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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 Rachel M. Frank, Simon Lee, Charles A. Bush-Joseph, Bryan T. Kelly, Michael J. Salata and Shane J. Nho Am J Sports Med 2014 42: 2634 originally published online September 11, 2014 DOI: 10.1177/0363546514548017 The online version of this article can be found at: http://ajs.sagepub.com/content/42/11/2634

Published by: http://www.sagepublications.com

On behalf of: American Orthopaedic Society for Sports Medicine

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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 Rachel M. Frank,*y MD, Simon Lee,y MPH, Charles A. Bush-Joseph,y MD, Bryan T. Kelly,z MD, Michael J. Salata,§ MD, and Shane J. Nho,y MD, MS Investigation performed at Rush University Medical Center, Chicago, Illinois, USA Background: Hip capsular management after hip arthroscopic surgery for femoroacetabular impingement (FAI) is controversial. Purpose/Hypothesis: To compare the clinical outcomes of patients undergoing hip arthroscopic surgery for FAI with T-capsulotomy with partial capsular repair (PR; closed vertical incision, open interportal incision) versus complete capsular repair (CR; full closure of both incisions). The hypothesis was that there would be improved clinical outcomes in patients undergoing CR compared with those undergoing PR. Study Design: Cohort study; Level of evidence, 3. Methods: Consecutive patients undergoing hip arthroscopic surgery for FAI by a single fellowship-trained surgeon from January 2011 to January 2012 were prospectively collected and analyzed. Inclusion criteria included all patients between ages 16 and 65 years with physical examination and radiographic findings consistent with symptomatic FAI, with a minimum 2-year follow-up. For analysis, patients were matched according to sex and age 62 years. Primary clinical outcomes were measured via the Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sport-Specific (HOS-SS) subscales, the modified Harris Hip Score (mHHS), patient satisfaction (measured on a visual analog scale), and clinical improvement at baseline, 6 months, 1 year, and 2 years. Statistical analysis was performed utilizing Student paired and unpaired t tests, with P \ .05 considered significant. Results: A total of 64 patients were included in the study, with 32 patients (12 male, 20 female) in each group. The average follow-up was 29.9 6 2.6 months. There were no significant demographic differences between the groups. The CR group demonstrated significantly superior outcomes in the HOS-SS at 6 months (PR: 63.8 6 31.1 vs CR: 72.2 6 16.1; P = .039), 1 year (PR: 72.7 6 14.7 vs CR: 82.5 6 10.7; P = .006), and 2.5 years (PR: 83.6 6 9.6 vs CR: 87.3 6 8.3; P \ .0001) after surgery. Patient satisfaction at final followup was significantly better in the CR group (PR: 8.4 6 1.0 vs CR: 8.6 6 1.1; P = .025). Both groups demonstrated significant improvements in the HOS-ADL (PR: 64.6 6 17.0 to 90.7 6 8.4 [P \ .0001]; CR: 66.1 6 15.7 to 92.1 6 7.9 [P \ .0001]) and HOS-SS (PR: 39.4 6 23.9 to 83.6 6 9.6 [P \ .0001]; CR: 39.1 6 24.2 to 87.3 6 8.3 [P \ .0001]) at final follow-up. There were no significant differences between the groups in the HOS-ADL at any time point. There were no significant differences in the mHHS between the groups at final follow-up (PR: 82.5 6 5.0 vs CR: 83.0 6 4.4; P = .364). The overall revision rate was 6.25%; all patients (n = 4) who required revision arthroscopic surgery were in the PR group (13% of 32 patients), while no patients in the CR group required revision surgery. Conclusion: While significant improvements were seen at 6 months, 1 year, and 2.5 years of follow-up regardless of the closure technique, patients who underwent CR of the hip capsule demonstrated superior sport-specific outcomes compared with those undergoing PR. There was a 13% revision rate in the PR group, but no patients in the CR group required revision surgery. While longer term outcome studies are needed to determine if these results are maintained over time, these data suggest improved outcomes after CR compared with PR at 2.5 years after hip arthroscopic surgery for FAI. Keywords: femoroacetabular impingement; capsular plication; laxity; hip arthroscopic surgery

The use of hip arthroscopic surgery in the treatment of nonarthritic hip disorders has increased tremendously over the past decade.2,8,9,10,21 With new developments in

The American Journal of Sports Medicine, Vol. 42, No. 11 DOI: 10.1177/0363546514548017 Ó 2014 The Author(s)

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arthroscopic instrumentation and implants as well as with an increased understanding of the correlation of physical examination findings with imaging studies, our ability to treat hip disorders with minimally invasive techniques has improved. Recently, there has been an exponential increase in the number of publications available in the literature discussing the outcomes of hip preservation surgery, namely, for femoroacetabular impingement (FAI).25,32-36,39 For appropriately indicated patients, hip arthroscopic surgery for FAI is clearly a beneficial procedure with acceptable short- and medium-term outcomes. However, there is no consensus among hip arthroscopic surgeons as to the surgical approach of choice, and several subtle nuances in the surgical technique remain under debate. Perhaps in no other area is this more contested than in the controversy over hip capsular closure. As noted in a recent systematic review by Domb and colleagues,12 the role of the hip capsuloligamentous structures in overall hip stability remains unclear. Hip joint stability is dependent on both static and dynamic stabilizers. The static stabilizers include the osseous congruency of the femoroacetabular joint (femoral head and acetabulum), the labrum, and the capsuloligamentous structures, while the dynamic stabilizers include the hip girdle musculature as well as neuromuscular control and proprioception. During ‘‘routine’’ hip arthroscopic surgery for cam and/or pincer FAI, every attempt is made to restore the native bony anatomy of the hip via acetabular rim trimming and/ or proximal femoral osteochondroplasty, with or without labral debridement or repair. To access the joint, either capsulotomy or capsulectomy is typically performed.12 After the procedure is performed in the central and peripheral compartments to address FAI, capsulotomy can be either left open, partially repaired, or completely repaired. As noted by multiple authors, the role of the hip capsule in restoring native hip mechanics, including rotation, translation, and axial stability, is important.5,13,42 Without restoration of the native anatomy, the hip joint may translate when patients attempt athletic activities, leading either to recurrent microinstability or frank dislocation, as noted in several case reports. At the time of the submission of this article, 6 cases of hip dislocation after hip arthroscopic surgery have been reported over the past 5 years.3,24,29,37,38 These findings were similarly noted in a recent systematic review analyzing the complications associated with hip arthroscopic surgery, with 4 dislocation events reported.16 In another study performed by McCormick and colleagues,27 78% of patients who underwent revision arthroscopic surgery after undergoing hip arthroscopic surgery for FAI had evidence of capsular defects on magnetic resonance arthrography (MRA) (Video Supplement 1). While rare, hip instability after arthroscopic surgery is a devastating complication, and

strategies for reducing, and ultimately preventing, this catastrophic outcome are warranted. The overall contribution of repairing the hip capsule after hip arthroscopic surgery for FAI is controversial. As hip arthroscopic surgery continues to evolve, there is a theoretical advantage to completely repair the hip capsule, but there are no published studies comparing the clinical outcome of a completely repaired capsule to a capsule that is left open. The purpose of the present study was to compare the clinical outcomes of patients undergoing hip arthroscopic surgery for FAI with T-capsulotomy with partial capsular repair (PR; closed vertical incision, open interportal incision) versus complete capsular repair (CR; full closure of both incisions) at a minimum 2-year follow-up. The hypothesis was that there would be improved clinical outcomes in patients undergoing CR compared with those undergoing PR.

MATERIALS AND METHODS Study Design This study was approved by our institutional review board. Prospective data on consecutive patients undergoing hip arthroscopic surgery for FAI by a single fellowship-trained surgeon from January 2011 to January 2012 were collected and analyzed. All consecutive patients between the ages of 16 and 65 years with physical examination and imaging findings consistent with symptomatic FAI who underwent unilateral hip arthroscopic surgery including acetabular rim trimming, femoral osteochondroplasty, labral repair or debridement, and capsular repair were included. Inclusion criteria included patients with failed nonoperative management (consisting of therapy and/or intra-articular corticosteroid injections) with a minimum 2-year follow-up. Exclusion criteria included patients with bilateral labral lesions, bilateral symptomatic FAI, history of significant ipsilateral hip or knee injury, history of ipsilateral hip or knee surgery, significant lumbosacral spine lesion, workers’ compensation cases, or other major medical comorbidities. All patients underwent T-capsulotomy with either PR or CR. Patients from January 2011 to June 2011 underwent PR, while patients from July 2011 to January 2012 underwent CR. All surgeries were performed via the senior surgeon’s standard of care. The senior surgeon changed his technique in July 2011, based on anecdotal evidence that patients with PR were coming into the office with less than desired subjective outcomes, and further, several patients required revision surgery. A sex- and age-matched (62 years) group of patients who underwent T-capsulotomy with CR was formed for comparison. Partial capsular repair was defined as closure of the vertical incision of T-capsulotomy,

*Address correspondence to Rachel M. Frank, MD, Department of Orthopaedic Surgery, Rush University Medical Center, 1611 West Harrison Street, Suite 200, Chicago, IL 60612, USA (e-mail: [email protected]). y Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA. z Hospital for Special Surgery, New York, New York, USA. § University Hospitals Case Medical Center, Cleveland, Ohio, USA. The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.

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Figure 1. Schematic of (A) partial capsular closure and (B) complete capsular closure. while the interportal incision remained unrepaired (Figure 1A). Complete capsular repair was defined as closure of the interportal incision in addition to the vertical incision of Tcapsulotomy (Figure 1B). Patients who met the study criteria completed a preoperative questionnaire that included relevant demographic information (age, sex, side of operative extremity). Intraoperative data included both diagnostic information as well as procedures performed (acetabular rim trimming, labral refixation, femoral osteochondroplasty, iliopsoas lengthening, type of capsular repair, trochanteric bursectomy, iliotibial band lengthening).

Surgical Technique All patients underwent hip arthroscopic surgery under general anesthesia using a previously described technique.17,41 Patients were placed in the supine position on a traction table with a well-padded perineal post. Axial traction was then applied,17,27,41 and the time onset of hip distraction was marked by the circulating nursing staff to ensure a safe duration of traction time. An anterolateral (AL) portal was first established. Before fluid introduction, needle-localized placement of an anterior portal was performed. After cannulation of the anterior portal, the arthroscope was then placed into it and used to assess the location of the AL portal (outside the labrum). Transverse interportal capsulotomy was performed from 12 o’clock to 2 o’clock about 5 to 8 mm from the labrum using an arthroscopic scalpel and approximately 4 cm in length. The capsule adjacent to the acetabulum was then reflected to expose the superior acetabular rim from the indirect head of the rectus femoris insertion (12-o’clock position) laterally to the iliopsoas tendon (3-o’clock position) anteriorly. Acetabular rim trimming and labral refixation with suture anchors were then performed as appropriate41 using a distal AL accessory (DALA) portal. Next, traction was released, and the hip was flexed roughly 30°. T-capsulotomy was then performed

using an arthroscopic scalpel through a 5.0-mm cannula in the DALA portal at the interval between the iliocapsularis and gluteus minimus muscles. T-capsulotomy was performed perpendicular to the prior transverse capsulotomy along the length of the femoral neck distally to the capsular reflection at the intertrochanteric line to access the femoral head-neck junction in the peripheral compartment. All indicated procedures, including femoral osteochondroplasty between 12 o’clock and 6 o’clock, were then performed, and the hip was taken through a dynamic examination. The surgical technique can be viewed online (Video Supplement 2). Closure of the capsulotomy was performed either with a PR technique with repair of the vertical incision of T-capsulotomy only (Figure 1A) or with a CR technique with repair of both the interportal and Tcapsulotomy incisions (Figure 1B). While viewing from the anterior portal, an 8.5 3 110–mm plastic cannula was inserted in the DALA portal, and an 8.5 3 90–mm plastic cannula was placed in the AL portal. The vertical portion of T-capsulotomy was closed first at the base of the iliofemoral ligament (IFL). A suture-shuttling device (Suture Lasso, Arthrex) was placed through the AL portal to pierce the lateral limb of the IFL and shuttle the nitinol wire, while a tissue penetrator (Arthrex) was used to pierce the medial limb of the IFL and retrieve the nitinol wire via the DALA portal. A No. 2 high–molecular weight polyethylene suture was placed in the nitinol wire, and the nitinol wire was pulled out of the AL portal to shuttle the suture. Next, both limbs of the suture were retrieved through the DALA portal and tied using reverse half-hitches and alternating posts. The vertical portion of T-capsulotomy was closed with 2 to 4 sutures and was the extent of PR (Figure 2A). In CR, the interportal incision of capsulotomy was then repaired using a capsular closure device (Injector, Pivot Medical). The Injector was placed through the AL portal to close the lateral aspect of interportal capsulotomy by placing the suture through the acetabular limb of the capsule and then through the lateral leaflet of the IFL. Through the DALA portal, the Injector was used to close the medial aspect of interportal capsulotomy by placing the suture through the acetabular limb and then through the medial leaflet of the IFL. Once the sutures were placed through the interportal incision, they were tied using standard arthroscopic tying techniques. With the capsule completely repaired, the articular cartilage of the femoral head was no longer visible (Figure 2B).

Rehabilitation Postoperatively, all patients were fitted with a hip orthosis and were restricted to a crutch-assisted gait with 20 lb of foot flat weightbearing for 3 weeks. The orthosis allows for 0° to 90° of hip flexion. Continuous passive motion and a stationary bicycle were used in the first 3 postoperative weeks as well as passive hip circumduction. It is important to avoid hip extension and external rotation, which are positions that may disrupt capsulolabral repair during the first 3 weeks. At 3 weeks after surgery, patients were weaned from the brace and crutches, and gentle hip extension and external rotation

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Figure 2. Arthroscopic photographs (A) demonstrating visualization after T-capsulotomy and (B) the result of complete capsular repair. were started to avoid loss of motion. Muscle strengthening (hip abductors, adductors, gluteus maximus, and core/trunk) was subsequently progressed, with the core/trunk advanced slowly to avoid iliopsoas tendinitis. Balance and proprioception were also retrained. Closed kinetic chain exercises were begun at 6 weeks postoperatively in combination with more aggressive stretching. Treadmill running was allowed at 12 weeks postoperatively. Return to sport was initiated slowly at 4 to 6 months after surgery.

Functional Outcome Evaluation Patients completed hip-specific outcome instruments including the Hip Outcome Score Activities of Daily Living (HOSADL) and Sport-Specific (HOS-SS) subscales (see the Appendix, available at http://ajsm.sagepub.com/supplemental)22,23 and the modified Harris Hip Score (mHHS)7,18 as well as patient-determined satisfaction (measured on a 1-10 visual analog scale, with 10 being most satisfied) and clinical improvement at baseline and 6 months, 1 year, and most recent follow-up (minimum 2 years) after surgery. At final follow-up, patients were examined by an independent observer, and forward elevation, external rotation with the hip flexed to 90°, and internal rotation with the hip flexed to 90° were recorded with a goniometer. All complications, including the need for revision surgery, were also recorded.

Radiographic Analysis Plain radiographs were obtained at baseline and final follow-up. All patients had standard anteroposterior (AP) radiographs for the pelvis as well as false profile and oblique lateral (Dunn) views with the patient in a supine position. All radiographs were obtained with the coccyx positioned midline, approximately 1 cm above the pubic symphysis (neutral tilt) and the obturator foramina and the trochanters symmetric (neutral rotation).11 The lateral center edge angle of Wiberg (AP view) and alpha angle (Dunn lateral view) were measured on plain radiographs using a digital picture archiving and communication system (PACS).11,43

Statistical Analysis Descriptive analysis consisted of frequencies and percentages for discrete data and means and SDs for continuous data. Paired t tests were performed to compare preoperative and postoperative measures including range of motion and HOS-ADL, HOS-SS, and mHHS scores. Unpaired t tests were used to compare clinical outcome scores between the PR and CR groups (SPSS Statistics v 21.0, IBM Corp). All reported P values were 2-tailed, with an a level of .05 detecting significant differences.

RESULTS A total of 64 patients were identified who met the study criteria, with 32 patients (12 male, 20 female) in each group. The average age at the time of surgery for all patents was 32.8 6 9.9 years (range, 16.5-62.7 years). For all patients, the average center edge angle (CEA) was 33.7° 6 5.5°, and the average alpha angle (AA) was 58.2° 6 9.8°; there were no differences between the PR and CR groups (Table 1). All 64 patients were available for follow-up (100%), with an average follow-up of 29.9 6 2.6 months (minimum 2 years). There were no significant differences in the average followup between the PR (30.1 6 2.9 months) and CR (29.7 6 2.5 months) groups (P = .507). There were no significant demographic differences between the PR and CR groups after stratification (Table 1). Similarly, there were no differences between the groups regarding the specific arthroscopic procedures performed or the operative duration (PR: 134 6 22 minutes vs CR: 129 6 25 minutes; P = .455) (Table 1).

Functional Outcomes For all patients, there was a significant increase at 2.5-year follow-up in the HOS-ADL (P \ .0001), HOS-SS (P \ .0001), mHHS (P \ .0001), and subjective satisfaction (P \ .0001) scores as compared with the preoperative state (Figures 3 and 4 and Table 2).

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TABLE 1 Patient Demographics

Patients, n Sex, n Male Female Age, mean 6 SD, y Side of surgery, n Left Right Center edge angle, mean 6 SD, deg Preoperative Postoperative Alpha angle, mean 6 SD, deg Preoperative Postoperative Body mass index, mean 6 SD, kg/m2 Follow-up, mean (range), mo Acetabular rim trimming, n Femoral osteochondroplasty, n Labral repair, n Psoas release, n

All Patients

Partial Closure

Complete Closure

64

32

32

24 40 32.79 6 9.87

12 20 32.87 6 9.84

12 20 32.65 6 10.16

33 31

13 19

20 12

33.73 6 5.51 30.37 6 4.83

33.27 6 5.51 29.49 6 4.70

34.15 6 5.57 31.31 6 4.80

.6256 .1461

58.19 6 9.79 41.75 6 4.24 24.86 6 3.47 29.9 (24.7-35.4) 58 64 64 25

56.91 6 11.15 42.38 6 3.51 24.98 6 3.19 30.1 (24.7-35.4) 30 32 32 14

59.43 6 8.27 40.40 6 4.58 24.75 6 3.77 29.7 (24.2-33.8) 28 32 32 11

.4504 .0667 .8113 .507 .6719 — — .6088

mHHS

100

9

80

8

70

7

60

6

50

5

40

4

30

3 2

20

1

10 0

.9291 .1328

Hip Sasfacon

10

90

P Value

Paral Repair

Complete Repair Pre-Op

0 Paral Repair

Complete Repair Pre-Op

2 Year

2 Year

Figure 3. Preoperative and postoperative (at latest follow-up) modified Harris Hip Score (mHHS) outcomes in patients undergoing partial capsular repair and complete capsular repair.

Figure 4. Preoperative and postoperative (at latest followup) subjective hip satisfaction outcomes in patients undergoing partial capsular repair and complete capsular repair.

Both groups demonstrated significant improvements at final follow-up compared with preoperative measurements in the HOS-ADL score. Specifically, the PR group improved from 64.6 6 17.0 to 90.7 6 8.4 postoperatively (P \ .0001), and the CR group improved from 66.1 6 15.7 to 92.1 6 7.9 postoperatively (P \ .0001) (Figure 5). There was also a significant improvement in the HOS-SS score, with the PR group improving from 39.4 6 23.9 to 83.6 6 9.6 (P \ .0001) and the CR group improving from 39.1 6 24.2 to 87.3 6 8.3 (P \ .0001) (Figure 6). Further stratification revealed that compared with the PR group, the CR group demonstrated significantly superior outcomes in the HOS-SS score at 6 months (PR: 63.8 6 31.1 vs CR: 72.2 6 16.1; P = .039), 1 year (PR: 72.7 6 14.7 vs CR: 82.5 6 10.7; P = .006), and 2.5 years (PR: 83.6 6 9.6 vs CR: 87.3 6 8.3; P = .001) after surgery. No such deviation was found when comparing the HOS-ADL scores at these time points.

The CR group had significantly improved HOS-SS scores at 6 months compared with baseline (P \ .0001), at 1 year compared with 6 months (P = .008), and at 2.5 years compared with 1 year (P = .017). In contrast, the PR group had significantly improved HOS-SS scores at 6 months (P \ .0001) and 1 year (P = .012) but did not have a significant improvement when comparing 2.5-year outcomes to 1-year outcomes (P = .059). There were no significant differences between the PR and CR groups in postoperative range of motion at final follow-up. The final average forward flexion was 120.5° 6 14.7° in the PR group compared with 126.1° 6 15.2° in the CR group (P = .1422), external rotation was 45.2° 6 13.0° in the PR group compared with 46.0° 6 11.5° in the CR group (P = .7936), and internal rotation was 22.7° 6 6.8° in the PR group compared with 23.7° 6 6.2° in the CR group (P = .5522) (Table 3).

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TABLE 2 Patient-Reported Outcomes for All Patientsa

HOS-SS 100 90

Preoperative All patients HOS-ADL HOS-SS mHHS Satisfaction Partial closure HOS-ADL HOS-SS mHHS Satisfaction Complete closure HOS-ADL HOS-SS mHHS Satisfaction

Postoperative (Final) P Value

*

*

70

64.62 39.42 59.94 4.46

6 6 6 6

17.04 23.85 10.18 1.23

90.74 83.62 82.45 8.35

6 6 6 6

839 9.57 4.97 1.02

\.0001 \.0001 \.0001 \.0001

64.62 39.42 59.94 4.46

6 6 6 6

17.04 23.85 10.18 1.23

90.74 83.62 82.45 8.35

6 6 6 6

8.39 9.57 4.97 1.02

\.0001 \.0001 \.0001 \.0001

66.14 39.06 58.81 4.66

6 6 6 6

15.72 24.24 11.74 1.15

92.06 87.34 83.00 8.63

6 6 6 6

7.90 8.27 4.38 1.07

\.0001 \.0001 \.0001 \.0001

60 50 40 30 20

a Values are expressed as mean 6 SD. ADL, Activities of Daily Living; HOS, Hip Outcome Score; mHHS, modified Harris Hip Score; SS, Sport-Specific.

10 Pre-Op

6 Month Paral Repair

1 Year

2 Year

Complete Repair

Figure 6. Preoperative, 6-month, 1-year, and 2-year Hip Outcome Score Sport-Specific (HOS-SS) subscale outcomes in patients undergoing partial capsular repair and complete capsular repair. *Significant differences between groups. average 16.5 6 4.5 months after the index procedure, for an overall revision rate of 6.25%. There were no infections, nerve palsies, fractures, or other complications.

HOS-ADL

100

DISCUSSION

90 80 70 60 50 40

*

80

Pre-Op

6 Month Paral Repair

1 Year

2 Year

Complete Repair

Figure 5. Preoperative, 6-month, 1-year, and 2-year Hip Outcome Score Activities of Daily Living (HOS-ADL) subscale outcomes in patients undergoing partial capsular repair and complete capsular repair.

Radiographic Outcomes For all patients, the preoperative average CEA was 33.7° 6 5.5°, and the AA was 58.2° 6 9.8°. The CEA improved from 33.3° 6 5.5° to 29.5° 6 4.7° in the PR group and from 34.2° 6 5.6° to 31.3° 6 4.8° in the CR group; the postoperative CEA values between the groups were not significantly different (P = .1461). Similarly, the AA improved from 56.9° 6 11.2° to 42.4° 6 3.5° in the PR group and from 59.4° 6 8.3° to 40.4° 6 4.6° in the CR group; the postoperative AA values between the groups were not significantly different (P = .0667) (Table 1).

Revisions and Complications Four patients in the PR group (13%) required revision hip arthroscopic surgery for persistent pain, while no patients in the CR group (0%) required revision surgery at an

This study aimed to determine the overall contribution of repairing the hip capsule after hip arthroscopic surgery for FAI by comparing the clinical outcomes of patients undergoing hip arthroscopic surgery with T-capsulotomy with PR versus CR. The principal findings of this study were that (1) there were no revisions in the CR group compared with 4 revisions (13%) in the PR group, (2) patients in the CR group demonstrated superior clinical outcomes on the HOS-SS compared with those undergoing PR at all time points, and (3) patients undergoing CR reported higher levels of satisfaction at final follow-up compared with those undergoing PR. Overall, the results from this study confirmed the authors’ hypothesis in that there were overall improved clinical outcomes in patients undergoing CR compared with those undergoing PR. Hip capsule management after hip arthroscopic surgery is controversial. Historically, capsular management consisted of capsulotomy or capsulectomy. Early outcome studies reported good short-term results with these techniques.10,26,32,36 However, recently, several authors have reported cases of instability after hip arthroscopic surgery for FAI, including frank hip dislocation.3,24,37 While the specific cause of instability is unknown, the capsule and labrum are likely to play a role. Determining if instability after hip arthroscopic surgery is iatrogenic (ie, from excessive capsulotomy or capsulectomy) versus traumatic or is a result of generalized ligamentous laxity is difficult to conclude. Ranawat and colleagues37 reported on a patient with generalized ligamentous laxity who fell 2 months after hip arthroscopic surgery, labral repair, cam resection, and anterior capsular repair. The patient was found to have an anterior hip dislocation and underwent revision hip arthroscopic surgery with anterior capsulorrhaphy.

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TABLE 3 Postoperative (Final) Radiographic and Physical Examination Findingsa All Patients Center edge angle, deg Alpha angle, deg Forward flexion, deg External rotation, deg Internal rotation, deg

30.37 41.75 123.31 45.58 23.17

6 6 6 6 6

4.83 4.24 15.10 12.20 6.44

Partial Closure 29.49 42.38 120.50 45.17 22.67

6 6 6 6 6

4.70 3.51 14.74 13.03 6.79

Complete Closure 31.31 40.40 126.10 46.00 23.67

6 6 6 6 6

4.80 4.58 15.15 11.48 6.15

P Value .1461 .0667 .1422 .7936 .5522

a

Values are expressed as mean 6 SD.

Matsuda24 also reported on a patient who had a dislocated hip in the recovery room after hip arthroscopic surgery for FAI with acetabular rim trimming, labral debridement, and femoral osteochondroplasty. The patient underwent immediate mini-open anterior capsulorrhaphy. Both cases required revision capsular plication to restore hip stability and therefore suggest that the hip capsule has a critical role in maintaining overall hip stability. These and other reported cases suggest that improper management of the hip capsule after hip arthroscopic surgery can lead to iatrogenic macroinstability on rare occasions, but iatrogenic microinstability may be more common but underreported because of the difficulty in diagnosis. Recently, McCormick and colleagues27 reported that 78% of patients who underwent revision arthroscopic surgery after undergoing hip arthroscopic surgery for FAI were observed to have evidence of capsular and iliofemoral defects on MRA. Thus, patients who have undergone hip arthroscopic surgery with persistent, vague hip pain and a sense of laxity that occurs with activities of daily living, as well as decreased athletic performance, should undergo MRA to evaluate the integrity of the hip capsule. Alternatively, less aggressive techniques for gaining exposure during hip arthroscopic surgery can be attempted by utilizing selective, limited incisions in situations that would allow for adequate visualization. Certainly, the benefits of improving visualization with a large capsualotomy must be weighed against the potential risks of destabilizing the joint. Based on the results from the present study, patients undergoing hip arthroscopic surgery for FAI with either partial or complete capsular closure can expect significant clinical improvements as noted by both the HOS and mHHS scores at 6 months, 1 year, and 2.5 years after surgery. Importantly, when breaking down the HOS into its various components, no difference was found between the CR and PR groups in the HOS-ADL score, demonstrating that at least some form of closure is beneficial for these patients and that return to activities of daily living can be expected in most cases. Also important to note is that the mHHS instrument was designed as a disease-specific score for patients with hip osteoarthritis, who represent a different group of patients with different physical demands and expectations than patients undergoing hip arthroscopic surgery. Thus, the use of the mHHS as a primary outcome after hip arthroscopic surgery, as utilized in several published studies, represents a source of detection bias, as the mHHS has a ‘‘ceiling’’ effect in these higher

level, higher demand patients, and may not be a sensitive enough outcome scale to evaluate the desired outcome. A recent systematic review conducted by Hetaimish and colleagues19 reported on the variability in reported outcomes after FAI surgery. Within the 29 included studies incorporating 2816 patients, the mHHS is the most commonly utilized outcome measure, used in 13 studies (45%), with range of motion as the most commonly reported physical examination outcome (10 studies; 34%). The authors concluded that a significant variation exists in the reported outcomes after hip arthroscopic surgery for FAI, clearly highlighting the challenge in evaluating these patients. When considering the HOS-SS score, patients in the CR group performed significantly better compared with those in the PR group at 6-month, 1-year, and final follow-up. Further, the magnitude of change from the preoperative HOS-SS scores to the final follow-up scores was substantially greater in the CR group (increase of 33 points at 6 months, 44 points at 1 year, 48 points at 2.5 years) compared with the PR group (increase of 25 points at 6 months, 34 points at 1 year, 45 points at 2.5 years), despite nearly equal baseline scores in both groups. Interestingly, not only were HOS-SS scores significantly better in the CR group compared with the PR group at final follow-up, but also, the patients in the PR group appeared to plateau at 1 year, as their 2.5-year scores were not significantly improved compared with their 1-year scores. In contrast, the CR group had significantly improved scores at 2.5 years compared with 1 year in addition to having significantly better scores than the PR group at both 1-year and final follow-up. The HOS-SS subscale asks patients to rate their level of difficulty in performing activities such as running 1 mile, jumping, swinging objects (golf club), landing, starting/ stopping quickly, cutting/lateral movements, low-impact activities, ability to perform a desired activity with their normal technique, and finally ability to participate in a desired sport for the desired duration. In the young athletic patient population that typically undergoes hip arthroscopic surgery for FAI, including those patients in the present study with an average age of 33 years, these activities are at least as important for function as the activities found in the HOS-ADL subscale. In addition, these activities, especially starting/stopping quickly and cutting/ lateral movements, likely require an intact hip capsule or one that is anatomically repaired after arthroscopic surgery, more so than do lower impact activities of daily living, given

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Vol. 42, No. 11, 2014

Complete Capsular Repair in Hip Arthroscopic Surgery for FAI 2641

the role of the capsule in maintaining normal kinematics of the hip joint.5,12,42 As such, the significantly improved HOS-SS scores in the CR group are perhaps even more clinically relevant than initially thought for higher levels of activity, given the improved scores for these activities in the CR group compared with the PR group. Several studies analyzing outcomes after hip arthroscopic surgery have utilized return-to-play rates as a major outcome.1,4,6,15,28,31,32,40 It is important to note that many of the patients in these studies are professional athletes, which introduces an entire separate set of additional biases, including socioeconomic motivations. Thus, using a validated outcome instrument such as the HOS-SS may be more useful and generalizable to the typical patient undergoing hip arthroscopic surgery as opposed to return to play, which is likely more applicable in the high-level athlete. The overall revision rate for the entire study group cohort was low at 6.25%. However, all patients (n = 4) requiring revision surgery were in the PR group (13% of these 32 patients) and none in the CR group (0%). All 4 patients who underwent revision surgery were female, with an average age of 27.5 years, and underwent revision arthroscopic surgery at an average 16.5 6 4.5 months after the index procedure. Although none of these patients dislocated their hip, each patient required revision surgery for persistent hip pain and a capsular defect identified on MRA. Three patients developed hip pain after returning to high levels of physical activity, and 1 patient developed an insidious onset of mechanical hip symptoms. None of these patients experienced an acute traumatic event after surgery, and all were noted to be compliant with their postoperative restrictions and therapy. Based on the clinical and intraoperative findings of these patients, the authors conclude that repetitive, and potentially subtle, hip microinstability, associated with a partial, nonanatomic capsular closure, contributes, at least in part, to the need for revision surgery. There may be concerns of hypermobility in these patients that could have contributed to their failure, but there were no revision cases in the CR group with a similar demographic profile. All patients underwent revision hip arthroscopic surgery incorporating debridement, acetabular rim trimming, femoral osteochondroplasty, labral repair, and CR. This study had several limitations, including its retrospective nature and relatively short-term follow-up period of 29.9 months. In addition, the outcome instruments utilized in this study, including the mHHS and HOS, represent limitations to this study. The mHHS is limited because of its ceiling effects, as it was initially designed as a diseasespecific score for hip osteoarthritis. Although a validated hip-specific outcome instrument, the HOS is limited, as it is a patient-reported outcome score but not patient derived. The authors currently use validated hip-specific outcome scores such as the International Hip Outcome Tool (iHOT12, iHOT-33)14,30; however, these data were not used at the time of data collection for the present study. The other potential limitation is that PR was performed initially, and then the senior author (S.J.N.) transitioned to CR, which may suggest an improvement in the overall surgical technique. The transition happened over a relatively short period of time, and no other variables were introduced in

the surgical technique. As noted by multiple authors, the suggested learning curve for competency in hip arthroscopic surgery is 30 cases, and as the senior author had performed over 500 hip arthroscopic procedures before the initiation of this study, a learning curve was likely not a relevant factor in the overall outcomes found in this study.20 The patient characteristics and procedures performed were similar in both groups, including operative duration, and the only difference was the status of the closure. As noted, over this time period, patients were only included in the study after meeting strict inclusion/exclusion criteria, with the goal of eliminating variables that may have confounded the results; however, this may have resulted in selection bias. This study also had several strengths, including the use of ageand sex-matched study groups, the use of multiple validated hip-specific outcome scores, and the use of both 6-month and 1-year data for all patients, allowing for comparisons and trending of outcomes over time. Overall, this is the first study to directly compare partial capsular closure to complete capsular closure after hip arthroscopic surgery for FAI in age- and sex-matched cohorts. Utilizing these preliminary short-term outcome data, the authors recommend performing complete capsular closure in all appropriate patients undergoing hip arthroscopic surgery for FAI. Future long-term studies are needed to determine if these results are maintained over time.

CONCLUSION This is the first study to compare the outcomes of PR and CR in an age-, sex-, and radiograph-matched cohort. Based on the results from the present study, complete capsular closure is our recommended technique for all patients undergoing hip arthroscopic surgery for FAI.17 Patients undergoing CR of the hip capsule after hip arthroscopic surgery for FAI have superior clinical outcomes with notably less revision surgery compared with those undergoing PR. Further, patients undergoing CR reported higher levels of satisfaction at 2.5 years compared with those undergoing PR. While longer term outcome studies are needed to determine if these results are maintained over time, and prospective studies are needed to confirm our findings, these data suggest improved outcomes after CR compared with PR at 2.5 years after hip arthroscopic surgery for FAI.

ACKNOWLEDGMENT The authors acknowledge Dr Adam Yanke for his original illustrations. A Video Supplement for this article is available in the online version or at http://ajsm.sagepub.com/supplemental.

REFERENCES 1. Amenabar T, O’Donnell J. Return to sport in Australian football league footballers after hip arthroscopy and midterm outcome. Arthroscopy. 2013;29(7):1188-1194.

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2642 Frank et al

The American Journal of Sports Medicine

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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.

Hip capsular management after hip arthroscopic surgery for femoroacetabular impingement (FAI) is controversial...
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