Capsular Management at the Time of Hip Arthroscopy for Femoroacetabular Impingement Syndrome Varies With Geography and Surgeon Subspecialty Training: A Cross-Sectional, Multinational Surgeon Survey

Similar Rates of Survivorship and Marginal Clinical Impact of Routine Interportal Capsular Repair Versus No Repair at 5 Years After Arthroscopic Correction of Femoroacetabular Impingement

PURPOSE

(1) To compare 5-year survivorship (avoiding repeat hip arthroscopy (HA)/total hip replacement conversion) between those undergoing routine capsular repair compared with where no repair was performed; (2) compare patient-reported outcome measures (PROMs) and achievability of metrics of clinically important improvement between these groups; and (3) evaluate the moderating influence of age and sex on outcomes.

METHODS

Review of prospectively collected data from an institutional hip preservation registry, of cases undergoing hip arthroscopy (HA) for femoroacetabular impingement between January 2011 and September 2018, with minimum 5-year follow-up, was undertaken. Cases undergoing routine interportal capsular repair (CR) were matched in a 1:1 ratio (age ± 2 years, sex, Tönnis grade) to hips with no capsular repair (NR). Exclusion criteria were dysplasia, Tönnis grade >1, age >50 years, and concomitant hip pathologies. Group survival was evaluated using Kaplan-Meier analysis and for levels of sex and age. Where revision surgery (repeat HA/total hip replacement) was avoided, PROMs (modified Harris Hip Score, University of California and Los Angeles Activity Scale [UCLA], Short Form 36 [SF-36]) were assessed at minimum 5 years, and proportion of cases achieving minimal clinically important difference (MCID) and substantial clinical benefit (SCB) determined.

RESULTS

In total, 285 CR cases were matched with 285 NR cases. The average age was 27.0 ± 5.9 years, and most patients (90%) were male. The overall total hip replacement rate was 0.7% (0.4% NR; 0.9% CR, P = .619) and was not significantly different between groups when adjusting for sex (χ2 = 0.474, P = .491), or age (χ2 = 0.463, P = .496). The overall repeat HA rate was 12.0% (12.9% NR; 11.1% CR, P = .538), which was not significantly different between groups when adjusting for sex (χ2 = 0.479, P = .489), or age (χ2 = 0.448, P = .503). Significant improvement in all PROMs was noted for both the NR and CR groups (P < .001 for all). At 5 years postoperatively, SF-36 was marginally greater for the NR group (P = .006, r = 0.169). No significant difference between groups at 5 years postoperatively were found: modified Harris Hip Score (P = .476), UCLA (P = .188). A greater proportion of CR cases achieved MCID in UCLA (69.4% vs 56.5%, P = .032, Φ = 0.131). MCID achievement rates were similar between groups for all other PROMs (P > .05). A greater proportion of patients in the NR group achieved SCB in SF-36 (54.0% vs 41.9%, P = .049, Φ = 0.127). SCB achievement rates were similar between groups for all other PROMs (P > .05).

CONCLUSIONS

Routine repair of an interportal capsulotomy makes no difference to survivorship at minimum 5 years post-HA compared with nonrepair, with marginal differences in PROMs, and achievability of MCID and SCB thresholds of clinically significant improvement. The impact of capsular management (repair/nonrepair) may be more apparent for specific patient cohorts rather than routine repair in all cases.

LEVEL OF EVIDENCE

Level III, retrospective matched comparative case series.

Editorial Commentary: Outcome of Hip Arthroscopy Is Determined by Diverse Intrinsic and Extrinsic Factors in Addition to Capsular Closure

There are contrasting findings between randomized controlled trials and systematic reviews that investigate capsular closure during arthroscopic treatment of femoroacetabular impingement syndrome. Some surgeons advocate that capsular closure is beneficial, as it reduces risks of instability and degeneration, while others argue that capsular closure could lead to joint stiffness and/or fibrosis, in addition to increased surgical time. Although unrepaired periportal or interportal capsulotomies may (or may not) compromise outcomes, it is beneficial to close larger incisions and extensions of T-type capsulotomies, especially in patients with a high risk of instability (concomitant borderline dysplasia, hyperlaxity, young age, etc.). Most studies focused on the effect of capsular closure do not identify other intrinsic and extrinsic factors-factors that could influence outcomes. Intrinsic factors include patient age, sex, type of femoroacetabular impingement syndrome (cam, pincer, or mixed), Tönnis grade, and presence of concomitant hypermobility or dysplasia. Extrinsic factors include surgeon experience, surgical technique, adjuvant procedures (such as labral repair), and type of capsulotomy (periportal, interportal, T-type).

Imaging evaluation of hip capsule disorders: a comprehensive review

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.

Editorial Commentary: Complete Capsular Closure in Hip Arthroscopy Shows Superiority in Expected Value Decision Analysis Compared to Incomplete Capsular Closure

In all aspects of orthopaedic surgery, restoring native patient anatomy has shown improved outcomes in comparison to nonanatomic reconstructions. Particular attention has been paid to the hip capsule, as the complex of the iliofemoral, pubofemoral, and ischiofemoral ligaments, as well as the zona orbicularis and iliocapsularis, all play an essential role in hip stability, mechanics, and maintenance of intra-articular pressures. An anatomic approach toward hip arthroscopy also includes labral repair or reconstruction with preservation of the chondrolabral junction and cam resection. Multiple recent studies have revealed improved patient-reported outcomes at long-term (>10-year) follow-up, as well as reduced revision rates and less progression to total hip replacement with complete capsular repairs compared to incomplete closure or no capsular management following hip arthroscopy. We perform an interportal capsulotomy with labral-sided capsular traction sutures for the central compartment, followed by the T-capsulotomy along the femoral neck with femoral-sided traction sutures for the peripheral compartment. At the end of every case, we ensure an anatomic complete capsular closure of the entire T-capsulotomy using a combination of self-retrieving suture guns and curved self-suture passers, often tying 7 or more sutures.

Editorial Commentary: Hip Capsular Preservation When Treating Femoroacetabular Impingement Syndrome Should Remain Universal, and Some Hip Phenotypes Necessitate Maximum Surgical Stability

Hip capsular preservation remains most common in the United States despite literature to-date showing varying outcomes. Different surgeons prefer, and different patients require, periportal capsulotomies versus wider exposure with T-type capsulotomy and traction stitches. In addition to revision cases, some hip phenotypes may require more aggressive capsular management. Patients with borderline hip dysplasia, acetabular retroversion, increased femoral anteversion, and greater Beighton scores necessitate more hip stability; thus, capsular preservation and closure is essential. However, patients with "tight" hips, thicker capsules, and larger cam deformities may require less-stringent capsular care. Regardless, adequate bony decompression is paramount in patients with femoroacetabular impingment syndrome.

Extended Interportal Capsulotomy for Hip Arthroscopy, a Single-Center Clinical Experience

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.