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

Postoperative Effusion-Synovitis Is Associated With Poor Clinical Outcomes in Patients With Femoroacetabular Impingement Syndrome

PURPOSE

To investigate the consecutive changes in effusion-synovitis after primary arthroscopic treatment for patients with femoroacetabular impingement syndrome (FAIS) and to determine the effect of postoperative effusion-synovitis on clinical outcomes.

METHODS

Data from March 2021 through January 2022 was reviewed. Patients diagnosed with FAIS and undergoing hip arthroscopic treatment were included. Exclusion criteria were incomplete magnetic resonance imaging (MRI) data, prior history of hip surgery, labral reconstruction, and concomitant hip conditions. MRI (noncontrast 3.0 T) was performed preoperatively and 3, 6, and 12 months postoperatively, and the measurement of the largest femoral neck fluid thickness (FTM) and cross-sectional area (CSA) of the effusion-synovitis were collected. Preoperative and a minimum of 2-year postoperative patient-reported outcome (PRO) scores including visual analog scale (VAS), modified Harris Hip Score (mHHS), and International Hip Outcome Tool, 12-component form (iHOT-12) were collected and compared. Postoperative Tegner Activity Scale was also collected. The PROs and achievements of minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) were compared between patients with and without postoperative effusion-synovitis. Multivariate linear regression analysis was performed to determine the effect of the effusion-synovitis size on PROs.

RESULTS

A total of 61 patients (61 hips) were included in the study. The 3-month postoperative FTM, CSA, and grade of effusion-synovitis presented a significant increase compared with the preoperative values (all P < .05). No significant differences were observed in the 6-month postoperative measurements compared with the preoperative values (all P > .05). At the 12-month follow-up, although there was a significant decrease in all measurements compared with the preoperative values (all P < .001), 39 patients (63.9%) still presented effusion-synovitis. Compared with the other 22 patients (36.1%) without effusion-synovitis, these patients presented inferior mHHS, iHOT-12 (all P < .05), as well as lower achievement of PASS of mHHS (82.1% vs 100%, P = .035) and iHOT-12 (38.5% vs 81.8%, P = .001). The achievement of MCID of mHHS (79.5% vs 77.3%, P = .839) and iHOT-12 (89.7% vs 95.5%, P = .839) were comparable between patients with and without effusion-synovitis. The postoperative sagittal CSA (beta = -.302, P = .039) were negatively related to mHHS in the regression analysis.

CONCLUSIONS

After arthroscopic treatment for FAIS, the level of effusion-synovitis presented an initial increase, then followed by a subsequent decrease. Effusion-synovitis was significantly alleviated at 12 months compared with the preoperative level. Patients with postoperative effusion-synovitis had inferior clinical outcomes and lower achievement of PASS compared to those without.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Current understanding of articular cartilage lesions in femoroacetabular impingement syndrome

The concept of femoroacetabular impingement syndrome (FAIS) has received much attention over the past 20 years. Currently, it is believed that FAIS can lead to intra-articular pathologies such as labral tears and articular cartilage lesions, resulting in clinical symptoms and subsequent poor clinical outcomes. FAIS-related articular cartilage lesions are common but unique, and their natural course always leads to early osteoarthritis of the hip. However, despite these cartilage lesions having gradually gained considerable attention, limited consensus has been reached on key aspects, such as diagnosis, mechanisms, classification, and management strategies, which limits clinical and research advances. Hence, an intensive comprehensive overview based on the existing evidence is necessary. The purpose of this review was to introduce the general consensus, controversial issues, and recent advances in FAIS-related articular cartilage lesions.

Clinical Outcomes of the Arthroscopic Capsular Suture-Lifting Technique in the Treatment of Femoroacetabular Impingement in Patients With Borderline Developmental Dysplasia of the Hip

Background

Patients with femoroacetabular impingement (FAI) are likely to present with borderline developmental dysplasia of the hip (BDDH). Considering the prolonged risk of negative prognosis in these patients, the need for surgical management of the capsule has been emphasized. Although previous studies have advocated different techniques of capsular closure during surgery, no consensus has been achieved. Therefore, the aim of this study was to evaluate the clinical outcomes of a new arthroscopic capsular suture-lifting technique for the treatment of FAI combined with BDDH.

Hypothesis

The arthroscopic capsular suture-lifting technique would achieve better anterior stability and show better clinical outcomes compared with routine capsular closure.

Study Design

Cohort study; Level of evidence, 3.

Methods

Consecutive patients diagnosed with FAI and BDDH and who underwent hip arthroscopy in our hospital between September 1, 2017, and April 30, 2021, were evaluated. Data were collected prospectively and analyzed retrospectively. Patients were divided into 2 groups according to the capsule closure methods used: capsular suture-lifting technique (lifting group) and routine capsular closure (control group). Anteroposterior hip radiography, Dunn view radiography, and computed tomography imaging were carried out for all patients preoperatively and postoperatively. Patient-reported outcomes, including the modified Harris Hip Score (mHHS) and visual analog scale (VAS) for pain, were collected preoperatively and at least 1 year after surgery and compared between the 2 groups. The Wilcoxon signed-rank test was used to evaluate changes in preoperative to postoperative mHHS scores and VAS. Mann-Whitney U test was used to evaluate significant differences in postoperative mHHS and VAS scores in the 2 groups.

Results

In all, 144 patients were included in this study, of whom 77 (53.5%) underwent the arthroscopic capsular suture-lifting technique and 67 (46.5%) underwent routine arthroscopic surgery. The patients in both groups had significant improvement in postoperative mHHS and VAS compared with the preoperative assessment (P < .05). The postoperative VAS score of patients in the suture-lifting group was significantly lower (2.6 vs 3.8; P < .05) and the mHHS score was significantly higher (75.2 vs 68.5; P < .05) than those of patients in the control group. Of the 77 patients in the suture-lifting group, 68 (88.3%) surpassed the minimal clinically important difference (MCID) and 49 (63.6%) achieved the Patient Acceptable Symptom State (PASS). Of the 67 patients in the control group, 26 (38.8%) surpassed MCID and 32 (47.8%) achieved PASS. The percentage of patients achieving MCID and PASS in the suture-lifting group was significantly greater than that in the control group (P = .007 for MCID; P = .03 for PASS).

Conclusion

The study demonstrated that the arthroscopic capsular suture-lifting technique provided good clinical outcomes in the treatment of patients with FAI combined with BDDH. This technique showed better improvement of postoperative clinical outcomes than routine capsular closure.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Arthroscopic Repair of Acetabular Cartilage Delamination Using Chondral Nail Fixation in Patients With Femoroacetabular Impingement

Acetabular cartilage delamination is commonly seen in patients with femoroacetabular impingement (FAI), especially ones with the cam deformity. However, the definition and classification of acetabular cartilage injuries caused by FAI to guide clinical treatment remain controversial. Moreover, treatment of acetabular cartilage damage always causes a dilemma for surgeon during surgery. We believe a reliable repair of the acetabular cartilage delamination will lead to a better long-term outcome for patients with FAI. In this Technical Note, we introduce the chondral nail fixation under hip arthroscopy for treating acetabular cartilage delamination in patients with FAI. This technique contributes to eliminating intra-articular unstable factors, preserving native cartilage as much as possible, and restoring cartilage surface intact at best.

Editorial Commentary: Arthroscopy With Labral Preservation or Reconstruction Plus Capsular Closure Shows Excellent Outcome in Patients With Borderline Hip Dysplasia and is Less Invasive Than Periacetabular Osteotomy

Borderline developmental dysplasia of the hip (BDDH), or borderline hip dysplasia (BHD), traditionally characterized by a relatively low lateral center-edge angle (LCEA), presents a complex challenge in treatment due to its multifaceted etiology involving instability, femoroacetabular impingement (FAI), or a combination thereof. The optimal approach to managing adult BDDH remains a subject of significant debate. Periacetabular osteotomy (PAO) is considered the preferred treatment for addressing severe acetabular under-coverage, as it rectifies the underlying bony deficiency and promotes stability. However, the treatment of BDDH is less straightforward, particularly with the advancement of hip arthroscopy techniques, specifically labral preservation and capsular management. Given the minimally invasive and rapid postoperative rehabilitation advantage for arthroscopic procedures over open surgeries, numerous attempts have been undertaken in this context. Research has revealed favorable patient-reported outcomes (PROs), low failure rates, and a significant proportion of returning to sports (RTS) after arthroscopic management for patients with BDDH. Although we might in the right direction, Level I evidence studies are needed to comprehensively compare long-term PROs, failure rates, and rates of RTS between arthroscopy and PAO in the treatment of BDDH.