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Andrews technique. 26 (ACL, anterior cruciate ligament; FCL, fibular collateral ligament; IT, iliotibial; lat, lateral; med, medial; PCL, posterior cruciate ligament.)
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Biomechanical and clinical studies have shown that the hip joint capsule plays an important role in maintaining stability and hip mechanics, including rotation and translation. The recent literature has shown that capsule closure after hip arthroscopy helps to restore stability. Without restoration of the native anatomy, the hip joint may translate...
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Hip microinstability is a recognized cause of hip pain in young patients. Intra-operative evaluation is used to confirm the diagnosis, but limited data exist associating magnetic resonance arthrography (MRA) findings with hip microinstability. To determine if a difference exists in the thickness of the anterior joint capsule and/or the width of the...
Citations
... [1][2][3][4][5] Several prior biomechanical and technical studies have noted the significant stabilizing function of the hip capsule and the biomechanical importance of hip capsular closure. [6][7][8] These studies highlight a paradigm shift in the management of the hip capsule in arthroscopic hip surgery. In this article, we present use of a knotless implant for arthroscopic hip capsular closure or plication. ...
The hip joint capsule plays a significant role in maintaining hip stability, including translation and rotation. Hip capsular closure or plication has been shown to increase stability of the joint following capsulotomy in hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS) and/or associated labral tears. This technique article describes a knotless method of closing the hip capsule.
... 14,17 Several new suture techniques have recently been described for capsular closure. Menge et al 19 reported on the Quebec City slider (QCS) technique, while Kizaki et al 16 and Uchida et al 27 detailed the arthroscopic shoelace and double shoelace capsular closure techniques. However, the biomechanical efficacy of these techniques as compared with standard suture has not yet been evaluated, and it remains unknown which technique best prevents postoperative hip instability. ...
... The 2 resultant loops were placed in one hand, and the free end of the suture was passed through both loops and pulled tight, in accordance with the previously described technique. 19 This stitch was secured with alternating half-hitch knots. Five QCS stitches were placed evenly to close the capsulotomy. ...
Background
The most reliable suture technique for capsular closure after a capsulotomy remains unknown.
Purpose
To determine which suture technique best restores native stability after a 5-cm interportal capsulotomy.
Study Design
Controlled laboratory study.
Methods
Ten human cadaveric hip specimens were tested using a 6-degrees-of-freedom robotic arm in 7 states: intact, capsular laxity, 5-cm capsulotomy, standard suture, shoelace, double shoelace, and Quebec City slider (QCS). Rotational range of motion (ROM) was measured across 9 tests: flexion, extension, abduction, abduction at 45° of flexion, adduction, external rotation, internal rotation, anterior impingement, and log roll. Distraction (ie, femoral head translation [FHT]) was measured across a range of flexion and abduction angles.
Results
When compared with the native state, the 5-cm capsulotomy state showed the largest laxity increases on all tests, specifically in external rotation ROM (+13.4°), extension ROM (+11.5°), and distraction FHT (+4.5 mm) ( P < .001 for all). The standard suture technique was not significantly different from the 5-cm capsulotomy on any test and demonstrated significantly more flexion ROM than the double shoelace suture (+1.41°; P = .049) and more extension ROM (+5.51°; P = .014) and external rotation ROM (+6.03°; P = .021) than the QCS. The standard suture also resulted in significantly higher distraction FHT as compared with the shoelace suture (+1.0 mm; P = .005), double shoelace suture (+1.4 mm; P < .001), and QCS (+1.1 mm; P = .003). The shoelace, double shoelace, and QCS techniques significantly reduced hip laxity when compared with the 5-cm capsulotomy state, specifically in external rotation ROM (respectively, –8.1°, –7.8°, and –10.2°), extension ROM (–6.3°, –7.3°, and –8.1°), and distraction FHT (–1.8, –2.2, and –1.9 mm) ( P ≤ .003 for all). These 3 techniques restored native stability (no significant difference from intact) on some but not all tests, and no significant differences were observed among them on any test.
Conclusion
Hip capsule closure with the standard suture technique did not prevent postoperative hip instability after a 5-cm capsulotomy, and 3 suture techniques were found to be preferable; however, none perfectly restored native stability at time zero.
Clinical Relevance
The shoelace, double shoelace, and QCS suture techniques are recommended when closing the hip capsule.
... Capsular plication is recommended when treating patients with hip instability, 2 and complete capsular closure with strong sutures can provide better clinical outcomes and lower revision rates compared with partial capsular closure in the treatment of femoroacetabular impingement. 3,4 In addition, Menge et al. 5 reported that the Quebec City slider could be stronger for capsular closure than other plication procedures using strong sutures. Portal placements for double shoelace hip capsular closing technique for a left hip. ...
Hip arthroscopy is an innovative surgical tool that is minimally invasive; however, the working space is very limited because of small surgical wounds. Recent literature has shown that capsular repair after capsulotomy during hip arthroscopy facilitates the restoration of hip joint stability. Previous Technical Notes have introduced the shoelace capsule closing technique using a single Ultratape. However, even with the shoelace capsule closing technique, we periodically have encountered difficult cases with extensive capsular laxity. In this Technical Note, we introduce an improved hip capsule plication technique using 2 pieces of Ultratape for treating borderline hip dysplasia with capsular laxity. This double shoelace capsule plication technique theoretically reduces tearing risks during closure of delicate and fragile capsules. Level of evidence: 1 (hip); 2 (other).
... The hip was secured in this position with 2 pins passing through the femur and pelvis. § References 3,4,8,9,17,19,20,21,23,24,26,28,38. ...
... The midportion of the lateral, medial, and distal edges of the graft were fixed in a side-to-side fashion with a No. 2 absorbable suture (Vicryl) using an arthroscopic knot that prevented inadvertent locking of the knot before capsular closure ( Figure 3C). 23 ...
Background: The capsular ligaments and the labral suction seal cooperatively manage distractive stability of the hip. Capsular
reconstruction using an iliotibial band (ITB) allograft aims to address capsular insufficiency and iatrogenic instability. However, the
extent to which this procedure may restore hip distractive stability after a capsular defect is unknown.
Purpose: To evaluate the biomechanical effects of capsular reconstruction on distractive stability of the hip joint.
Study Design: Controlled laboratory study.
Methods: Eight fresh-frozen cadaveric hip specimens were dissected to the level of the capsule and axially distracted in 3 testing
states: intact capsule, partial capsular defect, and capsular reconstruction with an ITB allograft. Each femur was compressed with
500 N of force and then distracted 6 mm relative to the neutral position at 0.5 mm/s. Distractive force was continuously recorded,
and the first peak delineating 2 phases of hip distractive stability in the force-displacement curve was analyzed.
Results: The median force at maximum distraction in the capsular reconstruction state (156 N) was significantly greater than that
in the capsular defect state (89 N; P = .036) but not significantly different from that in the intact state (218 N; P = .054). Median
values for distractive force at first peak (60 N, 72 N, and 61 N, respectively; P = .607), distraction at first peak (2.3 mm, 2.3 mm,
and 2.5 mm, respectively; P = .846), and percentage decrease in distractive force (35%, 78%, and 63%, respectively; P = .072)
after the first peak were not significantly different between the intact, defect, and reconstruction states.
Conclusion: Capsular reconstruction with an ITB allograft significantly increased the force required to distract the hip compared
with a capsular defect in a cadaveric model. To our knowledge, this is the first study to report an initial peak distractive force and
to propose 2 distinct phases of hip distractive stability.
Clinical Relevance: The consequences of a capsular defect on distractive stability of the hip may be underappreciated among
the orthopaedic community; with that said, capsular reconstruction using an ITB allograft provided significantly increased distractive
stability and should be considered an effective treatment option for patients with symptomatic capsular deficiency.
Keywords: hip instability; capsular reconstruction; hip suction seal; distractive stability; hip arthroscopic surgery
... The "Que- bec City Slider" is our preferred technique for capsular closure in order to restore the capsular integrity. 28 ...
Hip arthroscopy is an evolving procedure and its indications have expanded. The number of patients undergoing this procedure has increased significantly as well as the number of surgeons being trained. This has resulted in a notable increase in post-operative complication rates creating the need to develop advanced hip arthroscopic techniques. Revision hip arthroscopy is often complex and many factors should be considered to achieve a satisfactory clinical outcome. Careful pre-operative planning and agreement of expectations between the physician and patient regarding the procedure are important. This review describes several advanced treatment options that are used mainly in revision or complex primary hip arthroscopy cases. Labral reconstruction or augmentation technique is used in cases of severely deficient acetabular labral tissue to restore the fluid seal mechanism. In cases of symptomatic (often post-operative) adhesion formation, a spacer between the labrum and the joint capsule is useful for pain relief and prevention of future adhesions. Large defects of the capsule due to previous unrepaired capsulotomy or any other cause can be addressed with the capsular reconstruction technique. Ligamentum teres reconstruction using an anterior tibialis allograft is indicated in patients with hip instability and persistent pain after previous debridement or with complete tears of this structure. The senior author’s treatment of choice in cases of previous over-resection of CAM impingement is the remplissage technique to restore the bony defect of the femoral head-neck junction and preserve the joint seal.
... Once the intra-articular pathologies have been addressed, the hip capsule will be closed or left open depending on what the patient has been randomised to. If the capsule is to be closed, the hip is flexed to approximately 30° while the capsule is closed with two to three No. 2 Vicryl sutures (Ethicon), using a 'Quebec City Slider' knot technique as described by MP. 37 As Chahla et al 18 could not show a significant difference in using two or three sutures when performing capsular closure, the decision if two or three sutures are used, will be made by the surgeon in order to achieve complete closure. ...
Introduction
Hip arthroscopy has become a standard procedure in the treatment of hip joint pain not related to osteoarthritis or dysplasia in the young and active patient. There has been increasing focus on the contribution of the hip capsule to function and on stability following hip arthroscopy. It has been suggested that capsular closure after hip arthroscopy may prevent microinstability and macroinstability of the hip joint and reduce revision rate. However, it remains unknown whether capsular closure should be performed as a standard procedure when performing hip arthroscopies, especially in patients without additional risk factors for instability such as hypermobility or dysplasia of the hip. We hypothesised that capsular closure will lead to a superior outcome in hip arthroscopy for femoroacetabular impingement syndrome (FAIS) compared with non-capsular closure.
Methods and analysis
In this randomised controlled, multicentre trial, 200 patients scheduled for hip arthroscopy for FAIS will be cluster randomised into one of two groups (group I: hip arthroscopy without capsular closure, group II: hip arthroscopy combined with capsular closure). Inclusion criteria are: age between 18 years and 50 years and FAIS according to the Warwick agreement. Exclusion criteria are: previous hip surgery in either hip, previous conditions of Legg-Calvé-Perthes or slipped capital femoral epiphysis, malignant disease, recent hip or pelvic fractures, arthritis, Ehlers-Danlos or Marfan disease, recent (within 6 weeks) application of intra-articular corticosteroids, language problems of any kind, and radiological signs of osteoarthritis, acetabular dysplasia or acetabular retroversion. Surgery will be performed in Denmark at four centres by four surgeons, all performing an interportal capsulotomy and closure with at least two absorbable sutures. Patients in both groups, who are blinded for the intervention, will receive the same standardised rehabilitation programme. As primary outcome scores, HAGOS (sport) will be used with HAGOS (symptoms, pain, function in daily living, participation in physical activities and hip and/or groin-related quality of life), Hip Sports Activity Scale, short validated version of the International Hip Outcome Tool, EQ-5D, Visual Analogue Scale for pain, complications and reoperation rate as secondary outcome tools. Using HAGOS (sport) as primary outcome parameter the power analysis required a minimum of 84 individuals per group. Together with a clinical examination performed by the patient’s surgeon 1 year after surgery, patient reported outcome measures will be completed preoperatively, as well as at 3 months, 1 year, 2 years and 5 years postoperatively. In addition, adverse effects will be recorded.
Ethics and dissemination
The study is approved by the Central Denmark Region Committee on Biomedical research ethics. The results of this study will be presented at national and international congresses and published in peer-reviewed journals.
Trial registration number
NCT03158454 ; Pre-results.
... capsule. This procedure has to our knowledge no additional adverse effects compared to the complications 334 described after hip arthroscopy, such as nerve injury, infections, deep vein thrombosis, avascular femoral 335 head necrosis or hip fracture [37]. 336 337 ...
... 9,10 Capsular closure using 2 sutures and the Quebec City Slider knot technique was performed at the end of hip arthroscopy in 100% of the labral reconstructions and 100% of the revisions following labral reconstructions. 11 Post hip arthroscopy, all patients were kept on 20-lb weight-bearing using crutches for 3 weeks, a period that was extended to 6 weeks if microfractures were performed intraoperatively. Additional exercises included passive hip circumduction immediately after the procedure to minimize the formation of adhesions. ...
Purpose:
To determine the causes of revision hip arthroscopy in patients who underwent labral reconstruction and to compare outcomes of these patients with patients who did not require a revision following reconstruction.
Methods:
Patients who underwent revision hip arthroscopy after previous labral reconstruction from 2006 to 2014 were included. Patients with less than 2-year follow-up, preoperative joint space of ≤2 mm, or who underwent other reconstructive procedures at the time of labral reconstruction were excluded. Each patient was matched by year of surgery, age, gender, and the number of previous surgeries with 2 patients that underwent labral reconstruction but did not require a revision following the reconstruction. Preoperatively and at a minimum 2-year follow-up, outcome scores were collected including the Hip Outcome Score-Activities of Daily Living (HOS-ADL) and HOS-Sports Scale, modified Harris Hip Score, Western Ontario and McMaster Universities Index (WOMAC), the 12-Item Short Form Health Survey (SF-12) Physical Component Summary, and the patient satisfaction outcome were collected. Differences between the preoperative and the postoperative outcomes score of each patient in the 2 groups was assessed using the paired t test. The Mann-Whitney U test was used to compare the 2 groups.
Results:
From 347 patients who underwent iliotibial band autograft labrum reconstruction from 2006 to 2014, 28 hips (8%) in 26 patients (18 females and 8 males) had revision arthroscopy after labral reconstruction. The mean age was 32 years (range: 16-64). The mean number of hip surgeries prior to the labral reconstruction was 1.9 ± 1.2. The average time from the last labral reconstruction procedure to revision labral reconstruction was 27 months (range: 5-59). Procedures performed at revision included lysis of adhesions (100%), additional femoroacetabular impingement (FAI) correction (50%), ligamentum teres debridement (50%), psoas release (29%), labral augmentation or reconstruction (14%), and others. Following revision surgery after previous labral reconstruction, 4 patients (14%) underwent total hip arthroplasty and 2 (7%) patients required a subsequent revision arthroscopy (age 67 and 23) at 15 months and 16 months. The average follow-up time was 3.6 years ± 1 year after revision following labral reconstruction and after labral reconstruction in the nonrevision group. No significant difference was detected in the outcome scores and postoperative satisfaction between the 2 groups. The HOS-ADL improved 16 points in the nonrevision group and 19 points in the revision group.
Conclusions:
Patients who underwent revision surgery after labral reconstruction were mostly female, with 2 or more surgeries prior to reconstruction, and 14% required THA and 7% had recurrent scarring. In those who did not fail, outcomes significantly improved and were similar with patients who did not need revision. Adhesions and residual FAI were the most common findings during revision labral reconstruction.
Level of evidence:
Level III, retrospective comparative study.
... A total of 2 to 3 side-to-side sutures are placed to complete the capsular closure. 13 ...
Femoroacetabular impingement syndrome is a common hip pathology significantly affecting not only the intra- and extra-articular structures but also the biomechanical function of the joint. Cam and pincer bony lesions have been extensively studied. However, during recent years, other types of extra-articular impingement between the pelvic and femoral bone have been investigated. When a prominent or morphologically abnormal anterior-inferior iliac spine (AIIS) impinges repetitively on the femoral side during motion, the subspinal acetabular region becomes prominent and extends toward the intra-articular part of the joint. This results in restriction of the range of motion of the hip and pain, especially with flexion. Therefore, during hip arthroscopy, it is necessary to evaluate the subspinal region (triangular area located at 1:30 to 2:30 o'clock using the acetabular clock face system). For the correction of the acetabular bone pathology to be complete, the surgeon should focus both on the pincer and subspinal impingement lesions. This article describes our preferred technique to successfully address subspinal and pincer acetabular impingement during hip arthroscopy. The pearls and pitfalls of this technique are discussed.
... The capsule was closed in a side-to-side fashion between the proximal and distal segments of the capsuloligamentous flaps with 1, 2, or 3 No. 2 Vicryl sutures (Ethicon Inc) using our previously described capsular closure technique. 16 When 1 suture was utilized, it was placed in the middle of the capsulotomy site (position 2), and when 2 sutures were utilized, they were positioned equidistant from both ends of the previously performed capsulotomy site ( Figure 2). ...
Background:
Hip capsulotomy is routinely performed during arthroscopic surgery to achieve adequate exposure of the joint. Iatrogenic instability can result after hip arthroscopic surgery because of capsular insufficiency, which can be avoided with effective closure of the hip capsule. There is currently no consensus in the literature regarding the optimal quantity of sutures upon capsular closure to achieve maximal stability postoperatively. Purpose/Hypothesis: The purpose of this study was to determine the failure torques of 1-, 2-, and 3-suture constructs for hip capsular closure to resist external rotation and extension after standard anterosuperior interportal capsulotomy (12 to 3 o'clock). Additionally, the degree of external rotation at which the suture constructs failed was recorded. The null hypothesis of this study was that no significant differences with respect to the failure torque would be found between the 3 repair constructs.
Study design:
Controlled laboratory study.
Methods:
Nine pairs (n = 18) of fresh-frozen human cadaveric hemipelvises underwent anterosuperior interportal capsulotomy, which were repaired with 1, 2, or 3 side-to-side sutures. Each hip was secured in a dynamic biaxial testing machine and underwent a cyclic external rotation preconditioning protocol, followed by external rotation to failure.
Results:
The failure torque of the 1-suture hip capsular closure construct was significantly less than that of the 3-suture construct. The median failure torque for the 1-suture construct was 67.4 N·m (range, 47.4-73.6 N·m). The median failure torque was 85.7 N·m (range, 56.9-99.1 N·m) for the 2-suture construct and 91.7 N·m (range, 74.7-99.0 N·m) for the 3-suture construct. All 3 repair constructs exhibited a median 36° (range, 22°-64°) of external rotation at the failure torque.
Conclusion:
The most important finding of this study was that the 2- and 3-suture constructs resulted in comparable biomechanical failure torques when external rotation forces were applied to conventional hip capsulotomy in a cadaveric model. The 3-suture construct was significantly stronger than the 1-suture construct; however, there was not a significant difference between the 2- and 3-suture constructs. Additionally, all constructs failed at approximately 36° of external rotation.
Clinical relevance:
Re-establishing the native anatomy of the hip capsule after hip arthroscopic surgery has been reported to result in improved outcomes and reduce the risk of iatrogenic instability. Therefore, adequate capsular closure is important to restore proper hip biomechanics, and postoperative precautions limiting external rotation should be utilized to protect the repair.
