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Editorial Commentary: Hip Capsule: To Repair or Not?
Editorial Commentary: Hip Capsule: To Repair or Not? Dean K. Matsuda, M.D.
Abstract: Arthroscopic hip capsular repair is an area of intense interest. Basic science studies suggest that adverse changes in capsular stability/restraint may occur with capsulotomy and capsulectomy, that repair may ameliorate these changes, and, most recently, that the repaired capsule usually heals. Clinical studies suggest that in some conditions, most notably mild dysplasia, capsular repair or plication may improve short-term outcomes, but in general, the role of capsular closure is less clear. At present, perhaps a selective approach is merited, with capsular closure performed in patients with dysplasia, focal or generalized hyperlaxity, and/or increased femoral anteversion. The comparative outcomes from smaller, more vertically oriented capsulotomies with less violation of the iliofemoral ligament deserve investigation.
See related article on page 108
W
hen invited to provide a commentary on this study, I hesitated as I am apparently in the minority of experienced hip arthroscopists; a recent study suggests that most arthroscopists (88.9%) repair the majority of capsules.1 I repair less than 50% of capsules and individualize which patients are closed on the basis of selective criteria; my commentary is influenced by this perspective. I congratulate Drs. Weber, Kuhn, Cvetanovich, Lewis, Mather, Salata, and Nho on their study, “Does the Hip Capsule Remain Closed After Hip Arthroscopy With Routine Capsular Closure for Femoroacetabular Impingement? A Magnetic Resonance Imaging Analysis in Symptomatic Postoperative Patients.”2 Their study shows that arthroscopic capsular repairs appear to heal in most cases. The study does not investigate if capsular closure is necessary or beneficial, nor does it address whether there is a time-dependent healing response in the setting of capsulotomies sans repair, particularly with small capsulotomies. Albeit rare, catastrophic hip instability can occur with major loss of capsular integrity,3 and recent basic science investigations suggest at least partial restoration of hip stability with capsular repair.4,5 Although clinical outcomes appear to be better when capsular repair is performed in patients with mild dysplasia,6 the same has not been established in general.7
Marina Del Rey, California, U.S.A. Ó 2016 by the Arthroscopy Association of North America 0749-8063/161043/$36.00 http://dx.doi.org/10.1016/j.arthro.2016.10.023
116
Disadvantages to capsular repair include additional surgical and anesthesia time with the potential for increased risk of infection (longer exposure time and more foreign body material albeit suture), fluid extravasation, iatrogenic femoral head chondral damage, and postoperative restricted range of motion. Newer instrumentation enhancing technical efficiency may decrease (but not eliminate) these risks but come with additional financial cost. Moreover, some surgeons may use additional hip bracing and/or more conservative rehabilitation protocols in the setting of capsular closure, which might delay return to work, with secondary economic impact. Furthermore, emerging evidence supports concurrent bilateral hip arthroscopy in select patients as a safe and effective alternative to staged procedures.8 Having performed concurrent hip arthroscopies for almost a decade for bilateral symptomatic hips with definable pathology in young patients who can tolerate early weight bearing,9 I fear that capsular closures with bilateral bracing and prolonged capsular protection may preclude this potentially attractive option. Do all hip capsulotomies need repair? Historically, the majority of hip arthroscopies were performed without capsular closure yet yielded significant clinical improvement.10 Rather than an all-or-none approach, I submit that perhaps we should be selective. But if so, which ones? I currently use dysplasia (classic dysplasia measured by lateral center-edge angle and acetabular index but perhaps also anterior dysplasia with decreased anterior margin ratio11 even with normal lateral center-edge angle), hyperlaxity (perhaps Brighton score >4), and/or increased femoral anteversion.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 33, No 1 (January), 2017: pp 116-117
117
EDITORIAL COMMENTARY
Indeed, titrated capsular plication is sometimes performed and my indications may evolve as dictated by future evidence from sufficiently powered quality studies. Perhaps we need to define postoperative tests (eg, shuck test or comparative passive hip external rotation) to determine if capsular repair (and possible postoperative bracing and modified rehabilitation) is necessary. Furthermore, we are seeing a decrease in the incidence of iliopsoas release (either complete or partial at the level of joint) (D.K.M. et al., MASH Study Group, unpublished data, 2016), suggesting a greater respect for anatomic preservation to minimize anterior instability. Capsulotomy facilitates arthroscopic visualization and instrument navigation. Because larger capsulotomies have historically been made to better visualize and resect cam deformities (the surgical technique used in the study included a T-capsulotomy), a brief discussion of femoroplasty via small capsulotomies seems warranted. I prefer a short, relatively vertical interportal capsulotomy (anterolateral to modified miadanterior portal12) with less violation of the iliofemoral ligament. After initial arthroscopic lateral femoroplasty in extension and internal rotation via this small capsular “window,” moderate hip flexion in neutral rotation raises the anterior capsular “roof” whereas anterolateral femoroplasty lowers the bony “floor,” expanding the “room” for visualization as anterior cam decompression proceeds medially. Occasionally, anterolateral femoroplasty is sufficient, but often arthroscopic dynamic testing reveals residual cam impingement of the anteromedial “critical corner,”13 which I then resect with progressive external rotation. When further visualization is required, I add undersurface (articular side) partial-thickness capsular resection with a radiofrequency device as needed to improve anteromedial visualization without enlarging the capsulotomy. Keys are small capsulotomy, less iliofemoral ligament compromise, and sequential hip positioning to bring the desired regions to the small capsular window for sufficient cam decompression. It is unknown if capsular closure of this small capsulotomy is necessary or beneficial, but until proven otherwise, I typically repair those with 1 or more aforementioned risk factors for potential postoperative instability. So should we repair the hip capsule or not? Although I may be in the minority (reserving the right and responsibility to change my mind with future evidence), my current answer is sometimes (in the setting
of small vertical oblique capsulotomy) and selectively (in conditions at risk for instability). This study indirectly supports capsular healing in the presence of repair and although it will not change my current practice, it gives me more confidence that those patients I do repair will likely have successful capsular healing.
References 1. Gupta A, Suarez-Ahedo C, Redmond JM, et al. Best practices during hip arthroscopy: Aggregate recommendations of high-volume surgeons. Arthroscopy 2015;31: 1722-1727. 2. Weber AE, Kuhns BD, Cvetanovich GL, et al. Does the hip capsule remain closed after hip arthroscopy with routine capsular closure for femoroacetabular impingement? A magnetic resonance imaging analysis in symptomatic postoperative patients. Arthroscopy 2017;33:108-115. 3. Matsuda DK. Acute iatrogenic dislocation following hip impingement arthroscopic surgery. Arthroscopy 2009;25: 400-404. 4. Abrams GD, Hart MA, Takami K, et al. Biomechanical evaluation of capsulotomy, capsulectomy, and capsular repair on hip rotation. Arthroscopy 2015;31:1511-1517. 5. Wuerz TH, Song SH, Grzybowski JS, et al. Capsulotomy size affects hip joint kinematic stability. Arthroscopy 2016;32:1571-1580. 6. Larson CM, Ross JR, Stone RM, et al. Arthroscopic management of dysplastic hip deformities: predictors of success and failures with comparison to an arthroscopic FAI cohort. Am J Sports Med 2016;44:447-453. 7. Domb BG, Stake CE, Finley ZJ, Chen T, Giordano BD. Influence of capsular repair versus unrepaired capsulotomy on 2-year clinical outcomes after arthroscopic hip preservation surgery. Arthroscopy 2015;31:643-650. 8. Degen RM, Nawabi DH, Fields KG, Wentzel CS, Kelly BT, Coleman SH. Simultaneous versus staged bilateral hip arthroscopy in the treatment of femoroacetabular impingement. Arthroscopy 2016;32:1300-1307. 9. Jayasekera N, Aprato A, Villar RN. Are crutches required after hip arthroscopy? A case-control study. Hip Int 2013;23:269-273. 10. Byrd JW, Jones KS. Arthroscopic management of femoroacetabular impingement: Minimum 2-year follow-up. Arthroscopy 2011;27:1379-1388. 11. Gross CE, Salata MJ, Manno K, et al. New radiographic parameters to describe anterior acetabular rim trimming during hip arthroscopy. Arthroscopy 2012;28:1404-1409. 12. Matsuda DK, Villamor A. The modified mid-anterior portal for hip arthroscopy. Arthrosc Tech 2014;3: e469-e474. 13. Matsuda DK, Schnieder CP, Sehgal B. The critical corner of cam femoroacetabular impingement: clinical support of an emerging concept. Arthroscopy 2014;30:575-580.
Abstract: Arthroscopic hip capsular repair is an area of intense interest. Basic science studies suggest that adverse changes in capsular stability/restraint may occur with capsulotomy and capsulectomy, that repair may ameliorate these changes, and, most recently, that the repaired capsule usually heals. Clinical studies suggest that in some conditions, most notably mild dysplasia, capsular repair or plication may improve short-term outcomes, but in general, the role of capsular closure is less clear. At present, perhaps a selective approach is merited, with capsular closure performed in patients with dysplasia, focal or generalized hyperlaxity, and/or increased femoral anteversion. The comparative outcomes from smaller, more vertically oriented capsulotomies with less violation of the iliofemoral ligament deserve investigation.
See related article on page 108
W
hen invited to provide a commentary on this study, I hesitated as I am apparently in the minority of experienced hip arthroscopists; a recent study suggests that most arthroscopists (88.9%) repair the majority of capsules.1 I repair less than 50% of capsules and individualize which patients are closed on the basis of selective criteria; my commentary is influenced by this perspective. I congratulate Drs. Weber, Kuhn, Cvetanovich, Lewis, Mather, Salata, and Nho on their study, “Does the Hip Capsule Remain Closed After Hip Arthroscopy With Routine Capsular Closure for Femoroacetabular Impingement? A Magnetic Resonance Imaging Analysis in Symptomatic Postoperative Patients.”2 Their study shows that arthroscopic capsular repairs appear to heal in most cases. The study does not investigate if capsular closure is necessary or beneficial, nor does it address whether there is a time-dependent healing response in the setting of capsulotomies sans repair, particularly with small capsulotomies. Albeit rare, catastrophic hip instability can occur with major loss of capsular integrity,3 and recent basic science investigations suggest at least partial restoration of hip stability with capsular repair.4,5 Although clinical outcomes appear to be better when capsular repair is performed in patients with mild dysplasia,6 the same has not been established in general.7
Marina Del Rey, California, U.S.A. Ó 2016 by the Arthroscopy Association of North America 0749-8063/161043/$36.00 http://dx.doi.org/10.1016/j.arthro.2016.10.023
116
Disadvantages to capsular repair include additional surgical and anesthesia time with the potential for increased risk of infection (longer exposure time and more foreign body material albeit suture), fluid extravasation, iatrogenic femoral head chondral damage, and postoperative restricted range of motion. Newer instrumentation enhancing technical efficiency may decrease (but not eliminate) these risks but come with additional financial cost. Moreover, some surgeons may use additional hip bracing and/or more conservative rehabilitation protocols in the setting of capsular closure, which might delay return to work, with secondary economic impact. Furthermore, emerging evidence supports concurrent bilateral hip arthroscopy in select patients as a safe and effective alternative to staged procedures.8 Having performed concurrent hip arthroscopies for almost a decade for bilateral symptomatic hips with definable pathology in young patients who can tolerate early weight bearing,9 I fear that capsular closures with bilateral bracing and prolonged capsular protection may preclude this potentially attractive option. Do all hip capsulotomies need repair? Historically, the majority of hip arthroscopies were performed without capsular closure yet yielded significant clinical improvement.10 Rather than an all-or-none approach, I submit that perhaps we should be selective. But if so, which ones? I currently use dysplasia (classic dysplasia measured by lateral center-edge angle and acetabular index but perhaps also anterior dysplasia with decreased anterior margin ratio11 even with normal lateral center-edge angle), hyperlaxity (perhaps Brighton score >4), and/or increased femoral anteversion.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 33, No 1 (January), 2017: pp 116-117
117
EDITORIAL COMMENTARY
Indeed, titrated capsular plication is sometimes performed and my indications may evolve as dictated by future evidence from sufficiently powered quality studies. Perhaps we need to define postoperative tests (eg, shuck test or comparative passive hip external rotation) to determine if capsular repair (and possible postoperative bracing and modified rehabilitation) is necessary. Furthermore, we are seeing a decrease in the incidence of iliopsoas release (either complete or partial at the level of joint) (D.K.M. et al., MASH Study Group, unpublished data, 2016), suggesting a greater respect for anatomic preservation to minimize anterior instability. Capsulotomy facilitates arthroscopic visualization and instrument navigation. Because larger capsulotomies have historically been made to better visualize and resect cam deformities (the surgical technique used in the study included a T-capsulotomy), a brief discussion of femoroplasty via small capsulotomies seems warranted. I prefer a short, relatively vertical interportal capsulotomy (anterolateral to modified miadanterior portal12) with less violation of the iliofemoral ligament. After initial arthroscopic lateral femoroplasty in extension and internal rotation via this small capsular “window,” moderate hip flexion in neutral rotation raises the anterior capsular “roof” whereas anterolateral femoroplasty lowers the bony “floor,” expanding the “room” for visualization as anterior cam decompression proceeds medially. Occasionally, anterolateral femoroplasty is sufficient, but often arthroscopic dynamic testing reveals residual cam impingement of the anteromedial “critical corner,”13 which I then resect with progressive external rotation. When further visualization is required, I add undersurface (articular side) partial-thickness capsular resection with a radiofrequency device as needed to improve anteromedial visualization without enlarging the capsulotomy. Keys are small capsulotomy, less iliofemoral ligament compromise, and sequential hip positioning to bring the desired regions to the small capsular window for sufficient cam decompression. It is unknown if capsular closure of this small capsulotomy is necessary or beneficial, but until proven otherwise, I typically repair those with 1 or more aforementioned risk factors for potential postoperative instability. So should we repair the hip capsule or not? Although I may be in the minority (reserving the right and responsibility to change my mind with future evidence), my current answer is sometimes (in the setting
of small vertical oblique capsulotomy) and selectively (in conditions at risk for instability). This study indirectly supports capsular healing in the presence of repair and although it will not change my current practice, it gives me more confidence that those patients I do repair will likely have successful capsular healing.
References 1. Gupta A, Suarez-Ahedo C, Redmond JM, et al. Best practices during hip arthroscopy: Aggregate recommendations of high-volume surgeons. Arthroscopy 2015;31: 1722-1727. 2. Weber AE, Kuhns BD, Cvetanovich GL, et al. Does the hip capsule remain closed after hip arthroscopy with routine capsular closure for femoroacetabular impingement? A magnetic resonance imaging analysis in symptomatic postoperative patients. Arthroscopy 2017;33:108-115. 3. Matsuda DK. Acute iatrogenic dislocation following hip impingement arthroscopic surgery. Arthroscopy 2009;25: 400-404. 4. Abrams GD, Hart MA, Takami K, et al. Biomechanical evaluation of capsulotomy, capsulectomy, and capsular repair on hip rotation. Arthroscopy 2015;31:1511-1517. 5. Wuerz TH, Song SH, Grzybowski JS, et al. Capsulotomy size affects hip joint kinematic stability. Arthroscopy 2016;32:1571-1580. 6. Larson CM, Ross JR, Stone RM, et al. Arthroscopic management of dysplastic hip deformities: predictors of success and failures with comparison to an arthroscopic FAI cohort. Am J Sports Med 2016;44:447-453. 7. Domb BG, Stake CE, Finley ZJ, Chen T, Giordano BD. Influence of capsular repair versus unrepaired capsulotomy on 2-year clinical outcomes after arthroscopic hip preservation surgery. Arthroscopy 2015;31:643-650. 8. Degen RM, Nawabi DH, Fields KG, Wentzel CS, Kelly BT, Coleman SH. Simultaneous versus staged bilateral hip arthroscopy in the treatment of femoroacetabular impingement. Arthroscopy 2016;32:1300-1307. 9. Jayasekera N, Aprato A, Villar RN. Are crutches required after hip arthroscopy? A case-control study. Hip Int 2013;23:269-273. 10. Byrd JW, Jones KS. Arthroscopic management of femoroacetabular impingement: Minimum 2-year follow-up. Arthroscopy 2011;27:1379-1388. 11. Gross CE, Salata MJ, Manno K, et al. New radiographic parameters to describe anterior acetabular rim trimming during hip arthroscopy. Arthroscopy 2012;28:1404-1409. 12. Matsuda DK, Villamor A. The modified mid-anterior portal for hip arthroscopy. Arthrosc Tech 2014;3: e469-e474. 13. Matsuda DK, Schnieder CP, Sehgal B. The critical corner of cam femoroacetabular impingement: clinical support of an emerging concept. Arthroscopy 2014;30:575-580.