
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Mortensen AJ, Tomasevich KM, Ohlsen SM, O'Neill DC, Featherall J, Aoki SK. Previous Arthroscopic Hip Surgery Increases Axial Distractibility Compared to the Native Contralateral Hip and May Suggest Instability. Arthroscopy 2022; 38:1466-1477. [PMID: 34582993 DOI: 10.1016/j.arthro.2021.09.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 08/04/2021] [Accepted: 09/20/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare intraoperative hip joint distractibility between hips that previously underwent arthroscopic surgery and the contralateral hip with no history of surgical manipulation. METHODS Patients undergoing revision hip arthroscopy between April 2019 and December 2020, who previously underwent arthroscopic hip surgery for femoroacetabular impingement syndrome, were prospectively enrolled. Exclusion criteria were any contralateral hip surgery. Before instrumentation, fluoroscopic images of both hips were obtained at 25 lbs traction intervals up to 100 lbs. Total joint space was measured at each traction interval. Distraction was calculated as the difference between the baseline joint space and the total joint space at each subsequent traction interval. Wilcoxon signed ranks tests and McNemar tests were used to compare distraction between revision and native contralateral hips. RESULTS Forty-seven patients were included. Mean distraction of operative hips was significantly greater than mean distraction of nonoperative hips at traction intervals of 50 lbs (2.13 vs 1.04 mm, P = .002), 75 lbs (6.39 vs 3.70 mm, P < .001), and 100 lbs (8.24 vs 5.39, P < .001). Mean total joint space of operative hips was significantly greater than mean total joint space of nonoperative hips at traction intervals of 50 lbs (6.60 vs 5.39 mm, P < .001), 75 lbs (10.86 vs 8.05 mm, P < .001), and 100 lbs (12.73 vs 9.73, P < .001). A greater percentage of operative hips achieved all distraction thresholds, in 2-mm intervals up to 10-mm, at each traction interval. CONCLUSIONS In the majority of patients undergoing revision hip arthroscopy, previous arthroscopic hip surgery increases axial distractibility of the hip joint compared with the native contralateral hip at axial traction forces of 50-100 lbs. Increased axial distractibility following hip arthroscopy may be suggestive of hip instability and can be assessed on a stress examination with the patient under anesthesia. LEVEL OF EVIDENCE III, case-control study.
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Affiliation(s)
| | - Kelly M Tomasevich
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, U.S.A
| | - Suzanna M Ohlsen
- School of Medicine, University of Utah, Salt Lake City, Utah, U.S.A
| | - Dillon C O'Neill
- 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
| | - Stephen K Aoki
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, U.S.A..
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14
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Behandlungsalgorithmus bei der symptomatischen Grenzwertdysplasie. ARTHROSKOPIE 2022. [DOI: 10.1007/s00142-021-00510-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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15
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Voinier S, Moore A, Benson J, Price C, Burris D. The modes and competing rates of cartilage fluid loss and recovery. Acta Biomater 2022; 138:390-397. [PMID: 34800716 DOI: 10.1016/j.actbio.2021.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 11/10/2021] [Accepted: 11/11/2021] [Indexed: 11/27/2022]
Abstract
Cartilage loses, recovers, and maintains its thickness, hydration, and biomechanical functions based on competing rates of fluid loss and recovery under varying joint-use conditions. While the mechanics and implications of load-induced fluid loss have been studied extensively, those of fluid recovery have not. This study isolates, quantifies, and compares rates of cartilage recovery from three known modes: (1) passive swelling - fluid recovery within a static unloaded contact area; (2) free swelling - unrestricted fluid recovery by an exposed surface; (3) tribological rehydration - fluid recovery within a loaded contact area during sliding. Following static loading of adult bovine articular cartilage to between 100 and 500 μm of compression, passive swelling, free swelling, and tribological rehydration exhibited average rates of 0.11 ± 0.04, 0.71 ± 0.15, and 0.63 ± 0.22 μm/s, respectively, over the first 100 s of recovery; for comparison, the mean exudation rate just prior to sliding was 0.06 ± 0.04 μm/s. For this range of compressions, we detected no significant difference between free swelling and tribological rehydration rates. However, free swelling and tribological rehydration rates, those associated with joint articulation, were ∼7-fold faster than passive swelling rates. While previous studies show how joint articulation prevents fluid loss indefinitely, this study shows that joint articulation reverses fluid loss following static loading at >10-fold the preceding exudation rate. These competitive recovery rates suggest that joint space and function may be best maintained throughout an otherwise sedentary day using brief but regular physical activity. STATEMENT OF SIGNIFICANCE: Cartilage loses, recovers, and maintains its thickness, hydration, and biomechanical functions based on competing rates of fluid loss and recovery under varying joint-use conditions. While load-induced fluid loss is extremely well studied, this is the first to define the competing modes of fluid recovery and to quantify their rates. The results show that the fluid recovery modes associated with joint articulation are 10-fold faster than exudation during static loading and passive swelling during static unloading. The results suggest that joint space and function are best maintained throughout an otherwise sedentary day using brief but regular physical activities.
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16
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O'Neill DC, Tomasevich KM, Mortensen AJ, Featherall J, Ohlsen SM, Aoki SK. Capsular Repair During Hip Arthroscopy Demonstrates Restoration of Axial Distraction Resistance in an in Vivo Intraoperative Testing Model. J Bone Joint Surg Am 2021; 103:1977-1985. [PMID: 34314401 DOI: 10.2106/jbjs.20.01932] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Dillon C O'Neill
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Kelly M Tomasevich
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | | | - Joseph Featherall
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | | | - Stephen K Aoki
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
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17
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Pie-Crusting Capsulotomy Provides Similar Visualization With Increased Repair Stiffness Compared With a T-Capsulotomy: A Biomechanical Study. Arthroscopy 2021; 37:2832-2837. [PMID: 33812034 DOI: 10.1016/j.arthro.2021.03.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 03/21/2021] [Accepted: 03/21/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the area of visualization, capsular stiffness, and strength between the pie-crusting capsulotomy technique and the T-capsulotomy technique following repair. METHODS Eight matched pairs of fresh-frozen cadaveric hips (n = 16) were divided to either T-capsulotomy or pie-crusting capsulotomy followed by subsequent repair. The area of visualization was measured for all capsulotomy states using a digitizing probe. Hips were then distracted along the iliofemoral ligament in the intact, extended capsulotomy, and repair states. Afterwards, specimens were externally rotated to failure. RESULTS An average force of 250.1 ± 16.1 N was required to distract intact hips to 6 mm. Both extended capsulotomy techniques reduced the force required to distract the hip 6 mm with no statistical difference between the two (T-capsulotomy [T-cap] = 114.3 ± 63.4 N vs pie-capsulotomy [Pie-cap] = 170.1 ± 38.8 N), P = .07. Subsequent repair of the extended capsulotomies demonstrated the pie-crust capsulotomy required significantly greater force to reach 6 mm of distraction than those with a repaired T-capsulotomy (T-cap = 165.04 ± 40.43N vs Pie-cap = 204.43 ± 10.13N), P = .03. There was no significant difference in ultimate torque to failure between the 2 techniques (T-cap = 22.0 ± 7.41 N·m vs Pie-cap = 27.01 ± 11.13 N·m), P = .28. Visualization significantly increased with each extended capsulotomy, with an average increase of 62% (P < .001) and 48% (P < .001) for the pie- and T-capsulotomies, respectively. CONCLUSIONS The pie-crusting technique maintained similar strength and increased stiffness to the T-capsulotomy following repair while using less suture. Both techniques provided similar visualization. Clinically, the pie-crusting technique provides an alternative to the T-capsulotomy with similar biomechanical and visual outcomes. CLINICAL RELEVANCE Visualization during hip arthroscopy can be difficult with large cam morphology. Techniques to improve visualization while restoring the native biomechanics of the hip as best as possible are important.
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18
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Owens JS, Jimenez AE, Shapira J, Saks BR, Glein RM, Maldonado DR, Ankem HK, Sabetian PW, Lall AC, Domb BG. Capsular Repair May Improve Outcomes in Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement: A Systematic Review of Comparative Outcome Studies. Arthroscopy 2021; 37:2975-2990. [PMID: 33887416 DOI: 10.1016/j.arthro.2021.03.063] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 03/22/2021] [Accepted: 03/23/2021] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Jade S Owens
- American Hip Institute Research Foundation, Chicago, Illinois, U.S.A
| | - Andrew E Jimenez
- American Hip Institute Research Foundation, Chicago, Illinois, U.S.A
| | - Jacob Shapira
- American Hip Institute Research Foundation, Chicago, Illinois, U.S.A
| | - Benjamin R Saks
- American Hip Institute Research Foundation, Chicago, Illinois, U.S.A
| | - Rachel M Glein
- American Hip Institute Research Foundation, Chicago, Illinois, U.S.A
| | - David R Maldonado
- American Hip Institute Research Foundation, Chicago, Illinois, U.S.A
| | - Hari K Ankem
- American Hip Institute Research Foundation, Chicago, Illinois, U.S.A
| | - Payam W Sabetian
- American Hip Institute Research Foundation, Chicago, Illinois, U.S.A
| | - Ajay C Lall
- American Hip Institute Research Foundation, Chicago, Illinois, U.S.A.; AMITA Health St. Alexius Medical Center, Hoffman Estates, Chicago, Illinois, U.S.A.; Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, California, U.S.A
| | - Benjamin G Domb
- American Hip Institute Research Foundation, Chicago, Illinois, U.S.A.; AMITA Health St. Alexius Medical Center, Hoffman Estates, Chicago, Illinois, U.S.A.; Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, California, U.S.A..
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19
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Lazaro LE, Lim DP, Nelson TJ, Eberlein SA, Banffy MB, Metzger MF. Proximal Overresection During Femoral Osteochondroplasty Negatively Affects the Distractive Stability of the Hip Joint: A Cadaver Study. Am J Sports Med 2021; 49:2977-2983. [PMID: 34319841 DOI: 10.1177/03635465211028979] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Contact between the acetabular labrum and articular cartilage of the femoral head creates a suction seal that helps maintain stability of the femoral head in the acetabulum. A femoral osteochodroplasty may occasionally extend proximally into the femoral head, diminishing the articular surface area available for sealing contact. PURPOSE To determine whether proximal overresection decreases the rotational and distractive stability of the hip joint. STUDY DESIGN Controlled laboratory study. METHODS Six hemipelvises in the following conditions were tested: intact, T-capsulotomy, osteochondroplasty to the physeal scar, and 5- and 10-mm proximal extension. The pelvis was secured to a metal plate, and the femur was potted and attached to a multiaxial hip jig. Specimens were axially distracted using a load from 0 to 150 N. For rotational stability testing, 5 N·m of internal and external torque was applied. Both tests were performed at different angles of flexion (0°, 15°, 30°, 60°, 90°). Displacement and rotation were recorded using a 3-dimensional motion tracking system. RESULTS The T-capsulotomy decreased the distractive stability of the hip joint. A femoral osteochondroplasty up to the physeal scar did not seem to affect the distractive stability. However, a proximal extension of the resection by 5 and 10 mm increased axial instability at every angle of flexion tested, with the greatest increase observed at larger angles of flexion (P < .01). External rotation increased significantly after T-capsulotomy in smaller angles of flexion (0°, P = .01; 15°, P = .01; 30°, P = .03). Femoral osteochondroplasty did not create further external rotational instability, except when the resection was extended 10 mm proximally and the hip was in 90° of flexion (P = .04). CONCLUSION This cadaveric study demonstrated that proximal extension of osteochondroplasty into the femoral head compromises the distractive stability of the hip joint but does not affect hip rotational stability. CLINICAL RELEVANCE Clinically, this study highlights the importance of accuracy when performing femoral osteochondroplasty to minimize proximal extension that may increase iatrogenic instability of the hip joint.
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Affiliation(s)
- Lionel E Lazaro
- Cedar-Sinai Kerlan-Jobe Institute, Los Angeles, California, USA.,Miami Orthopedic and Sports Medicine Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Daniel P Lim
- Cedar-Sinai Kerlan-Jobe Institute, Los Angeles, California, USA.,Orthopedic Associates of Hawaii, Honolulu, Hawaii, USA
| | - Trevor J Nelson
- Biomechanics Laboratory, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sam A Eberlein
- Biomechanics Laboratory, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | - Melodie F Metzger
- Biomechanics Laboratory, Cedars-Sinai Medical Center, Los Angeles, California, USA
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20
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Yin QF, Wang L, Liang T, Zhao H, Wang XS. Longitudinal Capsulotomy in Hip Arthroscopy: A Safe and Feasible Procedure for Cam-Type Femoracetabular Impingement. Orthop Surg 2021; 13:1793-1801. [PMID: 34351688 PMCID: PMC8523749 DOI: 10.1111/os.13041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/08/2021] [Accepted: 04/13/2021] [Indexed: 11/29/2022] Open
Abstract
Objective To evaluate the surgical security, feasibility, and clinical efficacy of the longitudinal outside‐in capsulotomy in hip arthroscopic treatment for cam‐type femoracetabular impingement (FAI). Methods We retrospectively reviewed patients with cam‐type FAI who underwent hip arthroscopy in our institute from January 2018 to June 2019. All hip arthroscopic procedures were performed by one experienced surgeon in the same manner, except the fashions of capsulotomy. Fifty six patients with mean age of 39.1 and mean body mass index (BMI) of 24.5 were categorized into two groups according to the fashions of capsulotomy. Twenty six cases with longitudinal outside‐in capsulotomy were categorized into Group L, and 30 cases with transversal interportal capsulotomy were categorized into Group T as the control group. The demographic parameters were retrieved from medical documents and compared between the two groups. Surgical outcome including overall surgical time, traction time, complications, visual analogue score (VAS), and intraoperative radiation exposure were compared to investigate the security and feasibility. Radiographic assessment, and functional outcome were compared between the two groups to determine the clinical efficacy of the longitudinal capsulotomy. Results There was no significant difference in the demography and duration of follow‐up between the two groups. The overall surgical time demonstrated no significant difference between Group L and Group T (130.8 ± 16.6 min and 134.0 ± 14.7 min, P = 0.490). Significantly decreased traction time was found in Group L (43.2 ± 8.4 min and 62.2 ± 8.6 min, P < 0.001) compared to Group T. The Median of the fluoroscopic shot was 1 and 3 (P < 0.001). No major complications and reoperation were reported in both groups. The case of intraoperative iatrogenic injure was 0 (0%) and 6 (20%) in Group L and Group T respectively (P = 0.035), and the case of postoperative neurapraxia was 0 (0%) and 8 (26.6%) in Group L and Group T respectively (P = 0.017). The Median of postoperative VAS was 2 and 3 in Group L Group T (P = 0.002). The postoperative α angle was 42.3° ± 3.4° and 44.4° ± 3.5° in group L and group T respectively (P = 0.001). The postoperative iHOT‐12 score at final follow‐up was 79.3 ± 6.7 and 77.0 ± 7.9 respectively (P = 0.141). Conclusion Longitudinal outside‐in capsulotomy with less radiation exposure, reduced traction time, and reduced complications could be a safe and feasible procedure in arthroscopic treatment for cam FAI. Its clinical efficacy was not worse compared with traditional interportal capsulotomy in short‐term follow‐up.
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Affiliation(s)
- Qing-Feng Yin
- Department of Orthopedics, The Second Hospital of Shandong University, Jinan, China
| | - Long Wang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - Tao Liang
- Department of Orthopedics, The First People's Hospital of Ningyang county, Taian, China
| | - Heng Zhao
- Department of Orthopedics, The Second Hospital of Shandong University, Jinan, China
| | - Xue-Song Wang
- Department of Sports Medicine, Beijing Jishuitan Hospital, Beijing, China
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21
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Li ZY, Hu GF, Jin ZG, Li Q, Ling ZY, Shi GL, Dong QR, Xie ZG. Capsular Healing in Interportal and Periportal Capsulotomy Methods of Hip Arthroscopy. Orthop Surg 2021; 13:1863-1869. [PMID: 34351066 PMCID: PMC8523751 DOI: 10.1111/os.13132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 05/24/2021] [Accepted: 06/22/2021] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- Zi-Yuan Li
- Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Gang-Feng Hu
- Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhi-Gao Jin
- Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Qian Li
- Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhuo-Yan Ling
- Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Gao-Long Shi
- Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Qi-Rong Dong
- Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Zong-Gang Xie
- Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, Suzhou, China
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22
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Jimenez AE, Owens JS, Shapira J, Saks BR, Ankem HK, Sabetian PW, Lall AC, Domb BG. Hip Capsular Management in Patients With Femoroacetabular Impingement or Microinstability: A Systematic Review of Biomechanical Studies. Arthroscopy 2021; 37:2642-2654. [PMID: 33940133 DOI: 10.1016/j.arthro.2021.04.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/16/2020] [Accepted: 04/02/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate the correlation between hip capsular management (repair or reconstruction) and biomechanical results in the setting of femoroacetabular impingement and microinstability. METHODS A search of the PubMed and Embase databases was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included studies focused on hip biomechanics related to capsular release, repair of I- and T-capsulotomy, or capsular reconstruction. Studies were assessed for external/internal rotation of the femur, femoral head translation, rotational torque, and distraction force. Articles were excluded if they discussed treatment of the hip capsule related to surgical dislocation, mini-open surgery, arthroplasty, reorientation osteotomy, or traumatic dislocation. RESULTS Twenty-four biomechanical studies were included that evaluated rotation/translation (11 studies), distraction (3 studies), the capsular role in microinstability (simulated with anterior capsule pie crusting [2 studies] and cyclical loading [2 studies]), allograft reconstruction (3 studies), and anatomic properties (3 studies). Repair and reconstruction demonstrated improvements in maximum distractive force, total ROM, and torsional stability when compared to capsular release. Significant differences were observed between capsular repair and release in total ROM in the coronal plane with improved stability in the repair groups (standardized mean difference [SMD]: -1.3°, 95% confidence interval [CI] -1.68 , -0.854; P < .001). There was significantly increased total motion in the coronal plane in the capsular laxity state compared to the native state (SMD: 1.4° (95% CI 0.32, 2.49; P = .012). CONCLUSIONS Biomechanical evidence supports closure of the capsule after hip arthroscopy to reverse the significant effects of capsulotomy. Simulated capsule laxity models created altered joint motion and translation. Capsule reconstruction appears to restore the hip to its native capsule state. CLINICAL RELEVANCE Investigating the biomechanical outcomes of capsular repair and reconstruction will help surgeons better understand the rationale and implications of these capsular management strategies.
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Affiliation(s)
| | - Jade S Owens
- American Hip Institute Research Foundation, Chicago, Illinois
| | - Jacob Shapira
- American Hip Institute Research Foundation, Chicago, Illinois
| | - Benjamin R Saks
- American Hip Institute Research Foundation, Chicago, Illinois; AMITA Health St. Alexius Medical Center, Hoffman Estates, Illinois, U.S.A
| | - Hari K Ankem
- American Hip Institute Research Foundation, Chicago, Illinois
| | | | - Ajay C Lall
- American Hip Institute Research Foundation, Chicago, Illinois; American Hip Institute, Chicago, Illinois; AMITA Health St. Alexius Medical Center, Hoffman Estates, Illinois, U.S.A
| | - Benjamin G Domb
- American Hip Institute Research Foundation, Chicago, Illinois; AMITA Health St. Alexius Medical Center, Hoffman Estates, Illinois, U.S.A.
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23
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Patient outcomes after direct capsular closure following hip arthroscopy: a systematic review. CURRENT ORTHOPAEDIC PRACTICE 2021. [DOI: 10.1097/bco.0000000000001013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kunze KN, Vadhera A, Devinney A, Nwachukwu BU, Kelly BT, Nho SJ, Chahla J. Effect of Capsular Closure After Hip Arthroscopy for Femoroacetabular Impingement Syndrome on Achieving Clinically Meaningful Outcomes: A Meta-analysis of Prospective and Comparative Studies. Orthop J Sports Med 2021; 9:23259671211017467. [PMID: 34262982 PMCID: PMC8243105 DOI: 10.1177/23259671211017467] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 02/18/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Recent literature has demonstrated conflicting evidence as to whether
capsular closure after hip arthroscopy for femoroacetabular impingement
syndrome (FAIS) results in superior outcomes compared with capsulotomy
without repair. Additionally, these studies have not explored the effect of
capsular management on clinically significant outcome improvement. Purpose: To perform a meta-analysis of prospective and comparative studies to
determine whether capsular management influences the rate of clinically
significant outcome improvement after hip arthroscopy for FAIS. Study Design: Systematic review; Level of evidence, 3. Methods: PubMed, OVID/Medline, EMBASE, and Cochrane databases were queried in
September 2020 for studies with evidence levels 1 to 3 that directly
compared capsular management cohorts and reported rates of achieving the
minimal clinically important difference (MCID) at a minimum follow-up of 2
years. Studies of level 4 evidence, those not describing or directly
comparing capsular management techniques as well as those not reporting the
MCID were excluded. Methodological quality was assessed using the
methodological index for nonrandomized studies tool. Mantel-Haenszel
fixed-effects models were constructed to quantitatively evaluate the
association between capsular management and achievement of the MCID by
generating effect estimates in the form of relative risk (RR) with 95%
CIs. Results: A total of 6 studies with 1611 patients were included. The overall pooled
rate of MCID achievement for the modified Harris Hip Score (mHHS), Hip
Outcome Score Activities of Daily Living (HOS-ADL), and HOS Sports Subscale
(HOS-SS) were 84.4%, 80.3%, and 82.5%, respectively, at a mean follow-up of
40.8 months (range, 24-87.6 months). Capsular closure was associated with a
significantly higher rate of MCID achievement for the mHHS (RR, 1.06; 95%
CI, 1.01-1.10; P = .001) and trended toward statistical
significance for the HOS-ADL (RR, 1.11; 95% CI, 1.0-1.24; P
= .055) and the HOS-SS (RR, 1.09; 95% CI, 0.99-1.21; P =
.094). Conclusion: Although capsular closure appeared to result in higher rates of clinically
significant outcome improvement in hip function, there was no definitively
increased likelihood of achieving clinically significant improvement in
relevant hip outcome scores with capsular closure.
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Affiliation(s)
- Kyle N Kunze
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Amar Vadhera
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Annie Devinney
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Benedict U Nwachukwu
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Bryan T Kelly
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Shane J Nho
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Jorge Chahla
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
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Abstract
Advances in hip preservation surgery have to lead to increased utilization of hip arthroscopy. With this, there has also been a growth in the understanding of various hip conditions, therefore, leading to an increase in hip conditions amenable to arthroscopic intervention. The acetabular hip labrum has been at the forefront of arthroscopic advances in the hip. The labrum is important for hip stability, provision of the suction seal, and joint proprioception. Given the labrum's central role in hip biomechanics, there is increasing emphasis on labral preservation in the form of debridement and repair. In revision settings, advanced techniques such as labral augmentation and reconstruction may play a role in the management of labral pathology. Appropriate management of the hip labrum at the time of surgery can be an important mediator of the outcome. As such, an understanding of the evolving evidence base and surgical indications and techniques are integral to the treatment and management of labral pathology.
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26
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Shaw C, Warwick H, Nguyen KH, Link TM, Majumdar S, Souza RB, Vail TP, Zhang AL. Correlation of hip capsule morphology with patient symptoms from femoroacetabular impingement. J Orthop Res 2021; 39:590-596. [PMID: 32592526 PMCID: PMC7765744 DOI: 10.1002/jor.24788] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 06/02/2020] [Accepted: 06/24/2020] [Indexed: 02/04/2023]
Abstract
The relationship between morphological characteristics of the hip capsule and patient symptoms in the setting of femoroacetabular impingement (FAI) is undefined. In this study, patients with symptomatic FAI prospectively underwent 3T magnetic resonance (MR) imaging of the affected hip and completed the hip disability and osteoarthritis outcome score (HOOS) to determine the correlation between hip capsule anatomy and patient symptoms. Anterior hip capsule volume, posterior capsule volume, anterior-posterior capsule volume ratio, and proximal-distal volume ratio in the anterior capsule were quantified and measured using axial-oblique intermediate-weighted 3D fast spin echo MR images. A total of 35 patients (35 hips) were included for analysis (mean age: 30.6 years; mean body mass index [BMI]: 24.9 kg/m2 ; 57% male). The mean alpha angle was 62.2° ± 4.7°, the mean anterior hip capsule volume was 1705.1 ± 450.3 mm3 , the mean posterior hip capsule volume was 1284.8 ± 268.5 mm3 , the mean anterior to posterior capsule volume ratio was 1.1 ± 0.39, and the mean proximal to distal volume ratio of the anterior capsule was 0.65 ± 0.28. There was no correlation between age, gender, or BMI, and any hip capsule characteristics. Worse scores on the HOOS pain scale were correlated with increased anterior to posterior volume ratio (r = -.38; 95% confidence interval: -0.06 to -0.63). In conclusion, hip capsule morphology correlates with patient symptoms in the setting of FAI as increased anterior capsular volume, relative to posterior capsular volume, is associated with greater patient pain.
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Affiliation(s)
- Chace Shaw
- Department of Orthopaedic Surgery, University of California– San Francisco, San Francisco, California, USA
| | - Hunter Warwick
- Department of Orthopaedic Surgery, University of California– San Francisco, San Francisco, California, USA
| | - Kevin H. Nguyen
- Department of Orthopaedic Surgery, University of California– San Francisco, San Francisco, California, USA
| | - Thomas M. Link
- Musculoskeletal and Quantitative Imaging Research Group, Department of Radiology and Biomedical Imaging, University of California–San Francisco, San Francisco, California, USA
| | - Sharmila Majumdar
- Musculoskeletal and Quantitative Imaging Research Group, Department of Radiology and Biomedical Imaging, University of California–San Francisco, San Francisco, California, USA
| | - Richard B. Souza
- Musculoskeletal and Quantitative Imaging Research Group, Department of Radiology and Biomedical Imaging, University of California–San Francisco, San Francisco, California, USA
| | - Thomas P. Vail
- Department of Orthopaedic Surgery, University of California– San Francisco, San Francisco, California, USA
| | - Alan L. Zhang
- Department of Orthopaedic Surgery, University of California– San Francisco, San Francisco, California, USA.,Please address all correspondences to: Alan L. Zhang, Department of Orthopaedic Surgery, University of California- San Francisco, 1500 Owens Street, Box 3004, San Francisco, CA 94158, USA, , Phone: 415-353-4843
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27
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Editorial Commentary: Evidence-Based Guidelines for Management of the Hip Capsule During Arthroscopy: Has It Become Personal? Arthroscopy 2021; 37:95-97. [PMID: 33384105 DOI: 10.1016/j.arthro.2020.09.045] [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: 09/11/2020] [Accepted: 09/16/2020] [Indexed: 02/02/2023]
Abstract
The management of the capsule during hip arthroscopy for femoroacetabular impingement syndrome has been in the spotlight during the last decade. Although there is robust biomechanical evidence that preserving the anatomic integrity of the iliofemoral ligament is important for the stability of the hip joint, the effect of capsular management on patient outcomes is often debated in clinical studies. Mid-term and long-term follow-up studies have shown that capsular closure is associated with decreased risk of hip arthroscopy failure, but no difference in patient outcomes based on capsular management has been found by some case series studies. What is driving the controversy in the literature? It seems to stem from the variation in surgical techniques used to perform hip capsulotomy or capsular repair, worldwide. Given that improvement in patient outcomes must be prioritized, it is time to use the existing knowledge appropriately to establish evidence-based guidelines for the management of hip capsule during hip arthroscopy.
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28
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Ng KCG, El Daou H, Bankes MJK, Rodriguez Y Baena F, Jeffers JRT. Cam Osteochondroplasty for Femoroacetabular Impingement Increases Microinstability in Deep Flexion: A Cadaveric Study. Arthroscopy 2021; 37:159-170. [PMID: 32927001 DOI: 10.1016/j.arthro.2020.08.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 08/26/2020] [Accepted: 08/29/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE The purpose of this in vitro cadaveric study was to examine the contributions of each surgical stage during cam femoroacetabular impingement (FAI) surgery (i.e., intact-cam hip, T-capsulotomy, cam resection, and capsular repair) toward hip range of motion, translation, and microinstability. METHODS Twelve cadaveric cam hips were denuded to the capsule and mounted onto a robotic tester. The hips were positioned in several flexion positions-full extension, neutral (0°), 30° of flexion, and 90° of flexion-and performed internal-external rotations to 5 Nm of torque in each position. The hips underwent a series of surgical stages (T-capsulotomy, cam resection, and capsular repair) and were retested after each stage. Changes in range of motion, translation, and microinstability (overall translation normalized by femoral head radius) were measured after each stage. RESULTS Regarding range of motion, cam resection increased internal rotation at 90° of flexion (change in internal rotation = +6°, P = .001) but did not affect external rotation. Capsular repair restrained external rotation compared with the cam resection stage (change in external rotation = -8° to -4°, P ≤ .04). In terms of translation, the hip translated after cam resection at 90° of flexion in the medial-lateral plane (change in translation = +1.9 mm, P = .04) relative to the intact and capsulotomy stages. Regarding microinstability, capsulotomy increased microinstability in 30° of flexion (change in microinstability [ΔM] = +0.05, P = .003), but microinstability did not further increase after cam resection. At 90° of flexion, microinstability did not increase after capsulotomy (ΔM = +0.03, P = .2) but substantially increased after cam resection (ΔM = +0.08, P = .03), accounting for a 31% change with respect to the intact stage. CONCLUSIONS Cam resection increased microinstability by 31% during deep hip flexion relative to the intact hip. This finding suggests that iatrogenic microinstability may be due to separation of the labral seal and resected contour of the femoral head. CLINICAL RELEVANCE Our in vitro study showed that, at time zero and prior to postoperative recovery, excessive motion after cam resection could disrupt the labral seal. Complete cam resection should be performed cautiously to avoid disruption of the labral seal and postoperative microinstability.
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Affiliation(s)
- K C Geoffrey Ng
- MSk Lab, Department of Surgery and Cancer, Imperial College London, London, England; Department of Mechanical Engineering, Imperial College London, London, England.
| | - Hadi El Daou
- Department of Mechanical Engineering, Imperial College London, London, England
| | - Marcus J K Bankes
- Department of Orthopaedics, Guy's and St. Thomas' NHS Foundation Trust, London, England; Fortius Clinic, London, England
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29
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Suppauksorn S, Beck EC, Chahla J, Cancienne JM, Krivicich LM, Rasio J, Shewman E, Nho SJ. Comparison of Suction Seal and Contact Pressures Between 270° Labral Reconstruction, Labral Repair, and the Intact Labrum. Arthroscopy 2020; 36:2433-2442. [PMID: 32504714 DOI: 10.1016/j.arthro.2020.05.024] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 05/12/2020] [Accepted: 05/12/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To biomechanically compare the suction seal, contact area, contact pressures, and peak forces of the intact native labrum, torn labrum, 12- to 3-o'clock labral repair, and 270° labral reconstruction in the hip. METHODS A cadaveric study was performed using 8 fresh-frozen hemipelvises with intact labra and without osteoarthritis. Intra-articular pressure maps were produced for each specimen using an electromechanical testing system under the following conditions: (1) intact labrum, (2) labral tear, (3) labral repair between the 12- and 3-o'clock positions, and (4) 270° labral reconstruction using iliotibial band allograft. Specimens were examined in neutral position, 20° of extension, and 60° of flexion. In each condition, contact pressure, contact area, and peak force were obtained. Repeated-measures analysis of variance was used to identify differences in biomechanical parameters among the 3 conditions. Qualitative differences in suction seal were compared between labral repair and labral reconstruction using the Fisher exact test. RESULTS Repeated-measures analysis of variance for contact area in neutral position, extension, and flexion showed statistically significant differences between the normalized study states (P < .05). Post hoc analysis showed significantly larger contact areas measured in labral repair specimens than in labral reconstruction specimens in the extension and flexion positions. Region-of-interest analysis for the normalized contact area in the extension and flexion positions, as well as normalized contact pressures in neutral position, showed statistically significant differences between the labral states (P < .05). Finally, 8 labral repairs (100%) versus only 1 labral reconstruction (12.5%) retained the manually tested suction seal (P < .001). CONCLUSIONS In this in vitro biomechanical model, 270° labral reconstruction resulted in decreased intra-articular contact area and loss of suction seal when compared with labral repair. Clinically, labral reconstruction may not restore the biomechanical characteristics of the native labrum as compared with labral repair. CLINICAL RELEVANCE Labral reconstruction may result in lower intra-articular hip contact area and loss of suction seal, affecting the native biomechanical function of the acetabular labrum. Further biomechanical studies and clinical studies are necessary to determine whether there are any long-term consequences of 270° labral reconstruction.
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Affiliation(s)
- Sunikom Suppauksorn
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Edward C Beck
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, U.S.A..
| | - Jorge Chahla
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Jourdan M Cancienne
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Laura M Krivicich
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Jonathan Rasio
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Elizabeth Shewman
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Shane J Nho
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
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30
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Weber AE, Alluri RK, Makhni EC, Bolia IK, Mayer EN, Harris JD, Nho SJ. Anatomic Evaluation of the Interportal Capsulotomy Made with the Modified Anterior Portal versus Standard Anterior Portal: Comparable Utility with Decreased Capsule Morbidity. Hip Pelvis 2020; 32:42-49. [PMID: 32158728 PMCID: PMC7054079 DOI: 10.5371/hp.2020.32.1.42] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 01/23/2020] [Accepted: 01/23/2020] [Indexed: 12/21/2022] Open
Abstract
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.
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Affiliation(s)
- Alexander E. Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Ram K. Alluri
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Eric C. Makhni
- Division of Sports Medicine, Department of Orthopedic Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Ioanna K. Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Eric N. Mayer
- Department of Orthopedic Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Joshua D. Harris
- Department of Orthopaedics and Sports Medicine, Houston Methodist Hospital, Houston, TX, USA
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31
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Abstract
➤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.
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Affiliation(s)
- K C Geoffrey Ng
- MSk Lab, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Jonathan R T Jeffers
- Department of Mechanical Engineering, Imperial College London, London, United Kingdom
| | - Paul E Beaulé
- Division of Orthopaedic Surgery, University of Ottawa, Ottawa, Ontario, Canada
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32
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Abstract
PURPOSE OF REVIEW With the rapid growth of hip arthroscopy over the past decade, new treatment paradigms as well as recognition of new disease states have sprung forth. The ability to perform complex arthroscopic procedures of the hip such as labral augmentation and reconstruction is essential for hip arthroscopists in the revision setting, with patient selection and indications for various labral treatments the key driver for improved short- and mid-term clinical outcomes. RECENT FINDINGS Current techniques have been developed to address disease states where the labrum is either unstable, torn, deficient, or otherwise incompetent. Many early reports focused on the description of these techniques with new literature reporting short- and mid-term outcomes. A few of these have demonstrated improved outcomes with a contemporary arthroscopy with emphasis on capsule preservation and repair. Studies have demonstrated that labral repair has improved outcomes over labral debridement, with results of labral reconstruction in a revision approaching those of labral repair. In addition, newer reports have shown significantly improved outcomes and survivorship with capsule repair and therefore should be included in every hip arthroscopy.
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Affiliation(s)
- Dustin Woyski
- Department of Orthopaedic Surgery, Duke University Medical Center, Box 3000, Durham, NC, 27705, USA.
| | - Richard Chad Mather
- Department of Orthopaedic Surgery, Duke University Medical Center, Box 3000, Durham, NC, 27705, USA
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33
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Dukas AG, Gupta AS, Peters CL, Aoki SK. Surgical Treatment for FAI: Arthroscopic and Open Techniques for Osteoplasty. Curr Rev Musculoskelet Med 2019; 12:281-290. [PMID: 31264173 PMCID: PMC6684728 DOI: 10.1007/s12178-019-09572-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW To review the relevant literature and techniques regarding arthroscopic and open treatment of femoroacetabular impingement (FAI). To discuss both the senior authors' preferred method of arthroscopic and open treatment of FAI. RECENT FINDINGS Routine treatment of FAI has moved away from open techniques and is more focused arthroscopic methods. Arthroscopic treatment of FAI has more recently focused on differing techniques of hip access and capsular management. Open techniques still have a role in FAI, but indications for open management are focused on cases with more severe pathology. While arthroscopic techniques have shown better outcomes in the short term and higher return to play, it is not without risk and is a procedure with a steep learning curve. In cases of complex joint pathology, such as FAI coupled with dysplasia or Legg-Calve-Perthes, arthroscopy may be not indicated and an open approach preferred. We outline various techniques for both arthroscopic and open treatment of FAI and their outcomes when possible.
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Affiliation(s)
- Alex G Dukas
- Department of Orthopaedic Surgery, University of Utah Health Center, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Andrew S Gupta
- Department of Orthopaedic Surgery, University of Utah Health Center, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Christopher L Peters
- Department of Orthopaedic Surgery, University of Utah Health Center, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Stephen K Aoki
- Department of Orthopaedic Surgery, University of Utah Health Center, 590 Wakara Way, Salt Lake City, UT, 84108, USA.
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