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Boos AM, Wang AS, Lamba A, Okoroha KR, Ortiguera CJ, Levy BA, Krych AJ, Hevesi M. Long-term Outcomes of Primary Hip Arthroscopy: Multicenter Analysis at Minimum 10-Year Follow-up With Attention to Labral and Capsular Management. Am J Sports Med 2024; 52:1144-1152. [PMID: 38516883 DOI: 10.1177/03635465241234937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
BACKGROUND Hip arthroscopy is rapidly advancing, with positive published outcomes at short- and midterm follow-up; however, available long-term data remain limited. PURPOSE To evaluate outcomes of primary hip arthroscopy at a minimum 10-year follow-up at 2 academic centers by describing patient-reported outcomes and determining reoperation and total hip arthroplasty (THA) rates. STUDY DESIGN Case series; Level of evidence, 4. METHODS Patients with primary hip arthroscopy performed between January 1988 and April 2013 at 2 academic centers were evaluated for postoperative patient-reported outcomes-including the visual analog scale, Tegner Activity Scale score, Hip Outcome Score Activities of Daily Living and Sport Specific subscales, modified Harris Hip Score, Nonarthritic Hip Score, 12-item International Hip Outcome Tool, surgery satisfaction, and reoperations. RESULTS A total of 294 patients undergoing primary hip arthroscopy (age, 40 ± 14 years; 66% women; body mass index, 27 ± 6) were followed for 12 ± 3 years (range, 10-24 years) postoperatively. Labral debridement and repair were performed in 41% and 59% of patients, respectively. Of all patients who underwent interportal capsulotomy, 2% were extended to a T-capsulotomy, and 11% underwent capsular repair. At final follow-up, patients reported a mean visual analog scale at rest of 2 ± 2 and with use of 3 ± 3, a 12-item International Hip Outcome Tool of 68 ± 27, a Nonarthritic Hip Score of 81 ± 18, a modified Harris Hip Score of 79 ± 17, and a Hip Outcome Score Activities of Daily Living of 82 ± 19 and Sport Specific subscale of 74 ± 25. The mean surgical satisfaction was 8.4 ± 2.4 on a 10-point scale, with 10 representing the highest level of satisfaction. In total, 96 hips (33%) underwent reoperation-including 65 hips (22%) converting to THA. THA risk factors included older age, higher body mass index, lower lateral center-edge angle, larger alpha angle, higher preoperative Tönnis grade, as well as labral debridement and capsular nonrepair (P≤ .039). Patients undergoing combined labral and capsular repair demonstrated a THA conversion rate of 3% compared with 31% for patients undergoing combined labral debridement and capsular nonrepair (P = .006). Labral repair trended toward increased 10-year THA-free survival (84% vs 77%; P = .085), while capsular repair demonstrated significantly increased 10-year THA-free survival (97% vs 79%; P = .033). CONCLUSION At a minimum 10-year follow-up, patients undergoing primary hip arthroscopy demonstrated high satisfaction and acceptable outcome scores. In total, 33% of patients underwent reoperation-including 22% who underwent THA. Conversion to THA was associated with patient factors including older age, higher Tönnis grade, and potentially modifiable surgical factors such as labral debridement and capsular nonrepair.
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Affiliation(s)
- Alexander M Boos
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Allen S Wang
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Abhinav Lamba
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kelechi R Okoroha
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Cedric J Ortiguera
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Bruce A Levy
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron J Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mario Hevesi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Dasari SP, Kasson LB, Condon JJ, Mameri ES, Kerzner B, Khan ZA, Jackson GR, Gursoy S, Sivasundaram L, Hevesi M, Chahla J. Systematic Review and Meta-analysis of Studies Comparing Complete Capsular Closure Against Unrepaired Hip Capsules During Hip Arthroscopy. Orthop J Sports Med 2023; 11:23259671231197435. [PMID: 37868216 PMCID: PMC10585995 DOI: 10.1177/23259671231197435] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 04/26/2023] [Indexed: 10/24/2023] Open
Abstract
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.
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Affiliation(s)
- Suhas P. Dasari
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Luke B. Kasson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Joshua J. Condon
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Enzo S. Mameri
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Benjamin Kerzner
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Zeeshan A. Khan
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Garrett R. Jackson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Safa Gursoy
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Mario Hevesi
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Jorge Chahla
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
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Bech NH, Sierevelt IN, de Waard S, Joling BSH, Kerkhoffs GMMJ, Haverkamp D. Capsular closure versus unrepaired interportal capsulotomy after hip arthroscopy in patients with femoroacetabular impingement: results of a patient-blinded randomised controlled trial. Hip Int 2023; 33:94-101. [PMID: 33845615 DOI: 10.1177/11207000211005762] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Hip capsular management after hip arthroscopy remains a topic of debate. Most available current literature is of poor quality and are retrospective or cohort studies. As of today, no clear consensus exists on capsular management after hip arthroscopy. PURPOSE To evaluate the effect of routine capsular closure versus unrepaired capsulotomy after interportal capsulotomy measured with NRS pain and the Copenhagen Hip and Groin Outcome Score (HAGOS). MATERIALS AND METHODS All eligible patients with femoroacetabular impingement who opt for hip arthroscopy (n = 116) were randomly assigned to one of both treatment groups and were operated by a single surgeon. Postoperative pain was measured with the NRS score weekly the first 12 weeks after surgery. The HAGOS questionnaire was measured at 12 and 52 weeks postoperatively. RESULTS Baseline characteristics and operation details were comparable between treatment groups. Regarding the NRS pain no significant difference was found between groups at any point the first 12 weeks after surgery (p = 0.67). Both groups significantly improved after surgery (p < 0.001). After 3 months follow-up there were no differences between groups for the HAGOS questionnaire except for the domain sport (p = 0.02) in favour of the control group. After 12 months follow-up there were no differences between both treatment groups on all HAGOS domains (p > 0.05). CONCLUSIONS The results of this randomised controlled trial show highest possible evidence that there is no reason for routinely capsular closure after interportal capsulotomy at the end of hip arthroscopy. TRIAL REGISTRATION This trial was registered at the CCMO Dutch Trial Register: NL55669.048.15.
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Affiliation(s)
- Niels H Bech
- Specialized Center of Orthopaedic Research & Education (SCORE), Department of Orthopaedic Surgery, Xpert Orthopaedic Surgery Clinic, Amsterdam, The Netherlands.,Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Inger N Sierevelt
- Specialized Center of Orthopaedic Research & Education (SCORE), Department of Orthopaedic Surgery, Xpert Orthopaedic Surgery Clinic, Amsterdam, The Netherlands
| | - Sheryl de Waard
- Specialized Center of Orthopaedic Research & Education (SCORE), Department of Orthopaedic Surgery, Xpert Orthopaedic Surgery Clinic, Amsterdam, The Netherlands.,Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Boudijn S H Joling
- Specialized Center of Orthopaedic Research & Education (SCORE), Department of Orthopaedic Surgery, Xpert Orthopaedic Surgery Clinic, Amsterdam, The Netherlands
| | - Gino M M J Kerkhoffs
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands.,Academic Center for Evidence-Based Sports Medicine (ACES), Amsterdam, The Netherlands.,Amsterdam Collaboration on Health & Safety in Sports (ACHSS) AMC/Vumc, IOC Research Centre, Amsterdam, The Netherlands
| | - Daniel Haverkamp
- Specialized Center of Orthopaedic Research & Education (SCORE), Department of Orthopaedic Surgery, Xpert Orthopaedic Surgery Clinic, Amsterdam, The Netherlands
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Donnelly E, Vakili S, Getgood A, Willing R, Degen RM. Cadaveric Biomechanical Evaluation of Capsular Constraint and Microinstability After Hip Capsulotomy and Repair. Orthop J Sports Med 2022; 10:23259671221128348. [PMID: 36313006 PMCID: PMC9608050 DOI: 10.1177/23259671221128348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/02/2022] [Indexed: 11/06/2022] Open
Abstract
Background: It remains unclear if capsular management contributes to iatrogenic instability (microinstability) after hip arthroscopy. Purpose: To evaluate changes in torque, stiffness, and femoral head displacement after capsulotomy and repair in a cadaveric model. Study Design: Controlled laboratory study. Methods: A biomechanical analysis was performed using 10 cadaveric hip specimens. Each specimen was tested under the following conditions: (1) intact, (2) portals, (3) interportal capsulotomy (IPC), (4) IPC repair, (5) T-capsulotomy (T-cap), (6) partial T-cap repair, and (7) T-cap repair. Each capsular state was tested in neutral (0°) and then 30°, 60°, and 90° of flexion, with forces applied to achieve the displacement-controlled baseline limit of external rotation (ER), internal rotation (IR), abduction, and adduction. The resultant end-range torques and displacement were recorded. Results: For ER, capsulotomies significantly reduced torque and stiffness at 0°, 30°, and 60° and reduced stiffness at 90°; capsular repairs failed to restore torque and stiffness at 0°; and IPC repair failed to restore stiffness at 30° (P < .05 for all). For IR, capsulotomies significantly reduced torque and stiffness at 0°, 30°, and 60° and reduced stiffness at 90°; and capsular repairs failed to restore torque or stiffness at 0°, 30°, and 60° and failed to restore stiffness at 90° (P < .05 for all). For abduction, IPC significantly decreased torque at 60° and 90° and decreased stiffness at all positions; T-cap reduced torque and stiffness at all positions; IPC repair failed to restore stiffness at 0° and 90°; and T-cap repair failed at 0°, 60°, and 90° (P < .05 for all). For adduction, IPC significantly reduced torque at 0° and reduced stiffness at 0° and 30°; T-cap reduced torque at 0° and 90° and reduced stiffness at all positions; IPC repair failed to restore stiffness at 0° and 90°; and T-cap repair failed at 0°, 60°, and 90° (P < .05 for all). There were no statistically significant femoral head translations observed in any testing configurations. Conclusion: Complete capsular repair did not always restore intact kinematics, most notably at 0° and 30°. Despite this, there were no significant joint translations to corroborate concerns of microinstability. Clinical Relevance: Caution should be employed when applying rotational torques in lower levels of flexion (0° and 30°).
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Affiliation(s)
- Emma Donnelly
- Western University, London, Ontario, Canada.,Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada
| | | | - Alan Getgood
- Western University, London, Ontario, Canada.,Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Ryan Willing
- Western University, London, Ontario, Canada.,Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada
| | - Ryan M. Degen
- Western University, London, Ontario, Canada.,Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada.,Ryan M. Degen, MD, Fowler Kennedy Sport Medicine Clinic, Western University, London, ON, Canada ()
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Looney AM, McCann JA, Connolly PT, Comfort SM, Curley AJ, Postma WF. Routine Capsular Closure With Hip Arthroscopic Surgery Results in Superior Outcomes: A Systematic Review and Meta-analysis. Am J Sports Med 2022; 50:2007-2022. [PMID: 34403279 DOI: 10.1177/03635465211023508] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND In hip arthroscopic surgery, capsulotomy is performed to improve visualization and allow instrumentation of the joint. Traditionally, the defect has been left unrepaired; however, increasing evidence suggests that this may contribute to persistent pain and iatrogenic capsular instability. Nevertheless, the clinical benefit of performing routine capsular repair remains controversial. PURPOSE/HYPOTHESIS We conducted a systematic review and meta-analysis to investigate the effects of routine capsular closure on patient-reported outcomes (PROs), hypothesizing that superior PROs would be observed with routine capsular closure. STUDY DESIGN Meta-analysis and systematic review; Level of evidence, 4. METHODS A systematic review and meta-analysis was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The terms "hip,""arthroscopy,""capsule,""capsular,""repair," and "closure" were used to query Ovid MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), CINAHL (Cumulative Index to Nursing and Allied Health Literature), SPORTDiscus, and PubMed. Articles with PROs stratified by capsular management were included. Multivariate mixed-effects metaregression models were implemented with study-level random-effects and fixed-effects moderators for capsular closure versus no repair and after controlling for surgical indication and preoperative PROs. The effect of repair on both the postoperative score and the change in scores was evaluated via the Harris Hip Score (HHS)/modified HHS (mHHS), Hip Outcome Score (HOS)-Activities of Daily Living (ADL), and HOS-Sport Specific Subscale (SSS), with a supplemental analysis of additional outcomes. RESULTS Of 432 initial articles, 36 were eligible for analysis, with results for 5132 hip arthroscopic procedures. The capsule was repaired in 3427 arthroscopic procedures and unrepaired in 1705. Capsular repair was associated with significantly higher postoperative HHS/mHHS (2.011; SE, 0.743 [95% CI, 0.554-3.467]; P = .007), HOS-ADL (3.635; SE, 0.873 [95% CI, 1.923-5.346]; P < .001), and HOS-SSS (4.137; SE, 1.205 [95% CI, 1.775-6.499]; P < .001) scores as well as significantly superior improvement on the HHS/mHHS (2.571; SE, 0.878 [95% CI, 0.849-4.292]; P = .003), HOS-ADL (3.315; SE, 1.131 [95% CI, 1.099-5.531]; P = .003), and HOS-SSS (3.605; SE, 1.689 [95% CI, 0.295-6.915]; P = .033). CONCLUSION This meta-analysis is the largest to date evaluating the effect of capsular closure on PROs and demonstrates significantly higher mean postoperative scores and significantly superior improvement with repair, while controlling for the effects of preoperative score and surgical indication. The true magnitude of the benefit of capsular repair may be clarified by large prospective randomized studies using PRO measures specifically targeted and validated for hip arthroscopic surgery/preservation.
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Affiliation(s)
- Austin M Looney
- Division of Sports Medicine, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Julia A McCann
- Department of Orthopaedic Surgery, Georgetown University Hospital, Washington, DC, USA
| | | | | | - Andrew J Curley
- Department of Orthopaedic Surgery, Georgetown University Hospital, Washington, DC, USA
| | - William F Postma
- Department of Orthopaedic Surgery, Georgetown University Hospital, Washington, DC, USA
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Sahu D. Capsular repair is not an important part of the Latarjet-Walch procedure. J Shoulder Elbow Surg 2022; 31:948-56. [PMID: 34808352 DOI: 10.1016/j.jse.2021.10.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 10/14/2021] [Accepted: 10/23/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patte et al noted that the Latarjet procedure works by the triple blocking effect of (1) the conjoint tendon sling effect, (2) the bone block effect, and (3) the capsular repair. However, no clinical study has specifically investigated the role of capsular repair in the Latarjet procedure. AIMS The primary aim was to compare (1) the external rotation range of motion (ROM) achieved after the Latarjet procedure with and without the capsule to coracoacromial (CA-CAL) repair. The secondary aims were to compare the functional outcomes, forward elevation ROM, and internal rotation ROM after the Latarjet procedure with and without the CA-CAL repair. METHODS A prospective cohort of 30 patients who underwent the Latarjet-Walch procedure with a CA-CAL repair between October 2018 and February 2020 was compared with the preceding group of 31 patients who underwent the Latarjet-Walch procedure without any capsular repair between October 2016 and September 2018, at a minimum of 1-year of follow-up. RESULTS External rotation with the elbow abducted at 90° (ER2) deficit (compared to the normal opposite side) was significantly larger after the CA-CAL repair augmentation of the Latarjet procedure (mean difference = 6°, P = .03) than that after no repair. External rotation with the elbow adducted (ER1) deficit after the CA-CAL repair augmentation was not significantly different from that after no repair. ER2 deficit of more than 15° (minimum clinically important difference) was observed in 11 patients (38%) in the CA-CAL repair group and 3 patients (10%, P = .015) in the no repair group. Walch-Duplay score, Rowe score, and Subjective Shoulder Value were not significantly different between the CA-CAL repair group and the no repair group. Covariates of hand dominance, overhead sports, and glenoid defect size did not significantly affect the ER2 deficit and ER1 deficit outcomes. CONCLUSIONS This study disproved the long-held belief that capsular repair is an essential step of the Latarjet-Walch procedure. Capsular repair to the coracoacromial ligament in the Latarjet procedure leads to a clinically insignificant restriction of external rotation (with the arm abducted), no restriction of external rotation (with the arm adducted), but functional outcomes similar to those after Latarjet without a capsular repair in a nonoverhead athlete.
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7
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De Giacomo AF, Lu Y, Suh DH, McGarry MH, Banffy M, Lee TQ. Biomechanical Comparison of Capsular Repair, Capsular Shift, and Capsular Plication for Hip Capsular Closure: Is a Single Repair Technique Best for All? Orthop J Sports Med 2021; 9:23259671211040098. [PMID: 34671689 PMCID: PMC8521432 DOI: 10.1177/23259671211040098] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 05/04/2021] [Indexed: 11/29/2022] Open
Abstract
Background: In hip arthroscopy, the best capsular closure technique to prevent microinstability in some patients while preventing overconstraints in other patients has yet to be determined. Purpose: To evaluate the biomechanical effects of capsular repair, capsular shift, and combination capsular shift and capsular plication for closure of the hip capsule. Study Design: Controlled laboratory study. Methods: Eight cadaveric hips (4 male and 4 female hips; mean age, 55.7 years) were evaluated in 7 conditions: intact, vented, capsulotomy, side-to-side repair, side-to-side repair with capsular plication (interval closure between iliofemoral and ischiofemoral ligaments), capsular shift repair, and capsular shift repair with plication. Measurements, via a 360° goniometer, included internal and external rotation with 1.5 N·m of torque at 5° of extension and 0°, 30°, 60°, and 90° of flexion. In addition, the degree of maximum extension with 5 N·m of torque and the amount of femoral distraction with 40 N and 80 N of force were obtained. Repeated-measures analysis of variance and Tukey post hoc analyses were used to analyze differences between capsular conditions. Results: At lower hip positions (5° of extension, 0° and 30° of flexion), there was a significant increase in external rotation and total rotation after capsulotomy versus the intact state (P < .05). At all hip flexion angles, there was a significant increase in external rotation, internal rotation, and total rotation as well as a significant increase in maximum extension after capsulotomy versus capsular shift with plication (P < .05 for all). At all flexion angles, both capsular closure with side-to-side repair (with or without plication) and capsular shift without capsular plication were able to restore rotation, with no significant differences compared with the intact capsule (P > .05). Among repair constructs, there were significant differences in range of motion between side-to-side repair and combined capsular shift with plication (P < .05). Conclusion: At all positions, significantly increased rotational motion was seen after capsulotomy. Capsular closure was able to restore rotation similar to an intact capsule. Combined capsular shift and plication may provide more restrained rotation for conditions of hip microinstability but may overconstrain hips without laxity. Clinical Relevance: More advanced closure techniques or a combination of techniques may be needed for patients with hip laxity and microinstability. At the same time, simple repair may suffice for patients without these conditions.
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Affiliation(s)
| | - Young Lu
- University of California, Irvine, Orange, California, USA
| | - Dong Hun Suh
- Korea University Anam Hospital, Korea University College of Medicine, Goryeodae-ro, Seongbuk-gu, Seoul, Republic of Korea
| | - Michelle H McGarry
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, California, USA
| | - Michael Banffy
- Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, California, USA
| | - Thay Q Lee
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, California, USA
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O'Neill DC, Mortensen AJ, Cannamela PC, Aoki SK. Clinical and Radiographic Presentation of Capsular Iatrogenic Hip Instability After Previous Hip Arthroscopy. Am J Sports Med 2020; 48:2927-2932. [PMID: 32877211 DOI: 10.1177/0363546520949821] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The clinical and radiographic features of iatrogenic hip instability following hip arthroscopy have been described. However, the prevalence of presenting symptoms and associated imaging findings in patients with hip instability has not been reported. PURPOSE To detail the prevalence of clinical and magnetic resonance arthrogram (MRA) findings in a cohort of patients with isolated hip instability and to determine midterm patient-reported outcomes in this patient population. STUDY DESIGN Case series; Level of evidence, 4. METHODS We retrospectively reviewed patients from 2014 to 2016 who underwent an isolated capsular repair in the revision hip arthroscopy setting. Patients were excluded if they underwent any concomitant procedures, such as labral repair, reconstruction, femoral osteoplasty, or any other related procedure. Several clinical data points were reviewed, including painful activities, mechanical symptoms, subjective instability, Beighton scores, axial distraction testing (pain, toggle, and apprehension), and distractibility under anesthesia. Patient-reported outcomes-including modified Harris Hip Score, Hip Outcome Score-Sports Subscale, Patient-Reported Outcome Measurement Information System (PROMIS) Physical Function Computer Adaptive Test, and a return patient hip questionnaire-were collected pre- and postoperatively. Pre-revision radiographs were obtained, and lateral center-edge angle and alpha angle were measured on anteroposterior and frog-leg lateral views, respectively. Pre-revision MRAs were reviewed and evaluated for capsular changes. Capsular changes were defined as follows: 0, normal; 1, capsular redundancy; 2, focal capsular rent; and 3, gross extravasation of fluid from the capsule. RESULTS A total of 31 patients met inclusion criteria (5 male, 26 female; 14 right and 17 left hips). The mean age of patients was 36 years (range, 20-58 years). Overall, 27 (87%) reported hip pain with activities of daily living, and 31 (100%) experienced pain with sports or exercise. In addition, 24 (77%) had at least 1 positive finding on axial distraction testing. All patients had evidence of capsular changes on review of pre-revision MRAs. Out of 31 patients, 23 (74%) were available for follow-up at a minimum of 3.3 years and a mean ± SD of 4.6 ± 0.8 years. On average, modified Harris Hip Score improved by 20.3, Hip Outcome Score-Sports Subscale by 25.1, and PROMIS Physical Function Computer Adaptive Test by 6.4. Additionally, 20 (87%) patients reported improved or much improved physical ability, and 18 (78%) reported improved or much improved pain. CONCLUSION The current study suggests that patients with hip instability demonstrate high rates of pain with activities of daily living and exercise, positive findings on axial distraction testing, and evidence of capsular changes on magnetic resonance imaging. Furthermore, these patients improve with revision surgery for capsular repair at midterm follow-up.
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Affiliation(s)
- Dillon C O'Neill
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| | | | | | - Stephen K Aoki
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
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Weber AE, Neal WH, Mayer EN, Kuhns BD, Shewman E, Salata MJ, Mather RC, Nho SJ. Vertical Extension of the T-Capsulotomy Incision in Hip Arthroscopic Surgery Does Not Affect the Force Required for Hip Distraction: Effect of Capsulotomy Size, Type, and Subsequent Repair. Am J Sports Med 2018; 46:3127-3133. [PMID: 30307738 DOI: 10.1177/0363546518800710] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Interportal and T-capsulotomies are popular techniques for exposing femoroacetabular impingement deformities. The difference between techniques with regard to the force required to distract the hip is currently unknown. PURPOSE To quantify how increasing interportal capsulotomy size, conversion to T-capsulotomy, and subsequent repair affect the force required to distract the hip. STUDY DESIGN Controlled laboratory study. METHODS Eight fresh-frozen cadaveric hip specimens were dissected and fixed in a materials testing system, such that pure axial distraction of the iliofemoral ligament could be achieved. The primary outcome measure was the load required to distract the hip to a distance of 6 mm at a rate of 0.5 mm/s. Each hip was tested in the intact state and then sequentially under varying capsulotomy conditions: 2-cm interportal, 4-cm interportal, half-T (4-cm interportal and 2-cm T-capsulotomy), and full-T (4-cm interportal and 4-cm T-capsulotomy). After serial testing, isolated T-limb repair and then subsequent complete repair were performed. Repaired specimens underwent distraction testing as previously stated to assess the ability to restore hip stability to the native profile. Distraction force as well as the relative distraction force (percentage normalized to the intact capsule) were compared between all capsulotomy and repair conditions. RESULTS Increasing interportal capsulotomy size from 2 to 4 cm resulted in significantly less force required to distract the hip ( P < .001). The largest relative decrease in force was seen between the intact state (274.6 ± 71.2 N; 100%) and 2-cm interportal (209.7 ± 73.2 N; 76.4% ± 15.6%; P = .0008). There was no significant mean difference in distraction force when 4-cm interportal (160.4 ± 79.8 N) was converted to half-T (140.7 ± 73.5 N; P = .270) and then full-T (112.0 ± 70.2 N; P = .204). When compared with the intact state, isolated T-limb repair partially restored stability (177.3 ± 86.3 N; 63.5% ± 19.8%; P < .0001), while complete repair exceeded native values (331.7 ± 103.7 N; 122.7% ± 15.1%; P = .0008). CONCLUSION The conversion of interportal capsulotomy to T-capsulotomy did not significantly affect the force required to distract the hip in a cadaveric model. However, larger interportal capsulotomies resulted in significant stepwise decreases in distraction force. When performing interportal or T-capsulotomy, the iliofemoral ligament strength is significantly decreased, but complete capsular repair demonstrated the ability to restore joint stability to the native, intact hip. CLINICAL RELEVANCE Increasing interportal capsulotomy size decreases the force required to distract the hip. In an effort to maximize visualization and minimize the magnitude of iliofemoral ligament fibers cut, many surgeons have moved from extended interportal capsulotomy to T-capsulotomy. Interportal and T-capsulotomies result in equivalent hip distraction, partial capsular repair marginally improves hip stability, and only complete repair has the ability to restore the hip to its native biomechanical profile.
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Affiliation(s)
- Alexander E Weber
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - William H Neal
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Erik N Mayer
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Benjamin D Kuhns
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, New York, USA
| | - Elizabeth Shewman
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Michael J Salata
- Department of Orthopaedics, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - R Chad Mather
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Shane J Nho
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
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Hatakeyama A, Utsunomiya H, Nishikino S, Kanezaki S, Matsuda DK, Sakai A, Uchida S. Predictors of Poor Clinical Outcome After Arthroscopic Labral Preservation, Capsular Plication, and Cam Osteoplasty in the Setting of Borderline Hip Dysplasia. Am J Sports Med 2018; 46:135-143. [PMID: 28992426 DOI: 10.1177/0363546517730583] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Borderline developmental dysplasia of the hip (BDDH) is frequently diagnosed concurrently with cam impingement. While hip arthroscopy has advanced the treatment of hip joint pathology, including femoroacetabular impingement (FAI), arthroscopic treatment for FAI in the setting of BDDH remains a challenge amid a subset of patients. The risk factors of poor clinical results after hip arthroscopic labral preservation and FAI corrections in the setting of BDDH patients have not been well established. HYPOTHESIS Pre- and intraoperative findings can predict the poor clinical outcomes after hip arthroscopic surgery for FAI in the setting of BDDH. STUDY DESIGN Case control study; Level of evidence, 3. METHODS Of patients with BDDH (defined as lateral center edge [LCE] angle between 20° and 25°) who underwent arthroscopic procedures for FAI between 2009 and 2014, 45 met inclusion criteria (45 hips: 15 males and 30 females). Their mean age was 31.4 years (range, 12-65 years), and the mean LCE angle was 23.2°. Clinical and radiographic follow-up evaluations up to a minimum of 2 years after surgery were performed for all patients. Failure of the procedure was defined as conversion to subsequent surgery or having a Tönnis osteoarthritis grade of 2, and success was defined as patients who did not need subsequent surgery. Univariate analysis and Cox hazard proportional analysis were performed for both cohorts. RESULTS Of 45 patients, 11 (24%) had revision surgery (endoscopic shelf acetabuloplasty for 5 patients, total hip arthroplasty for 2, and revision hip arthroscopy for 2) or advanced to Tönnis grade ≥2 osteoarthritis and thus constituted the failure group. In the success group, modified Harris Hip Score (median, pre- vs postoperative: 72.1 vs 100, P< .001, Wilcoxon signed-rank test) and nonarthritic hip score (58.8 vs 98.8, P< .001) were significantly improved at the minimum 2-year follow-up. The median age of the failure group was significantly higher than that of the success group (47.0 vs 20.0, P< .001, Mann-Whitney Utest). Risk factors of poor clinical outcomes were identified as follows: age ≥42 years (hazard ratio [HR], 11.6; 95% CI, 2.5-53.9; P= .002, Cox hazard model), broken Shenton line (HR, 6.4; 95% CI, 1.9-22.3; P= .003), Tönnis angle ≥15° (HR, 3.9; 95% CI, 1.2-12.9; P= .03), vertical center anterior (VCA) angle ≤17° (HR, 5.0; 95% CI, 1.5-17.1; P= .01), Tönnis grade 1 at preoperative radiograph (HR, 3.6; 95% CI, 1.1-11.7; P= .04), severe cartilage delamination at acetabulum (HR, 11.8; 95% CI, 3.0-46.1; P< .001), and mild cartilage damage at femoral head (HR, 8.1; 95% CI, 2.1-30.8; P= .002). CONCLUSION Preoperative predictors of poorer outcomes from hip arthroscopic labral preservation, capsular plication, and cam osteoplasty in the setting of BDDH are age ≥42 years old, broken Shenton line, osteoarthritis, Tönnis angle ≥15°, and VCA angle ≤17° on preoperative radiographs. Intraoperative predictors of poorer outcomes are severe acetabular chondral damage and even mild femoral chondral damage. Although the patients in the setting of BDDH may have good outcomes from isolated hip arthroscopy, caution is suggested for those with the aforementioned risk factors.
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Affiliation(s)
- Akihisa Hatakeyama
- Wakamatsu Hospital of University of Occupational and Environmental Health, Kitakyusyu, Japan
| | - Hajime Utsunomiya
- Wakamatsu Hospital of University of Occupational and Environmental Health, Kitakyusyu, Japan
| | | | - Shiho Kanezaki
- Wakamatsu Hospital of University of Occupational and Environmental Health, Kitakyusyu, Japan
| | - Dean K Matsuda
- The DISC Sports and Spine, Marina Del Rey, California, USA
| | - Akinori Sakai
- University of Occupational and Environmental Health, Kitakyusyu, Japan
| | - Soshi Uchida
- Wakamatsu Hospital of University of Occupational and Environmental Health, Kitakyusyu, Japan
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Kuhns BD, Weber AE, Levy DM, Bedi A, Mather RC, Salata MJ, Nho SJ. Capsular Management in Hip Arthroscopy: An Anatomic, Biomechanical, and Technical Review. Front Surg 2016; 3:13. [PMID: 26973840 PMCID: PMC4778552 DOI: 10.3389/fsurg.2016.00013] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 02/15/2016] [Indexed: 11/24/2022] Open
Abstract
Hip arthroscopy has become an increasingly utilized surgical technique for the treatment of the young, active patients with hip pain. The clinical outcomes of hip arthroscopy in this patient population have been largely successful; however, there is increasing interest in the contribution of hip capsule in postoperative clinical and functional outcomes. The structure and function of the normal hip capsule will be reviewed. Capsular contributions to hip stability will be discussed in the setting of hip arthroscopy with an emphasis on diagnosis-based considerations. Lastly, clinical outcomes following hip arthroscopy will be discussed as they relate to capsular management.
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Affiliation(s)
- Benjamin D Kuhns
- Department of Orthopedic Surgery, Division of Sports Medicine, Hip Preservation Center, Rush University Medical Center, Rush Medical College of Rush University , Chicago, IL , USA
| | - Alexander E Weber
- Department of Orthopedic Surgery, Division of Sports Medicine, University of Michigan Health System , Ann Arbor, MI , USA
| | - David M Levy
- Department of Orthopedic Surgery, Division of Sports Medicine, Hip Preservation Center, Rush University Medical Center, Rush Medical College of Rush University , Chicago, IL , USA
| | - Asheesh Bedi
- Department of Orthopedic Surgery, Division of Sports Medicine, University of Michigan Health System , Ann Arbor, MI , USA
| | - Richard C Mather
- Department of Orthopedic Surgery, Duke University Hospital , Durham, NC , USA
| | - Michael J Salata
- Department of Orthopedic Surgery, University Hospitals , Cleveland, OH , USA
| | - Shane J Nho
- Department of Orthopedic Surgery, Division of Sports Medicine, Hip Preservation Center, Rush University Medical Center, Rush Medical College of Rush University , Chicago, IL , USA
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McDonald LS, Maher PL, McDonald VS, Chin C, Dines JS. Pulmonary Embolism in a Baseball Pitcher Following Open Shoulder Capsular Repair. HSS J 2016; 12:81-4. [PMID: 26855633 DOI: 10.1007/s11420-015-9471-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 09/11/2015] [Indexed: 02/07/2023]
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Abstract
BACKGROUND Management of the hip capsule has been a topic of recent debate in hip arthroscopic surgery. Postoperative instability after hip arthroscopic surgery has been reported and can lead to poor outcomes. PURPOSE To determine the outcome of patients diagnosed with symptomatic instability after hip arthroscopic surgery at a minimum of 12 months and 24 months after revision surgery for capsular repair. STUDY DESIGN Case series; Level of evidence, 4. METHODS In a cohort of approximately 1100 patients who underwent hip arthroscopic surgery, 33 patients (33 hips) developed symptomatic instability requiring a revision surgery. Two patients suffered anterior dislocations following their initial surgery. Radiographs were reviewed to evaluate for acetabular dysplasia. Three patients were lost to follow-up and 10 patients were excluded as they were <1 year out from the revision surgery. A total of 20 patients (18 female, 2 male) completed a preoperative and postoperative modified Harris Hip Score (mHHS) and Hip Outcome Score (HOS) at a minimum of 12 months. Eleven of these patients had a minimum follow-up of 24 months. All patients filled out a Likert scale of perceived improvement in physical ability at final follow-up. RESULTS The mean age of the patients was 29.7 years (range, 15.2-55.5 years). The mean lateral center-edge angle was 25°, and the mean acetabular index was 7° before revision. All patients underwent interportal capsulotomy during the index arthroscopic procedure. After their index arthroscopic procedures, patients had minimal improvement at a mean of 19.1 months postoperatively on the mHHS (from 57.1 to 57.6; P = .423), HOS-Activities of Daily Living (ADL) (from 62.7 to 66.4; P = .260), and HOS-Sports (from 42.0 to 39.1; P = .800). For the patients with a minimum 1-year follow-up after revision surgery (n = 20; mean follow-up, 21.3 months), the mean mHHS (from 57.6 preoperatively to 85.8 at final follow-up; P < .001), HOS-ADL (from 66.4 to 85.7; P < .001), and HOS-Sports (from 39.1 to 79.8; P < .001) all improved significantly. The results were similar when looking at only the patients with a minimum 2-year follow-up after revision surgery (n = 11; mean follow-up, 26.1 months); the mean mHHS (from 56.0 preoperatively to 91.5 at final follow-up; P = .001), HOS-ADL (from 68.3 to 89.9; P = .009), and HOS-Sports (from 35.7 to 87.9; P = .001) all improved significantly. When comparing patients with isolated capsular repair to those with additional procedures performed, there were no differences between the groups (all P > .05). At final follow-up, all but 1 patient had improved overall physical ability levels. CONCLUSION Revision hip arthroscopic surgery for capsular repair in patients with symptomatic instability after hip arthroscopic surgery provides good functional outcomes at a minimum of 1 and 2 years postoperatively.
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Affiliation(s)
- James D Wylie
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, USA
| | - James T Beckmann
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Travis G Maak
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Stephen K Aoki
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, USA
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