Impact of Capsulotomy on Hip Biomechanics during Arthroscopy

Lee, Hyeon Jun; Lim, Wonbong; Lee, Seung–Hyun; Jo, Sungmin; Jo, Suenghwan

doi:10.3390/medicina58101418

Cited by 6 publications

(4 citation statements)

References 29 publications

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“…Under fluoroscopic guidance, the anterolateral portal was first established using intra-articular fluid distention. 2,10,24 Next, under direct arthroscopic visualization, anterior and midanterior portals were established, followed by a Dienst portal (placed one-third the distance between the anterior superior iliac spine and the anterolateral portal). 10 A thorough diagnostic survey was performed to assess the extent of damage to the labrum, chondrolabral junction, and cartilage surfaces.…”

Section: Methodsmentioning

confidence: 99%

Outcomes of Hip Arthroscopy in the Setting of Concomitant Symptomatic Lumbosacral Spine Pathology: A Matched Control Study With Minimum 24-Month Follow-up

Torabian,

Cherian,

Dean

et al. 2023

Am J Sports Med

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Background: The overlapping biomechanical relationship between the lumbosacral spine and pelvis poses unique challenges to patients with concomitant pathologies limiting spinopelvic range of motion. Purpose: To assess the influence of concomitant, symptomatic lumbosacral spine pathology on patient-reported outcome measures (PROMs) after hip arthroscopy for the treatment of femoroacetabular impingement (FAI) and symptomatic labral tears. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective query of prospectively collected data identified patients aged ≥18 years with a minimum 24-month follow-up who underwent hip arthroscopy by a single surgeon for the treatment of symptomatic labral tears secondary to FAI. Patients were stratified into cohorts based on the presence (hip-spine [HS]) or absence (matched control [MC]) of symptomatic lumbosacral spine pathology. Inclusion within the HS cohort required confirmation of lower back pain/symptoms on preoperative surveys plus a diagnosis of lumbosacral spine pathology verified by radiology reports and correlating clinical documentation. Patients with previous spine surgery were excluded. PROMs were compared between groups, along with rates of achieving minimal clinically important difference (MCID) thresholds, Patient Acceptable Symptom State (PASS) thresholds, revision arthroscopy, and conversion to total hip arthroplasty (THA). Results: A total of 70 patients with lumbosacral pathology were coarsened exact matched to 87 control patients without spinal pathology. The HS cohort had preoperative baseline scores that were significantly worse for nearly all PROMs. Follow-ups at 3, 6, 12, and 24 months displayed similar trends, with the HS cohort demonstrating significantly worse scores for most collected outcomes. However, at every time point, HS and MC patients exhibited similar magnitudes of improvement across all PROM and pain metrics. Furthermore, while significantly fewer HS patients achieved PASS for nearly all PROMs at 12- and 24-month follow-ups, MCID thresholds were reached at similar or greater rates across all PROMs relative to the MC cohort. Finally, there were no significant differences in rates of revision or THA between cohorts at maximum available follow-up. Conclusion: After hip arthroscopy to address labral tears in the setting of FAI, patients with symptomatic lumbosacral pathologies and no history of spine surgery were found to exhibit inferior pre- and postoperative PROMs but achieved statistically similar clinical benefit and rates of PROM improvement through 24-month follow-up compared with the MC cohort with isolated hip disease. These findings aid in providing a realistic recovery timeline and evidence that coexisting hip and spine disorders are not a contraindication for arthroscopic hip preservation surgery.

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Section: Methodsmentioning

confidence: 99%

Outcomes of Hip Arthroscopy in the Setting of Concomitant Symptomatic Lumbosacral Spine Pathology: A Matched Control Study With Minimum 24-Month Follow-up

Torabian,

Cherian,

Dean

et al. 2023

Am J Sports Med

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“…Alternative approaches to the hip capsule include interportal and T-capsulotomies, with or without capsular closure 1,2,4,6,7,16 . Although the most frequently utilized, these approaches transect the iliofemoral ligament and thus may introduce capsuloligamentous instability 1,4-7,17 .…”

Section: Alternativesmentioning

confidence: 99%

“…Alternatives: Alternative approaches to the hip capsule interportal and T-capsulotomies, with or without capsular closure 1,2,4,6,7,16 . Although the most frequently utilized, these approaches transect the iliofemoral ligament and thus may introduce capsuloligamentous instability 1,[4][5][6][7]17 . Rationale: The puncture capsulotomy technique has the advantage of maintaining the integrity of the capsule through the placement of 4 small portals.…”

mentioning

confidence: 99%

Puncture Capsulotomy Technique During Hip Arthroscopy

Gillinov,

Siddiq,

Cherian

et al. 2024

JBJS Essential Surgical Techniques

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Background: A number of techniques have been described to enter the capsule and gain access to the hip joint during hip arthroscopy 1,2 . Among these, the interportal and T-capsulotomies are the most commonly utilized; however, these approaches transect the iliofemoral ligament, which normally resists anterior subluxation and stabilizes extension 3 . Thus, these approaches may introduce capsuloligamentous instability 1,4–7 and have been associated with complications such as dislocation, postoperative pain, microinstability, seroma, and heterotopic ossification 5,8–12 . Although prior literature has demonstrated durable mid-term results for patients undergoing capsulotomies with capsular closure 6,13 , avoidance of iatrogenic injury to the hip capsule altogether is preferable. Thus, the puncture capsulotomy technique we present is minimally invasive, preserves the biomechanics of the hip joint and capsule without disrupting the iliofemoral ligament, and allows for appropriate visualization of the joint through placement of multiple small portals. Description: Following induction of anesthesia and with the patient supine on a hip traction table, the nonoperative leg is positioned at 45° abduction with support of a well-padded perineal post, and the operative hip is placed into valgus against the post 14 . Intra-articular fluid distention with normal saline solution is utilized to achieve approximately 9 mm of inferior migration of the femoral head and decrease risk of iatrogenic nerve injury 15 . Then, under fluoroscopic guidance, an anterolateral portal is created 1 cm anterior and 1 cm superior to the greater trochanter at an approximately 15° to 20° angle. Second, via arthroscopic visualization, the anterior portal is created 1 cm distal and 1 cm lateral to the intersection of a vertical line drawn at the anterior superior iliac spine and a horizontal line at the level of the anterolateral portal. Third, equidistant between the anterior and anterolateral portals, the mid-anterior portal is created distally. Finally, at one-third of the distance between the anterior superior iliac spine and the anterolateral portal, the Dienst portal is created. Thus, these 4 portals form a quadrilateral arrangement through which puncture capsulotomy can be performed 5 . Alternatives: Alternative approaches to the hip capsule include interportal and T-capsulotomies, with or without capsular closure 1,2,4,6,7,16 . Although the most frequently utilized, these approaches transect the iliofemoral ligament and thus may introduce capsuloligamentous instability 1,4–7,17 . Rationale: The puncture capsulotomy technique has the advantage of maintaining the integrity of the capsule through the placement of 4 small portals. The technique does not transect the iliofemoral ligament and thus does not introduce capsuloligamentous instability. Furthermore, although good mid-term outcomes have been reported with capsular closure 6,13,18 , the present technique avoids creating unnecessary injury to the capsule and complications of an unrepaired capsule or, conversely, of plication. Expected Outcomes: Patients who underwent the puncture capsulotomy technique showed significant improvements in multiple functional outcome scores at a mean follow-up of 30.4 months, including the International Hip Outcome Tool (iHOT-33) (39.6 preoperatively to 76.1 postoperatively), Hip Outcome Score-Activities of Daily Living subscale (HOS-ADL) (70.0 to 89.3), HOS Sport-Specific Subscale (HOS-SSS) (41.8 to 75.7), and modified Harris hip score (mHHS) (60.1 to 84.9). At 2 years postoperatively with respect to iHOT-33, 81.0% of patients achieved the minimal clinically important difference, 62.0% achieved the patient acceptable symptom state, and 58.9% achieved substantial clinical benefit. In addition, mean visual analog scale pain scores improved significantly over the follow-up period (6.3 to 2.2; p < 0.001). Finally, there were zero occurrences of infection, osteonecrosis of the femoral head, dislocation or instability, or femoral neck fracture in patients treated with puncture capsulotomy 19,20 . Important Tips: Anterolateral portal placement should be performed using the intra-articular fluid distention technique with fluoroscopy to avoid risk of iatrogenic labral damage and distraction-induced neurapraxia. Subsequent portals must then be placed under direct arthroscopic visualization.On establishment of the anterolateral portal, the scope should be switched to the anterior portal to ensure that the anterolateral portal has not been placed through the labrum and to adjust its placement to better access pathology. This portal, as well as all others, may be subsequently modified by adjusting the angle of the cannula, without making a new skin incision.If a cam lesion is located more anteromedially or posterolaterally, an additional accessory portal may be made distal or proximal to the anterolateral portal, respectively, in order to enhance visualization.Intermittent traction is utilized throughout the surgery. No traction is utilized during preparing and draping, suture tensioning and tie-down, and femoroplasty, with minimal traction during acetabuloplasty; these precautions serve to prevent iatrogenic superficial peroneal nerve injury.There can be a steep learning curve for this technique. In particular, greater surgical experience is required to perform adequate femoral osteoplasty for large cam lesions with this approach 21 .Instrument maneuverability and visualization can be somewhat constrained with this approach.It is more difficult to perform certain procedures with this technique, including segmental and circumferential labral reconstructions, particularly with remote grafts 5 . Acronyms and Abbreviations: iHOT-33 = International Hip Outcome Tool-33HOS-ADL = Hip Outcome Score-Activities of Daily Living subscaleHOS-SSS = Hip Outcome Score—Sport-Specific SubscaleAP = anteroposteriorMRA = magnetic resonance arthrogramMRI = magnetic resonance imagingCT = computed tomographyASIS = anterior superior iliac spinemHHS = modified Harris hip score

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“…This is mostly due to he deep position of the hip joint, which is encompassed by thick muscles and articular capsule ligaments. 3 Most surgeons who perform hip arthroscopic surgery opt for interportal capsulotomy, 4 a procedure that entails creating a transverse incision in the anterior articular capsule of the hip joint. The iliofemoral ligament (ILF) and the anterior articular capsule of the hip joint, which affect the stifle, could be harmed by certain surgeons who employ a “T”-incision technique to manipulate the joint capsule for better visibility or even excising a portion of the articular capsule for better vision.…”

mentioning

confidence: 99%

Dual Cannula Combined With Modified Shoelace Continuous Capsular Closure Technique in Hip Arthroscopic Surgery

Yang,

Zeng,

Gao

et al. 2024

Arthroscopy Techniques

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Impact of Capsulotomy on Hip Biomechanics during Arthroscopy

Cited by 6 publications

References 29 publications

Outcomes of Hip Arthroscopy in the Setting of Concomitant Symptomatic Lumbosacral Spine Pathology: A Matched Control Study With Minimum 24-Month Follow-up

Outcomes of Hip Arthroscopy in the Setting of Concomitant Symptomatic Lumbosacral Spine Pathology: A Matched Control Study With Minimum 24-Month Follow-up

Puncture Capsulotomy Technique During Hip Arthroscopy

Dual Cannula Combined With Modified Shoelace Continuous Capsular Closure Technique in Hip Arthroscopic Surgery

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