Regarding “Routine Interportal Capsular Repair Does Not Lead to Superior Clinical Outcome Following Arthroscopic Femoroacetabular Impingement Correction With Labral Repair”

We have recently reviewed the article by Filan and Carton1Filan D. Carton P. Routine interportal capsular repair does not lead to superior clinical outcome following arthroscopic femoroacetabular impingement correction with labral repair.Arthroscopy. 2020; 36: 1323-1334Abstract Full Text Full Text PDF Scopus (17) Google Scholar entitled “Routine Interportal Capsular Repair Does Not Lead to Superior Clinical Outcome Following Arthroscopic Femoroacetabular Impingement Correction With Labral Repair” in Arthroscopy. The article attempts to add to our clinical knowledge on an important topic in hip arthroscopy, namely the significance of capsular management for arthroscopic treatment of femoroacetabular impingement syndrome (FAIS). The goal of the study was to determine whether there are any significant differences in terms of patient-reported outcomes based on whether the capsule is repaired. Although the study presented a large cohort of patients with a high follow-up rate,1Filan D. Carton P. Routine interportal capsular repair does not lead to superior clinical outcome following arthroscopic femoroacetabular impingement correction with labral repair.Arthroscopy. 2020; 36: 1323-1334Abstract Full Text Full Text PDF Scopus (17) Google Scholar we found a number of methodologic errors that are concerning for the ultimate conclusions of the article. Primarily, the 2 cohorts were said to have similar preoperative characteristics, but the preoperative outcome scores were not analyzed. Therefore, although no significant demographic factors were found, these groups may have been significantly different preoperatively in terms of starting outcome scores, thus rendering the postoperative outcome comparison inaccurate. Regarding the outcome measures chosen for this study, Filan and Carton1Filan D. Carton P. Routine interportal capsular repair does not lead to superior clinical outcome following arthroscopic femoroacetabular impingement correction with labral repair.Arthroscopy. 2020; 36: 1323-1334Abstract Full Text Full Text PDF Scopus (17) Google Scholar elected to use the modified Harris Hip Score (mHHS); University of California, Los Angeles activity score; Short Form 36 score; and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. They do mention the ceiling effect of the mHHS in the “Discussion” section. Although frequently used for FAIS outcomes, the mHHS has also been shown specifically to have poor interval validity.2Ramisetty N. Kwon Y. Mohtadi N. Patient-reported outcome measures for hip preservation surgery—A systematic review of the literature.J Hip Preserv Surg. 2015; 2: 15-27Crossref PubMed Google Scholar Whereas the authors defend the outcome measures by using the University of California, Los Angeles activity score, Short Form 36 score, and WOMAC score, the reality is that none of these scores were developed for FAIS, nor are they traditionally used in the literature.2Ramisetty N. Kwon Y. Mohtadi N. Patient-reported outcome measures for hip preservation surgery—A systematic review of the literature.J Hip Preserv Surg. 2015; 2: 15-27Crossref PubMed Google Scholar In fact, the WOMAC was proved not to be valid specifically for FAIS.3Rothenfluh D.A. Reedwisch D. Müller U. Ganz R. Tennant A. Leunig M. Construct validity of a 12-item WOMAC for assessment of femoro-acetabular impingement and osteoarthritis of the hip.Osteoarthritis Cartilage. 2008; 16: 1032-1038Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar Simply having a diversity of nonspecific scores does not obviate disease-specific measuring tools. From a technical standpoint, there was no mention of the size of the interportal capsulotomy relative to the number of sutures, and in some cases, a single suture was used for repair.1Filan D. Carton P. Routine interportal capsular repair does not lead to superior clinical outcome following arthroscopic femoroacetabular impingement correction with labral repair.Arthroscopy. 2020; 36: 1323-1334Abstract Full Text Full Text PDF Scopus (17) Google Scholar Prior literature by Chahla et al.4Chahla J. Mikula J.D. Schon J.M. et al.Hip capsular closure: A biomechanical analysis of failure torque.Am J Sports Med. 2017; 45: 434-439Crossref PubMed Scopus (27) Google Scholar has shown that 1-suture constructs for interportal capsulotomy closure do not result in a significantly stable repair compared with the native iliofemoral ligament. As a result, these findings may not represent appropriate capsular closure and thus may lead to confusion in the literature when contrasting findings with other contemporary techniques. Perhaps most important, the study did find significantly better outcomes with capsular repair based on age, given that younger patients were significantly less likely to require revision arthroscopy with repair versus without.1Filan D. Carton P. Routine interportal capsular repair does not lead to superior clinical outcome following arthroscopic femoroacetabular impingement correction with labral repair.Arthroscopy. 2020; 36: 1323-1334Abstract Full Text Full Text PDF Scopus (17) Google Scholar These are important findings because they add to the body of knowledge previously reported on both the importance of capsular stability5Abrams G.D. Hart M.A. Takami K. et al.Biomechanical evaluation of capsulotomy, capsulectomy, and capsular repair on hip rotation.Arthroscopy. 2015; 31: 1511-1517Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar, 6Myers C.A. Register B.C. Lertwanich P. et al.Role of the acetabular labrum and the iliofemoral ligament in hip stability: An in vitro biplane fluoroscopy study.Am J Sports Med. 2011; 39 (suppl): 85S-91SCrossref PubMed Scopus (212) Google Scholar, 7Mygind-Klavsen B. Winge S. Lund B. et al.Danish Hip Arthroscopy Registry: Capsular closing in patients with femoroacetabular impingement (FAI): Results of a matched-cohort controlled study.J Hip Preserv Surg. 2016; 3 (hnw030.017 (suppl 1))Google Scholar, 8Bolia I. Briggs K.K. Philippon M.J. Superior clinical outcomes with capsular closure versus non-closure in patients undergoing arthroscopic hip labral repair.Orthop J Sports Med. 2018; 6 (2325967118S00009 (suppl))Crossref Google Scholar, 9Khair M.M. Grzybowski J.S. Kuhns B.D. Wuerz T.H. Shewman E. Nho S.J. The effect of capsulotomy and capsular repair on hip distraction: A cadaveric investigation.Arthroscopy. 2017; 33: 559-565Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar and capsular laxity being one of most common indications for revision arthroscopy.10Cvetanovich G.L. Harris J.D. Erickson B.J. Bach B.R. Bush-Joseph C.A. Nho S.J. Revision hip arthroscopy: A systematic review of diagnoses, operative findings, and outcomes.Arthroscopy. 2015; 31: 1382-1390Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar They also have very important treatment implications in this high-demand age group from both a quality-of-life standpoint and the provision of cost-effective care. Despite these significant findings, the results are in direct contrast to the article title and conclusions stating that there were no differences. There are 2 conclusions within this article that are quite different from our experience treating FAIS patients.1Filan D. Carton P. Routine interportal capsular repair does not lead to superior clinical outcome following arthroscopic femoroacetabular impingement correction with labral repair.Arthroscopy. 2020; 36: 1323-1334Abstract Full Text Full Text PDF Scopus (17) Google Scholar First, the article concludes that patients have similar outcomes after arthroscopic FAIS surgery regardless of whether the capsule is closed. However, contradictory to this finding, we have all found noticeable improvement in patient-reported outcomes in our practice with routine capsular closure in FAIS patients. This has improved our outcomes and has minimized the risk of subsequent iatrogenic hip instability.11Frank R.M. Lee S. Bush-Joseph C.A. Kelly B.T. Salata M.J. Nho S.J. 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: 2634-2642Crossref PubMed Scopus (209) Google Scholar,12Wylie J.D. Beckmann J.T. Maak T.G. Aoki S.K. Arthroscopic capsular repair for symptomatic hip instability after previous hip arthroscopic surgery.Am J Sports Med. 2016; 44: 39-45Crossref PubMed Scopus (76) Google Scholar Second, this article states that the female patients who underwent capsular repair had lower outcome scores at 2-year follow-up than those not undergoing capsular repair. When we look at our patients, female patients have the highest risk of postoperative instability and are the patient population that benefits the most from routine capsular closure after hip arthroscopy. In summary, we found a number of significant methodologic concerns with this article including a direct contradiction between the stated results and the article title.1Filan D. Carton P. Routine interportal capsular repair does not lead to superior clinical outcome following arthroscopic femoroacetabular impingement correction with labral repair.Arthroscopy. 2020; 36: 1323-1334Abstract Full Text Full Text PDF Scopus (17) Google Scholar We additionally found that the chosen groups were not shown to have insignificant preoperative scores and the outcome scores were not necessarily appropriate for the purpose of this study. We fear that these discrepancies may be confusing for the reader and lead to future study misrepresentation. Download .pdf (.53 MB) Help with pdf files ICMJE author disclosure forms Author Reply to “Regarding ‘Routine Interportal Capsular Repair Does Not Lead to Superior Clinical Outcome Following Arthroscopic Femoroacetabular Impingement Correction With Labral Repair’”ArthroscopyVol. 36Issue 7PreviewWe would like to thank Parvaresh, Mather, Aoki, and Nho for their interest in our article “Routine Interportal Capsular Repair Does Not Lead to Superior Clinical Outcome Following Arthroscopic Femoroacetabular Impingement Correction With Labral Repair”1 in Arthroscopy, and we wish to address their concerns with some aspects of the study. First, Parvaresh et al. are incorrect in stating that the preoperative outcomes were not analyzed and suggesting that the postoperative outcome comparison may therefore be inaccurate. Full-Text PDF

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