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

Abstract

We 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”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 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. The median scores and interquartile ranges of all the preoperative outcomes were calculated and presented, and the mean change in outcome from preoperatively to postoperatively was used for calculation of the minimal clinically important difference (MCID) for each group (no difference meeting the MCID was evident between groups); the comparison of final outcome between groups was calculated independently of preoperative values and again showed no significant difference between groups. Comprehensive demographic and radiographic details were presented to the reader to show that the 2 preoperative groups were closely matched. Regarding the choice of outcome measures used in this study, Parvaresh et al. have essentially repeated what was already disclosed in the “Limitations” section of the article for readers to clearly observe.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 It was also mentioned in the article that more recently used outcome tools such as the International Hip Outcome Tool 33 (iHOT-33) and Hip and Groin Outcome Score (HAGOS) were not established at the outset of the study period and therefore could not be used. We did, however, select separate, internationally validated joint-specific (mHHS, Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]), general physical and mental well-being (Short Form 36 [SF-36]), and activity-level (University of California, Los Angeles [UCLA]) outcome tools to capture the greatest amount of detail with respect to all aspects of patient improvement. The modified Harris Hip Score (mHHS) is the most widely used outcome score in the femoroacetabular impingement (FAI) literature and has in fact been regularly used by the correspondence authors Nho, Aoki, and Mather in their own publications on FAI and capsular repair.2Stone A.V. Mehta N. Beck E.C. et al.Comparable patient-reported outcomes in females with or without joint hypermobility after hip arthroscopy and capsular plication for femoroacetabular impingement syndrome.J Hip Preserv Surg. 2019; 6: 33-40Crossref PubMed Google Scholar, 3Wylie 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, 4Cvetanovich G.L. Weber A.E. Kuhns B.D. et al.Hip arthroscopic surgery for femoroacetabular impingement with capsular management: Factors associated with achieving clinically significant outcomes.Am J Sports Med. 2018; 46: 288-296Crossref PubMed Scopus (68) Google Scholar The WOMAC score has formed the basis for the development of a number of the more recent “disease-specific scores,” such as the Non-Arthritic Hip Score (NAHS),5Christensen C. Althausen P. Mittleman M. Lee J. McCarthy J. The Nonarthritic Hip Score: Reliable and validated.Clin Orthop Relat Res. 2013; 406: 75-83Crossref Scopus (295) Google Scholar HAGOS,6Thorborg K. Hölmich P. Christensen R. Petersen J. Roos E.M. The Copenhagen Hip and Groin Outcome Score (HAGOS): Development and validation according to the COSMIN checklist.Br J Sports Med. 2011; 45: 478-491Crossref PubMed Scopus (274) Google Scholar and Hip Disability and Osteoarthritis Outcome Score (HOOS),7Klässbo M. Larsson E. Mannevik E. Hip disability and osteoarthritis outcome score. An extension of the Western Ontario and McMaster Universities Osteoarthritis Index.Scand J Rheumatol. 2003; 32: 46-51Crossref PubMed Scopus (284) Google Scholar with each of these scoring systems integrating almost all of the individual WOMAC questions within their pain, stiffness, and activity-limitation sections; the main differences between these more recent scoring systems and the WOMAC is the addition of sports and activity–related and quality of life–related sections, for which we have separately used the UCLA rating and the SF-36. The SF-36 is one of the most versatile and widely used international health and well-being questionnaires, fulfilling roles in outcome measurement across an enormous number of medical and surgical specialties, and has been used to assess the construct validity of the HAGOS,6Thorborg K. Hölmich P. Christensen R. Petersen J. Roos E.M. The Copenhagen Hip and Groin Outcome Score (HAGOS): Development and validation according to the COSMIN checklist.Br J Sports Med. 2011; 45: 478-491Crossref PubMed Scopus (274) Google Scholar Hip Outcome Score (HOS),8Martin R.L. Philippon M.J. Evidence of validity for the Hip Outcome Score in hip arthroscopy.Arthroscopy. 2007; 23: 822-826Abstract Full Text Full Text PDF PubMed Scopus (177) Google Scholar and Hip Disability and Osteoarthritis Outcome Score (HOOS).9Kemp J.L. Collins N.J. Roos E.M. Crossley K.M. Psychometric properties of patient-reported outcome measures for hip arthroscopic surgery.Am J Sports Med. 2013; 41: 2065-2073Crossref PubMed Scopus (260) Google Scholar Harris-Hayes et al.10Harris-Hayes M. McDonough C.M. Leunig M. Lee C.B. Callaghan J.J. Roos E.M. Clinical outcomes assessment in clinical trials to assess treatment of femoroacetabular impingement: Use of patient-reported outcome measures.J Am Acad Orthop Surg. 2013; 21: S39-S46Crossref PubMed Scopus (37) Google Scholar reported, “Well-developed and validated generic measures can be regarded as being ‘fit-for-purpose,’ even in clinical settings in which content validity has not been documented previously. Hence, any of the established generic measures may be considered suitable for use in patients with FAI.” Additional efforts are now required to ensure that research focuses on outcomes that patients value.11Impellizzeri FM, Jones DM, Griffin D, et al. Patient-reported outcome measures for hip-related pain: A review of the available evidence and a consensus statement from the International Hip-related Pain Research Network, Zurich 2018 [published online February 17, 2020]. Br J Sports Med. doi:10.1136/bjsports-2019-101456.Google Scholar There has been recent enthusiasm for clinical outcome studies to analyze the psychometric response to surgery. Two different, well-recognized techniques were used in our study to measure the MCID: an anchor-based method (mean change) and distribution-based method (0.5 standard deviations).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 No significant difference was found using either method in the proportion of patients meeting MCID for any of the outcome tools, whether the capsule was repaired or not. A significant proportion of FAI patients will progress to osteoarthritis development with longer-term follow-up; the outcomes selected are also widely used in the assessment of patients with osteoarthritis and will permit continued long-term outcome assessment of these patient groups. No outcome tool is optimal but more recent disease-specific outcome tools may become less valid with the reduction of sports and physical activities and with the advancement of osteoarthritis and therefore less suitable for longer-term review of FAI patients. The diversity of outcome scoring techniques including joint-specific (mHHS, WOMAC), activity-level (UCLA), and general health status and well-being (SF-36) outcome tools is one of the many strengths of this large comparative cohort study. With respect to the technical aspects mentioned by Parvaresh et al., measurement of the interportal capsulotomy is both difficult and inaccurate when using a 2-portal technique; however, given that we used a standardized surgical technique, the size of the capsulotomy was unlikely to vary significantly. The number of sutures used was guided more by the quality of the capsular tissue and stability of the repair, not necessarily the size of the capsulotomy. In the referenced published work by Chahla et al.,12Chahla 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 it was clearly shown that the failure of 1-, 2-, or 3-suture repairs actually occurred at the same testing endpoint of 36° of external rotation. The significant limitations of comparing biomechanical cadaveric studies with the clinical environment are well known; however, in all our patients (repair and nonrepair groups), external rotation was routinely avoided for 4 weeks after surgery. Nevertheless, a single suture was used in only 37 cases (8.2%). We agree that the findings of a reduced revision rate in the younger age group is an important observation, and this was highlighted both in the “Discussion” section and again in the last sentence in the “Conclusions” section.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 note that some of the results of this study differ from the personal experience of Parvaresh et al.; however, in their referenced published work by Frank et al.,13Frank 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 a T-capsulotomy was used that permits wide exposure of both the acetabular rim and femoral neck but to the detriment of capsular integrity and stability.14Abrams 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,15Baha P. Burkhart T.A. Getgood A. Degen R.M. Complete capsular repair restores native kinematics after interportal and T-capsulotomy.Am J Sports Med. 2019; 47: 1451-1458Crossref PubMed Scopus (23) Google Scholar The need to repair the capsule in what is a more extensive technique is therefore unsurprising. The difference in technique may also explain the reported benefits of capsular repair in female patients undergoing a more destabilizing T-capsulotomy, as opposed to an interportal capsulotomy, presented in our study.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 The referenced publication by Wylie et al.3Wylie 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 focused on the importance of capsular repair in patients undergoing revision surgery with capsular insufficiency. Neither of these referenced studies are applicable to the findings of our study, which focuses on the routine repair of an interportal capsulotomy in primary hip arthroscopy. Moreover, in a recent meta-analysis comparing clinical outcomes between patients undergoing arthroscopic FAI correction with capsular repair and those undergoing no capsular repair, no significant difference was reported between groups.16Lin Y. Li T. Deng X. et al.Repaired or unrepaired capsulotomy after hip arthroscopy: A systematic review and meta-analysis of comparative studies.Hip Int. 2020; 30: 256-266Crossref Scopus (12) Google Scholar In our experience with capsular management techniques, low-tension apposition of the capsule may be clinically more beneficial than a tightly repaired capsule, with the emphasis on conservation and apposition of the capsule rather than wide exposure and complete repair. In summary, our study represents the largest published comparative cohort study assessing the overall improvement in clinical outcomes after routine capsular repair versus unrepaired capsules.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 The primary aim of the study was to examine routinely repairing the capsule in all patients and not specific groups. Important findings in subgroups, when evident, were clearly highlighted, such as the potential benefits in the younger, more active patient and the potentially poorer outcome in female patients. The results serve to challenge the idea that repairing the capsule is needed in all patients undergoing arthroscopic FAI surgery; capsular repair is time-consuming, and with improved surgical techniques that permit better preservation of the capsule, with a limited interportal capsulotomy, repair may not be routinely required. Repair may be detrimental in some patients, resulting in limitation of hip movement and capsular stiffness. However, capsular repair in others may help optimize the stability of the hip, restoring more natural hip function, which could protect the hip from development of progressive degeneration. Further research into the longer-term outcomes is needed to continue to assess the true benefits of routine capsular repair, which at this point, remains controversial. Download .pdf (.09 MB) Help with pdf files ICMJE author disclosure forms Regarding “Routine Interportal Capsular Repair Does Not Lead to Superior Clinical Outcome Following Arthroscopic Femoroacetabular Impingement Correction With Labral Repair”ArthroscopyVol. 36Issue 7PreviewWe have recently reviewed the article by Filan and Carton1 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. Full-Text PDF