Does Capsular Laxity Lead to Microinstability of the Native Hip?

Han, Shuyang; Alexander, Jerry W.; Thomas, Vijai S.; Choi, Joshua; Harris, Joshua D.; Doherty, David B.; Jeffers, Jonathan R.T.; Noble, Philip C.

doi:10.1177/0363546518755717

Cited by 70 publications

(71 citation statements)

References 37 publications

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“…Microinstability has been classified based on bony or soft tissue origin, with 2 of the most common causes being acetabular undercoverage and ligamentous laxity. 10,14 Signs of microinstability on physical examination were extremely prevalent in this (11/14), and 81.8% of patients (9/11) presented with a Beighton score of 4 or higher. A recent study reported a Beighton score of 4 or higher in only 18.9% of patients undergoing hip arthroscopy, significantly less common than the demonstrated rate in the current study.…”

Section: Discussionmentioning

confidence: 86%

The Femoral Head “Divot” Sign: A Useful Arthroscopic Sign of Hip Microinstability

Rosinsky

Mayo

Kyin

et al. 2020

Orthopaedic Journal of Sports Medicine

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Background: A femoral head “divot” is a rare finding during hip arthroscopy. A linear chondral indentation can be observed on the femoral head, just lateral and parallel to the acetabular labrum. Purpose/Hypothesis: The purpose of this study was to describe a novel arthroscopic sign and retrospectively review patients with this finding. We hypothesized that this sign would be found in patients with characteristics consistent with hip microinstability. Study Design: Case series; Level of evidence, 4. Methods: Intraoperative images of patients undergoing primary hip arthroscopy between July 2017 and July 2019 were reviewed for evidence of a femoral head divot. Preoperative characteristics, physical examination findings, radiographic measurements, and magnetic resonance imaging (MRI) findings were described. Results: Of 690 available cases, 14 cases (13 patients; 2.0%) had evidence of a femoral head divot. The mean patient age was 29.1 years, and all but 1 patient (92.3%) were female. Ligamentous laxity was present in 81.8% of patients, anterior apprehension test was positive in 78.6%, and painful internal snapping was present in 50.0%. The mean lateral center-edge angle, anterior center-edge angle, and Tönnis angle were 19.2°, 20.3°, and 12.4°, respectively. The divot was identified in 5 of 12 available MRI scans, most commonly on axial proton density sequence. Intraoperatively, all hips had labral tears, iliopsoas bursitis was demonstrated in 78.6%, and the ligamentum teres was damaged in 42.9%. Labral repair was performed in 12 of the 14 hips, with 2 patients undergoing labral reconstruction. Iliopsoas fractional lengthening was performed in 50.0%, capsular plication was performed in 78.6%, and capsular repair was performed in the remainder. Conclusion: The femoral head divot sign is a rare arthroscopic finding during hip arthroscopy. The results of this study demonstrated that patients who have a divot also present with characteristic radiographic or physical examination findings of hip microinstability due to either acetabular dysplasia or ligamentous laxity. Recognition of a femoral head divot may be valuable for the diagnosis of microinstability during hip arthroscopy and may help guide appropriate management, such as capsular plication. Further studies are needed to determine the exact prevalence of the femoral head divot in patients with microinstability and to evaluate the effect of this finding on patient outcomes.

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Section: Discussionmentioning

confidence: 86%

The Femoral Head “Divot” Sign: A Useful Arthroscopic Sign of Hip Microinstability

Rosinsky

Mayo

Kyin

et al. 2020

Orthopaedic Journal of Sports Medicine

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“…The positional relationship between the femoral head and the acetabulum with hip neutral position was reported as not different between supine AP pelvic radiographs and weight-bearing conditions [32]. Additionally, this positional relationship is concentric within 30˚of flexion in the normal hip [33]. Nevertheless, we have made effort to obtain the hip neutral position CT images.…”

Section: Plos Onementioning

confidence: 96%

Three-dimensional curvature mismatch of the acetabular radius to the femoral head radius is increased in borderline dysplastic hips

et al. 2020

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Whether borderline hip dysplasia is pathologic remains unclear. In order to evaluate the three-dimensional joint congruity, this study sought to answer the question: are borderline dysplastic hip curvature mismatch and eccentricity between the acetabulum and the femoral head different from dysplastic or control hips three-dimensionally? The 113 hips, categorized as: dysplastic (LCEA � 20˚), 47 hips; borderline (20˚� LCEA < 25˚), 32 hips; and control (25˚� LCEA < 35˚), 34 hips; were evaluated. Three-dimensional (3D) femoral and coxal bone models were reconstructed from CT images. Using a custom-written Visual C++ routine, the femoral head and acetabular radii of curvature, and the femoral head and the acetabular curvature center were calculated. Then the ratio of the acetabular radius to the femoral head radius (3D curvature mismatch ratio), and the distance between the acetabular curvature center and the femoral head center (3D center discrepancy distance) were calculated. These indices were compared statistically among the three groups using Tukey's post hoc test. The mean 3D curvature mismatch ratio in the borderline (1.13 ± 0.05) was smaller than in the dysplasia (1.23 ± 0.08, p < 0.001), and larger than in the control (1.07 ± 0.02, p < 0.001). The mean 3D center discrepancy distance in the borderline (3.2 ± 1.4 mm) was smaller than in the dysplasia (4.8 ± 2.3, p < 0.001) and larger than in the control (1.6 ± 0.7, p < 0.001). These results demonstrated that three-dimensional congruity of the borderline dysplastic hip is impaired, but its incongruity is not as severe as in dysplastic hips. The 3D curvature mismatch ratio and the 3D center discrepancy distance can be valuable signs of joint congruity in patients with borderline dysplasia. However, future studies are necessary to clarify any associations between curvature mismatch and pathogenesis of osteoarthritis in borderline dysplasia.

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“…Earlier studies explored the biomechanical contributions of local hip anatomy to stability, 4,5 and this evolved into a greater understanding of how the capsule itself taken together with pericapsular structures contributes to hip stability. 3,[6][7][8] More recently, the debate over the importance of capsular repair 9,10 and various repair strategies [11][12][13] has culminated with several outcome studies that leave no question as to the evidence in support of superior surgical outcomes with capsular repair. 14,15 Yes, folks, it is quite clear that the capsule must be addressed during routine arthroscopy.…”

Section: See Related Article On Page 116mentioning

confidence: 99%

Editorial Commentary: #Capsule-ophilesRejoice! The Evidence in Support of Diligent Capsular Management During Hip Arthroscopy Can No Longer Be Ignored

Walters

2020

Arthroscopy: The Journal of Arthroscopic & Related Surgery

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From its infancy until now, the enthusiasm and growth of the field of hip arthroscopy have been exciting to watch. Perhaps, it could be argued that there has not been a more hotly debated topic in recent years than what to do with the hip capsule. Once merely an afterthought in the context of hip arthroscopy, the oft overlooked and underappreciated intricacies of hip capsular anatomy and its role in hip stability have now taken center stage. As surgical indications continue to expand, our surgical techniques have rapidly evolved. Despite the rapid growth and advent of industry, the leaders in this field have remained steadfast in their relentless quest to improve their scientific knowledge and understanding of the native hip joint. If we have learned nothing else from watching the capsular debate evolve, it is that without an advanced understanding of the critical and complex marriage of anatomy and function that exists in a healthy hip joint, we cannot begin to master the surgical treatment of its pathologic states.

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Does Capsular Laxity Lead to Microinstability of the Native Hip?

Abstract: Capsular laxity alters normal kinematics (joint rotation and femoral head translation) of the hip, potentially leading to abnormal femoral-acetabular contact and joint degeneration.

Cited by 70 publications

References 37 publications

The Femoral Head “Divot” Sign: A Useful Arthroscopic Sign of Hip Microinstability

The Femoral Head “Divot” Sign: A Useful Arthroscopic Sign of Hip Microinstability

Three-dimensional curvature mismatch of the acetabular radius to the femoral head radius is increased in borderline dysplastic hips

Editorial Commentary: #Capsule-ophilesRejoice! The Evidence in Support of Diligent Capsular Management During Hip Arthroscopy Can No Longer Be Ignored

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