Effect of Capsular Closure After Hip Arthroscopy for Femoroacetabular Impingement Syndrome on Achieving Clinically Meaningful Outcomes: A Meta-analysis of Prospective and Comparative Studies

Abstract

Background: Recent literature has demonstrated conflicting evidence as to whether capsular closure after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) results in superior outcomes compared with capsulotomy without repair. Additionally, these studies have not explored the effect of capsular management on clinically significant outcome improvement. Purpose: To perform a meta-analysis of prospective and comparative studies to determine whether capsular management influences the rate of clinically significant outcome improvement after hip arthroscopy for FAIS. Study Design: Systematic review; Level of evidence, 3. Methods: PubMed, OVID/Medline, EMBASE, and Cochrane databases were queried in September 2020 for studies with evidence levels 1 to 3 that directly compared capsular management cohorts and reported rates of achieving the minimal clinically important difference (MCID) at a minimum follow-up of 2 years. Studies of level 4 evidence, those not describing or directly comparing capsular management techniques as well as those not reporting the MCID were excluded. Methodological quality was assessed using the methodological index for nonrandomized studies tool. Mantel-Haenszel fixed-effects models were constructed to quantitatively evaluate the association between capsular management and achievement of the MCID by generating effect estimates in the form of relative risk (RR) with 95% CIs. Results: A total of 6 studies with 1611 patients were included. The overall pooled rate of MCID achievement for the modified Harris Hip Score (mHHS), Hip Outcome Score Activities of Daily Living (HOS-ADL), and HOS Sports Subscale (HOS-SS) were 84.4%, 80.3%, and 82.5%, respectively, at a mean follow-up of 40.8 months (range, 24-87.6 months). Capsular closure was associated with a significantly higher rate of MCID achievement for the mHHS (RR, 1.06; 95% CI, 1.01-1.10; P = .001) and trended toward statistical significance for the HOS-ADL (RR, 1.11; 95% CI, 1.0-1.24; P = .055) and the HOS-SS (RR, 1.09; 95% CI, 0.99-1.21; P = .094). Conclusion: Although capsular closure appeared to result in higher rates of clinically significant outcome improvement in hip function, there was no definitively increased likelihood of achieving clinically significant improvement in relevant hip outcome scores with capsular closure.

A higher proportion of patients may reach the MCID with capsular closure in patients undergoing arthroscopic surgery for femoroacetabular impingement: a systematic review and meta-analysis

“…Patients who underwent capsular closure after interportal capsulotomy were more likely to achieve the MCID for the mHHS score postoperatively than those who underwent no closure. This inding is in keeping with a recent review of 5 comparative studies by Kunze et al who found that interportal capsulotomy closure appeared to result in clinically improved outcomes postoperatively, although similar to this review, these results were not statistically signiicant [23]. The irst randomized controlled trial on this topic published recently by Bech et al showed no diference between groups at inal follow-up for pain and functional outcomes [4].…”

Intramedullary core decompression combined with endoscopic intracapsular decompression and debridement for pre-collapse non-traumatic osteonecrosis of the femoral head

“…The blood in the femoral head and neck is mainly supplied by the four groups of retinaculum arteries that originate from the medial and lateral circumflex arteries. These medial and lateral circumflex arteries pass through the attachment of the joint capsule at the femoral neck and supply more than 70% of the blood to the femoral head after entering the capsule [ 35 , 36 ]. The increase in IAP can damage the blood flow to the femoral head and may lead to osteonecrosis [ 37 ].…”

“…Vidyadhar evaluated the correlation between IAP and epiphyseal perfusion pressure using a pig model and believed that decompression and IAP reduction could reduce the risk of avascular necrosis in patients with intra-articular proximal femoral fractures who underwent hip capsulotomy [ 15 ]. A meta-analysis study showed whether to suture the joint capsule has no significant effect on the post-operative function after hip arthroscopy [ 35 ]. Therefore, in the present study, the joint capsule was not sutured after hip arthroscopy to reduce the pressure in the hip joint.…”

Pre- and intraoperative decision-making challenges in hip arthroscopy for femoroacetabular impingement

“…A meta-analysis assessing the effects of capsular closure following hip arthroscopy reported significantly higher rates of achieving the minimally clinical important difference for the mHHS (relative risk 1.0 (95% confidence interval (CI) 1.01 to 1.1); p = 0.001) when the capsule closed versus when it was not closed. 102 However, another review concluded that no difference in reoperation rates could be found between the two groups. 103 In addition, one study compared partial and complete repair of the capsule and found there to be a 13% revision arthroscopy rate in the partial repair group, in contrast to 0% within the complete repair group.…”