Biomechanical Evaluation of 4 Suture Techniques for Hip Capsular Closure

A retrospective cohort study: dual cannula combined with modified shoelace continuous capsular closure technique versus nonrepair in hip arthroscopic surgery of femoroacetabular impingement

BACKGROUND

Over the years, with the improvement of diagnostic and therapeutic capabilities for hip joint diseases and the advancements in surgical technology, hip arthroscopy has been extensively used. At present, there is ongoing controversy among scholars about whether it is necessary to close the joint capsule after hip arthroscopy. In addition, the clinical effect of repairing the hip joint capsule after hip arthroscopy remains uncertain.

PURPOSE

To evaluate the effect of our modified shoelace suture technique on postoperative hip function and to investigate whether complete closure of the hip capsule is reliable and safe.

STUDY DESIGN

Retrospective study; Levels of evidence: III.

METHODS

A retrospective review was conducted on patients undergoing hip arthroscopy by a solitary high-volume hip arthroscopic surgeon. The patients were categorized into two groups. The first group consisted of patients who underwent the modified shoelace continuous capsular closure technique. The other group consisted of those who did not receive capsular closure after hip arthroscopy. Patient-reported outcomes including modified Harris Hip Score (mHHS), Hip Outcome Score of Activities of Daily Living (HOS-ADL), Hip Outcome Score Sport-Specific Subscale (HOS-SSS), and visual analogue scale (VAS) were obtained at a minimum of 12 months. Any complications during follow-up were identified and recorded.

RESULTS

A total of 100 patients were followed up for 12-15 months, with an average of (12.3 ± 5.3) months in the study. There were 50 patients in the shoelace capsular closure group (CC group) and 50 patients in the non-capsular closure group (NC group). The surgical time in the suture group was significantly longer than that in the non-suture group. However, there was no statistically significant disparity in the length of hospital stay between the two groups. The mHHS, HOS-SSS, HOS-ADL, and VAS of the CC and NC group were significantly improved compared to preoperative scores at 6 and 12 postoperative months (P < 0.001). Compared with the NC group, the CC group showed a significant improvement in the mHHS, HOS-SSS, HOS-ADL, and VAS at 6 postoperative months (t = 4.885, P<0.001; t = 5.984, P<0.001; t = 4.279, P<0.001; t = 3.875, P<0.001). The mHHS, HOS-SSS, HOS-ADL, and VAS at 12 postoperative months were significantly better in the CC group than in the NC group (t = 5.165, P<0.001; t = 3.697, P<0.001; t = 4.840, P<0.001; t = 3.579, P = 0.001). There were no serious complications during the perioperative period.

CONCLUSION

The modified shoelace continuous capsular closure technique is a reliable and secure method that can be used as an alternative to the conventional capsular closure. It is recommended to perform routine intraoperative repair of the articular capsule at the end of hip arthroscopy, as this has a positive influences on the functional results at short-term follow-up.

The Contribution of Soft Tissue and Bony Stabilizers to the Hip Suction Seal: A Systematic Review of Biomechanical Studies

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.

Editorial Commentary: Protected Physical Therapy and Rehabilitation Is Essential After Hip Capsule and Labral Repair

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."

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

Background

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

Purpose

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

Study Design

Systematic review; Level of evidence, 1.

Methods

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

Results

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

Conclusion

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

Hip Labral and Capsular Repair Are Unable to Restore Distractive Stability in a Biomechanical Model

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.

Capsular Management During Hip Arthroscopy

PURPOSE OF REVIEW

Hip arthroscopy is widely used for the management of intra-articular pathology and there has been growing interest in strategies for management of the hip capsule during surgery. The hip capsule is an essential structure that provides stability to the joint and it is necessarily violated during procedures that address intra-articular pathology. This article reviews different approaches to capsular management during hip arthroscopy including anatomical considerations for capsulotomy, techniques, clinical outcomes, and the role of routine capsular repair. This article also reviews the concept of hip microinstability and its potential impact on capsular management options as well as iatrogenic complications that can occur as a result of poor capsular management.

RECENT FINDINGS

Current research highlights the key functional role of the hip capsule and the importance of preserving its anatomy during surgery. Capsulotomies that involve less tissue violation (periportal and puncture-type approaches) do not appear to require routine capsular repair to achieve good outcomes. Many studies have investigated the role of capsular repair following more extensive capsulotomy types (interportal and T-type), with most authors reporting superior outcomes with routine capsular repair. Strategies for capsular management during hip arthroscopy range from conservative capsulotomy techniques aimed to minimize capsular violation to more extensive capsulotomies with routine capsule closure, all of which have good short- to mid-term outcomes. There is a growing trend towards decreasing iatrogenic capsular tissue injury when possible and fully repairing the capsule when larger capsulotomies are utilized. Future research may reveal that patients with microinstability may require a more specific approach to capsular management.

Superior outcomes after arthroscopic treatment of femoroacetabular impingement and labral tears with closed versus open capsule

PURPOSE

The purpose of the study was the clinical evaluation of the capsular management with arthroscopic treatment of femoroacetabular impingement and labral tears by comparing the functional outcomes of closed versus open capsule.

METHODS

Patients with a median age of 38 years (18-55), clinical and radiological features of FAI and/or labral tear, and non-arthritic non-dysplastic hips were selected for arthroscopic treatment. Capsulotomy was performed primarily as an interportal section, then a distal extension preserving the zona orbicularis was added. The study compared two matched groups: patients with open capsule versus patients with closed capsule. Clinical outcomes were assessed by Non-Arthritic Hip Score, hip outcome scores of daily living activities and sports-specific scales. Scores were collected preoperatively and 6 months, 2 years and 5 years postoperatively. Rate of revision arthroscopy and conversion to total hip arthroplasty were used for comparing groups. Minimal clinically important differences were calculated for both groups.

RESULTS

The study included 42 patients in the OC group and 44 patients in the CC group. Significant improvement of postoperative PROMs was recorded in both groups compared to preoperative scores. CC group significantly improved more than the OC group based on NAHS, HOS-ADL and HOS-SSS over all check points except for NAHS and HOS-ADL at 6 months, which were statistically non-significant. A non-significant difference was observed in the percentage of patients who met the MCID for all reported outcome scores at 5 years in both groups. The rate of reoperation was similar in both groups, but with different indications.

CONCLUSION

Arthroscopic treatment of FAI and labral repair with complete closure of the hip capsule led to significantly improved functional outcomes after 5 years follow-up compared with open capsule. Closed capsule can provide greater improvement in the sports-specific outcomes at early follow-up. Controlled capsulotomy limited by zona orbicularis did not produce instability at any postoperative stage. Similar proportions of patients achieved minimal clinically important difference, and similar rates of reoperation were reported in both groups.

LEVEL OF EVIDENCE

III.

Biomechanical Analysis of Hip Braces after Hip Arthroscopic Surgery for Femoroacetabular Impingement Syndrome: An Observational Study

Currently, hip braces are recommended and typically worn by femoroacetabular impingement (FAI) patients after hip arthroscopic surgery. However, there is currently a lack of literature regarding the biomechanical effectiveness of hip braces. The purpose of this study was to investigate the biomechanical effect of hip braces after hip arthroscopic surgery for FAI. Overall, 11 patients who underwent arthroscopic FAI correction and labral preservation surgery were included in the study. Standing-up and walking tasks in unbraced and braced conditions were performed at 3 weeks postoperatively. For the standing-up task, videotaped images of the hip's sagittal plane were recorded while patients stood from a seated position. After each motion, the hip flexion-extension angle was calculated. For the walking task, acceleration of the greater trochanter was measured using a triaxial accelerometer. For the standing-up motion, the mean peak hip flexion angle was found to be significantly lower in the braced condition than in the unbraced condition. Furthermore, the mean peak acceleration of the greater trochanter was significantly lower in the braced condition than in the unbraced condition. Patients undergoing arthroscopic FAI correction surgery would benefit from usage of a hip brace in terms of protecting repaired tissues during early postoperative recovery.