Capsular plication in the non-deformity hip: impact on post-operative joint stability

Abstract

Purpose and hypothesisThe aim of this study was to evaluate the hip joint range of motion after different capsular plication. The study hypothesis proposed that capsular plication after hip arthroscopy may reduce hip external rotation and thus prevent the hip joint instability created by arthroscopic capsulotomies.MethodsSix fresh frozen human cadavers were studied in the intact state (5 males, 1 females) for a total of 12 non-deformity hips tested. They were fixed to the operating room table using a custom-made apparatus. Three Steinman pins were inserted, the first into ASIS, a parallel pin into the distal femur proximal to inter-epicondylar axis and the third pin into the lateral epicondyle. Simulation of arthroscopic capsulotomies was done progressively with simulation of three capsular plication techniques. The first plication technique consisted of a primary plication shift of the antero-lateral capsule. The distal-medial arm of the iliofemoral ligament was shifted toward the proximal-lateral arm. The second plication technique consisted in adding a longitudinal arm to the capsulotomy, between the lateral arm and the medial arm of the iliofemoral ligament, to create a T-shaped capsulotomy. The resulting two triangular capsular flaps were overlaid onto each other by approximately 5 mm, plicated fully and tighly sutured in a double-breast manner. The third plication technique, called redrapping, consisted in excising the inferior capsular triangular flap (previously made in the second technique), and suturing the latero-anterior superior capsular flap to the medial arm of the iliofemoral ligament, superimposing the capsular edges for closure. External rotation of the hip at 0°, 15° and 30° of flexion were obtained after the capsulotomy and each capsular plication technique to quantify the increase in hip stability after plication. Data were assessed using a two-way repeated measure analysis of variance (ANOVAs) and Student’s T-test when necessary to determine if the change in external rotation was significantly different.ResultsAfter capsulotomy, external rotation averaged 26.3°, 29.1° and 31.1° at 0°, 15° and 30° of flexion. With the primary plication shift, external rotation averaged 24.9°, 30.3° and 34.0°. With the two-triangle technique, external rotation averaged 26.1°, 31.9° and 33.3°. With the re-draping technique, external rotation averaged 25.8°, 30.9° and 32.0°. A significant relationship was found between «Plication Technique» and «Angle of flexion» factors for the measured angle of external rotation (P = 0.04).A decomposition of the interaction showed that external rotation decreased at 0° of hip flexion and increased as the hip flexion angle increased. The only significant difference found corresponded to the two triangles technique at 15° flexion (mean difference compared to the non-repaired state = 2.8° ± 3.8° or 8.8% increase in external rotation; P = 0.03).ConclusionsDifferent techniques of capsular plication result in a non-significant increase in hip external rotation when compared to unrepa...

Comparison of Pain Scores and Functional Outcomes of Patients Undergoing Arthroscopic Hip Labral Repair and Concomitant Capsular Repair or Plication Versus No Closure

“…Biomechanical studies support the correlation between hip capsular management and stability of the hip joint postoperatively and suggest closure of the capsule to preserve stability. 3,4,6,29,39 Some studies demonstrated that preservation of the iliofemoral ligament was critical to maintain native external rotation and anterior translation of the head of the femur, an important mechanism in protecting the hip from dislocating. 3,30,31,39 Other studies that evaluated the kinematics and torsional load of the hip joint concluded that the capsule should be routinely repaired in any hip procedure for patients with a predisposition to hip microinstability.…”

“…1,37,39,45,49 However, repair or plication of the capsule in patients with low risk of postoperative instability may be deleterious to hip range of motion without improving stability. 6,14,18,23 Prior clinical studies have reported mixed findings, possibly related in part to limited historical cohort sizes. The largest clinical study to date assessing the influence of capsular closure during a variety of arthroscopic hip procedures found no differences on multiple patient-reported outcomes between groups after adjustment for age, body mass index, sex, preoperative patient-reported outcomes, and degree of chondral damage.…”

Patient outcomes after direct capsular closure following hip arthroscopy: a systematic review

“…23,24 Others point to lower risk for arthritis development. 25,26 Skeptics of routine capsular closure cite the theoretical risk of over-constraint 27 and increased operative time with no proven benefits. 28 Past reviews have attempted to address the question of the best way to manage the capsule after hip arthroscopy.…”

“…Others point to lower risk for arthritis development 25,26. Skeptics of routine capsular closure cite the theoretical risk of over-constraint27 and increased operative time with no proven benefits 28…”