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Current Reviews in Musculoskeletal Medicine

Erschienen in:

05.07.2019 | Femoroacetabular impingement/labral tears (A Zhang, Section Editor)

Contemporary Management of the Hip Capsule During Arthroscopic Hip Preservation Surgery

verfasst von: Shane J. Nho, Edward C. Beck, Kyle N. Kunze, Kelechi Okoroha, Sunikom Suppauksorn

Erschienen in: Current Reviews in Musculoskeletal Medicine | Ausgabe 3/2019

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Abstract

Purpose of Review

The importance of the hip capsule and its effect on hip biomechanics, functional outcomes, and hip arthroscopy success rates has been demonstrated in recent studies. These results have led to a shift in management of the hip capsule, where an increasing number of surgeons routinely perform complete capsular closure. The purpose of this review is to highlight recent studies evaluating the hip capsule and describe contemporary capsular management and repair.

Recent Findings

Biomechanical studies using cadaveric models have demonstrated that complete capsular closure restores hip distraction, rotation, and extension forces back to the native, intact state. Additionally, capsular closure by plication results in quantifiable intraarticular volume reduction, which increases hip stability, particularly in cases of patulous capsule and hypermobility. Clinical studies have demonstrated superior patient-reported functional outcomes and decreased failure rates when undergoing hip arthroscopy with comprehensive capsular management for femoroacetabular impingement surgery.

Summary

Complete capsular management, including appropriate capsulotomy and subsequent closure, is critical for restoring biomechanical properties of the hip, ensuring high survivorship and improving functional outcomes. This review provides an update on the effects of contemporary capsular management as well as a detailed description of efficient T-capsulotomy and comprehensive capsule closure via plication.

• Hoppe DJ, et al. The learning curve for hip arthroscopy: a systematic review. Arthroscopy. 2014;30(3):389–97 Purpose: the learning curve for hip arthroscopy is consistently characterized as “steep.” The purpose of this systematic review was to (1) identify the various learning curves reported in the literature, (2) examine the evidence supporting these curves, and (3) determine whether this evidence supports an accepted number of cases needed to achieve proficiency. Methods: the electronic databases Embase and Medline were screened for any clinical studies reporting learning curves in hip arthroscopy. Two reviewers conducted a full-text review of eligible studies and a hand search of conference proceedings and reference sections of the included articles. Inclusion/exclusion criteria were applied, and a quality assessment was completed for each included article. Descriptive statistics were compiled. Results: we identified 6 studies with a total of 1063 patients. Studies grouped surgical cases into “early” vs “late” in a surgeon’s experience, with 30 cases being the most common cutoff used. Most of these studies used descriptive statistics and operative time and complication rates as measures of competence. Five of 6 studies showed improvement in these measures between early and late experiences, but only one study proposed a bona fide curve. Conclusions: this review shows that when 30 cases were used as the cutoff point to differentiate between early and late cases in a surgeon’s experience, there were significant reductions in operative time and complication rates. However, there was insufficient evidence to quantify the learning curve and validate 30, or any number of cases, as the point at which the learning curve plateaus. As a result, this number should be interpreted with caution. Level of evidence: level IV, systematic review of level IV studies. CrossRefPubMed

• Domb BG, et al. Arthroscopic capsulotomy, capsular repair, and capsular plication of the hip: relation to atraumatic instability. Arthroscopy. 2013;29(1):162–73 Purpose: the purpose of this systematic review was to critically evaluate the available literature exploring the role of the hip joint capsule in the normal state (stable) and pathologic states (instability or stiffness). Furthermore, we examined the various ways that arthroscopic hip surgeons address the capsule intraoperatively: (1) capsulotomy or capsulectomy without closure, (2) capsulotomy with closure, and (3) capsular plication. Methods: two independent reviewers (B.D.G. and B.G.D.) performed a systematic review of the literature using PubMed and the reference lists of related articles by means of defined search terms. Relevant studies were included if these criteria were met: (1) written in English, (2) levels of evidence I to V, (3) focus on capsule and its role in hip stability, and (4) human studies and reviews. Articles were excluded if they evaluated (1) total hip arthroplasty constructs using bony procedures or prosthetic revision, (2) developmental dysplasia of the hip where reorientation osteotomies were used, (3) syndromic instability, and (4) traumatic instability with associated bony injury. Results: by use of the search method described, 5,085 publications were reviewed, of which 47 met appropriate criteria for inclusion in this review. Within this selection group, there were multiple publications that specifically addressed more than 1 of the inclusion criteria. Relevant literature was organized into the following areas: (1) capsular anatomy, biomechanics, and physiology; (2) the role of the capsule in total hip arthroplasty stability; (3) the role of the capsule in native hip stability; and (4) atraumatic instability and capsulorrhaphy. Conclusions: as the capsuloligamentous stabilizers of the hip continue to be studied, and their role defined, arthroscopic hip surgeons should become facile with arthroscopic repair or plication techniques to restore proper capsular integrity and tension when indicated. Level of evidence: level IV, systematic review. CrossRefPubMed

Ekhtiari S, de SA D, Haldane CE, Simunovic N, Larson CM, Safran MR, et al. Hip arthroscopic capsulotomy techniques and capsular management strategies: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2017;25(1):9–23.CrossRefPubMed

Mei-Dan O, et al. Catastrophic failure of hip arthroscopy due to iatrogenic instability: can partial division of the ligamentum teres and iliofemoral ligament cause subluxation? Arthroscopy. 2012;28(3):440–5 Hip arthroscopy is an evolving surgical tool, and with any new procedure, it is important to learn from the complications encountered. A patient with mild hip dysplasia and a symptomatic labral tear underwent uneventful hip arthroscopy and labral repair including partial debridement of a hypertrophied ligamentum teres. Despite preservation of the labrum, no pincer resection, and a modest capsulotomy, 3 months, subluxation and joint space narrowing were noted. One year, end-stage arthritis was present, requiring total hip replacement. Instability after hip arthroscopy is due to a number of factors, including excessive rim trimming, capsulotomy, overzealous labral resection, or inadequate labral repair. This report emphasizes the importance of the ligamentum teres and small disruptions of the capsule in patients with mild dysplasia. CrossRefPubMed

Uchida S, Pascual-Garrido C, Ohnishi Y, Utsunomiya H, Yukizawa Y, Chahla J, et al. Arthroscopic shoelace capsular closure technique in the hip using Ultratape. Arthrosc Tech. 2017;6(1):e157–61.CrossRefPubMedPubMedCentral

•• Weber AE, et al. Complications in hip arthroscopy: a systematic review and strategies for prevention. Sports Med Arthrosc Rev. 2015;23(4):187–93 The primary objective of this study was to determine the minor and major complication rates of hip arthroscopy. The secondary objective was to provide strategies for avoiding complications. A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and checklist. Therapeutic hip arthroscopy investigations that reported on adverse events or complications were included. Narrative and other systematic reviews, meta-analyses, conference abstracts or proceedings, and level V evidence studies were excluded. No follow-up minimum was imposed. The results yielded 53 studies (8189 hip arthroscopies in 8071 subjects). Most studies were level IV evidence (74%) with a mean of 2.2 ± 2.1 years of follow-up. Femoroacetabular impingement (FAI) and labral pathology were the 2 most common indications for surgery, and osteochondroplasty for FAI and labral treatment were the 2 most common procedures performed. The minor and major complication rates were 7.9% and 0.45%, respectively. Iatrogenic chondrolabral damage and temporary nerve injury were the 2 most common minor complications. Extraarticular fluid extravasation was the most common major complication encountered. Minor complications associated with hip arthroscopy are generally technical in nature and may be related to the learning curve associated with hip arthroscopy. As surgeon experience increases and patient selection improves, a corresponding decline should be observed in minor complications. Strategies to prevent complications include careful preoperative planning, appropriate surgical indications, attention to detail in the operating room, and proper postoperative rehabilitation. CrossRefPubMed

•• Riff AJ, et al. Systematic review of hip arthroscopy for femoroacetabular impingement: the importance of labral repair and capsular closure. Arthroscopy. 2019;35(2):646–656 e643 Purpose: to evaluate the safety and efficacy of hip arthroscopy for femoroacetabular impingement syndrome by assessing complications, comprehensive procedure survivorship, and the influence of labral and capsular management on procedure survivorship. Methods: a systematic review of multiple medical databases was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklist. All clinical outcome studies that reported on the presence or absence of reoperation after hip arthroscopy for femoroacetabular impingement syndrome were eligible for inclusion. Data pertaining to patient demographic characteristics, surgical technique (specifically labral and capsular management), patient-reported outcomes, complications, reoperation, and conversion to arthroplasty were extracted from each study. Results: a total of 68 studies (7,241 hips) were included. Most were level IV studies (63%). Complications occurred in 1.9% of cases. The most common complications were neurologic (53%), heterotopic ossification (24%), infection (15%), and thromboembolic (7%). Conversion to total hip arthroplasty (456 cases) was the most common reason for reoperation, followed by revision hip arthroscopy (226 cases) and periacetabular osteotomy (7 cases). The rate of arthroplasty conversion was lower than 10% in 43 of 59 studies reporting this outcome. The average interval to arthroplasty conversion was 58 months. Between 2009 and 2017, the performance of labral repair increased from 19 to 81% of cases and capsular closure increased from 7 to 58% of cases. Conclusions: arthroplasty conversion occurred in fewer than 10% of cases in the clear majority of series. Labral repair (compared with labral debridement) and capsular closure (compared with unrepaired capsulotomy) were associated with a lower risk of conversion to arthroplasty. Throughout the study interval, there were shifts in surgical technique favoring labral repair over debridement and capsular repair over unrepaired capsulotomy. The study is limited by selection bias because cases in which labral and capsular repair was performed may have had superior tissue that was more amenable to repair. Level of evidence: level IV, systematic review. CrossRefPubMed

Nam D, Osbahr DC, Choi D, Ranawat AS, Kelly BT, Coleman SH. Defining the origins of the iliofemoral, ischiofemoral, and pubofemoral ligaments of the hip capsuloligamentous complex utilizing computer navigation. HSS J. 2011;7(3):239–43.CrossRefPubMedPubMedCentral

10.

Ito H, Song Y, Lindsey DP, Safran MR, Giori NJ. The proximal hip joint capsule and the zona orbicularis contribute to hip joint stability in distraction. J Orthop Res. 2009;27(8):989–95.CrossRefPubMed

11.

Mygind-Klavsen B, et al. Danish Hip Arthroscopy Registry: capsular closing in patients with femoroacetabular impingement (FAI): results of a matched-cohort controlled study. J Hip Preserv Surg. 2016;3(suppl_1):hnw030.017.PubMedCentral

12.

Bolia I, Briggs KK, Philippon MJ. Superior clinical outcomes with capsular closure versus non-closure in patients undergoing arthroscopic hip labral repair. Orthop J Sports Med. 2018;6(3_suppl):2325967118S0000.CrossRef

13.

Zurück zum Zitat • Domb BG, et al. Patient-reported outcomes of capsular repair versus capsulotomy in patients undergoing hip arthroscopy: minimum 5-year follow-up-a matched comparison study. Arthroscopy. 2018;34(3):853–863 e851 Purpose: to elucidate whether capsular closure during hip arthroscopy affected patient outcomes over midterm follow-up. Methods: between 2008 and 2011, data were prospectively collected and retrospectively reviewed on patients who underwent hip arthroscopy. Patients were then matched for age, gender, worker’s compensation, body mass index, and acetabular coverage. The inclusion criteria were capsular repair or unrepaired capsulotomy, lateral-center edge angle ≥ 18°, and minimum of a 5-year follow-up. The exclusion criteria were previous hip surgery or conditions and Tonnis grade > 1. Patient-reported outcome scores (PROs) included modified Harris Hip Score (mHHS), nonarthritic hip score, hip outcome score sport-specific subscale, and visual analog score for pain, which were collected preoperatively, at 3 months and annually thereafter. Minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) for both groups were analyzed. Patient satisfaction was noted as well as any complications, secondary surgery, and conversion to arthroplasty. Results: minimum of a 5-year follow-up was available for 82.5% (287 of 348) hips that met the inclusion criteria and were eligible for matching. Ultimately, 65 patients who underwent capsular repair could be matched in a 1:1 ratio to 65 patients with release. Both groups had significant improvements in all mean PROs. The repair group had significant improvement of mean PROs, visual analog score, and patient satisfaction at both 2-year and minimum 5-year follow-ups. The unrepaired group had a significant decrease in mHHS ( P = 0.001) and patient satisfaction ( P = 0.01) between 2- and 5-year follow-ups. Despite decreasing mHHS in the repair group between 2- and 5-year follow-ups, both groups met the MCID and PASS criteria with no significant difference between them. More patients in the release group required conversion to hip arthroplasty (18.5% vs 10.8%). Subgroup analysis considering various perioperative factors confirmed this trend. Rate of revision arthroscopy was the same in both groups (15.4%). Complication rate was low (4.6% vs 6.4%) in both groups. Conclusions: patients undergoing hip arthroscopy and who have minimal or no arthritis have significant short-term improvement, whether the capsule is closed or left unrepaired. However, at midterm follow-up, patients who had unrepaired capsules had deterioration in mHHS as well as a higher rate of conversion to arthroplasty, even when controlling for various perioperative variables. Despite this, patients in both groups met the MCID and PASS criteria. This study suggests that routine capsular closure may lead to more consistently durable outcome in patients undergoing hip arthroscopy, but also that individual patient pathology may dictate capsular management. Level of evidence: level III, retrospective comparative study. CrossRefPubMed • Domb BG, et al. Patient-reported outcomes of capsular repair versus capsulotomy in patients undergoing hip arthroscopy: minimum 5-year follow-up-a matched comparison study. Arthroscopy. 2018;34(3):853–863 e851 Purpose: to elucidate whether capsular closure during hip arthroscopy affected patient outcomes over midterm follow-up. Methods: between 2008 and 2011, data were prospectively collected and retrospectively reviewed on patients who underwent hip arthroscopy. Patients were then matched for age, gender, worker’s compensation, body mass index, and acetabular coverage. The inclusion criteria were capsular repair or unrepaired capsulotomy, lateral-center edge angle ≥ 18°, and minimum of a 5-year follow-up. The exclusion criteria were previous hip surgery or conditions and Tonnis grade > 1. Patient-reported outcome scores (PROs) included modified Harris Hip Score (mHHS), nonarthritic hip score, hip outcome score sport-specific subscale, and visual analog score for pain, which were collected preoperatively, at 3 months and annually thereafter. Minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) for both groups were analyzed. Patient satisfaction was noted as well as any complications, secondary surgery, and conversion to arthroplasty. Results: minimum of a 5-year follow-up was available for 82.5% (287 of 348) hips that met the inclusion criteria and were eligible for matching. Ultimately, 65 patients who underwent capsular repair could be matched in a 1:1 ratio to 65 patients with release. Both groups had significant improvements in all mean PROs. The repair group had significant improvement of mean PROs, visual analog score, and patient satisfaction at both 2-year and minimum 5-year follow-ups. The unrepaired group had a significant decrease in mHHS ( P = 0.001) and patient satisfaction ( P = 0.01) between 2- and 5-year follow-ups. Despite decreasing mHHS in the repair group between 2- and 5-year follow-ups, both groups met the MCID and PASS criteria with no significant difference between them. More patients in the release group required conversion to hip arthroplasty (18.5% vs 10.8%). Subgroup analysis considering various perioperative factors confirmed this trend. Rate of revision arthroscopy was the same in both groups (15.4%). Complication rate was low (4.6% vs 6.4%) in both groups. Conclusions: patients undergoing hip arthroscopy and who have minimal or no arthritis have significant short-term improvement, whether the capsule is closed or left unrepaired. However, at midterm follow-up, patients who had unrepaired capsules had deterioration in mHHS as well as a higher rate of conversion to arthroplasty, even when controlling for various perioperative variables. Despite this, patients in both groups met the MCID and PASS criteria. This study suggests that routine capsular closure may lead to more consistently durable outcome in patients undergoing hip arthroscopy, but also that individual patient pathology may dictate capsular management. Level of evidence: level III, retrospective comparative study. CrossRefPubMed

14.

• Abrams GD. Editorial commentary: the importance of capsular closure in hip arthroscopy: is there a limit to the benefit? Arthroscopy. 2018;34(3):864–5 Capsular closure is an important concept in hip arthroscopy and should be performed in nearly all patients. However, in patients with stiff hips and borderline arthritic changes, leaving the capsule unrepaired or performing a partial repair in the setting of a T-capsulotomy could result in successful outcomes. CrossRefPubMed

15.

Zurück zum Zitat • Strickland CD, et al. MRI evaluation of repaired versus unrepaired interportal capsulotomy in simultaneous bilateral hip arthroscopy: a double-blind, randomized controlled trial. J Bone Joint Surg Am. 2018;100(2):91–8 Background: techniques used in hip arthroscopy continue to evolve, and controversy surrounds the need for capsular repair following this surgical intervention. The purpose of this study was to evaluate the magnetic resonance imaging (MRI) appearance of the hip capsule in patients with femoroacetabular impingement (FAI) who underwent simultaneous bilateral hip arthroscopy through an interportal capsulotomy with each hip randomized to undergo capsular repair or not undergo such a repair. Methods: this double-blind, randomized controlled trial included 15 patients (30 hips), with a mean age of 29.2 years, who underwent simultaneous bilateral hip arthroscopy utilizing a small (< 3 cm) interportal capsulotomy for the treatment of FAI. The first hip treated in each patient was intraoperatively randomized to undergo capsular repair or no capsular repair. The contralateral hip then received the opposite treatment. MRI was performed at 6 and 24 weeks postoperatively, and the scans were analyzed by 2 musculoskeletal radiologists. The patients and the radiologists were blinded to the treatment performed on each hip. Capsular dimensions were measured at the level of the healing capsulotomy site and, for hips with a persistent defect, at locations both proximal and distal to the defect. These values were then analyzed at both time points to assess the rate and extent of capsular healing. Results: at 6 weeks postoperatively, a continuous hip capsule (with no apparent capsulotomy defect) was observed in 8 hips treated with capsular repair and 3 hips without such a repair. Of the 19 hips with a discontinuous capsule at 6 weeks, 17 were available for follow-up at 24 weeks postoperatively; all 17 demonstrated progression to healing, with a contiguous appearance without defects and no difference in capsular dimensions between treatment cohorts. Conclusions: arthroscopic repair of a small interportal hip capsulotomy site yields an insignificant increase in the percentage of continuous hip capsules seen on MRI at 6 weeks postoperatively compared with no repair. Repaired and unrepaired capsulotomy sites progressed to healing with a contiguous appearance on MRI by 24 weeks postoperatively. Level of evidence: therapeutic level I. See Instructions for Authors for a complete description of levels of evidence. CrossRefPubMed • Strickland CD, et al. MRI evaluation of repaired versus unrepaired interportal capsulotomy in simultaneous bilateral hip arthroscopy: a double-blind, randomized controlled trial. J Bone Joint Surg Am. 2018;100(2):91–8 Background: techniques used in hip arthroscopy continue to evolve, and controversy surrounds the need for capsular repair following this surgical intervention. The purpose of this study was to evaluate the magnetic resonance imaging (MRI) appearance of the hip capsule in patients with femoroacetabular impingement (FAI) who underwent simultaneous bilateral hip arthroscopy through an interportal capsulotomy with each hip randomized to undergo capsular repair or not undergo such a repair. Methods: this double-blind, randomized controlled trial included 15 patients (30 hips), with a mean age of 29.2 years, who underwent simultaneous bilateral hip arthroscopy utilizing a small (< 3 cm) interportal capsulotomy for the treatment of FAI. The first hip treated in each patient was intraoperatively randomized to undergo capsular repair or no capsular repair. The contralateral hip then received the opposite treatment. MRI was performed at 6 and 24 weeks postoperatively, and the scans were analyzed by 2 musculoskeletal radiologists. The patients and the radiologists were blinded to the treatment performed on each hip. Capsular dimensions were measured at the level of the healing capsulotomy site and, for hips with a persistent defect, at locations both proximal and distal to the defect. These values were then analyzed at both time points to assess the rate and extent of capsular healing. Results: at 6 weeks postoperatively, a continuous hip capsule (with no apparent capsulotomy defect) was observed in 8 hips treated with capsular repair and 3 hips without such a repair. Of the 19 hips with a discontinuous capsule at 6 weeks, 17 were available for follow-up at 24 weeks postoperatively; all 17 demonstrated progression to healing, with a contiguous appearance without defects and no difference in capsular dimensions between treatment cohorts. Conclusions: arthroscopic repair of a small interportal hip capsulotomy site yields an insignificant increase in the percentage of continuous hip capsules seen on MRI at 6 weeks postoperatively compared with no repair. Repaired and unrepaired capsulotomy sites progressed to healing with a contiguous appearance on MRI by 24 weeks postoperatively. Level of evidence: therapeutic level I. See Instructions for Authors for a complete description of levels of evidence. CrossRefPubMed

16.

• Shin JJ, de SA DL, Burnham JM, Mauro CS. Refractory pain following hip arthroscopy: evaluation and management. J Hip Preserv Surg. 2018;5(1):3–14 With increased knowledge and understanding of hip pathology, hip arthroscopy is rapidly becoming a popular treatment option for young patients with hip pain. Despite improved clinical and radiographic outcomes with arthroscopic treatment, some patients may have ongoing pain and less than satisfactory outcomes. While the reasons leading to failed hip arthroscopy are multifactorial, patient selection, surgical technique, and rehabilitation all play a role. Patients with failed hip arthroscopy should undergo a thorough history and physical examination, as well as indicated imaging. A treatment plan should then be developed based on pertinent findings from the workup and in conjunction with the patient. Depending on the etiology of failed hip arthroscopy, management may be nonsurgical or surgical, which may include revision arthroscopic or open surgery, periacetabular osteotomy, or joint arthroplasty. Revision surgery may be appropriate in settings including, but not limited to, incompletely treated femoroacetabular impingement, postoperative adhesions, heterotopic ossification, instability, hip dysplasia, or advanced degeneration. CrossRefPubMedPubMedCentral

17.

• Krych AJ, et al. Is posterior hip instability associated with cam and pincer deformity. Clin Orthop Relat Res. 2012;470(12):3390–7 Background: posterior hip instability is an increasingly recognized injury in athletes; however, the function of patients after these injuries and an understanding of the pathoanatomy and underlying mechanism are currently unclear. Questions/purposes: we determined (1) the function of patients after these hip injuries using validated, self-reported outcome instruments and (2) the specific pathoanatomy sustained in these events to better understand the mechanism of posterior hip instability. Methods: we reviewed the records of all 22 athletes presenting to our clinics with a posterior acetabular rim fracture confirming a posterior hip instability episode. Radiograph, CT, and MRI findings were documented in all patients. Intraoperative findings were recorded in patients undergoing surgery. There were 19 males and three females with an average age of 22 years (range, 13–31 years). Minimum follow-up was 2 years (average, 4 years; range, 2–16 years). Results: the mean modified Harris Hip Score was 94, Hip Outcome Scores for Activities of Daily Living and Sport were 99 and 87, respectively, and 20 of 22 athletes returned to sport. The most common constellation of pathoanatomy was a posterior labral tear with rim fracture, anterior labral tear, capsular tear, ligamentum teres avulsion, and chondral injury of the femoral head with loose bodies. Sixteen of the 18 patients with femoroacetabular impingement (FAI) had a twisting or noncontact mechanism of injury. Conclusions: when posterior hip subluxation is recognized and avascular necrosis avoided, these athletes generally have high functional outcome scores and high rates of return to sport. There is an apparent association between the occurrence of posterior hip instability and the presence of structural abnormalities often associated with FAI, which may contribute to a mechanism of FAI-induced posterior subluxation. Level of evidence: level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence. CrossRefPubMedPubMedCentral

18.

•• Canham CD, et al. Does femoroacetabular impingement cause hip instability? A systematic review. Arthroscopy. 2016;32(1):203–8 Purpose: to determine whether femoroacetabular impingement (FAI) is associated with hip instability. Methods: a systematic search examining FAI and hip instability was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Clinical and basic science studies were included. Instability had to be documented with either a clinical or imaging examination. Studies were excluded if they did not define diagnostic criteria for FAI, involved prosthetic hips, were not in English, were review articles, or reported level V evidence (case reports, expert opinion). Rates of FAI morphologic features in patients with documented hip instability were determined. Mechanisms and rates of FAI-induced hip subluxation were examined in basic science studies. Results: the search yielded 1,630 relevant studies. Seven studies (4 clinical and 3 basic science) met inclusion criteria. Four studies investigated an association between FAI and hip instability in 92 patients with an average age of 31 years. Seventy-six patients experienced frank dislocations, and 16 experienced posterior subluxation events. The prevalence of FAI was documented in 89 patients with hip instability. The rates of cam and pincer morphologic characteristics were 74% and 64%, respectively. The average lateral center edge angle and prevalence of acetabular retroversion were 30° and 70%, respectively ( n = 76 patients). All 3 basic science studies had real-time visualization of FAI-induced hip subluxations. Conclusions: high rates of FAI morphologic characteristics are present in patients with hip instability. FAI morphologic characteristics may predispose the hip to instability through anatomic conflict caused by pincer or cam lesions (or both) levering the femoral head posteriorly. Level of evidence: level IV, systematic review of level III, level IV, and nonclinical studies. CrossRefPubMed

19.

• Duplantier NL, et al. Hip dislocation or subluxation after hip arthroscopy: a systematic review. Arthroscopy. 2016;32(7):1428–34 Purpose: to determine patient- and surgery-specific characteristics of patients sustaining postarthroscopic hip dislocation or subluxation. Methods: a systematic review of multiple medical databases was registered with PROSPERO and performed using Preferred Reporting Items for Systemic Reviews and Meta-Analysis guidelines. Level I to IV clinical outcome studies reporting the presence of hip dislocation or subluxation after hip arthroscopy were eligible. Length of follow-up was not an exclusion criterion. All patient- and surgery-specific variables were extracted from each, specifically evaluating osseous morphology and resection details; labral, iliopsoas, ligamentum teres, and capsular management; generalized ligamentous laxity; instability direction and mechanism; management; and outcome. Study authors were individually contacted to assess most recent outcome. Results: ten articles with 11 patients were analyzed (mean patient age 36.6 ± 12.3 years). There were 9 hip dislocations and 2 subluxations. Mean time between surgery and dislocation was 3.2 ± 4.0 months (range: recovery room to 14 months). Anterior was the most frequent dislocation direction (8 cases). Acetabular undercoverage (preoperative dysplasia or iatrogenic rim overresection) was observed in 5 cases. Labral debridement was performed in 5 cases, iliopsoas tenotomy in 3 cases, and ligamentum teres debridement in 1 case. A “T” capsulotomy was created in 1 case (isolated interportal in other 10 cases). Capsular closure was performed in 2 cases (both interportal). Generalized ligamentous laxity was diagnosed in 1 case. A combination of external rotation and extension was observed in 5 of the 6 cases reporting the mechanism of anterior dislocation. Four cases were successfully treated with closed reductio, 4 required total hip arthroplasty, and 3 required revision capsulorrhaphy. Conclusions: Postarthroscopic hip instability was observed in patients with acetabular undercoverage (including iatrogenic resection), labral debridement, capsular insufficiency, or iliopsoas tenotomy. Most dislocations were anterior, occurring with hip extension and external rotation. Level of evidence: level IV, systematic review of level IV studies. CrossRefPubMed

20.

•• Abrams GD, et al. Biomechanical evaluation of capsulotomy, capsulectomy, and capsular repair on hip rotation. Arthroscopy. 2015;31(8):1511–7 Purpose: to determine the effect of different types of capsulotomies on hip rotational biomechanical characteristics. Methods: seven fresh-frozen cadaveric hip specimens were thawed and dissected, leaving the hip capsule and labrum intact. The femur was transected and potted, and each specimen was placed in a custom loading apparatus that allowed for adjustment of flexion, extension, and axial rotation of the femur. Six reflective infrared markers were attached to the specimens to track the motion of the femoral head with respect to the acetabulum in real time, and external rotation was produced by applying a torque of 10 nm to the hip specimens. Data analysis was performed using the 3-dimensional position of the markers in space. The specimens were tested in neutral flexion and 40° of flexion in the following capsular states: intact, interportal capsulotomy, T-capsulotomy, repaired capsulotomy, and capsulectomy. Paired t tests and analysis of variance were used with an alpha value of 0.05 set as significant. Results: with the hip in neutral flexion, there was increased external rotation with a T-capsulotomy (91.1° ± 20.3°, P = 0.029) and capsulectomy (91.9° ± 19.6°, P = 0.015) compared with the intact hip (83.2° ± 20.5°). After complete repair of the T-capsulotomy (87.4° ± 20.6°), there was no significant difference in external rotation compared with the intact hip. No significant differences were seen between groups at 40° of hip flexion. Conclusions: a T-capsulotomy showed significantly increased external rotation vs the intact and interportal capsulotomy states. The repaired T-capsulotomy restored the rotational profile back to the native state. Clinical relevance: many methods of capsular treatment during hip arthroscopy exist. Capsulotomy and capsulectomy do not restore the external rotation restraint of the hip back to its native state. CrossRefPubMed

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22.

23.

Stone AV, et al. Comparable patient-reported outcomes in females with or without joint hypermobility after hip arthroscopy and capsular plication for femoroacetabular impingement syndrome. J Hip Preserv Surg. 2019;6:33–40.CrossRefPubMedPubMedCentral

24.

Titel: Contemporary Management of the Hip Capsule During Arthroscopic Hip Preservation Surgery
verfasst von: Shane J. Nho
Edward C. Beck
Kyle N. Kunze
Kelechi Okoroha
Sunikom Suppauksorn
Publikationsdatum: 05.07.2019
Verlag: Springer US
Erschienen in: Current Reviews in Musculoskeletal Medicine / Ausgabe 3/2019
Elektronische ISSN: 1935-9748
DOI: https://doi.org/10.1007/s12178-019-09564-4

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A Systematic Review of Complications Following Minimally Invasive Spine Surgery Including Transforaminal Lumbar Interbody Fusion

Surgical Treatment of Labral Tears: Debridement, Repair, Reconstruction

The Current State of Minimally Invasive Approaches to Adult Spinal Deformity

Economic Value in Minimally Invasive Spine Surgery

Arthropedia

Neu im Fachgebiet Orthopädie und Unfallchirurgie

Stereotaktische Radiatio schlägt konventionelle Bestrahlung

Vorsicht mit hohen NSAR-Dosen bei ankylosierender Spondylitis!

Brustkrebs in der Vorgeschichte macht Gelenkersatz komplikationsträchtiger

„Nur wer sich gut aufgehoben fühlt, kann auch für Patientensicherheit sorgen“

Update Orthopädie und Unfallchirurgie