Hip Capsular Management in Patients With Femoroacetabular Impingement or Microinstability: A Systematic Review of Biomechanical Studies

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Background: Return to sports (RTS) and patient-reported outcomes (PROs) for elite athletes with femoral version abnormalities undergoing hip arthroscopy have not been well established. Purposes: To (1) report minimum 2-year PROs and RTS rates in elite athletes with femoral retroversion who underwent primary hip arthroscopy and (2) compare clinical results to those of a propensity-matched control group of elite athletes with normal femoral version who underwent primary hip arthroscopy. Study Design: Cohort study; Level of evidence, 3. Methods: Data were prospectively collected and retrospectively reviewed for elite (professional and collegiate) athletes with femoral version <5°, as measured on magnetic resonance imaging scans, who underwent hip arthroscopy for femoroacetabular impingement syndrome between March 2010 and April 2018. Inclusion criteria were preoperative and minimum 2-year follow-up PROs for the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score–Sports Specific Subscale (HOS-SSS), and visual analog scale for pain. Exclusion criteria were Tönnis grade >1, hip dysplasia, and previous ipsilateral hip surgery or conditions. Rates of achieving the minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), and maximum outcome improvement satisfaction threshold were recorded in addition to RTS. Athletes with retroversion were propensity matched in a 1:2 ratio to elite athletes with normal femoral version (5°-20°) for comparison. Results: A total of 33 elite athletes (33 hips) with femoral retroversion who underwent hip arthroscopy met the inclusion criteria, and follow-up was available for 30 hips in 30 athletes (90.9%) at an average of 36.1 ± 25.6 months. Elite athletes with femoral retroversion demonstrated significant improvements in all recorded PROs, achieved the MCID and PASS for the HOS-SSS at high rates (86.7%), and returned to sports at a rate of 83.3%. PROs, rates of achieving MCID and PASS for the HOS-SSS, and RTS rates were similar between the study and propensity-matched control group. Conclusion: Elite athletes with femoral retroversion undergoing primary hip arthroscopy demonstrated favorable PROs and high RTS rates at a minimum 2-year follow-up. These results were comparable with those of a propensity-matched control group of elite athletes with normal femoral version.

Section: Discussionmentioning

confidence: 99%

Outcomes and Return-to-Sport Rates for Elite Athletes With Femoral Retroversion Undergoing Hip Arthroscopy: A Propensity-Matched Analysis With Minimum 2-Year Follow-up

Owens

Jimenez

Lee

et al. 2022

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“…As a result, some patients in the present study cohorts who underwent capsulotomy without repair would currently be treated with capsular repair/plication. 29 , 48 …”

Section: Discussionmentioning

confidence: 99%

Sex-Based Differences in Athletes Undergoing Primary Hip Arthroscopy With Labral Reconstruction: A Propensity-Matched Analysis With Minimum 2-Year Follow-up

Owens

Lee

Jimenez

et al. 2022

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Background: There is a paucity of literature comparing sex-based outcome differences in athletes after primary hip arthroscopy with labral reconstruction for femoroacetabular impingement syndrome (FAIS) and irreparable labral tears. Purpose: To report sex-based differences in clinical characteristics, patient-reported outcome (PRO) scores, and return-to-sports (RTS) rates in athlete who underwent primary hip arthroscopy with labral reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: Data were reviewed for recreational, organized amateur, high school, collegiate, and professional athletes who underwent primary hip arthroscopy with labral reconstruction for FAIS and irreparable labral tears between July 2014 and May 2019. Inclusion criteria included preoperative and minimum 2-year postoperative PRO scores (modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score–Sports Specific Subscale, International Hip Outcome Tool [iHOT-12], and visual analog scale [VAS] for pain). Exclusion criteria were Tönnis grade >1, hip dysplasia (lateral center-edge angle, <18°), or prior ipsilateral hip surgery/conditions. Patients were divided into groups by sex and were propensity-matched in a 1:1 ratio by age, body mass index, graft type, labral tear size, and sports level. Results: A total of 101 hips were eligible, and 94 hips (93.1%) had a minimum 2-year follow-up. Twenty-nine female athlete hips were propensity-matched to 29 male athlete hips. Female athletes underwent higher rates of capsular repair (79.3% vs 24.1% for men; P < .001) and lower rates of acetabular microfracture (0.0% vs 20.7% for men; P = .024). Both female and male athletes experienced significant improvement on all PRO scores ( P < .001 for all), high RTS rates (women, 84% vs men, 80.8%), and high rates of achieving the minimal clinically important difference for the iHOT-12 and VAS pain (women, 88.5% vs men, 71.4% for both) and achieving the patient acceptable symptom state for the iHOT-12 (women, 88.5% vs men, 71.4%), with no significant difference between the sexes. Conclusion: Despite different clinical characteristics and surgical procedures, both female and male athletes undergoing primary hip arthroscopy with labral reconstruction had significant improvements in all PROs at the minimum 2-year follow-up, high RTS rates, and similar rates of achieving the minimal clinically important difference and patient acceptable symptom state.

“…10,18,19,24 For example, several case reports noted that without restoration of the native anatomy, the hip joint may translate during athletic activities, leading to recurrent microstability or even dislocation. 10,14,21,26 In addition, biomechanical evidence strongly supports the role of capsular repair in maintaining stability of the hip. 10,21,26,27 Further, capsular closure has also improved patient-reported outcomes.…”

Section: The Orthopaedic Journal Of Sports Medicinementioning

confidence: 92%

“… 10 , 18 , 19 , 24 A growing body of evidence seems to support repair, mainly in prevention of so-called microinstability, and both improved outcome and accelerated return to full activity have been demonstrated after adequate capsular repair. 11 , 14 , 21 , 26 – 28 , 38 , 41 Yet, ligaments are adaptive biological tissues. They cellularly respond and structurally adapt to their mechanical requirements.…”

mentioning

confidence: 99%

Handle With Care: The Anterior Hip Capsule Plays a Key Role in Daily Hip Performance

Duquesne

Pattyn

Vanderstraeten

et al. 2022

Background: Passive energy storage and return has long been recognized as one of the central mechanisms for minimizing the energy cost needed for terrestrial locomotion. Although the iliofemoral ligament (IFL) is the strongest ligament in the body, its potential role in energy-efficient walking remains unexplored. Purpose: To identify the contribution of the IFL to the amount of work performed by the hip muscles for normal, straight-level walking. Study Design: Controlled laboratory study. Methods: Straight-level walking of 50 healthy and injury-free adults was simulated using the AnyBody Modeling System. For each participant, the bone morphology and soft tissue properties were nonuniformly scaled. The superior and inferior parts of the IFL were represented by 2 springs each, and a linear force-strain relation was defined. A parameter study was conducted to account for the uncertainty surrounding the mechanical properties of the IFL. The work required from the gluteus, quadriceps, iliopsoas, and sartorius with and without inclusion of the IFL was calculated. Analysis of variance with subsequent post hoc paired t test was used to test the significance of IFL presence on the required mechanical work. Results: During walking, the strain in the IFL reached a median of 18.7% (95% CI, 8.0%-26.5%), with the largest values obtained at toe-off. With the IFL undamaged and fully operational, the effort required by the hip flexor muscles was reduced by a median of 54% (99% CI, 45%-62%) for the iliopsoas and by a median of 41% (99% CI, 27%-54%) for the sartorius muscles. The inclusion of the IFL did not significantly alter the work required by the gluteus and the quadriceps. Conclusion: The findings emphasized the key role the IFL plays in hip flexion by working synergistically with the hip musculature. Clinical Relevance: The importance of the contribution of the IFL to the hip flexors warrants careful handling and repair of these ligaments in cases of surgery and structural damage.