Puncture Capsulotomy Technique for Hip Arthroscopy: Midterm Functional Outcomes

Association Between Global Overcoverage and Long-term Survivorship, Chondrolabral Junction Breakdown, and Reduced Joint Space Width: Minimum 8-Year Follow-up

BACKGROUND

Although previous literature has established the association between femoroacetabular impingement and progressive hip osteoarthritis, there exists a paucity of studies investigating the effects of global acetabular overcoverage on chondral wear and long-term outcomes.

PURPOSE

To compare baseline joint space width (JSW), intraoperative findings, long-term total hip arthroplasty (THA)-free survivorship, patient-reported outcome measures (PROMs), pain levels, and patient satisfaction in patients who underwent hip arthroscopy with global overcoverage (GO) to a matched-control (MC) cohort.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

In this retrospective analysis, the authors queried patients who underwent hip arthroscopy for acetabular labral tears secondary to femoroacetabular impingement. Patients with complete PROMs at a minimum 8-year follow-up, the presence of coxa profunda as indicated by an acetabular wall projecting medial to the ilioischial line, and a lateral center-edge angle >40° were matched 1:1 by sex, age, body mass index, Tönnis grade, and labral treatment to a MC cohort of patients who had normal acetabular coverage. Baseline radiographic and intraoperative findings were compared between cohorts. Collected outcomes include the modified Harris Hip Score, Nonarthritic Hip Score, Lower Extremity Functional Scale score, Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports Specific Subscale, 33-item International Hip Outcome Tool score, pain levels, patient satisfaction, and conversion to THA.

RESULTS

In total, 38 patients with GO were 1:1 matched to a MC cohort. The GO cohort had significantly decreased baseline JSW at 50° (P = .002) and greater chondrolabral junction breakdown (P = .037). The GO and MC cohorts achieved similar outcomes for all 6 PROMs, rates of conversion to THA, pain levels, and patient satisfaction. Kaplan-Meier survival analysis demonstrated that the patients experienced a similar overall 18-year THA-free survival rate (GO: 71.1% vs MC: 84.2%; P = .101). To isolate the long-term effects of GO on hip arthroscopy outcomes, 6- to 18-year THA-free survivorship was examined, revealing that the GO cohort (-13.1%) experienced a significantly greater decrease compared with the MC cohort (-5.3%) (P = .008).

CONCLUSION

Patients with GO had significantly lower baseline ipsilateral JSW at 50° and greater intraoperative severity of chondrolabral junction breakdown. Furthermore, the GO cohort experienced a significantly greater decrease in long-term THA-free survivorship 6 to 18 years after hip arthroscopy.

Arthroscopic Management of Femoroacetabular Impingement: Current Concepts

Background: Femoroacetabular impingement (FAI) is a common cause of hip pain and dysfunction, especially in young and active individuals, and it may require surgical management for associated labral tears and cartilage damage. The management of FAI has advanced radically over the last few years, and hip arthroscopy has gained a leading role. However, despite the increasing number of published research and technological advancements, a comprehensive systematic review summarising current evidence is still missing. Methods: All the clinical studies investigating the arthroscopic management of FAI were accessed. Only studies with a minimum of six months of follow-up were considered. The 2020 PRISMA guidelines were followed. In December 2024, PubMed, Web of Science, and Embase were accessed without time constraints. Results: The present systematic review included 258 clinical investigations (57,803 patients). The mean length of follow-up was 34.2 ± 22.7 months. The mean age was 34.7 ± 5.3, and the mean BMI was 25.1 ± 2.0 kg/m2. Conclusions: The present systematic review updates current evidence on patients who have undergone arthroscopic surgery for FAI, updating and discussing current progress in managing labral injuries and patient selection, emphasising outcomes and pitfalls. Progress in surgery and improvement in eligibility criteria, as well as current controversies and prospects, were also discussed.

Patients Undergoing Hip Arthroscopy With Periportal and Puncture Capsulotomy Demonstrate Favorable Outcomes at Short-Term Follow-Up: A Systematic Review

PURPOSE

To evaluate whether patients undergoing primary hip arthroscopy with periportal or puncture capsulotomy demonstrate improved patient-reported outcomes (PROs) at minimum 2-year follow-up when compared with preoperative PROs.

METHODS

A systematic review was performed and registered in PROSPERO under ID: CRD42023466053. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and Scopus were searched in October of 2024 using the following string: (capsul∗ OR puncture OR periportal) and (hip OR femoroacetabular impingement) AND (arthroscop∗). Articles were included if they reported preoperative and minimum 2-year follow-up PROs in patients who underwent hip arthroscopy for the treatment of femoroacetabular impingement and/or labral tears with periportal or puncture capsulotomy and were written in English.

RESULTS

Six studies were included, with 5 studies reporting outcomes on periportal capsulotomy (313 hips) and 1 study on puncture capsulotomy (163 hips). Three studies were Level IV evidence and 3 were Level III. Study periods ranged from 2013 to 2020. Average improvement in the modified Harris Hip Score ranged from 21.1 to 32.56 (I2 = 97%). Average improvement in the visual analog scale for pain ranged from -2.5 to -5.3 (I2 = 94%). Minimal clinically important difference was achieved by 65.0% to 100% of patients for Hip Outcome Score - Activities of Daily Living, 71.8% to 88% for Hip Outcome Score-Sport, and 62.5% to 78% for analog scale for pain. Three studies reported rates of secondary total hip arthroplasty, ranging from 0% to 1.7%.

CONCLUSIONS

Patients undergoing hip arthroscopy with periportal capsulotomy showed improvements in multiple PROs at a minimum of 2-year follow-up. Periportal capsulotomy appears to be an effective capsulotomy technique in patients undergoing hip arthroscopy for the treatment of femoroacetabular impingement and/or labral tears. Preliminary evidence shows puncture capsulotomy may be an effective way to access the capsule during hip arthroscopy, but conclusions are limited, given the lack of studies available.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

No Difference in 2-Year Outcomes for Non-Hypermobile Femoroacetabular Impingement Syndrome Patients Undergoing Hip Arthroscopy With and Without Closure of Periportal Capsulotomy

PURPOSE

To assess whether capsular closure during hip arthroscopy with periportal capsulotomy affects 2-year postoperative outcomes for patients with femoroacetabular impingement syndrome (FAIS) without hypermobility.

METHODS

A matched-cohort retrospective analysis of a single institutional database of patients who underwent hip arthroscopy with periportal capsulotomy for management of FAIS between 2014 and 2022 was performed. Study inclusion criteria consisted of patients with FAIS who exhibited no signs of generalized ligamentous laxity (GLL) (Beighton score 0). Patients with evidence of hip osteoarthritis (Tönnis grade >1) and hip dysplasia and those undergoing revision surgery were excluded. Capsular closure was performed via a simple suture configuration through the mid-anterior portal. The capsular closure group (n = 51) was matched 1:1 by age, sex, and body mass index with the nonclosure group. Patient-reported outcome (PRO) surveys, including the Hip Disability and Osteoarthritis Outcome Score, 12-item Short-Form Survey, and visual analog scale for pain, were completed preoperatively and 2 years postoperatively. Mean score change was calculated across all PROs, and unpaired samples t tests were used to compare groups.

RESULTS

The overall matched cohort included 90 patients and 102 hips (age: 30.5 ± 9.5 years; body mass index: 23.3 ± 2.6; 66.7% male), with no differences in demographic or preoperative hip characteristics. Both groups achieved significant score improvements in all PROs at 2 years (P < .001), except 12-item Short-Form Survey Mental Component Summary, which remained unchanged. There was no difference in 2-year postoperative mean score change between the closure and nonclosure groups, and both groups achieved minimal clinically important difference (60.8%-84.3% vs 54.9%-86.3%), patient acceptable symptom state (60.8%-84.3% vs 52.9%-76.5%), and substantial clinical benefit (54.9%-76.5% vs 47.1%-64.7%) thresholds at similar rates across all PROs, with no complications or conversions to total hip arthroplasty, respectively.

CONCLUSIONS

Among patients with FAIS without hypermobility (Beighton score of 0) undergoing periportal capsulotomy during hip arthroscopy, capsular closure showed no differences in 2-year postoperative outcomes compared to nonclosure.

LEVEL OF EVIDENCE

Level III, retrospective matched-cohort study.

Arthroscopic Reconstruction of the Acetabular Labrum Using an Autograft Hip Capsule

Background

Whereas uncomplicated labral tears with preserved fibers can be effectively treated with use of labral repair techniques, complex tears and hypoplastic labra require labral reconstruction1-3. Standard reconstruction techniques feature grafted tissue that is added to existing, deficient tissue or that is utilized to replace a hypoplastic labrum entirely4-9. However, such approaches utilizing allografts or remote autografts are limited because they often necessitate extensive debridement of the existing labrum to prepare a site for graft implantation, an approach that can damage and devascularize the chondrolabral junction10-14. The presently described technique, arthroscopic capsular autograft labral reconstruction, is suitable for simple tears as well as hypoplastic, degenerative, and complex tears, and negates the challenges of utilizing allografts or remote autografts by supplementing the labrum. In addition, this technique avoids substantial resection, thus preserving the chondrolabral junction15-22.

Description

Following induction of anesthesia and appropriate patient positioning, puncture capsulotomy is performed to enter the hip joint26. In the presence of a sufficiently intact labrum, 3 to 5 mm of capsule is elevated to augment the labrum and preserve the blood supply. In the presence of a severely deficient or hypoplastic labrum, the capsule is elevated 5 to 10 mm to reconstruct the labrum. Following capsular augmentation and potential acetabuloplasty, 2.3-mm bioabsorbable composite anchors are utilized to secure the elevated capsular tissue and the remaining labral tissue to the acetabular rim. Loop suture or a vertical mattress suture technique is then utilized to complete the repair. A Weston knot and several half-hitches are placed while dynamically tensioning along the capsular aspect of the repair in order to secure the labral reconstruction to the acetabular rim with concurrent release of traction. Anchors are placed roughly 1 cm apart to prevent strangulation of the capsular vessels29.

Alternatives

Labral reconstruction options include autografts or allografts7. Potential allografts include the semitendinosus, tibialis anterior, iliotibial band, tensor fasciae latae, and peroneus brevis8-14. Remote autograft sites include the gracilis and quadriceps tendons16,17. These options are limited by increased donor site morbidity and operative time to obtain the grafts. Local autograft sites include the ligamentum teres, indirect head of the rectus femoris, iliotibial band, and hip capsule15,18-23,25.

Rationale

Relative to autografts, the allografts most commonly utilized in labral reconstruction feature a heightened risk of disease transmission, increased cost, and a potentially lengthened time to graft incorporation15. Among the local autograft sites, the utility of ligamentum teres graft is limited because its harvesting requires an open approach21,22. Rectus femoris autografts lack empirical support for their ability to recreate the suction seal19,20. The iliotibial band has known soft-tissue complications at the harvest site, in addition to requiring an additional incision10,18. Hip capsule autograft is not limited by these constraints25. The presently described technique improves on existing remote and local autograft-harvesting techniques, supporting the labrum and reinforcing its seal through the use of a graft with an intact blood supply. Given the various degrees of capsular augmentation that can be performed, this technique may be utilized in some form for all degrees of acetabular labral repair.

Expected Outcomes

Labral reconstruction with capsular augmentation from the hip capsule showed significant improvement over baseline in functional outcomes at 3, 6, 12, and 24 months postoperatively in patients with complex labral tears that could not be treated with simple repair. Additionally, at 24 months postoperatively, 76.3%, 65.5%, and 60.8% of patient International Hip Outcome Tool-33 (iHOT-33) scores exceeded threshold values for the minimal clinically important difference, patient acceptable symptom state, and substantial clinical benefit, respectively30.

Important Tips

For large cam lesions, 3D computed tomography is performed during preoperative planning.The anterolateral portal should be placed under fluoroscopic guidance with use of the intra-articular fluid-distention technique in order to minimize the risk of iatrogenic injury to the labrum and/or articular cartilage of the joint.The amount of capsular tissue to be elevated is determined by the extent of labral damage.When elevating the capsular tissue, meticulous care is required to preserve the blood supply to the capsule and labrum.Final suture tiedown is performed with no traction applied, which assures an in-round repair and restores the labral suction seal.Intermittent traction is utilized to minimize the risk of nerve palsies. No traction is applied for prepping and draping, bone marrow aspirate harvesting, suture tie-down, or femoral neck osteoplasty. Minimal traction is applied for capsular elevation, acetabuloplasty, anchor placement, and suture tensioning.Our approach utilizes the puncture capsulotomy technique, which was shown in a previous study of 163 patients to have zero risk of common arthroplasty complications, such as microinstability and revision for capsular plication26,31.In revision cases with severe loss of the labrum and chondrolabral junction, reconstruction of the labrum with use of remote autograft or allograft may be required.Note that this procedure has a steep learning curve and requires meticulous technique.

Acronyms and Abbreviations

FAI = femoroacetabular impingementITB = iliotibial bandTFL = tensor fasciae lataeLT = ligamentum teresiHOT-33 = International Hip Outcome Tool-33MCID = minimal clinically important differencePASS = patient acceptable symptom stateSCB = substantial clinical benefitCT = computed tomographyAP = anteroposteriorMRI = magnetic resonance imagingASIS = anterior superior iliac spineBMAC = bone marrow aspirate concentrateDVT = deep vein thrombosis.

Relationship Between Neighborhood-Level Socioeconomic Status and Functional Outcomes After Hip Arthroscopy

BACKGROUND

Despite the growing volume of neighborhood-level health disparity research, there remains a paucity of prospective studies investigating the relationship between Area Deprivation Index (ADI) and functional outcomes for patients undergoing hip arthroscopy.

PURPOSE

To investigate the relationship between neighborhood-level socioeconomic status and functional outcomes after hip arthroscopy.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective analysis of prospectively collected data was performed on patients aged ≥18 years with minimum 1-year follow-up who underwent hip arthroscopy for the treatment of symptomatic labral tears. The study population was divided into ADILow and ADIHigh cohorts according to ADI score: a validated measurement of neighborhood-level socioeconomic status standardized to yield a score between 1 and 100. Patient-reported outcome measures (PROMs) included the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports-Specific Subscale, 33-item International Hip Outcome Tool, visual analog scale for pain, and patient satisfaction.

RESULTS

A total of 228 patients met inclusion criteria and were included in the final analysis. After patients were stratified by ADI score (mean ± SD), the ADILow cohort (n = 113; 5.8 ± 3.0; range, 1-12) and ADIHigh cohort (n = 115; 28.0 ± 14.5; range, 13-97) had no differences in baseline patient demographics. The ADIHigh cohort had significantly worse preoperative baseline scores for all 5 PROMs; however, these differences were not present by 1-year follow-up. Furthermore, the 2 cohorts achieved similar rates of the minimal clinically important difference for all 5 PROMs and the Patient Acceptable Symptom State for 4 PROMs. When controlling for patient demographics, patients with higher ADI scores had greater odds of achieving the minimal clinically important difference for all PROMs except the 33-item International Hip Outcome Tool.

CONCLUSION

Although hip arthroscopy patients experiencing a greater neighborhood-level socioeconomic disadvantage exhibited significantly lower preoperative baseline PROM scores, this disparity resolved at 1-year follow-up. In fact, when adjusting for patient characteristics including ADI score, more disadvantaged patients achieved greater odds of achieving the minimal clinically important difference. The present study is merely a first step toward understanding health inequities among patients seeking orthopaedic care. Further development of clinical guidelines and health policy research is necessary to advance care for patients from disadvantaged communities.

Hip Arthroscopy Versus Physical Therapy for the Treatment of Symptomatic Acetabular Labral Tears in Patients Older Than 40 Years: 24-Month Results From a Randomized Controlled Trial

BACKGROUND

The indications for hip arthroscopy in patients aged ≥40 years remain controversial, as observational studies have suggested that advanced age portends poor functional outcomes, poor durability of improvement, and high rates of conversion to total hip arthroplasty.

PURPOSE

To compare hip arthroscopy versus nonoperative management for symptomatic labral tears in patients aged ≥40 years with limited radiographic osteoarthritis.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

This single-surgeon, parallel randomized controlled trial included patients aged ≥40 years with limited osteoarthritis (Tönnis grades 0-2) who were randomized 1:1 to arthroscopic surgery with postoperative physical therapy (SPT) or physical therapy alone (PTA). Patients who received PTA and achieved unsatisfactory improvement were permitted to cross over to SPT after completing ≥14 weeks of physical therapy (CO). The primary outcomes were the International Hip Outcome Tool-33 score and modified Harris Hip Score at 24 months after surgery, and secondary outcomes included other patient-reported outcome measures and the visual analog scale for pain. The primary analysis was performed on an intention-to-treat basis using linear mixed-effects models. Sensitivity analyses included modified as-treated and treatment-failure analyses.

RESULTS

A total of 97 patients were included, with 52 (53.6%) patients in the SPT group and 45 (46.4%) patients in the PTA group. Of the patients who underwent PTA, 32 (71.1%) patients crossed over to arthroscopy at a mean of 5.10 months (SD, 3.3 months) after physical therapy initiation. In both intention-to-treat and modified as-treated analyses, the SPT group displayed superior mean patient-reported outcome measure and pain scores across the study period for nearly all metrics relative to the PTA group. In the treatment-failure analysis, the SPT and CO groups showed greater improvement across all metrics compared with PTA; however, post hoc analyses revealed no significant differences in improvement between the SPT and CO groups. No significant differences were observed between groups in rates of total hip arthroplasty conversion.

CONCLUSION

In patients ≥40 years of age with limited osteoarthritis, hip arthroscopy with postoperative physical therapy led to better outcomes than PTA at a 24-month follow-up. However, additional preoperative physical therapy did not compromise surgical outcomes and allowed some patients to avoid surgery. When surgery is indicated, age ≥40 years should not be considered an independent contraindication to arthroscopic acetabular labral repair.

REGISTRATION

NCT03909178 (ClinicalTrials.gov identifier).

Association Between Severity of Chondrolabral Junction Breakdown and Functional Outcomes After Hip Arthroscopy for Acetabular Labral Tears

BACKGROUND

Despite focus on surgical preservation of the chondrolabral junction (CLJ), the transition zone between the acetabular cartilage and labrum, the association between severity of CLJ breakdown and functional outcomes after hip arthroscopy remains unexplored.

PURPOSE

To assess the influence of CLJ breakdown on patient-reported outcome measures (PROMs) at a 24-month follow-up after hip arthroscopy for symptomatic labral tears.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective review of prospectively collected data was conducted to identify patients ≥18 years of age with a minimum 24-month follow-up who underwent hip arthroscopy by a single surgeon for the treatment of symptomatic labral tears secondary to femoroacetabular impingement. The Beck classification of transition zone cartilage was used to grade CLJ damage; patients with grades 0 to 2 were stratified into the mild CLJ damage cohort, and those with grades 3 and 4 were stratified into the severe CLJ damage cohort. PROMs were collected at baseline and at 3, 6, 12 months, and annually thereafter postoperatively. Linear mixed-effects models were used to compare PROMs. Rates of achieving clinically meaningful thresholds and subsequent surgery rates were also compared.

RESULTS

In total, 198 patients met the inclusion criteria, with a mean follow-up of 3.54 ± 1.26 years. A total of 95 patients with severe CLJ damage (mean age, 34.9 ± 10.5 years) were compared with 103 patients with mild CLJ damage (mean age, 38.2 ± 11.9 years). Hip Outcome Score-Activities of Daily Living (HOS-ADL), Non-Arthritic Hip Score (NAHS), and visual analog score for pain were inferior in the severe CLJ group at enrollment and all follow-up time points (P≤ .05). However, patients with severe CLJ breakdown exhibited greater improvements in HOS-ADL and NAHS at the 24-month follow-up and achieved clinically meaningful thresholds at equivalent rates to patients with mild CLJ breakdown. Subsequent surgery rates were 6.8% and 12.6% in patients with mild versus severe CLJ damage, respectively (P = .250).

CONCLUSION

Severe CLJ breakdown is associated with increased pain and decreased functional level preoperatively and up to 24 months after hip arthroscopy. Despite this, patients with severe CLJ breakdown experienced greater improvements in functional outcomes at a 24-month follow-up and achieved clinical thresholds at similar rates to patients with mild CLJ damage. Thus, while worse baseline pain and functional levels may indicate severe CLJ breakdown, these patients still benefit substantially from hip arthroscopy.

Preoperative Paralabral Cysts Predict More Significant Chondral Damage but Not 2-Year Functional Outcomes Following Arthroscopic Labral Repair

PURPOSE

To investigate whether paralabral cysts identified incidentally on preoperative magnetic resonance imaging/arthrography predict 2-year functional outcomes after arthroscopic acetabular labral repair.

METHODS

Prospectively collected data for patients undergoing primary hip arthroscopy by a single surgeon from 2014 to 2020 were retrospectively reviewed. Included patients were ≥18 years and completed baseline patient-reported outcome measures (PROMs) with additional follow-up at 3, 6, 12, and 24 months. Exclusion criteria were labral debridement, hip dysplasia, advanced hip osteoarthritis (Tönnis > 1), or previous ipsilateral hip surgery. Patients were stratified based on the presence of paralabral cysts identified on magnetic resonance imaging/arthrography. Primary outcomes were International Hip Outcome Tool and modified Harris Hip Score. Secondary outcomes included other PROMs and the visual analog pain scale. Outcomes were compared between cohorts using linear mixed-effects models and Fisher's exact tests. Sensitivity analyses accounted for preoperative PROMs, nonlinear improvement trajectories, and relevant baseline characteristics.

RESULTS

Of the 182 included hips (47.8% female; mean ± standard deviation age, 36.9 ± 11.4), 30 (16.4%) had paralabral cysts. During the 2-year study period, there were no significant differences between patients with and without paralabral cysts in terms of International Hip Outcome Tool scores (weighted difference = 1.60; 95% confidence interval [CI], -5.09, 8.28; P = .64), modified Harris Hip Scores (weighted difference = 0.56; 95% CI, -4.16, 5.28; P = .82), or any secondary outcomes (except for HOS-Sports Subscale at 3 months [mean difference = -11.85; 95% CI, -22.85, -0.84; P = .035]). Furthermore, there were no significant differences in clinically meaningful outcomes (P > .05 for all), revision rates (P > .99), or conversion to total hip arthroplasty between cohorts (P > .99). These results held across all sensitivity analyses.

CONCLUSIONS

Although preoperative paralabral cysts were associated with worse cam impingement and more severe chondral damage observed intraoperatively, they did not predict 2-year functional outcomes or clinically meaningful improvements, suggesting that incidentally discovered paralabral cysts are not a contraindication for arthroscopic labral repair.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

The Effect of Pelvic Incidence on Outcomes After Hip Arthroscopy for Femoroacetabular Impingement and Acetabular Labral Tears

BACKGROUND

In the setting of femoroacetabular impingement (FAI), decompression osteoplasties reconcile deleterious loading patterns caused by cam and pincer lesions. However, native variations of spinopelvic sagittal alignment may continue to perpetuate detrimental effects on the labrum, chondrolabral junction, and articular cartilage after hip arthroscopy.

PURPOSE

To evaluate the effect of pelvic incidence (PI) on postoperative outcomes after hip arthroscopy for acetabular labral tears in the setting of FAI.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective query of prospectively collected data identified patients ≥18 years of age who underwent primary hip arthroscopy for FAI and acetabular labral tears between February 2014 and January 2022, with 3-, 6-, 12-, and 24-month follow-ups. Measurements for PI, pelvic tilt (PT), sacral slope (SS), and acetabular version were obtained via advanced diagnostic imaging. Patients were stratified into low-PI (<45°), moderate-PI (45°≤ PI ≤ 60°), and high-PI (>60°) cohorts. Patient-reported outcome measures (PROMs), clinically meaningful outcomes (ie, minimal clinically important difference, Patient Acceptable Symptom State, substantial clinical benefit, and maximal outcome improvement), visual analog scale (VAS) pain scores, and patient satisfaction were compared across cohorts.

RESULTS

A total of 74 patients met eligibility criteria and were stratified into low-PI (n = 28), moderate-PI (n = 31), and high-PI (n = 15) cohorts. Correspondingly, patients with high PI displayed significantly greater values for PT (P = .001), SS (P < .001), acetabular version (P < .001), and acetabular inclination (P = .049). By the 12- and 24-month follow-ups, the high-PI cohort was found to have significantly inferior PROMs, VAS pain scores, rates of clinically meaningful outcome achievement, and satisfaction relative to patients with moderate and/or low PI. No significant differences were found between cohorts regarding rates of revision arthroscopy, subsequent spine surgery, or conversion to total hip arthroplasty.

CONCLUSION

After hip arthroscopy, patients with a high PI (>60°) exhibited inferior PROMs, rates of achieving clinically meaningful thresholds, and satisfaction at 12 and 24 months relative to patients with low or moderate PI. Conversely, the outcomes of patients with low PI (<45°) were found to match the trajectory of those with a neutral spinopelvic alignment (45°≤ PI ≤ 60°). These findings highlight the importance of analyzing spinopelvic parameters preoperatively to prognosticate outcomes before hip arthroscopy for acetabular labral tears and FAI.

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.

Outcomes of Hip Arthroscopy in the Setting of Concomitant Symptomatic Lumbosacral Spine Pathology: A Matched Control Study With Minimum 24-Month Follow-up

BACKGROUND

The overlapping biomechanical relationship between the lumbosacral spine and pelvis poses unique challenges to patients with concomitant pathologies limiting spinopelvic range of motion.

PURPOSE

To assess the influence of concomitant, symptomatic lumbosacral spine pathology on patient-reported outcome measures (PROMs) after hip arthroscopy for the treatment of femoroacetabular impingement (FAI) and symptomatic labral tears.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective query of prospectively collected data identified patients aged ≥18 years with a minimum 24-month follow-up who underwent hip arthroscopy by a single surgeon for the treatment of symptomatic labral tears secondary to FAI. Patients were stratified into cohorts based on the presence (hip-spine [HS]) or absence (matched control [MC]) of symptomatic lumbosacral spine pathology. Inclusion within the HS cohort required confirmation of lower back pain/symptoms on preoperative surveys plus a diagnosis of lumbosacral spine pathology verified by radiology reports and correlating clinical documentation. Patients with previous spine surgery were excluded. PROMs were compared between groups, along with rates of achieving minimal clinically important difference (MCID) thresholds, Patient Acceptable Symptom State (PASS) thresholds, revision arthroscopy, and conversion to total hip arthroplasty (THA).

RESULTS

A total of 70 patients with lumbosacral pathology were coarsened exact matched to 87 control patients without spinal pathology. The HS cohort had preoperative baseline scores that were significantly worse for nearly all PROMs. Follow-ups at 3, 6, 12, and 24 months displayed similar trends, with the HS cohort demonstrating significantly worse scores for most collected outcomes. However, at every time point, HS and MC patients exhibited similar magnitudes of improvement across all PROM and pain metrics. Furthermore, while significantly fewer HS patients achieved PASS for nearly all PROMs at 12- and 24-month follow-ups, MCID thresholds were reached at similar or greater rates across all PROMs relative to the MC cohort. Finally, there were no significant differences in rates of revision or THA between cohorts at maximum available follow-up.

CONCLUSION

After hip arthroscopy to address labral tears in the setting of FAI, patients with symptomatic lumbosacral pathologies and no history of spine surgery were found to exhibit inferior pre- and postoperative PROMs but achieved statistically similar clinical benefit and rates of PROM improvement through 24-month follow-up compared with the MC cohort with isolated hip disease. These findings aid in providing a realistic recovery timeline and evidence that coexisting hip and spine disorders are not a contraindication for arthroscopic hip preservation surgery.

Labral Reconstruction via Capsular Augmentation Maintains Perfusion to the Acetabular Labrum and Locally Transferred Autograft: An in Vivo Laser Doppler Flowmetry Analysis

Background

The purpose of the present study was to examine the effects of arthroscopic labral repair with capsular augmentation on blood flow in vivo with use of laser Doppler flowmetry (LDF) to measure microvascular perfusion of the labrum and autograft tissue.

Methods

The present prospective case series included patients ≥18 years old who underwent arthroscopic acetabular labral repair with capsular augmentation; all procedures were performed by a single surgeon between 2018 and 2022. The LDF probe measured microvascular blood flow flux within 1 mm3 of the surrounding labral and capsular tissue of interest. Mean baseline measurements of flux were compared with readings immediately following capsular elevation and after completing labral augmentation. Blood flux changes were expressed as the percent change from the baseline measurements.

Results

The present study included 41 patients (24 men [58.5%] and 17 women [41.5%]) with a mean age (and standard deviation) of 31.3 ± 8.4 years, a mean BMI of 24.6 ± 3.4 kg/m2, a mean lateral center-edge of angle 35.3° ± 4.9°, a mean Tönnis angle of 5.8° ± 5.8°, and a mean arterial pressure of 93.7 ± 10.9 mm Hg. Following capsular elevation, the mean percent change in capsular blood flow flux was significantly different from baseline (-9.24% [95% confidence interval (CI), -18.1% to -0.04%]; p < 0.001). Following labral augmentation, the mean percent change in labral blood flow flux was significantly different from baseline both medially (-22.3% [95% CI, -32.7% to -11.9%]; p < 0.001) and laterally (-32.5% [95% CI, -41.5% to -23.6%]; p = 0.041). There was no significant difference between the changes in medial and lateral perfusion following repair (p = 0.136).

Conclusions

Labral repair with capsular augmentation sustains a reduced blood flow to the native labrum and capsular tissue at the time of fixation. The biological importance of this reduction is unknown, but these findings may serve as a benchmark for other labral preservation techniques and support future correlations with clinical outcomes.

Level of Evidence

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.