Capsular closure versus unrepaired interportal capsulotomy after hip arthroscopy in patients with femoroacetabular impingement: results of a patient-blinded randomised controlled trial

Patient Factors Influencing Outcomes at 12-Year Follow-up of Hip Arthroscopy for Femoroacetabular Impingement

BACKGROUND

Arthroscopic treatment of femoroacetabular impingement has increased in popularity since the early 2000s when it was first described, although only a few midterm follow-up studies have been published.

PURPOSE

To describe the outcomes of patients undergoing hip arthroscopy for femoroacetabular impingement at a mean 12-year follow-up and to determine the risk factors for failure.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

The Non-Arthritic Hip Score (NAHS) and a radiographic evaluation were completed preoperatively and at midterm follow-up. Participants were divided into 2 groups according to their clinical evolution. The success group consisted of patients whose NAHS at the final follow-up was above the established Patient Acceptable Symptom State (PASS) threshold of 81.9, whereas patients who underwent a second surgical intervention or did not reach the PASS threshold at final follow-up were assigned to the failure group. These groups were compared to identify preoperative differences in demographic, pathological, and surgical factors.

RESULTS

A total of 95 hips were included, after 23 were lost to follow-up (80.5% follow-up). At a mean follow-up of 12.1 years (range, 9.2-16.0 years), 9 hips required total hip arthroplasty (9.5%), 5 required revision hip arthroscopy (5.3%), 29 did not achieve the NAHS PASS threshold (30.5%), and 52 achieved the NAHS PASS threshold (54.7%). The mean NAHS was 82.4 at final follow-up compared with 66.9 preoperatively (mean difference = 15.5; P < .001). Higher mean body mass index (24.9 vs 23.0; P = .030), older age (30.0 vs 27.2; P = .035), and inferior preoperative lateral joint space width (3.9 vs 4.4; P = .019) were associated with inferior prognosis in the failure group versus success group. Osteoarthritis progression was observed in 69.2% of the failure group and in 34.8% of the success group (P = .082). Labral ossification was observed in 78.3% of all patients, and its lateral projection length was statistically associated with failure (P = .015).

CONCLUSION

At a mean 12-year follow-up, hip arthroscopy for femoroacetabular impingement led to significant clinical improvement, with 55% PASS achievement. In total, 31% of patients were below the PASS threshold, 5% had revision arthroscopy, and only 9% had conversion to total hip arthroplasty for a 45% global failure rate. Increased body mass index, older age, and smaller preoperative lateral joint space width were significant negative prognostic factors. Postoperative degenerative changes were highly prevalent and demonstrated association with failure.

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.

Noninterportal capsulotomy of hip arthroscopy showed improved outcomes in borderline hip dysplasia: A retrospective study with minimum 2-year follow-up

PURPOSE

The present study aimed to evaluate the functional outcomes of hip arthroscopy using a noninterportal capsulotomy technique to address labral tears in patients with borderline hip dysplasia (BHD). Additionally, we also compared these outcomes with those of patients with BHD who underwent the standard repaired interportal capsulotomy (RIPC) arthroscopy.

METHODS

Data from patients with BHD were retrieved from a database of patients who underwent arthroscopic hip surgery with noninterportal capsulotomy or RIPC to treat labral tears between January 2014 and December 2020. Data collected included both pre- and postoperative patient-reported outcomes (PROs).

RESULTS

A total of 58 patients (noninterportal capsulotomy, n = 37; RIPC, n = 21) with a mean age of 30.9 ± 5.6 and 28.6 ± 5.5 years, respectively, met the inclusion criteria. All of the patients underwent a minimal 2-year follow-up. The mean lateral centre-edge angle was 23.3 ± 1.2° in the noninterportal capsulotomy group and 23.7 ± 1.0° in the RIPC group, with no significant difference. The PROs improved from the preoperative to the latest follow-up, with a p < 0.001. There were no differences between the groups.

CONCLUSION

Using strict patient selection criteria, hip arthroscopy with noninterportal capsulotomy demonstrated significant pre- to postoperative improvements in patients with BHD and achieved results comparable to those from hip arthroscopy with RIPC.

LEVEL OF EVIDENCE

Level III.

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.

Demographic and Socioeconomic Patient Data Are Rarely Included in Randomized Controlled Trials for Femoral Acetabular Impingement and Hip Arthroscopy: A Systematic Review

Purpose

To determine the rate of reporting for sociodemographic variables in randomized controlled trials (RCTs) investigating femoral acetabular impingement (FAI) and hip arthroscopy.

Methods

PubMed, Scopus, and Web of Science were queried for articles relating to FAI and hip arthroscopy. Articles included in final analysis were RCTs investigating operative management of FAI. Included RCTs were analyzed for reporting of age and sex or gender as well as the following sociodemographic variables: race, ethnicity, insurance status, income, housing status, work status, and education level in the results section or any section of the paper. Data was analyzed using χ2 and Fisher exact tests with significance defined as P < .05.

Results

Forty-eight RCTs were identified from 2011 to 2023. Age was reported in 48 of 48 (100%) of included papers; sex or gender was reported in 47 of 48 (97.9%). Reporting of sociodemographic variables in any section respectively was: race (7/48, 14.6%), ethnicity (4/48, 8.33%), insurance status (0/48, 0%), income (1/48, 2.08%), housing status (0/48, 0%), work status (3/48, 6.25%), and education (2/48, 4.17%). There was no significant difference for reporting demographic variables with respect to journal or year of publication (P = .666 and P = .761, respectively). Sociodemographic variables (9/48) were reported significantly less frequently than age and sex or gender (48/48) (P < .001).

Conclusions

This study found that sociodemographic variables in FAI and hip arthroscopy RCTs are reported with much lower frequency than age and sex or gender. These findings may demonstrate the need to include patient sociodemographic data in RCTs so that their results can be better generalized and applied to the appropriate patient population.

Level of Evidence

Level II, systematic review of level I and II evidence.

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.

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.

The impact of surgical randomised controlled trials on the management of FAI syndrome: a citation analysis

PURPOSE

To identify and assess the clinical impact of randomised controlled trials (RCTs) assessing the surgical management of femoroacetabular impingement syndrome (FAIS) through a citation analysis.

METHODS

MEDLINE, EMBASE and CENTRAL were searched from inception to April 22, 2023 for RCTs assessing the surgical management of FAIS. Study characteristics were directly abstracted from included trials and citation metrics were obtained from the Clarivate Web of Knowledge database on May 19, 2023. The continuous fragility index (CFI) was calculated for eligible outcomes. Univariate regression models were used to explore correlations between total citations per year and various study characteristics.

RESULTS

Ten studies comprising one thousand two hundred ninetypatients were eligible for analysis. Studies were published from 2013 to 2023. Eight countries were represented across various trials with 91% being either North American or European. The mean journal impact factor of published studies was 39.684 (median 2.982; range 1.31-202.73). The mean citation density was 14.17 (range 0.33-48.67). The median CFI was 4.8 (range 1-32.2). Correlation analysis demonstrated strong and statistically significant correlations to study sample size (R = 0.75, p = 0.012), journal impact factor (R = 0.80, p = 0.006) and continuous fragility index (R = 0.95, p = 0.015).

CONCLUSION

Trials assessing the surgical management of FAIS present with a wide range of clinical uptake based on citation density and are published in journals of broadly variable impact factor. Despite promising citation metrics, high-quality evidence on arthroscopy for FAIS is limited to the United States and Europe with an unclear international impact. Future knowledge translation efforts are warranted to maximise the international uptake of evidence regarding arthroscopic management of FAIS.

LEVEL OF EVIDENCE

I.

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.

Systematic Review and Meta-analysis of Studies Comparing Complete Capsular Closure Against Unrepaired Hip Capsules During Hip Arthroscopy

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.

Hip Capsular Repair Results in Improved Patient-Reported Outcomes and Survivorship: A Systematic Review of the Literature

PURPOSE

To determine whether routine capsular closure following hip arthroscopy for femoroacetabular impingement (FAI) in patients without dysplasia results in improved patient-reported outcomes (PROs) and increased survivorship rates.

METHODS

A literature search of the PubMed, Embase, and Cochrane Library databases was performed using the Preferred Reporting for Systematic Reviews and Meta-Analyses guidelines for clinical studies reporting PROs following arthroscopic hip labral repair for FAI. A quality assessment was performed using the Methodological Index for Non-randomized Studies grading system. Inclusion criteria consisted of comparative clinical studies investigating routine capsular closure with nonclosure in patients undergoing hip arthroscopy for the treatment of FAI and labral tears. Exclusion criteria included non-English language, minimum follow-up of less than 2 years after surgery, technique articles, case reports, noncomparative case series of fewer than 10 patients, failure to report surgical technique, absence of postoperative PROs, or partial repair. Data collection included study characteristics, demographics, indications, radiographic metrics, perioperative findings, surgical technique, baseline and most recent PROs, and subsequent surgeries.

RESULTS

A total of 531 articles were reviewed, of which 3 were included with 249 hips that underwent capsular repair and 157 hips that underwent capsulotomy with no repair. There were 2 Level III studies and 1 Level II study, with an average The Methodological Index for Non-randomized Studies score of 16.7. All studies cited FAI and labral tear as an indication for surgery. All studies demonstrated improved PROs from baseline to most recent follow-up. Postoperatively, the repair group reported modified Harris Hip Score values ranging from 80.8 to 87, whereas the nonrepair group reported scores ranging from 76 to 81.7. In addition, the repair group reported postoperative Hip Outcome Score - Sports-Specific Subscale values ranging from 68.1 to 9, whereas the nonrepair group reported scores ranging from 65.3 to 76.1. The studies also reported minimal clinically important difference for modified Harris Hip Score, with the repair group reporting percentages ranging from 71 to 100 and the nonrepair group reporting percentages ranging from 52 to 95.6. All 3 studies also observed a lower rate of hip survivorship in the nonrepair group, ranging from 94.6 to 100 in the repair group and 90.8 to 100 in the nonrepair group. There were no significant differences in the rate of revision arthroscopy between groups.

CONCLUSIONS

Patients without dysplasia who undergo capsular repair have greater improvements in PROs and greater survivorship rates at early- and mid-term follow-up than patients who do not undergo capsular repair.

LEVEL OF EVIDENCE

III, systematic review of level II and III studies.

Acetabular retroversion does not affect outcome in primary hip arthroscopy for femoroacetabular impingement

PURPOSE

The surgical treatment of femoral-acetabular impingement syndrome (FAIS) in patients with acetabular retroversion (AR) is arthroscopical or by a reverse periacetabular osteotomy (PAO). The purpose of the present study was to investigate the results after arthroscopic treatment of FAIS in patients with and without radiographic signs of AR in a large, prospective cohort from the Danish Hip Arthroscopy Registry (DHAR). The hypothesis was there is no difference in clinical outcome between the two groups.

METHODS

Data on 4914 hip arthroscopies performed during 2012-2019 were obtained from DHAR. Patients with radiographic signs of osteoarthritis (Tönnis > 1), hip dysplasia (CEA < 25°), other hip pathologies or previous hip surgery were excluded. The clinical outcomes for patients with AR [defined by a positive posterior wall sign (PWS) in combination with a positive Ischial Spine Sign (ISS)] and patients without AR (no PWS, no ISS) were analyzed 1 and 2 years after surgery. The primary outcomes were the six domains of the Copenhagen Hip and Groin Outcome score (HAGOS), while secondary outcomes were the Hip Sports Activity Scale (HSAS), a visual analogue pain scale (VAS) and a numeric rating scale (NRS) for pain.

RESULTS

A total of 3135 hip arthroscopies were included, of which 339 had AR, 1876 did not, and 920 presented one of the two signs (PWS and ISS). There were no statistically significant differences 1 and 2 years after surgery (n.s.) between patients with and without AR in HAGOS domain scores, HSAS, VAS, or NRS. Both groups showed improvement at both follow-ups. The two groups did not differ in relation to intraoperative findings and the procedures they have had.

CONCLUSION

The outcome 1 and 2 years after arthroscopic treatment of FAIS is not different for patients with and without AR.

LEVEL OF EVIDENCE

III.

A higher proportion of patients may reach the MCID with capsular closure in patients undergoing arthroscopic surgery for femoroacetabular impingement: a systematic review and meta-analysis

PURPOSE

The purpose of this review is to provide a summary of the techniques and outcomes of various capsular management strategies in patients undergoing hip arthroscopy for femoroacetabular impingement (FAI). The information this review provides on capsular management strategies will provide surgeons with operative guidance and decision-making when managing patients with FAI lesions arthroscopically.

METHODS

Three databases MEDLINE, EMBASE, and PubMed were searched from database inception to November 2nd 2021, for literature addressing capsular management of patients undergoing hip arthroscopy for FAI. All level I-IV data on capsular management strategy as well as postoperative functional outcomes were recorded. A meta-analysis was used to combine the mean postoperative functional outcomes using a random-effects model.

RESULTS

Overall, there were a total of 36 studies and 4744 patients included in this review. The mean MINORS score was 10.7 (range 8-13) for non-comparative studies and 17.6 (range 15-20) for comparative studies. Three comparative studies in 1302 patients examining the proportion of patients reaching the MCID for the mHHS score in patients undergoing interportal capsulotomy with either capsular repair or no repair found that the capsular repair group had a higher odds ratio of reaching the MCID at 1.46 (95% CI 0.61-3.45, I² = 67%, Fig. 2, Table 3); however, this difference was not significant with a p value of 0.39. When looking at only level 1 and 2 studies, four studies in 1308 patients reporting on the mHHS score in patients undergoing capsular closure regardless of capsulotomy type, found a pooled standardized mean difference in the mHHS score of 2.1 (95% CI 1.7-2.55, I² = 70%, Fig. 3), while four studies in 402 patients reporting on the mHHS score in patients not undergoing capsular closure regardless of capsulotomy type found a pooled standardized mean difference in the mHHS score of 1.46 (95% CI 1.2-1.7, I² = 30%, Fig. 4).

CONCLUSION

This review may demonstrate improved postoperative outcomes in patients undergoing complete capsular closure regardless of capsulotomy type based on postoperative mHHS score. Furthermore, this review may suggest improved postoperative outcomes after closure of an interportal capsulotomy. There are limited published outcome data regarding T-type capsulotomy without closure. This review provides surgeons with operative guidance on capsular management strategies when treating patients with FAI lesions arthroscopically.

LEVEL OF EVIDENCE

IV.

Integrity of the hip capsule measured with magnetic resonance imaging after capsular repair or unrepaired capsulotomy in hip arthroscopy

BACKGROUND

Current literature shows no clear answer on the question how to manage the capsule after hip arthroscopy. Regarding patient reported outcome measures there seems to be no difference between capsular repair or unrepaired capsulotomy.

AIM

To evaluate and compare the integrity of the hip capsule measured on a magnetic resonance imaging (MRI) scan after capsular repair or unrepaired capsulotomy.

METHODS

A case series study was performed; a random sample of patients included in a trial comparing capsular repair vs unrepaired capsulotomy had a postoperative MRI scan. The presence of a capsular defect and gap size were independently evaluated on MRI.

RESULTS

A total of 28 patients (29 hips) were included. Patient demographics were comparable between treatment groups. There were 2 capsular defects in the capsular repair group and 7 capsular defects in the unrepaired capsulotomy group (P = 0.13). In the group of patients with a defect, median gap sizes at the acetabular side were 5.9 mm (range: 2.7-9.0) in the repaired and 8.0 mm (range: 4.5-18.0) in the unrepaired group (P = 0.462). At the muscular side gap sizes were 6.6 mm (range: 4.1-9.0) in the repaired group and 11.5 mm (range: 3.0-18.0) in the unrepaired group (P = 0.857). The calculated Odds ratio (OR) for having a capsular defect with an increasing lateral center-edge (CE) angle was 1.12 (P = 0.06). The OR for having a capsular defect is lower in the group of patients that underwent a labral repair with an OR of 0.1 (P = 0.05).

CONCLUSION

There is no significant difference in capsular defects between capsular repair or unrepaired capsulotomy. Regarding clinical characteristics our case series shows that a larger CE angle increases the likelihood of a capsular defect and the presence of a labral repair decreases the likelihood of a capsular defect.

Hip Capsular Deficiency-A Cause of Post-Surgical Instability in the Revision Setting Following Hip Arthroscopy for Femoroacetabular Impingement

PURPOSE OF REVIEW

To characterize current concepts in capsular repair and hip instability, and examine findings from biomechanical and clinical studies on hip capsular management strategies as they pertain to hip stability, patient outcomes, and hip arthroscopy failure. Further, we discuss the clinical evaluation and treatment of capsular deficiency.

RECENT FINDINGS

There remains debate regarding the optimal capsular management strategies in hip arthroscopy, particularly concerning the necessity of routine capsular repair. A variety of capsulotomy techniques exist and may be used to access the hip joint. Additionally, a wide variety of techniques are employed to repair the hip capsule. Biomechanical evidence supports capsular closure restores hip joint stability to that of the intact, native state. Several clinical studies in both primary and revision hip arthroscopy settings have demonstrated improved pain and functional outcomes in patients who underwent capsular repair or capsular reconstruction. Studies have shown capsular repair may be especially important in patients with ligamentous laxity and hip dysplasia, and in competitive athletes. Post-surgical hip instability secondary to capsular insufficiency is increasingly recognized as a cause of hip arthroscopy failure. Capsular closure restores native biomechanical stability to the hip joint, and several clinical studies report improved pain and functional outcomes following capsular repair or capsular reconstruction in both the primary and revision hip arthroscopy settings. There remains much to learn regarding capsular hip instability as it relates to optimal capsular management surgical technique, intra-operative capsular management decision-making, clinical diagnosis, and related advanced imaging findings.