Prospective Randomized Comparison of Capsular Management Techniques During Hip Arthroscopy

Abstract

Background: Capsular management during hip arthroscopy remains controversial. Studies evaluating this topic consist mostly of retrospective comparative reviews of prospectively gathered data on a large series of patients. Purpose/Hypothesis: The purpose was to perform a prospective randomized trial to comparatively assess 3 commonly performed capsular management techniques. It was hypothesized that capsular closure during hip arthroscopy would result in superior outcomes when compared with unclosed capsulotomy management techniques. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: Patients (N = 150) who had hip arthroscopy with labral repairs and femoral osteoplasties performed by the senior author were randomly assigned into 3 groups at the time of their surgery: T-capsulotomy without closure (TC), interportal capsulotomy without closure (IC), and interportal capsulotomy with closure (CC). All patients underwent labral repair and femoral osteoplasty. Patient-reported outcomes were obtained preoperatively and at 3, 6, 12, and 24 months postoperatively. Other outcomes obtained included the need for future hip surgery. Results: Patient demographics, preoperative patient-reported outcomes, and radiographic measurements were similar among all 3 groups. Revision hip arthroscopy was performed in 5 TC cases, 2 IC cases, and 1 CC case ( P = .17). Conversion to hip arthroplasty occurred in 4 patients in the TC group and none in the IC and CC groups ( P = .02). The CC group showed higher modified Harris Hip Score (mHHS) and Hip Outcome Score–Activities of Daily Living (HOS-ADL) at the 2-year follow-up when compared with the IC group ( P = .003 and P < .001, respectively). When compared with the TC group, the CC group demonstrated superior mHHS (86.2 vs 76), HOS-ADL (85.6 vs 76.8), and HOS-SSS (Hip Outcome Score–Sports-Specific Subscale; 74.4 vs 65.3) at the final 2-year follow-up ( P < .001). At the 2-year follow-up, the IC group had a higher mHHS (81.7 vs 76), HOS-ADL (82 vs 76.8), and HOS-SSS (71.4 vs 65.3; P > .001) as compared with the TC group. Conclusion: Patients undergoing complete capsular closure during hip arthroscopy showed improved patient-reported and surgical outcomes when compared with those with unrepaired T-capsulotomy or interportal capsulotomy. These results suggest that repair after capsulotomy may be a favorable arthroscopic capsular management technique.

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

“…Filan and Carton 11 found that 89.3% of patients who underwent capsular repair achieved the MCID for the mHHS, while 87.1% who had an unrepaired capsulotomy achieved the MCID for the mHHS, although this difference failed to reach statistical significance. Other comparative studies 10 have observed the trend toward increased yet nonsignificant rates of MCID achievement on the mHHS for patients with versus without capsular closure, while studies that have compared capsular management have reported significantly improved mHHS at latest follow-up when assessing raw scores but not MCID achievement. 8 , 31 Indeed, a recent meta-analysis of 10 studies with an evidence level of 4 or greater reported an improvement in the mHHS with capsular repair compared with nonrepair (mean difference, 4.01; P = .03), though it did not assess the MCID.…”

“…Five studies 5 , 9 – 11 , 15 reported MCID achievement rates for the mHHS. For patients who underwent capsular closure, MCID achievement rates were in the range of 71% to 100%.…”

Top Ten Pearls for Successful Hip Arthroscopy for Femoroacetabular Impingement

“…26 Regardless of the approach, capsulotomy closure has been shown to be beneficial following access to either compartment. 21,27,28 The management of labral tears in FAI is also debated.…”

“…In this Technical Note, we have described our preferred method for arthroscopic treatment of FAI, detailing a straightforward checklist of technical pearls that may be used to minimize complications and optimize patient outcomes. [17][18][19] Under-resection of cam lesions may lead to the need for revision hip arthroscopy 11,20 Failure to completely close the capsule may result in microinstability and worse clinical outcomes 21 DALA, distal anterolateral accessory; mMAP, modified mid-anterior portal.…”

Editorial Commentary: Finally, a Salvage Procedure for Hip Capsular Insufficiency!

“…This can eventually lead to iatrogenic hip instability and poor outcomes when excess capsular tissue is lost or unrepaired. Economopoulos et al, 3 in their prospective randomized study on capsulotomy versus capsular repair, showed that patients who underwent repair of the capsule achieved better surgical outcomes than those who had unrepaired interportal capsulotomies and T-capsulotomies. This finding further highlights the importance of careful and meticulous management of the capsular tissue.…”