Capsular Closure Does Not Affect Development of Heterotopic Ossification After Hip Arthroscopy

doi:10.1016/j.arthro.2014.08.026

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 31, Issue 2, February 2015, Pages 225-230

https://doi.org/10.1016/j.arthro.2014.08.026 Get rights and content

Purpose

The purpose of this study was to evaluate the role of capsular closure after hip arthroscopy in reduction of the incidence of heterotopic ossification (HO).

Methods

One hundred (50 study group, 50 control group) consecutive hip arthroscopy procedures with radiographic follow-up of more than 9 weeks were included in the study. The study group consisted of 50 patients in whom capsular closure with 2 No. 1 polydioxanone (PDS) sutures was performed, and a control group consisted of 50 patients in whom the capsule remained open after capsulotomy. HO was assessed by radiographs using the Brooker classification. Statistical analysis of the data was carried out with the χ-square or Fisher exact test and Student t test, when appropriate, at a significance level of .05.

Results

Thirty-six (36%) patients had radiographic evidence of postoperative HO (14 patients in the capsular closure group). No significant difference was found regarding sex, side of operation, age, or HO rate between the study and the control groups (P = .778, P = .123, P = .744, and P = .144, respectively). Furthermore, no significant difference was found in the rate of HO with potential clinical significance (Brooker classification > I) between the control and study groups (P = .764).

Conclusions

Capsular closure did not seem to alter the rate of HO when compared with a control group of patients in whom the capsulotomy was not repaired.

Level of Evidence

Level III, retrospective comparative study.

Section snippets

Methods

This was a retrospective comparative study. At our center, clinical and outcomes data are collected on all patients undergoing arthroscopic surgery of the hip. This study was approved by the local institutional review board. The study period was between July 2011 and March 2013. The study included evaluation of 143 consecutive hip arthroscopies performed by the senior author (E.R.) for hip joint–related pain. Exclusion criteria were radiographic follow-up of less than 9 weeks, previous hip

Results

In this study, 100 patients with a mean age of 37.5 years (range, 18 to 68 years) were recruited. The control group consisted of 31 men and 19 women; the mean age of the control group was 36.7 years (range, 18 to 68 years). The study group consisted of 30 men and 20 women; the mean age of the study group was 38.2 years (range, 18 to 68 years) (Table 2). The mean follow-up was 12.7 months (range, 6 to 23.3 months). The control group did not significantly differ from the study group regarding

Discussion

The control and study groups did not differ statistically regarding age, sex, surgery time, and HO rate. The principal result of this study showed an incidence of 44% HO in the control group and 28% HO in the study group.

Despite numerous reports in the literature about HO after open hip surgery, little is known and documented about this complication after hip arthroscopy. In the few studies found in the literature, this incidence ranges from 1.6% to 44%3, 4, 5, 6, 7, 8, 15 (Table 3).

Soft tissue

Conclusions

Capsular closure did not seem to alter the rate of HO when compared with a control group of patients in whom the capsulotomy was not repaired.

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Cited by (24)

Capsular Repair May Improve Outcomes in Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement: A Systematic Review of Comparative Outcome Studies
2021, Arthroscopy - Journal of Arthroscopic and Related Surgery
Citation Excerpt :
Outcome scores are outlined in Table 2. The most commonly reported PRO measure was mHHS, which was reported on in 13 comparative outcome studies of 2,817 hips.14-18,20,21,24-26,28,34,35,39 Preoperative average reported scores ranged from 60.1 to 65.1 for the capsular plication group, 54.2 to 64.3 for the capsular repair group and 52.8 to 81.0 in the unrepaired group.
To review the existing literature in order to determine the effect of hip capsule repair on outcomes after hip arthroscopy for femoroacetabular impingement syndrome.
This study used Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to find articles by using PubMed and Embase. Included studies were Level I through III studies that focused on patient outcomes as a function of hip capsular treatments: capsulotomy repair, partial repair, plication, and unrepaired capsulotomies. The Methodological Index for Non-randomized Studies was used for quality assessment of clinical outcome studies. After applying inclusion and exclusion criteria, a total of 16 comparative outcome studies evaluating 2,996 hips were included; they evaluated the following capsular management techniques: complete repair (n = 1,112, 37.1%), partial repair (n = 32, 1.1%), plication (n = 223, 7.4%), and unrepaired capsulotomy (n = 1629, 54.4%).
Of the 16 studies, 13 included patient-reported outcome scores (PROs), 3 included imaging outcomes data, and 2 reported on reoperation. Of the studies, 10 directly compared patient-reported outcomes between a capsular repair group and an unrepaired group. Of the 10 studies that directly compared PROs between a group with unrepaired capsulotomy and a group with capsular repair, 8 studies demonstrated statistically significantly better PROs in the repaired group compared to the unrepaired group, and 2 studies found no difference between the groups. Reoperation rates demonstrated mixed results between groups, and no difference was found in regard to imaging outcomes.
Midterm outcome studies suggest that capsular repair is safe and effective in patients without arthritis who are undergoing hip arthroscopy, and it may result in superior PROs compared with those found after unrepaired capsulotomy. Studies consistently demonstrate similar or superior outcomes in cohorts after capsular repair compared to unrepaired capsulotomy, and no studies reported superior results in unrepaired capsulotomy patients.
Level IV, systematic review of Level I through Level III studies.
Femoroacetabular impingement treatment using the arthroscopic extracapsular outside-in approach: Does capsular suture affect functional outcome?
2020, Orthopaedics and Traumatology: Surgery and Research
Over the last decades, the arthroscopic treatment of hip pathology has highly grown thanks to the evolution of surgical techniques and instrumentation development. An alternative approach consisting in making a first outside-in longitudinal capsulotomy was described by Laude at the end of the 2000s and is experiencing significant development in France. The clinical results of this technique have rarely been reported and in particular the influence of the repair of the capsule is unknown. Therefore we performed a retrospective case control study aiming to asses: (1) the clinical outcomes and complication rates of the outside-in extracapsular approach for the treatment of FemoroAcetabular Impingement (FAI) and (2) the effect of capsular closure on the functional outcome.
We hypothesize that the outside-in extracapsular approach is a safe and efficient technique and the capsular closure at the end of the procedure positively affects the functional outcome.
A retrospective study was conducted on prospectively collected data of a consecutive series of hip arthroscopies performed for surgical treatment of FAI using the outside-in extracapsular approach. Any complications during follow-up were identified and recorded. Linear regression models were used to estimate the influence of capsular closure on the functional outcome. Functional outcome was assessed using modified Harris Hip Score (mHHS) and Non-arthritic Hip Score (NAHS).
Sixty-four hips in 57 patients operated by a single surgeon between October 2013 and December 2016 were analyzed at the time of final follow-up of 34.17 months (range 24 to 53). As the surgical technique evolved over time, a side-to-side capsular closure was performed at the end of the procedure for 25 hips and the capsule was left open for the remaining 39 patients. Functional outcome measurements showed an improvement from the preoperative to the last follow-up: 63.5 ± 11.0 to 88.1 ± 11.2 for mHHS, 63.1 ± 13.8 to 86.4 ± 13.4 for NAHS. Capsular closure leads to a significantly improved clinical outcome: gain in mHHS: 25.8 ± 2.3 vs. 20.6 ± 1.9 (p ≤ 0.044), gain in NAHS: 26.1 ± 2.5 vs. 19.6 ± 2.1, (p = 0.023). No major complications occurred. One case of postoperative tensor fascia latae atrophy was documented in the group “capsule left open”.
Hip arthroscopy in the management of FAI with an extraarticular starting point (outside-in) is a safe technique with functional results and postoperative morbidity comparable to previously reported techniques. Side-to-side capsular closure at the end of the procedure might positively affect the final functional outcome.
III, case control retrospective study.
Femoroacetabular impingement treatment using the arthroscopic extracapsular outside-in approach: Does capsular suture affect functional outcome?
2020, Revue de Chirurgie Orthopedique et Traumatologique
Au cours des dernières décennies, le traitement arthroscopique du conflit fémoro-acétabulaire (CFA) a largement évolué grâce aux avancées en matière de techniques chirurgicales et d’instrumentation. Une approche alternative basée sur une capsulotomie longitudinale première de dehors en dedans a été décrite par Laude à la fin des années 2000 et connaît un essor important en France. Les résultats cliniques de cette technique ont été rarement rapportés et l’influence de la réparation capsulaire reste méconnue. Aussi, nous avons conduit une étude rétrospective cas-témoin avec comme objectifs : 1) d’étudier le résultat clinique et le taux de complications du traitement arthroscopique du conflit de hanche par la technique capsulotomie de dehors en dedans dans le traitement du conflit fémoro-acétabulaire (CFA) et 2) d’évaluer l’effet de la fermeture capsulaire sur le résultat fonctionnel à court terme.
L’approche arthroscopique extracapsulaire de dehors en dedans est fiable et reproductible dans le traitement du conflit de hanche et la fermeture capsulaire influence positivement le résultat fonctionnel.
Une étude rétrospective a été conduite sur des données collectées prospectivement sur une série d’arthroscopies de hanche faites dans le cadre de traitement de CFA en utilisant l’approche extracapsulaire de dehors en dedans. Les scores Non Arthritic Hip Score (NAHS) et le score modifié de Harris (mHHS) ont été collectés en préopératoire et lors du dernier recul. Les complications lors du contrôle clinique et radiologique ont été identifiées et comptabilisées. Des modèles de régression linéaire ont été employés afin d’estimer l’impact de la fermeture capsulaire sur le résultat fonctionnel.
Soixante-quatre hanches chez 57 patients, opérés par un chirurgien entre octobre 2013 et décembre 2016 ont été étudiées et évaluées au recul de 34,17 mois (extrêmes : 24–53 mois). Avec l’évolution de la technique chirurgicale, une fermeture capsulaire bord à bord a été effectuée à la fin de l’intervention dans 25 cas alors que la capsule a été laissée ouverte dans 39 cas. Les scores fonctionnels ont été améliorés entre le préopératoire et le dernier contrôle : 63,5 ± 11 à 88,1 ± 11,2 pour le mHHS et 63,1 ± 13,8 à 86,4 ± 13,4 pour le NAHS. La fermeture capsulaire améliorait significativement le pronostic fonctionnel : gain en mHHS : 25,8 ± 2,3 vs 20,6 ± 1,9 (p ≤ 0,044) ; gain en NAHS : 26,1 ± 2,5 vs 19,6 ± 2,1 (p = 0,023). Aucune complication majeure n’est survenue. Un seul cas d’atrophie postopératoire du tenseur du Fascia Lata a été trouvé dans le groupe sans fermeture capsulaire.
L’arthroscopie de la hanche dans le traitement du CFA à point de départ extra-articulaire (de dehors en dedans) est une technique sûre avec des résultats fonctionnels et une morbidité postopératoire qui sont comparables aux autres techniques conventionnelles. La fermeture capsulaire bord à bord à la fin de la procédure semble améliorer le résultat fonctionnel final.
III, étude rétrospective type cas-témoin.
Puncture Capsulotomy During Hip Arthroscopy for Femoroacetabular Impingement: Preserving Anatomy and Biomechanics
2017, Arthroscopy Techniques
We describe an arthroscopic technique for the treatment of labral pathology and femoroacetabular impingement that provides excellent access to the central and peripheral compartments while preserving the biomechanically crucial components of hip joint stability. The hip capsule and the ligaments within it have been shown to be integral to hip biomechanical stability. Other popular techniques such as interportal and T-capsulotomy inherently damage the capsuloligamentous complex of the hip and can be associated with postoperative gross instability, micro-instability, heterotopic ossification, and seroma. Capsular closure may mitigate some of these effects but has been associated with capsular insufficiency and requires postoperative restrictions that can be prolonged. Our surgical technique focuses on careful portal placement, replacement when necessary, use of a switching stick to maximize peripheral compartment visualization, and joint access in the most minimally invasive manner while avoiding complications associated with extended capsulotomy. The objective of this Technical Note is to describe a technique by which full access to the joint can be obtained while not disrupting the biomechanics of the joint capsule.
Hip Arthroscopy in Patients Age 40 or Older: A Systematic Review
2017, Arthroscopy - Journal of Arthroscopic and Related Surgery
To (1) report clinical outcomes, complication rates, and total hip arthroplasty (THA) conversion rates for patients age 40 or older who underwent hip arthroscopy, and (2) report any age-related predictors of outcome identified in the literature.
MEDLINE, EMBASE, and PubMed were searched for relevant studies and pertinent data were abstracted from eligible studies. No meta-analysis was performed because of heterogeneity amongst studies.
Seventeen studies were included in this review comprising 16,327 patients, including 9,954 patients age 40 or older. All studies reported statistically significant improvements in outcomes after hip arthroscopy for femoral osteochondroplasty, labral repair, or unspecified indications. In patients 40 or older who underwent labral debridement, these improvements were not clinically significant. Obesity and osteoarthritic changes predicted poorer outcomes. Only 1 of 3 studies directly comparing the 2 groups found that patients 40 or older had a significantly less improvement in a standardized hip outcome score than patients under 40 after hip arthroscopy, but all found that patients 40 or older had significantly higher rates of THA conversion. The rate of conversion to THA was 18.1% for patients 40 or older, 23.1% for patients over 50, and 25.2% for patients over 60 with a mean of 25.0 months to THA.
Indications for hip arthroscopy including femoral osteochondroplasty and labral repair resulted in clinically significant improvements in patients 40 or older in most research studies examined in this review, whereas labral debridement did not produce clinically significant improvements postoperatively in the same studies. In these studies, the rate of conversion to THA is higher than in patients under 40 and increases with each decade of life, with many individual studies showing a significant increase in the rate of THA conversion. Hip arthroscopy may be suitable for some patients 40 or older, but patient selection is key and patients should be informed of the higher risk of conversion to THA.
Level IV, systematic review of Level III and IV studies.
Capsulotomy Size Affects Hip Joint Kinematic Stability
2016, Arthroscopy - Journal of Arthroscopic and Related Surgery
To evaluate the effect of capsulotomy size and subsequent repair on the biomechanical stability of hip joint kinematics through external rotation of a cadaveric hip in neutral flexion.
Eight fresh-frozen cadaveric hip specimens were used in this study. Each hip was tested under torsional loads of 6 N·m applied by a servohydraulic frame and transmitted by a pulley system. The test conditions were (1) neutral flexion with the capsule intact, (2) neutral flexion with a 4-cm interportal capsulotomy, (3) neutral flexion with a 6-cm capsulotomy, and (4) neutral flexion with capsulotomy repair. Soft tissue was retained during all interventions. Measures indicating joint kinematics (range of motion [ROM], hysteresis area [HA], and neutral zone [NZ]) were obtained for each condition.
For all hip specimens, the average ROM, HA, and NZ were calculated relative to the intact capsular state (100%) and expressed in terms of percentage (± SD). The findings for ROM were as follows: intact, 100%; 4 cm, 107.42% ± 5.69%; 6 cm, 113.40% ± 7.92%; and repair, 99.78% ± 3.77%. The findings for HA were as follows: intact, 100%; 4 cm, 108.30% ± 9.30%; 6 cm, 115.30% ± 13.92%; and repair, 99.47% ± 4.12%. The findings for NZ were as follows: intact, 100%; 4 cm, 139.61% ± 62.35%; 6 cm, 169.25% ± 78.19%; and repair, 132.03% ± 64.38%. Statistically significant differences in ROM existed between the intact and 4-cm conditions (P = .039), the intact and 6-cm conditions (P < .0001), the 4-cm and repair conditions (P = .033), and the 6-cm and repair conditions (P < .0001). There was no statistically significant difference between the intact and repair conditions (P > .99) or between the 4- and 6-cm conditions (P = .126).
Under laboratory-based conditions, larger-sized capsulotomies were accompanied by increases in all 3 measures of joint mobility: ROM, HA, and NZ at time zero. Complete capsular closure effectively restored these measures when compared with the intact condition.
Cadaveric models consisting of the hip joint with surrounding soft tissue were used under laboratory testing conditions to investigate potential iatrogenic joint instability resulting from expansive capsulotomies, showing that complete capsular closure leads to reconstitution of original joint stability properties at time zero.

View all citing articles on Scopus

: The authors report the following potential conflict of interest or source of funding: T.G.S. received fees for expert testimony from Allstate, State Farm, and others. E.Atoun receives support from Mininvasive Ltd.

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Original ArticleCapsular Closure Does Not Affect Development of Heterotopic Ossification After Hip Arthroscopy

Purpose

Methods

Results

Conclusions

Level of Evidence

Section snippets

Methods

Results

Discussion

Conclusions

Arthroscopy

Arthroscopy

Oper Tech Orthop

Arthroscopy

Injury

Arthroscopy

Arthroscopy

Arthrosc Tech

Arthrosc Tech

Arthrosc Tech

Heterotopic ossification: Two rare forms and what they can teach us

J Am Acad Orthop Surg

Overexpression of an osteogenic morphogen in fibrodysplasia ossificans progressiva

N Engl J Med

Combined hip arthroscopy and limited open osteochondroplasty for anterior femoroacetabular impingement

J Bone Joint Surg Am

Original Article
Capsular Closure Does Not Affect Development of Heterotopic Ossification After Hip Arthroscopy