Effect of Capsular Closure on Outcomes of Hip Arthroscopy for Femoracetabular Impingement: A Systematic Review and Meta-analysis

Evaluating the Impact of Capsular Closure on Clinical Outcomes, Revision Rates, and Return to Sports in Adolescent Females Undergoing Hip Arthroscopy for Femoroacetabular Impingement

Background

Young female patients undergoing hip arthroscopy have an increased prevalence of baseline capsular laxity of the hip joint. This laxity, along with superimposed postoperative iatrogenic capsular deficiency secondary to an unrepaired capsule, could potentially lead to worse outcomes after arthroscopic treatment of femoroacetabular impingement (FAI) in this population.

Purpose

To compare outcomes and revision rates for young female patients undergoing hip arthroscopy for FAI and labral tear with capsular closure (CC group) versus capsular nonclosure (CNC group).

Study Design

Cohort study; Level of evidence, 3.

Methods

A retrospective review of prospectively collected data of patients who underwent index hip arthroscopy using interportal capsulotomies by a single surgeon between January 2014 and February 2020 was performed. Female patients aged 12 to 21 years who underwent hip arthroscopy with cam or pincer osteoplasty and labral repair with a 2-year minimum follow-up were included. The Beighton score was assessed. The Hip Outcome Score-Activities of Daily Living (HOS-ADL) and Hip Outcome Score-Sport-Specific Subscale (HOS-SSS) were obtained preoperatively and at 3 months, 1 year, and 2 years postoperatively. Data were analyzed using the Mann-Whitney U test and Fisher exact test.

Results

A total of 23 hips (20 patients) were included in the CC group and 17 hips (16 patients) were included in the CNC group. The groups were not different regarding characteristics and preoperative patient-reported outcome scores. At all follow-up intervals postoperatively, the CC group scored significantly higher HOS-ADL and HOS-SSS. Fifteen of 17 (88.2%) patients in the CC group returned to sports versus 8 of 14 (57.1%) in the CNC group (P = .03). Four (17.4%) hips in the CC group had revision surgery compared with 9 (52.9%) hips in the CNC group (odds ratio, 5.1; 95% CI, 1.2-22.5; P = .02).

Conclusion

Young female patients treated with CC while undergoing arthroscopic FAI had improved outcomes, fewer revisions, and a higher return-to-sports rate than those treated without CC.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Capsular 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.

Eighty-One Percent of Unrepaired Interportal Capsulotomies Showed Healed Capsules on Magnetic Resonance Imaging 5 Years After Primary Hip Arthroscopy

Purpose

To evaluate whether unrepaired interportal capsulotomy presents with capsular defect on magnetic resonance imaging (MRI) 5 years after primary hip arthroscopy and to determine its effect on functional results and findings of osteoarthritis on radiographs or MRI scans.

Methods

Patients with femoroacetabular impingement (without arthritis or dysplasia) were retrospectively reviewed after arthroscopic labral repair or debridement and femoroplasty through interportal capsulotomy without closure. Patients were assessed preoperatively and at a minimum of 5 years postoperatively using patient-reported outcomes (Hip Outcome Score-Activities of Daily Living scale, modified Harris Hip Score, and visual analog scale pain score), radiographic measures, and MRI scans.

Results

Forty patients (42 hips) were deemed eligible for the study and were evaluated. Of the hips, 81% had healed capsules, whereas 8 (19%) had capsular defects on the latest MRI scan. There were 3 hips with subchondral edema in the defect group compared with 1 in the healed-capsule group (P = .01) on the latest MRI scan, which was not present on preoperative MRI (still positive on multivariate analysis when the preoperative alpha angle was also taken into consideration). Functional results did not differ between the groups (P > .05).

Conclusions

In this study, 81% of interportal capsulotomies healed without repair at 5 years after primary hip arthroscopy.

Clinical Relevance

Understanding the prevalence and implications of unhealed capsulotomies could encourage surgeons to be meticulous in capsular closure.

Capsule closure has better hip function than non-closure in hip arthroscopy for femoracetabular impingement: A systematic review and meta-analysis

Background

The impact of capsular closure vs non-closure in hip arthroscopy for femoracetabular impingement (FAI) was assessed by a meta-analysis.

Methods

With the most recent search update occurring in August 2022, relevant studies were found by searching the Pubmed and EMBASE databases. A collection of studies was made that conducted hip arthroscopy for FAI. Review Manager 5.3 was used to carry out the meta-analysis. The dichotomous and continuous factors were compared using the odds ratios (OR) and mean differences (MD). A fixed-effect or random-effect model was chosen, depending on the degree of heterogeneity (I2). Forest plots were used to assess the results. A significance level of P < 0.05 was applied to the statistical analysis.

Results

Ultimately, 15 studies were incorporated into the meta-analysis. The surgery time was longer for the capsular closure group (CC group) compared to the non-closure (NC group) group. (P < 0.001, SMD = 8.59, 95%CI [7.40, 9.77], I2 = 32 %). Following hip arthroscopy, the CC group's mHHS was superior to that of the NC group (P = 0.001, MD = 2.05, 95%CI [0.83, 3.27], I2 = 42 %), HOS-ADL (P < 0.001, MD = 4.29, 95%CI [3.08, 5.50], I2 = 0 %). The capsular closure group had a reduced rate of postoperative complications (P = 0.001, OR = 0.21, 95%CI [0.08, 0.54], I2 = 0 %) and conversion to THA (P = 0.01, OR = 0.42, 95%CI [0.21, 0.83], I2 = 0 %) following hip arthroscopy than the non-closure group. The revision rate, VAS, and postoperative HOS-SSS did not significantly differ between these two groups (P＞0.05).

Conclusion

The current meta-analysis found that the closed group had a lower complication rate and considerably greater mHHS and HOS-ADL following surgery compared to the non-closed capsule group. Whether this is related to the continuous progress of biomechanical and clinical research techniques deserves our attention.

Level of evidence

Level IV, systematic review of Level I through Level III studies.

Predicting Outcomes in Hip Arthroscopy for Femoroacetabular Impingement Syndrome

PURPOSE OF REVIEW

Arthroscopic treatment of femoroacetabular impingement syndrome (FAIS) continues to rise in incidence, and thus there is an increased focus on factors that predict patient outcomes. The factors that impact the outcomes of arthroscopic FAIS treatment are complex. The purpose of this review is to outline the current literature concerning predictors of patient outcomes for arthroscopic treatment of FAIS.

RECENT FINDINGS

Multiple studies have shown that various patient demographics, joint parameters, and surgical techniques are all correlated with postoperative outcomes after arthroscopic FAIS surgery, as measured by both validated patient-reported outcome (PRO) scores and rates of revision surgery including hip arthroplasty. To accurately predict patient outcomes for arthroscopic FAIS surgery, consideration should be directed toward preoperative patient-specific factors and intraoperative technical factors. The future of accurately selecting patient predictors for outcomes will only improve with increased data, improved techniques, and technological advancement.

Arthroscopic Hip Capsular Repair Improves Patient-Reported Outcome Measures and Is Associated With a Decreased Risk of Revision Surgery and Conversion to Total Hip Arthroplasty

Purpose

To perform a systematic review to assess the effect of capsular repair compared with nonrepair on patient-reported outcome measures (PROMs) and conversion to total hip arthroplasty (THA) after hip arthroscopy in patients with femoroacetabular impingement syndrome.

Methods

We initially searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and PubMed databases, as well as ongoing clinical trials (https://clinicaltrials.gov), on December 15, 2022. The eligibility criteria were randomized controlled trials (Level Ⅰ) and prospective comparative studies (Level II) of patients who underwent capsular repair and nonrepair via hip arthroscopy with a minimum follow-up period of 2 years. We registered this protocol a priori on PROSPERO (identification No. CRD42021239306). We assessed the risk of bias using the Methodological Index for Non-randomized Studies (MINORS) appraisal tool.

Results

This review included 5 studies with a total of 639 patients (270 with capsular repair [average age, 35.4 years; 41% female patients] and 369 with nonrepair [average age, 37.3 years; 38% female patients]). In the included studies, surgical procedures consisting of labral repair and pincer or cam osteoplasty were performed via hip arthroscopy. The modified Harris Hip Score was measured in all the included studies, and the standardized mean difference in PROMs for capsular repair versus nonrepair in the included studies was 0.42 (95% confidence interval [CI], 0.20 to 0.63). A sensitivity analysis of randomized controlled trials achieved consistent results (standardized mean difference in PROMs, 0.31; 95% CI, 0.02 to 0.60). Capsular repair was not associated with a reduction in revision surgery (risk difference, -0.02; 95% CI, -0.06 to 0.03; 26 of 270 patients with capsular repair vs 42 of 369 with nonrepair) but was associated with a reduction in conversion to THA (risk difference, -0.05; 95% CI -0.09 to -0.01; 12 of 270 patients with capsular repair vs 38 of 369 with nonrepair). The average Methodological Index for Non-randomized Studies (MINORS) score in the included studies was 20.

Conclusions

Patients who undergo capsular repair in conjunction with other arthroscopic hip preservation techniques have better PROMs and a lower incidence of THA conversion.

Level of Evidence

Level II, systematic review of Level I and II investigations.

Effect of Capsular Closure After Hip Arthroscopy for Femoroacetabular Impingement Syndrome on Achieving Clinically Meaningful Outcomes: A Meta-analysis of Prospective and Comparative Studies

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.

Editorial Commentary: Evidence-Based Guidelines for Management of the Hip Capsule During Arthroscopy: Has It Become Personal?

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.