Routine Capsular Closure With Hip Arthroscopic Surgery Results in Superior Outcomes: A Systematic Review and Meta-analysis

Abstract

Background: In hip arthroscopic surgery, capsulotomy is performed to improve visualization and allow instrumentation of the joint. Traditionally, the defect has been left unrepaired; however, increasing evidence suggests that this may contribute to persistent pain and iatrogenic capsular instability. Nevertheless, the clinical benefit of performing routine capsular repair remains controversial. Purpose/Hypothesis: We conducted a systematic review and meta-analysis to investigate the effects of routine capsular closure on patient-reported outcomes (PROs), hypothesizing that superior PROs would be observed with routine capsular closure. Study Design: Meta-analysis and systematic review; Level of evidence, 4. Methods: A systematic review and meta-analysis was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The terms “hip,”“arthroscopy,”“capsule,”“capsular,”“repair,” and “closure” were used to query Ovid MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), CINAHL (Cumulative Index to Nursing and Allied Health Literature), SPORTDiscus, and PubMed. Articles with PROs stratified by capsular management were included. Multivariate mixed-effects metaregression models were implemented with study-level random-effects and fixed-effects moderators for capsular closure versus no repair and after controlling for surgical indication and preoperative PROs. The effect of repair on both the postoperative score and the change in scores was evaluated via the Harris Hip Score (HHS)/modified HHS (mHHS), Hip Outcome Score (HOS)–Activities of Daily Living (ADL), and HOS–Sport Specific Subscale (SSS), with a supplemental analysis of additional outcomes. Results: Of 432 initial articles, 36 were eligible for analysis, with results for 5132 hip arthroscopic procedures. The capsule was repaired in 3427 arthroscopic procedures and unrepaired in 1705. Capsular repair was associated with significantly higher postoperative HHS/mHHS (2.011; SE, 0.743 [95% CI, 0.554-3.467]; P = .007), HOS-ADL (3.635; SE, 0.873 [95% CI, 1.923-5.346]; P < .001), and HOS-SSS (4.137; SE, 1.205 [95% CI, 1.775-6.499]; P < .001) scores as well as significantly superior improvement on the HHS/mHHS (2.571; SE, 0.878 [95% CI, 0.849-4.292]; P = .003), HOS-ADL (3.315; SE, 1.131 [95% CI, 1.099-5.531]; P = .003), and HOS-SSS (3.605; SE, 1.689 [95% CI, 0.295-6.915]; P = .033). Conclusion: This meta-analysis is the largest to date evaluating the effect of capsular closure on PROs and demonstrates significantly higher mean postoperative scores and significantly superior improvement with repair, while controlling for the effects of preoperative score and surgical indication. The true magnitude of the benefit of capsular repair may be clarified by large prospective randomized studies using PRO measures specifically targeted and validated for hip arthroscopic surgery/preservation.

Editorial Commentary: Differences in Femoral Torsion Measurements Based on Axial Versus Axial–Oblique Magnetic Resonance Imaging Sequences—Let’s Begin to Standardize Hip-Preservation Techniques to Improve Research and Clinical Outcomes

“…The field of hip-preservation surgery is rapidly evolving. In recent years, we've learned more about the effects of femoroacetabular impingement (FAI) and adult hip dysplasia on future osteoarthritis 1 ; the importance of hip capsular management in patients undergoing hip arthroscopy 2,3 ; the suction seal of the acetabular labrum and the significance of labral repair/ reconstruction versus debridement 4,5 ; and even various patient positioning techniques during hip arthroscopy and the risks of perineal nerve and soft-tissue complications. [6][7][8] As more and more research is published within this specialized field, we must begin to standardize our research and clinical techniques such that outcomes may be appropriately compared across studies.…”

Editorial Commentary: Successful Revision Hip Arthroscopy Requires Accurate Diagnosis of the Cause of Failure: “One-Size-Fits-All Surgery Is Not Appropriate”

“…It could mean capsular laxity or deficiency from a previous unclosed capsulotomy. 3,4 It could be subtle alterations of acetabular and femoral version that resulted in previously undiagnosed causes for impingement or effective dysplasia. 5 The more effort we put into identifying the specific cause of patient symptoms, the better…”

Hip Capsular Reconstruction With Indirect Head of the Rectus Femoris Tendon

“…While historically the capsule had been left unrepaired following hip arthroscopy, there has been a paradigm shift to a growing tendency favoring complete capsular repair, as the biomechanical role of the capsule and the clinical benefit of repair are increasingly highlighted in recent literature. 9 , 10 , 11 , 12 , 13 Although frank hip dislocation is uncommon, patients with capsular insufficiency will experience microinstability of the hip, which often causes hip pain and subjective instability. 6 , 14 This pattern of increased micromotion leads to degeneration of the articular cartilage and labrum, ultimately resulting in hip osteoarthritis.…”

“… 7 In addition, current literature shows that those undergoing complete repair of T-capsulotomy have demonstrated significantly improved patient-reported outcomes over those who underwent only partial repair. 10 , 11 Furthermore, recent evidence demonstrates that patients who underwent capsular closure after hip arthroscopy for FAI had a greater probability of achieving clinically significant improvement in hip-specific function than those who underwent capsulotomy without repair. 15 , 16 …”