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Femoroacetabular impingement treatment using the arthroscopic extracapsular outside-in approach: Does capsular suture affect functional outcome?
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Original article
Femoroacetabular impingement treatment using the arthroscopic extracapsular outside-in approach: Does capsular suture affect functional outcome? Mathieu Thaunat ∗ , Saliou Sarr , Thanos Georgeokostas , Abdul Azeem , Colin G Murphy , Samih Kacem , Gilles Clowez , Timothy Roberts Groupe Ramsay Santé, FIFA Medical Center of Excellence, Centre Orthopédique Santy, 24, avenue Paul-Santy, 69008 Lyon, France
a r t i c l e
i n f o
Article history: Received 29 April 2019 Accepted 15 November 2019 Available online xxx Keywords: Femoroacetabular impingement Extracapsular approach Outside-in capsulotomy
a b s t r a c t Background: Over the last decades, the arthroscopic treatment of hip pathology has highly grown thanks to the evolution of surgical techniques and instrumentation development. An alternative approach consisting in making a first outside-in longitudinal capsulotomy was described by Laude at the end of the 2000s and is experiencing significant development in France. The clinical results of this technique have rarely been reported and in particular the influence of the repair of the capsule is unknown. Therefore we performed a retrospective case control study aiming to asses: (1) the clinical outcomes and complication rates of the outside-in extracapsular approach for the treatment of FemoroAcetabular Impingement (FAI) and (2) the effect of capsular closure on the functional outcome. Hypothesis: We hypothesize that the outside-in extracapsular approach is a safe and efficient technique and the capsular closure at the end of the procedure positively affects the functional outcome. Methods: A retrospective study was conducted on prospectively collected data of a consecutive series of hip arthroscopies performed for surgical treatment of FAI using the outside-in extracapsular approach. Any complications during follow-up were identified and recorded. Linear regression models were used to estimate the influence of capsular closure on the functional outcome. Functional outcome was assessed using modified Harris Hip Score (mHHS) and Non-arthritic Hip Score (NAHS). Results: Sixty-four hips in 57 patients operated by a single surgeon between October 2013 and December 2016 were analyzed at the time of final follow-up of 34.17 months (range 24 to 53). As the surgical technique evolved over time, a side-to-side capsular closure was performed at the end of the procedure for 25 hips and the capsule was left open for the remaining 39 patients. Functional outcome measurements showed an improvement from the preoperative to the last follow-up: 63.5 ± 11.0 to 88.1 ± 11.2 for mHHS, 63.1 ± 13.8 to 86.4 ± 13.4 for NAHS. Capsular closure leads to a significantly improved clinical outcome: gain in mHHS: 25.8 ± 2.3 vs. 20.6 ± 1.9 (p ≤ 0.044), gain in NAHS: 26.1 ± 2.5 vs. 19.6 ± 2.1, (p = 0.023). No major complications occurred. One case of postoperative tensor fascia latae atrophy was documented in the group “capsule left open”. Conclusion: Hip arthroscopy in the management of FAI with an extraarticular starting point (outside-in) is a safe technique with functional results and postoperative morbidity comparable to previously reported techniques. Side-to-side capsular closure at the end of the procedure might positively affect the final functional outcome. Levels of evidence: III, case control retrospective study. © 2020 Elsevier Masson SAS. All rights reserved.
1. Introduction Over the last decades, the arthroscopic treatment of hip pathology has highly grown thanks to the evolution of surgical
∗ Corresponding author. E-mail address: [email protected] (M. Thaunat).
and diagnostic techniques and instrumentation development. Hip arthroscopy has recently gained significant importance in the surgical treatment of femoroacetabular impingement. Two different approaches have been described initially in the literature; one involving a central starting point, another with a peripheralcompartment starting point. In these standard approaches, a limited interportal capsulotomy is done in an inside-out fashion as required [1–3]. Laude described a novel approach for hip
https://doi.org/10.1016/j.otsr.2019.11.023 1877-0568/© 2020 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Thaunat M, et al. Femoroacetabular impingement treatment using the arthroscopic extracapsular outside-in approach: Does capsular suture affect functional outcome? Orthop Traumatol Surg Res (2020), https://doi.org/10.1016/j.otsr.2019.11.023
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arthroscopy which consists of an extra-articular starting point with an initial outside-in capsulotomy similar to a mini open anterior Hueter approach but under endoscopic visualization [4]. This technique which requires an endoscopic extracapsular sequence in order to adequately visualize the hip capsule before performing a minimally invasive capsulotomy has subsequently been proposed in order to reduce the risk of iatrogenic instability after hip arthroscopy [5]. However, we routinely use this technique as we believe it helps to gain quick and safe access into the joint. It also allows for minimal traction time and less forces while achieving an appropriate distraction [4,6]. Moreover, apart from the acetabulum, the acetabular labrum and the hip capsule contribute significantly to hip joint stability [7,8]. Capsular suturing after hip arthroscopy has been suggested to prevent hip joint instability and decrease revision rate [9,10]. Currently, there is very limited data in the literature regarding outcomes and the complication rates of outside-in approach [6]. At this time, it remains unclear whether capsular suturing should be performed as a routine procedure in hip arthroscopy, especially in cases without additional risk factors for instability such as hypermobility or hip dysplasia [11,12]. Therefore we performed a retrospective case control study aiming to assess: • the clinical outcomes and complication rates of the outside-in extracapsular approach for the treatment of FemoroAcetabular Impingement (FAI); • the effect of capsular closure on the functional outcome. We hypothesize that the outside-in extracapsular approach is a safe and efficient technique and the capsular closure at the end of the procedure positively affects the functional outcome. 2. Material and methods 2.1. Patients A retrospective analysis of prospectively collected data was performed of patients who underwent hip arthroscopy for femoroacetabular impingement between October 1, 2013, and December 30, 2016, by one senior surgeon (M.T.). Inclusion criteria were: adult men or women aged from 15 to 50 years, hip pain for greater than 6 months without relief from non-operative means (physiotherapy, non-steroidal anti-inflammatory medication, rest), documentation of failed physiotherapy, including core conditioning of the hip, back, and abdomen, Cam or Mixed Type FAI as diagnosed on x-rays and magnetic resonance imaging (MRI) or magnetic resonance arthrogram (MRA) or CT arthrogram (CTA) and a minimum of 2 years follow-up from index surgery. Exclusion criteria were: evidence of hip dysplasia (centre edge angle less than 20◦ ), coxa profunda (centre edge angle more than 40◦ ), presence of advanced hip osteoarthritis (Tönnis Grade 2 or 3), presence of other hip syndromes (concurrent non-FAI related pathology), previous trauma to the affected hip, previous surgery on the affected hip and severe acetabular deformities. 2.2. Methods Under general anesthesia, the patient was placed in a supine position on an orthopaedic traction table with the hip slightly flexed, abducted and internally rotated, using a well-padded perineal post to avoid any neuropraxia of the pudendal nerve and to reduce pressure ulcers. The instrumentation comprised of a conventional 70◦ scope, a pump which can control inflow and outflow to maintain a constant pressure (set at 50 mmHg), a 4.0 mm VAPR,
90◦ Electrode (Depuy Mitek, Raynham, MA, USA) and a 3.5 mm hook electrode (Depuy Mitek, Raynham, MA, USA). The arthroscope was introduced in a portal located 2 cm anterior and distal to the superior tip of the greater trochanter. A second anterior portal for the instruments was created medial to the tensor fascia lata and is located at least 4 to 5 cm anterior to the optical portal and 1 cm distal. We take careful attention to not over take the line drawn between the antero-superior iliac spine and the superolateral patella corner. A blunt dissection of the subcutaneous and muscular tissues with the electrocoagulation probe allows exposing the anterior surface of the femoral neck which is the only area of the capsule where there is no muscle insertion (Fig. 1). At this point precapsular fatty tissue was seen, which could be easily debrided with the VAPR electrode (Depuy Mitek, Raynham, MA, USA) to visualize the white fibers of the capsule. After debriding the precapsular fatty tissue, a longitudinal capsulotomy was performed with the hook electrode (Fig. 1). Proximally, a simple debulking of the capsule perpendicular to direction of the initial capsulotomy was completed by a shaver to avoid iatrogenic labral injuries. If required, a T-shaped capsulotomy was performed to obtain better access to the joint. Labral injuries, if present, were either resected by a 4.5 mm shaver (Stryker, Kalamazoo, MI, USA) when hypotrophic or when the lesion is unrepairable, left alone in the absence of lesion and in the absence of indication for acetabuloplasty or sutured with non resorbable Ethibond No 2 secured with a 2.9 mm pushlock (Arthrex, Naples, FL, USA) if repairable or when an acetabuloplasty was required. Pincer deformities of the acetabulum were resected by a motorized burr (Stryker, Kalamazoo, MI, USA) when needed. Microfractures with a chondropick were created if associated chondral injuries were present. Traction was then released. The lower limb was placed in flexion and alternative internal and external rotation was performed in order to resect the Cam deformities using a 5 mm motorized burr and under fluoroscopic control. After the intra-articular procedure was completed, the capsule was either left open or closed with 2 side-to-side sutures in the vertical arm of the capsulotomy using a Scorpion suture passer (Arthrex, Naples, FL, USA) with a resorbable Polysorb No 2 suture. The decision to suture the capsule was based on the senior surgeon’s evolving indications. This is due to the confidence built on an increasing duration of follow-up with excellent clinical outcomes of patients who underwent capsular closure and because of the recommendation found in literature following the first series of capsular repair in FAI treatment [13,14] (Fig. 1). Fluoroscopy was used in order to control the amount of cam resection intra-operatively. Postoperatively, all patients were mobilized with partial weight-bearing protected with two crutches for four weeks and were advised to avoid extremes of hip movement for the first 6 weeks after surgery. All patients had a heterotopic ossification prophylactic treatment consisting of 100 mg dose of ketoprofen 2 times a day prescribed for 3 weeks.
2.3. Methods of assessment Data were collected at a preoperative clinic visit, 1 year postoperatively, and at the last follow-up, via phone call. The hip status, labral and chondral treatment, the use of microfractures as well as traction time were recorded. Any complications during early, intermediate or long-term follow-up were identified and recorded. The difference in the functional outcome scores from the preoperative period to those at the time of last follow-up was analyzed. Two patient-reported outcome (PROs) scores were used to evaluate hip arthroscopy, specifically modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS) [15]. The ␣-angle (Dunn’s lateral view) was measured on plain radiographs using a digital picture archiving and communication system (PACS) [16], and the
Please cite this article in press as: Thaunat M, et al. Femoroacetabular impingement treatment using the arthroscopic extracapsular outside-in approach: Does capsular suture affect functional outcome? Orthop Traumatol Surg Res (2020), https://doi.org/10.1016/j.otsr.2019.11.023
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Fig. 1. Outside-in capsulotomy technique. A. The anterior surface of the femoral neck, underneath the tensor fascia lata (TFL), is the only area of the capsule where there is no muscle insertion. Instead, a precapsular fatty tissue is seen, which can be easily debrided to show the white fibers of the capsule between the gluteus minimus muscle (GM) and the iliocapsularis muscle (ICM). B. The capsular incision is performed along the neck of the femur and, only if necessary, (C) is extended over the labrum and then along the acetabular rim so as to expose the area from the base of the femoral neck to the supra-acetabular ilium. This extension is performed with a shaver, consisting of a simple debulking of the capsule rather than an extensive T-shape capsulotomy. D. Capsular suture is performed with resorbable No 2 suture in a side-to-side fashion. E and F. Usually, two sutures are necessary in order to obtain a complete closure of the capsulotomy.
difference between the preoperative and postoperative ␣-angle was measured. 2.4. Statistical analysis All calculations were made with SAS for Windows (v 9.4; SAS Institute Inc), with the level of statistical significance set at p < 0.05. Descriptive data analysis was conducted depending on the nature of the considered criteria: number of observed (and missing, if any) values, mean and standard-deviation, median, first and third quartiles, minimum and maximum for quantitative data; number of observed (and missing, if any) values, number and percentage of patients per class, for qualitative data. The Wilcoxon rank-sum test, for quantitative variables, and the Chi2 or the Fisher exact test, for qualitative variables, were carried out to compare the demographics and surgery characteristics between the 2 types of procedure
studied (capsular suture or capsule left open). The Harris score and NAHS variations from baseline were each analyzed considering a linear model adjusted for the baseline value, the type of capsular procedure (suture or left open), labral procedure (suture or debridement), the Tönnis score, as well as the patient’s class of age and gender. 3. Results Continuous series of 70 hips with the same surgical procedure were eligible for evaluation (Fig. 2). Six hips (6 patients) could not be reached by phone at last follow-up (mean follow-up: 36.3 months, range 26–48) and were lost to follow-up (after a minimal one year of follow-up without complication) and excluded from the study (2 in the capsular suture group and 4 in the group without capsular suture). As shown in Table 1, a total of 64 hips (57 patients including
Please cite this article in press as: Thaunat M, et al. Femoroacetabular impingement treatment using the arthroscopic extracapsular outside-in approach: Does capsular suture affect functional outcome? Orthop Traumatol Surg Res (2020), https://doi.org/10.1016/j.otsr.2019.11.023
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Fig. 2. Flowchart.
Table 1 Surgical characteristics of the study cohort. pa
Variable
Total (%)
Without capsular closure
With capsular closure
Hips Sex Female Male Mean age of patients (±SD) Labrum Debridement Left alone Suture Microfractures No Yes Tönnis arthrosis Scale [17] Grade 0 Grade 1 Type of femoro – acetabular Impingement Cam Mixed
64
39
25
13 (20.3%) 51 (79.7%) 28.7 ± 7.5 (range 15–45)
9 (23.1%) 30 (76.9%) 28.8 ± 7.2 (range 15–44)
4 (16.0%) 21 (84.0%) 28.5 ± 8.2 (range 16–45)
0.4924
40 (62.5%) 1 (1.6%) 23 (35.9%)
29 (74.4%)
0.0218
10 (25.6%)
11 (44.0%) 1 (4.0%) 13 (52.0%)
56 (87.5%) 8 (12.5%)
32 (82.1%) 7 (17.9%)
24 (96.0%) 1 (4.0%)
0.1349
16 (25.0%) 48 (75.0%)
10 (25.6%) 29 (74.4%)
6 (24.0%) 19 (76.0%)
0.8824
14 (21.9%) 50 (78.1%)
6 (15.4%) 33 (86.6%)
8 (32.0%) 17 (68.0%)
0.2431
a
0.7565
Bold characters indicate significant differences.
45 males and 12 females) were included in the study. Complete radiological analysis was possible for only 32 hips. Seven patients had bilateral procedures. The average age at the time of surgery was 28.7 ± 7.7 years (range, 15–45 years). The average traction time was found to be 19.79 ± 7.11 minutes (range 8–40). Demographic and surgical characteristics of the population studied are summarized in Table 1. Functional outcomes measurements at the time of final followup of 34.17 months (range, 24 to 53) showed a significant
improvement from the initial preoperative scores for the mHHS and the NAHS. All PROs showed a statistically significant improvement at the final follow-up compared with preoperative levels: 63.5 ± 11.0 (range, 29 to 92) to 88.1 ± 11.2 (range, 58 to 100). Radiographically, the femoral ␣-angle decreased from 70.9◦ ± 7.1 (range, 60 to 80) preoperatively to 47.2◦ ± 6.5 (range, 35 to 60) postoperatively. After adjustment for the use of sutures, age, sex, labral procedure (suture [S] or debridement [D]) and Tönnis Scale,
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Table 2 Variation of modified Harris Hip Score (mHHS) [15] – linear model. mHHS: difference between pre-operative and follow-up values Variable Capsular management Without capsular suture With capsular suture Age ≤28 years >28 years Sex Female Male Labrum management Debridement Suture Tonnis arthrosis scale [17] Grade 0 Grade 1
Adjusted mean(SD)
Difference of adjusted mean(SD)
95% confidence intervals of the difference
p-valuea
20.6 ± 1.9 25.8 ± 2.3
5.2 ± 2.5
25.9 ± 2.2 20.5 ± 2.0
−5.3 ± 2.5
22.5 ± 2.9 23.8 ± 1.5
1.3 ± 3.2
[−5.234; 7.854]
0.69
24.8 ± 1.9 21.6 ± 2.3
−3.1 ± 2.5
[−8.347; 2.053]
0.23
20.6 ± 2.5 25.8 ± 1.8
5.1 ± 2.7
[−0.373; 10.643]
0.067
[0.15; 10.336]
[−10.468; −0.328]
0.044
0.037
Linear model on the variation between the preoperative and follow-up values of the mHHS, considering the following adjustment factors: use of a capsular suture, age class, patient’s sex, labral procedure (Debridement /Suture, Tonnis Scale [17] [0/1]). a Bold characters indicate significant differences.
Table 3 Variation of Non-Arthritic Hip Score (NAHS) [15] – linear model. NAHS: difference between pre-operative and follow-up values Variable Capsular management Without capsular suture With capsular suture Age ≤28 years >28 years Sex Female Male Labrum management Debridement Suture Tonnis arthrosis scale [17] Grade 0 Grade 1
Adjusted mean(SD)
Difference of adjusted mean(SD)
95% confidence intervals of the difference
p-valuea
19.6 ± 2.1 26.1 ± 2.5
6.5 ± 2.7
[0.92; 12.089]
25.2 ± 2.4 20.6 ± 2.2
−4.6 ± 2.7
[−10.178; 0.916]
22.3 ± 3.2 23.5 ± 1.7
1.1 ± 3.5
[−5.917; 8.295]
0.739
24.4 ± 2.1 21.4 ± 2.5
−3.1 ± 2.8
[−8.734; 2.571]
0.28
22.1 ± 2.7 23.8 ± 1.9
1.5 ± 2.9
[−4.416; 7.521]
0.604
0.023
0.1
Linear model on the variation between the preoperative and follow-up values of the NAHS, considering the following adjustment factors: use of a capsular suture, age class, patient’s sex, labral procedure(Debridement/Suture), Tonnis Scale [17] (0/1). a Bold characters indicate significant differences.
mHHS seemed to be significantly improved in patients younger than 28 years old, and when capsular sutures were used (Table 2). Respectively, NAHS was significantly improved with the use of capsular sutures (Table 3). No major complications (dislocations, compartment syndrome due to fluid extravasation, femoral neck fractures or neurovascular injuries) occurred. In one patient in the group “capsule left open”, who underwent a labral debridment, atrophy of the tensor fascia latae was observed. Apart from normal postoperative discomfort, no complication was first noticed. After a normal postoperative course, at review 4 months after surgery, atrophy was noted in the region of the left hip. The strength of the medial rotation and abduction of the hip was decreased. An electromyogram of the tensor fascia latae at 6 months revealed no motor unit action potentials with attempted contraction of the muscle. An MRI showed signs of denervation with muscle atrophy and fat replacement. The reason for this problem is not known, but the electrophysiological studies are suggestive of a superior gluteal nerve palsy that can be explained by the anterior portal placement, a fluid extravasation compression or a traction related injury. There were no conversions to hip arthroplasty. No iatrogenic labral or chondral injuries occurred. One patient underwent a further procedure for recalcitrant trochanteric bursitis.
4. Discussion The most important finding of this study is that extracapsular outside-in approach is a safe and reliable technique, which appears to be an alternative to the traditional approach of a central or peripheral starting point, and that routine closure of the capsule at the end of the procedure is advocated, as it positively influences the functional results at short-term follow-up. Traditionally, hip arthroscopy starts in the central compartment. One concern of a central compartment starting point is the potential for iatrogenic chondral or labral injury. Because the hip capsulotomy has not been performed initially, a tight hip joint increases the risk of chondral scuffing or labral penetration and the potential requirement for increased traction [18]. Laude developed the extracapsular outsidein approach with a capsulotomy-first technique, as a response to the difficulty in finding the initial arthroscopic punctures when changing instruments [4]. By contrast, Sampson [19] advocates performing an extensive capsulotomy to gain sufficient exposure to allow treatment in hip arthroscopy. The longitudinal capsulotomy is performed in an area where no muscle is inserted. It can be done in a variety of ways depending on the anticipated pathology and can be easily closed at the end of the procedure [20,21]. In our study, a routine minimal longitudinal capsulotomy over the anterior part
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of the femoral neck is performed using an electrocoagulation hook and additional debulking of the capsule is done with a shaver to reduce the force required for traction without compromising hip stability. The mean traction time in hip arthroscopy has been shown to be 51.8 mins ± 24.2 [18]. In our study, the mean traction time is 19.8 minutes ± 7.1 (range 8–40). This decreased traction time can be explained in our series by the high rate of labral debridement that is less time consuming that labral repair, but also by the fact that traction is applied only for access into the central compartment and the traction strength required is decreased as the capsulotomy has already been performed. This might reduce the risk of pudendal nerve palsy which is a common reported complication after hip arthroscopy [22]. Another advantage of this technique is that a conventional 30◦ optic system can be used without fluoroscopy [4]. No specific instrumentation is required, avoiding the use of expensive single use set or a nitinol guide wire that can break in the joint. During the last decade, the frequency of hip arthroscopy has increased rapidly, evolving to become the standard procedure in the treatment of intra-articular non-osteoarthritic hip pathologies, such as FAI. Clinical outcomes of hip arthroscopy have improved as the understanding of hip biomechanics is further clarified. The role of instability on the clinical result following hip arthroscopy has recently been a topic of debate [9]. The question of whether the hip capsule should be sutured in every hip arthroscopy or if this decision should be personalized according to the patient’s biomechanical preconditions, has been a matter of controversy. In our study, we have concluded that hip arthroscopy with an extraarticular starting point (outside-in) for the management of FAI is a safe technique with significant improvement of clinical scores, especially after capsular closure. It is believed that capsular suturing after hip arthroscopy re-establishes anatomical hip stability [22]; however, the beneficial effects on the clinical results have not yet been proven [9] and to date, there is only few studies in the literature which assess the influence of routine capsular closure in primary hip arthroscopy for the treatment of femoroacetabular impingement [9,23–25]. In a recent study, no significant differences in clinical outcome were reported when capsular closure was compared to non-closure, retrospectively [23]. When different types of capsular suturing were compared, full closure seems to be more effective than partial closure. In a prospective study, Frank et al. [24] suggested better clinical results after hip arthroscopy for FAI in patients with full closure of a T-capsulotomy in comparison to patients where the interportal part of the T-capsulotomy was left unrepaired. Moreover, we found that age below 28 years has been correlated with an improved mHHS, as it has been suggested by a recent study by Cvetanovich et al. [25]. In accordance with most studies, we have found a beneficial effect of hip arthroscopy with the outside-in capsulotomy in the treatment of FAI, as measured by clinical scores (mHHS, NAHS) and radiological markers (␣-angle) [26]. Our only complication related to the surgical technique in this series was a single case of tensor fascia latae denervation. In our patient, a direct injury to the superior gluteal nerve could not be proven. We had no wound-related issues in this study. The risk of fluid extravasation exists but is no higher for this particular technique. Our arthropump is set at 50 mmHg and we have never found it necessary to increase pressure. Each step is under arthroscopic control; thus, no instrument is inserted with force or blind puncture, in particular for the tight hip joint, reducing the risk of cartilage damage. Several authors advise closure of the capsule to help soft tissue healing, prevent dislocation or heterotopic ossification [27,28], and improve functional outcomes [9,24]. As the capsulotomy is done in a longitudinal fashion, capsular suture with an automated suture passer can easily be performed at the end of the procedure [4]. In our series, we did not find any case of postoperative subluxation or dislocation. Although leaving the capsulotomy open seldom causes frank instability, microinstability can occur
which manifests as unexplained hip pain [11,12]. We now recommend, in agreement with other authors, suturing the capsule at the end of the procedure, especially in women with increased laxity, despite capsular repair can be technically demanding and time consuming [29–31]. Our study has certain limitations. The sample size is relatively small and the study is retrospective with no control group to compare the efficacy of our method. The radiological analysis of the correction of the Alpha angle has been possible in only half of the patients, due to the retrospective design of the study. Another limitation of this study is the choice between capsular closure or not was not randomized but rather reflects the evolution of our practice; however, both groups were strictly comparable in terms of age, sex ratio, and radiographic degenerative changes, making comparison between the 2 groups possible. The only significant difference between the two groups was the rate of labral suture, which was higher in the capsular suture group. However, we have not been able to show a significant difference between the labral suture group and the labral debridement group like other authors before us [32] and believe that this does not invalidate the conclusions of our study. 5. Conclusions The outside-in capsulotomy for the management of FAI is a safe, reproducible technique of hip arthroscopy with low complication rates. Functional outcome scores are comparable to the other techniques, while capsular closure seems to generate improved clinical outcome. We believe this technique is easy to master and represents an undeniable progress in our practice. Longer-term studies will be required to assess the efficacy of the outside-in technique relative to other techniques of hip arthroscopy in the management of FAI. Disclosure of interest MT is consultant for Arthrex. SK received a grant from Ramsay Santé. GC received a grant from Arthrex. The other authors declare that they have no competing interest. Funding No funding. Contribution MT., SS., TG., AA. and GC. contributed to the design and implementation of the research, to the analysis of the results and to the writing of the manuscript. SK, CGM and TR corrected the manuscript. References [1] Gédouin JE. Arthroscopic treatment of femoroacetabular impingement: technical review. Orthop Traumatol Surg Res 2012;98:583–96. [2] Dienst M, Seil R, Kohn DM. Safe arthroscopic access to the central compartment of the hip. Arthroscopy 2005;21:1510–4. [3] Glick JM, Valone F, Safran MR. Hip arthroscopy: from the beginning to the future – an innovator’s perspective. Knee Surg Sports Traumatol Arthrosc 2014;22:714–21. [4] Thaunat M, Murphy CG, Chatellard R, Sonnery-Cottet B, Graveleau N, et al. Capsulotomy first: a novel concept for hip arthroscopy. Arthrosc Tech 2014;3:e599–603. [5] Forster-Horvath C, Domb BG, Ashberg L, Herzog RF. A method for capsular management and avoidance of iatrogenic instability: minimally invasive capsulotomy in hip arthroscopy. Arthrosc Tech 2017;6:e397–400. [6] Di Benedetto P, Barbattini P, Povegliano L, Beltrame A, Gisonni R, et al. Extracapsular vs standard approach in hip arthroscopy. Acta Biomed 2016;87:41–5.
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[21] Bedi A, Galano G, Walsh C, Kelly BT. Capsular management during hip arthroscopy: from femoroacetabular impingement to instability. Arthroscopy 2011;27:1720–31. [22] Wuerz TH, Song SH, Grzybowski JS, Martin HD, Mather RC, et al. Capsulotomy size affects hip joint kinematic stability. Arthroscopy 2016;32:1571–80. [23] 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;31:643–50. [24] Frank RM, Lee S, Bush-Joseph CA, Kelly BT, Salata MJ, Nho SJ. Improved outcomes after hip arthroscopic surgery in patients undergoing T-capsulotomy with complete repair versus partial repair for femoroacetabular impingement: a comparative matched-pair analysis. Am J Sports Med 2014;42:2634–42. [25] Cvetanovich GL, Weber AE, Kuhns BD, Alter J, Harris JD, Mather RC, et al. Hip arthroscopic surgery for femoroacetabular impingement with capsular management: factors associated with achieving clinically significant outcomes. Am J Sports Med 2018;46:288–96. [26] Minkara AA, Westermann RW, Rosneck J, Lynch TS. Systematic review and meta-analysis of outcomes after hip arthroscopy in femoroacetabular impingement. Am J Sports Med 2019;47:488–500. [27] Amar E, Warschawski Y, Sampson TG, Atoun E, Steinberg EL, Rath E. Capsular closure does not affect development of heterotopic ossification after hip arthroscopy. Arthroscopy 2015;31:225–30. [28] Gupta A, Suarez-Ahedo C, Redmond JM, Gerhardt MB, Hanypsiak B, et al. Best practices during hip arthroscopy: aggregate recommendations of high-volume surgeons. Arthroscopy 2015;31:1722–7. [29] Konan S, Rhee SJ, Haddad FS. Hip arthroscopy: analysis of a single surgeon’s learning experience. J Bone Joint Surg Am 2011;93:52–6. [30] Park MS, Yoon SJ, Kim YJ, Chung WC. Hip arthroscopy for femoroacetabular impingement: the changing nature and severity of associated complications over time. Arthroscopy 2014;30:957–63. [31] Harris JD, Slikker W, Gupta AK, McCormick FM, Nho SJ. Routine complete capsular closure during hip arthroscopy. Arthrosc Tech 2013;2:e89–94. [32] Menge TJ, Briggs KK, Dornan GJ, McNamara SC, Philippon MJ. Survivorship and outcomes 10 years following hip arthroscopy for femoroacetabular impingement: labral debridement compared with labral repair. J Bone Joint Surg Am 2017;99:997–1004.
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Original article
Femoroacetabular impingement treatment using the arthroscopic extracapsular outside-in approach: Does capsular suture affect functional outcome? Mathieu Thaunat ∗ , Saliou Sarr , Thanos Georgeokostas , Abdul Azeem , Colin G Murphy , Samih Kacem , Gilles Clowez , Timothy Roberts Groupe Ramsay Santé, FIFA Medical Center of Excellence, Centre Orthopédique Santy, 24, avenue Paul-Santy, 69008 Lyon, France
a r t i c l e
i n f o
Article history: Received 29 April 2019 Accepted 15 November 2019 Available online xxx Keywords: Femoroacetabular impingement Extracapsular approach Outside-in capsulotomy
a b s t r a c t Background: Over the last decades, the arthroscopic treatment of hip pathology has highly grown thanks to the evolution of surgical techniques and instrumentation development. An alternative approach consisting in making a first outside-in longitudinal capsulotomy was described by Laude at the end of the 2000s and is experiencing significant development in France. The clinical results of this technique have rarely been reported and in particular the influence of the repair of the capsule is unknown. Therefore we performed a retrospective case control study aiming to asses: (1) the clinical outcomes and complication rates of the outside-in extracapsular approach for the treatment of FemoroAcetabular Impingement (FAI) and (2) the effect of capsular closure on the functional outcome. Hypothesis: We hypothesize that the outside-in extracapsular approach is a safe and efficient technique and the capsular closure at the end of the procedure positively affects the functional outcome. Methods: A retrospective study was conducted on prospectively collected data of a consecutive series of hip arthroscopies performed for surgical treatment of FAI using the outside-in extracapsular approach. Any complications during follow-up were identified and recorded. Linear regression models were used to estimate the influence of capsular closure on the functional outcome. Functional outcome was assessed using modified Harris Hip Score (mHHS) and Non-arthritic Hip Score (NAHS). Results: Sixty-four hips in 57 patients operated by a single surgeon between October 2013 and December 2016 were analyzed at the time of final follow-up of 34.17 months (range 24 to 53). As the surgical technique evolved over time, a side-to-side capsular closure was performed at the end of the procedure for 25 hips and the capsule was left open for the remaining 39 patients. Functional outcome measurements showed an improvement from the preoperative to the last follow-up: 63.5 ± 11.0 to 88.1 ± 11.2 for mHHS, 63.1 ± 13.8 to 86.4 ± 13.4 for NAHS. Capsular closure leads to a significantly improved clinical outcome: gain in mHHS: 25.8 ± 2.3 vs. 20.6 ± 1.9 (p ≤ 0.044), gain in NAHS: 26.1 ± 2.5 vs. 19.6 ± 2.1, (p = 0.023). No major complications occurred. One case of postoperative tensor fascia latae atrophy was documented in the group “capsule left open”. Conclusion: Hip arthroscopy in the management of FAI with an extraarticular starting point (outside-in) is a safe technique with functional results and postoperative morbidity comparable to previously reported techniques. Side-to-side capsular closure at the end of the procedure might positively affect the final functional outcome. Levels of evidence: III, case control retrospective study. © 2020 Elsevier Masson SAS. All rights reserved.
1. Introduction Over the last decades, the arthroscopic treatment of hip pathology has highly grown thanks to the evolution of surgical
∗ Corresponding author. E-mail address: [email protected] (M. Thaunat).
and diagnostic techniques and instrumentation development. Hip arthroscopy has recently gained significant importance in the surgical treatment of femoroacetabular impingement. Two different approaches have been described initially in the literature; one involving a central starting point, another with a peripheralcompartment starting point. In these standard approaches, a limited interportal capsulotomy is done in an inside-out fashion as required [1–3]. Laude described a novel approach for hip
https://doi.org/10.1016/j.otsr.2019.11.023 1877-0568/© 2020 Elsevier Masson SAS. All rights reserved.
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arthroscopy which consists of an extra-articular starting point with an initial outside-in capsulotomy similar to a mini open anterior Hueter approach but under endoscopic visualization [4]. This technique which requires an endoscopic extracapsular sequence in order to adequately visualize the hip capsule before performing a minimally invasive capsulotomy has subsequently been proposed in order to reduce the risk of iatrogenic instability after hip arthroscopy [5]. However, we routinely use this technique as we believe it helps to gain quick and safe access into the joint. It also allows for minimal traction time and less forces while achieving an appropriate distraction [4,6]. Moreover, apart from the acetabulum, the acetabular labrum and the hip capsule contribute significantly to hip joint stability [7,8]. Capsular suturing after hip arthroscopy has been suggested to prevent hip joint instability and decrease revision rate [9,10]. Currently, there is very limited data in the literature regarding outcomes and the complication rates of outside-in approach [6]. At this time, it remains unclear whether capsular suturing should be performed as a routine procedure in hip arthroscopy, especially in cases without additional risk factors for instability such as hypermobility or hip dysplasia [11,12]. Therefore we performed a retrospective case control study aiming to assess: • the clinical outcomes and complication rates of the outside-in extracapsular approach for the treatment of FemoroAcetabular Impingement (FAI); • the effect of capsular closure on the functional outcome. We hypothesize that the outside-in extracapsular approach is a safe and efficient technique and the capsular closure at the end of the procedure positively affects the functional outcome. 2. Material and methods 2.1. Patients A retrospective analysis of prospectively collected data was performed of patients who underwent hip arthroscopy for femoroacetabular impingement between October 1, 2013, and December 30, 2016, by one senior surgeon (M.T.). Inclusion criteria were: adult men or women aged from 15 to 50 years, hip pain for greater than 6 months without relief from non-operative means (physiotherapy, non-steroidal anti-inflammatory medication, rest), documentation of failed physiotherapy, including core conditioning of the hip, back, and abdomen, Cam or Mixed Type FAI as diagnosed on x-rays and magnetic resonance imaging (MRI) or magnetic resonance arthrogram (MRA) or CT arthrogram (CTA) and a minimum of 2 years follow-up from index surgery. Exclusion criteria were: evidence of hip dysplasia (centre edge angle less than 20◦ ), coxa profunda (centre edge angle more than 40◦ ), presence of advanced hip osteoarthritis (Tönnis Grade 2 or 3), presence of other hip syndromes (concurrent non-FAI related pathology), previous trauma to the affected hip, previous surgery on the affected hip and severe acetabular deformities. 2.2. Methods Under general anesthesia, the patient was placed in a supine position on an orthopaedic traction table with the hip slightly flexed, abducted and internally rotated, using a well-padded perineal post to avoid any neuropraxia of the pudendal nerve and to reduce pressure ulcers. The instrumentation comprised of a conventional 70◦ scope, a pump which can control inflow and outflow to maintain a constant pressure (set at 50 mmHg), a 4.0 mm VAPR,
90◦ Electrode (Depuy Mitek, Raynham, MA, USA) and a 3.5 mm hook electrode (Depuy Mitek, Raynham, MA, USA). The arthroscope was introduced in a portal located 2 cm anterior and distal to the superior tip of the greater trochanter. A second anterior portal for the instruments was created medial to the tensor fascia lata and is located at least 4 to 5 cm anterior to the optical portal and 1 cm distal. We take careful attention to not over take the line drawn between the antero-superior iliac spine and the superolateral patella corner. A blunt dissection of the subcutaneous and muscular tissues with the electrocoagulation probe allows exposing the anterior surface of the femoral neck which is the only area of the capsule where there is no muscle insertion (Fig. 1). At this point precapsular fatty tissue was seen, which could be easily debrided with the VAPR electrode (Depuy Mitek, Raynham, MA, USA) to visualize the white fibers of the capsule. After debriding the precapsular fatty tissue, a longitudinal capsulotomy was performed with the hook electrode (Fig. 1). Proximally, a simple debulking of the capsule perpendicular to direction of the initial capsulotomy was completed by a shaver to avoid iatrogenic labral injuries. If required, a T-shaped capsulotomy was performed to obtain better access to the joint. Labral injuries, if present, were either resected by a 4.5 mm shaver (Stryker, Kalamazoo, MI, USA) when hypotrophic or when the lesion is unrepairable, left alone in the absence of lesion and in the absence of indication for acetabuloplasty or sutured with non resorbable Ethibond No 2 secured with a 2.9 mm pushlock (Arthrex, Naples, FL, USA) if repairable or when an acetabuloplasty was required. Pincer deformities of the acetabulum were resected by a motorized burr (Stryker, Kalamazoo, MI, USA) when needed. Microfractures with a chondropick were created if associated chondral injuries were present. Traction was then released. The lower limb was placed in flexion and alternative internal and external rotation was performed in order to resect the Cam deformities using a 5 mm motorized burr and under fluoroscopic control. After the intra-articular procedure was completed, the capsule was either left open or closed with 2 side-to-side sutures in the vertical arm of the capsulotomy using a Scorpion suture passer (Arthrex, Naples, FL, USA) with a resorbable Polysorb No 2 suture. The decision to suture the capsule was based on the senior surgeon’s evolving indications. This is due to the confidence built on an increasing duration of follow-up with excellent clinical outcomes of patients who underwent capsular closure and because of the recommendation found in literature following the first series of capsular repair in FAI treatment [13,14] (Fig. 1). Fluoroscopy was used in order to control the amount of cam resection intra-operatively. Postoperatively, all patients were mobilized with partial weight-bearing protected with two crutches for four weeks and were advised to avoid extremes of hip movement for the first 6 weeks after surgery. All patients had a heterotopic ossification prophylactic treatment consisting of 100 mg dose of ketoprofen 2 times a day prescribed for 3 weeks.
2.3. Methods of assessment Data were collected at a preoperative clinic visit, 1 year postoperatively, and at the last follow-up, via phone call. The hip status, labral and chondral treatment, the use of microfractures as well as traction time were recorded. Any complications during early, intermediate or long-term follow-up were identified and recorded. The difference in the functional outcome scores from the preoperative period to those at the time of last follow-up was analyzed. Two patient-reported outcome (PROs) scores were used to evaluate hip arthroscopy, specifically modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS) [15]. The ␣-angle (Dunn’s lateral view) was measured on plain radiographs using a digital picture archiving and communication system (PACS) [16], and the
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Fig. 1. Outside-in capsulotomy technique. A. The anterior surface of the femoral neck, underneath the tensor fascia lata (TFL), is the only area of the capsule where there is no muscle insertion. Instead, a precapsular fatty tissue is seen, which can be easily debrided to show the white fibers of the capsule between the gluteus minimus muscle (GM) and the iliocapsularis muscle (ICM). B. The capsular incision is performed along the neck of the femur and, only if necessary, (C) is extended over the labrum and then along the acetabular rim so as to expose the area from the base of the femoral neck to the supra-acetabular ilium. This extension is performed with a shaver, consisting of a simple debulking of the capsule rather than an extensive T-shape capsulotomy. D. Capsular suture is performed with resorbable No 2 suture in a side-to-side fashion. E and F. Usually, two sutures are necessary in order to obtain a complete closure of the capsulotomy.
difference between the preoperative and postoperative ␣-angle was measured. 2.4. Statistical analysis All calculations were made with SAS for Windows (v 9.4; SAS Institute Inc), with the level of statistical significance set at p < 0.05. Descriptive data analysis was conducted depending on the nature of the considered criteria: number of observed (and missing, if any) values, mean and standard-deviation, median, first and third quartiles, minimum and maximum for quantitative data; number of observed (and missing, if any) values, number and percentage of patients per class, for qualitative data. The Wilcoxon rank-sum test, for quantitative variables, and the Chi2 or the Fisher exact test, for qualitative variables, were carried out to compare the demographics and surgery characteristics between the 2 types of procedure
studied (capsular suture or capsule left open). The Harris score and NAHS variations from baseline were each analyzed considering a linear model adjusted for the baseline value, the type of capsular procedure (suture or left open), labral procedure (suture or debridement), the Tönnis score, as well as the patient’s class of age and gender. 3. Results Continuous series of 70 hips with the same surgical procedure were eligible for evaluation (Fig. 2). Six hips (6 patients) could not be reached by phone at last follow-up (mean follow-up: 36.3 months, range 26–48) and were lost to follow-up (after a minimal one year of follow-up without complication) and excluded from the study (2 in the capsular suture group and 4 in the group without capsular suture). As shown in Table 1, a total of 64 hips (57 patients including
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Fig. 2. Flowchart.
Table 1 Surgical characteristics of the study cohort. pa
Variable
Total (%)
Without capsular closure
With capsular closure
Hips Sex Female Male Mean age of patients (±SD) Labrum Debridement Left alone Suture Microfractures No Yes Tönnis arthrosis Scale [17] Grade 0 Grade 1 Type of femoro – acetabular Impingement Cam Mixed
64
39
25
13 (20.3%) 51 (79.7%) 28.7 ± 7.5 (range 15–45)
9 (23.1%) 30 (76.9%) 28.8 ± 7.2 (range 15–44)
4 (16.0%) 21 (84.0%) 28.5 ± 8.2 (range 16–45)
0.4924
40 (62.5%) 1 (1.6%) 23 (35.9%)
29 (74.4%)
0.0218
10 (25.6%)
11 (44.0%) 1 (4.0%) 13 (52.0%)
56 (87.5%) 8 (12.5%)
32 (82.1%) 7 (17.9%)
24 (96.0%) 1 (4.0%)
0.1349
16 (25.0%) 48 (75.0%)
10 (25.6%) 29 (74.4%)
6 (24.0%) 19 (76.0%)
0.8824
14 (21.9%) 50 (78.1%)
6 (15.4%) 33 (86.6%)
8 (32.0%) 17 (68.0%)
0.2431
a
0.7565
Bold characters indicate significant differences.
45 males and 12 females) were included in the study. Complete radiological analysis was possible for only 32 hips. Seven patients had bilateral procedures. The average age at the time of surgery was 28.7 ± 7.7 years (range, 15–45 years). The average traction time was found to be 19.79 ± 7.11 minutes (range 8–40). Demographic and surgical characteristics of the population studied are summarized in Table 1. Functional outcomes measurements at the time of final followup of 34.17 months (range, 24 to 53) showed a significant
improvement from the initial preoperative scores for the mHHS and the NAHS. All PROs showed a statistically significant improvement at the final follow-up compared with preoperative levels: 63.5 ± 11.0 (range, 29 to 92) to 88.1 ± 11.2 (range, 58 to 100). Radiographically, the femoral ␣-angle decreased from 70.9◦ ± 7.1 (range, 60 to 80) preoperatively to 47.2◦ ± 6.5 (range, 35 to 60) postoperatively. After adjustment for the use of sutures, age, sex, labral procedure (suture [S] or debridement [D]) and Tönnis Scale,
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Table 2 Variation of modified Harris Hip Score (mHHS) [15] – linear model. mHHS: difference between pre-operative and follow-up values Variable Capsular management Without capsular suture With capsular suture Age ≤28 years >28 years Sex Female Male Labrum management Debridement Suture Tonnis arthrosis scale [17] Grade 0 Grade 1
Adjusted mean(SD)
Difference of adjusted mean(SD)
95% confidence intervals of the difference
p-valuea
20.6 ± 1.9 25.8 ± 2.3
5.2 ± 2.5
25.9 ± 2.2 20.5 ± 2.0
−5.3 ± 2.5
22.5 ± 2.9 23.8 ± 1.5
1.3 ± 3.2
[−5.234; 7.854]
0.69
24.8 ± 1.9 21.6 ± 2.3
−3.1 ± 2.5
[−8.347; 2.053]
0.23
20.6 ± 2.5 25.8 ± 1.8
5.1 ± 2.7
[−0.373; 10.643]
0.067
[0.15; 10.336]
[−10.468; −0.328]
0.044
0.037
Linear model on the variation between the preoperative and follow-up values of the mHHS, considering the following adjustment factors: use of a capsular suture, age class, patient’s sex, labral procedure (Debridement /Suture, Tonnis Scale [17] [0/1]). a Bold characters indicate significant differences.
Table 3 Variation of Non-Arthritic Hip Score (NAHS) [15] – linear model. NAHS: difference between pre-operative and follow-up values Variable Capsular management Without capsular suture With capsular suture Age ≤28 years >28 years Sex Female Male Labrum management Debridement Suture Tonnis arthrosis scale [17] Grade 0 Grade 1
Adjusted mean(SD)
Difference of adjusted mean(SD)
95% confidence intervals of the difference
p-valuea
19.6 ± 2.1 26.1 ± 2.5
6.5 ± 2.7
[0.92; 12.089]
25.2 ± 2.4 20.6 ± 2.2
−4.6 ± 2.7
[−10.178; 0.916]
22.3 ± 3.2 23.5 ± 1.7
1.1 ± 3.5
[−5.917; 8.295]
0.739
24.4 ± 2.1 21.4 ± 2.5
−3.1 ± 2.8
[−8.734; 2.571]
0.28
22.1 ± 2.7 23.8 ± 1.9
1.5 ± 2.9
[−4.416; 7.521]
0.604
0.023
0.1
Linear model on the variation between the preoperative and follow-up values of the NAHS, considering the following adjustment factors: use of a capsular suture, age class, patient’s sex, labral procedure(Debridement/Suture), Tonnis Scale [17] (0/1). a Bold characters indicate significant differences.
mHHS seemed to be significantly improved in patients younger than 28 years old, and when capsular sutures were used (Table 2). Respectively, NAHS was significantly improved with the use of capsular sutures (Table 3). No major complications (dislocations, compartment syndrome due to fluid extravasation, femoral neck fractures or neurovascular injuries) occurred. In one patient in the group “capsule left open”, who underwent a labral debridment, atrophy of the tensor fascia latae was observed. Apart from normal postoperative discomfort, no complication was first noticed. After a normal postoperative course, at review 4 months after surgery, atrophy was noted in the region of the left hip. The strength of the medial rotation and abduction of the hip was decreased. An electromyogram of the tensor fascia latae at 6 months revealed no motor unit action potentials with attempted contraction of the muscle. An MRI showed signs of denervation with muscle atrophy and fat replacement. The reason for this problem is not known, but the electrophysiological studies are suggestive of a superior gluteal nerve palsy that can be explained by the anterior portal placement, a fluid extravasation compression or a traction related injury. There were no conversions to hip arthroplasty. No iatrogenic labral or chondral injuries occurred. One patient underwent a further procedure for recalcitrant trochanteric bursitis.
4. Discussion The most important finding of this study is that extracapsular outside-in approach is a safe and reliable technique, which appears to be an alternative to the traditional approach of a central or peripheral starting point, and that routine closure of the capsule at the end of the procedure is advocated, as it positively influences the functional results at short-term follow-up. Traditionally, hip arthroscopy starts in the central compartment. One concern of a central compartment starting point is the potential for iatrogenic chondral or labral injury. Because the hip capsulotomy has not been performed initially, a tight hip joint increases the risk of chondral scuffing or labral penetration and the potential requirement for increased traction [18]. Laude developed the extracapsular outsidein approach with a capsulotomy-first technique, as a response to the difficulty in finding the initial arthroscopic punctures when changing instruments [4]. By contrast, Sampson [19] advocates performing an extensive capsulotomy to gain sufficient exposure to allow treatment in hip arthroscopy. The longitudinal capsulotomy is performed in an area where no muscle is inserted. It can be done in a variety of ways depending on the anticipated pathology and can be easily closed at the end of the procedure [20,21]. In our study, a routine minimal longitudinal capsulotomy over the anterior part
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of the femoral neck is performed using an electrocoagulation hook and additional debulking of the capsule is done with a shaver to reduce the force required for traction without compromising hip stability. The mean traction time in hip arthroscopy has been shown to be 51.8 mins ± 24.2 [18]. In our study, the mean traction time is 19.8 minutes ± 7.1 (range 8–40). This decreased traction time can be explained in our series by the high rate of labral debridement that is less time consuming that labral repair, but also by the fact that traction is applied only for access into the central compartment and the traction strength required is decreased as the capsulotomy has already been performed. This might reduce the risk of pudendal nerve palsy which is a common reported complication after hip arthroscopy [22]. Another advantage of this technique is that a conventional 30◦ optic system can be used without fluoroscopy [4]. No specific instrumentation is required, avoiding the use of expensive single use set or a nitinol guide wire that can break in the joint. During the last decade, the frequency of hip arthroscopy has increased rapidly, evolving to become the standard procedure in the treatment of intra-articular non-osteoarthritic hip pathologies, such as FAI. Clinical outcomes of hip arthroscopy have improved as the understanding of hip biomechanics is further clarified. The role of instability on the clinical result following hip arthroscopy has recently been a topic of debate [9]. The question of whether the hip capsule should be sutured in every hip arthroscopy or if this decision should be personalized according to the patient’s biomechanical preconditions, has been a matter of controversy. In our study, we have concluded that hip arthroscopy with an extraarticular starting point (outside-in) for the management of FAI is a safe technique with significant improvement of clinical scores, especially after capsular closure. It is believed that capsular suturing after hip arthroscopy re-establishes anatomical hip stability [22]; however, the beneficial effects on the clinical results have not yet been proven [9] and to date, there is only few studies in the literature which assess the influence of routine capsular closure in primary hip arthroscopy for the treatment of femoroacetabular impingement [9,23–25]. In a recent study, no significant differences in clinical outcome were reported when capsular closure was compared to non-closure, retrospectively [23]. When different types of capsular suturing were compared, full closure seems to be more effective than partial closure. In a prospective study, Frank et al. [24] suggested better clinical results after hip arthroscopy for FAI in patients with full closure of a T-capsulotomy in comparison to patients where the interportal part of the T-capsulotomy was left unrepaired. Moreover, we found that age below 28 years has been correlated with an improved mHHS, as it has been suggested by a recent study by Cvetanovich et al. [25]. In accordance with most studies, we have found a beneficial effect of hip arthroscopy with the outside-in capsulotomy in the treatment of FAI, as measured by clinical scores (mHHS, NAHS) and radiological markers (␣-angle) [26]. Our only complication related to the surgical technique in this series was a single case of tensor fascia latae denervation. In our patient, a direct injury to the superior gluteal nerve could not be proven. We had no wound-related issues in this study. The risk of fluid extravasation exists but is no higher for this particular technique. Our arthropump is set at 50 mmHg and we have never found it necessary to increase pressure. Each step is under arthroscopic control; thus, no instrument is inserted with force or blind puncture, in particular for the tight hip joint, reducing the risk of cartilage damage. Several authors advise closure of the capsule to help soft tissue healing, prevent dislocation or heterotopic ossification [27,28], and improve functional outcomes [9,24]. As the capsulotomy is done in a longitudinal fashion, capsular suture with an automated suture passer can easily be performed at the end of the procedure [4]. In our series, we did not find any case of postoperative subluxation or dislocation. Although leaving the capsulotomy open seldom causes frank instability, microinstability can occur
which manifests as unexplained hip pain [11,12]. We now recommend, in agreement with other authors, suturing the capsule at the end of the procedure, especially in women with increased laxity, despite capsular repair can be technically demanding and time consuming [29–31]. Our study has certain limitations. The sample size is relatively small and the study is retrospective with no control group to compare the efficacy of our method. The radiological analysis of the correction of the Alpha angle has been possible in only half of the patients, due to the retrospective design of the study. Another limitation of this study is the choice between capsular closure or not was not randomized but rather reflects the evolution of our practice; however, both groups were strictly comparable in terms of age, sex ratio, and radiographic degenerative changes, making comparison between the 2 groups possible. The only significant difference between the two groups was the rate of labral suture, which was higher in the capsular suture group. However, we have not been able to show a significant difference between the labral suture group and the labral debridement group like other authors before us [32] and believe that this does not invalidate the conclusions of our study. 5. Conclusions The outside-in capsulotomy for the management of FAI is a safe, reproducible technique of hip arthroscopy with low complication rates. Functional outcome scores are comparable to the other techniques, while capsular closure seems to generate improved clinical outcome. We believe this technique is easy to master and represents an undeniable progress in our practice. Longer-term studies will be required to assess the efficacy of the outside-in technique relative to other techniques of hip arthroscopy in the management of FAI. Disclosure of interest MT is consultant for Arthrex. SK received a grant from Ramsay Santé. GC received a grant from Arthrex. The other authors declare that they have no competing interest. Funding No funding. Contribution MT., SS., TG., AA. and GC. contributed to the design and implementation of the research, to the analysis of the results and to the writing of the manuscript. SK, CGM and TR corrected the manuscript. References [1] Gédouin JE. Arthroscopic treatment of femoroacetabular impingement: technical review. Orthop Traumatol Surg Res 2012;98:583–96. [2] Dienst M, Seil R, Kohn DM. Safe arthroscopic access to the central compartment of the hip. Arthroscopy 2005;21:1510–4. [3] Glick JM, Valone F, Safran MR. Hip arthroscopy: from the beginning to the future – an innovator’s perspective. Knee Surg Sports Traumatol Arthrosc 2014;22:714–21. [4] Thaunat M, Murphy CG, Chatellard R, Sonnery-Cottet B, Graveleau N, et al. Capsulotomy first: a novel concept for hip arthroscopy. Arthrosc Tech 2014;3:e599–603. [5] Forster-Horvath C, Domb BG, Ashberg L, Herzog RF. A method for capsular management and avoidance of iatrogenic instability: minimally invasive capsulotomy in hip arthroscopy. Arthrosc Tech 2017;6:e397–400. [6] Di Benedetto P, Barbattini P, Povegliano L, Beltrame A, Gisonni R, et al. Extracapsular vs standard approach in hip arthroscopy. Acta Biomed 2016;87:41–5.
Please cite this article in press as: Thaunat M, et al. Femoroacetabular impingement treatment using the arthroscopic extracapsular outside-in approach: Does capsular suture affect functional outcome? Orthop Traumatol Surg Res (2020), https://doi.org/10.1016/j.otsr.2019.11.023
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Please cite this article in press as: Thaunat M, et al. Femoroacetabular impingement treatment using the arthroscopic extracapsular outside-in approach: Does capsular suture affect functional outcome? Orthop Traumatol Surg Res (2020), https://doi.org/10.1016/j.otsr.2019.11.023