While hip arthroscopy utilization continues to increase, capsular management remains a controversial topic. Therefore the purpose of this research was to investigate the biomechanical effect of capsulotomy and capsular repair techniques on hip joint kinematics in varying combinations of sagittal and coronal joint positions. Eight fresh-frozen hemipelvises (4 left, 6 male) were dissected of all overlying soft tissue, with the exception of the hip joint capsule. The femur was potted and attached to a load cell, while the pelvis was secured to a custom-designed fixture allowing static alteration of the flexion/extension arc. Optotrak markers were rigidly attached to the femur and pelvis to track motion of the femoral head with respect to the acetabulum. Following specimen preparation, seven conditions were tested: i) intact, ii) after portal placement (anterolateral and mid-anterior), iii) interportal capsulotomy (IPC) [35 mm in length], iv) IPC repair, v)T-capsulotomy [15 mm longitudinal incision], vi) partial T-repair (vertical limb), vii) full T-repair. All conditions were tested in 15° of extension (−15˚), 0°, 30°, 60° and 90° of flexion. Additionally, all flexion angles were tested in neutral, as well as maximum abduction and adduction, resulting in 15 testing positions. 3Nm internal and external rotation moments were manually applied to the femur via the load cell at each position. Rotational range of motion and joint kinematics were recorded. IPC and T-capsulotomies increased rotational ROM and mediolateral (ML) joint translation in several different joint configurations, most notably from 0–30˚ in neutral abduction/adduction. Complete capsular repair restored near native joint kinematics, with no significant differences between any complete capsular repair groups and the intact state, regardless of joint position. An unrepaired IPC resulted in increased rotational ROM, but no other adverse translational kinematics. However, an unrepaired or partially repaired T-capsulotomy resulted in increased rotational ROM and ML translation. The results of this study show that complete capsular repair following interportal or T-capsulotomy adequately restores rotational ROM and joint translation to near intact levels. Where feasible, complete capsular closure should be performed, especially following T-capsulotomy. However, further clinical evaluation is required to determine if adverse kinematics of an unrepaired capsule are associated with patient reported outcomes

Introduction:. Repair of the arthrotomy is a performed at the end of every total knee arthroplasty (TKA). After the arthrotomy is performed, most surgeons attempt to close the arthrotomy with the medial and lateral edges anatomically approximated. If no landmarks are made prior to performing the arthrotomy however, there is a risk that anatomic approximation may not be obtained. This study looked into the biomechanical changes in stiffness of the knee before and after a medial parapatellar approach repaired with an anatomic, and shifted capsular repair with the medial side of the arthrotomy shifted up or down when repaired to determine if capsular closure may have an effect on the stiffness of the joint. Methods:. Fourteen cadaveric TKA specimens were retrieved through the Medical Education and Research Institute (Memphis TN). For each specimen tested, the skin and muscle tissue was removed, and the femur and tibia were cut transversely 180 mm from the joint center. Specimens were fixed in extension in a custom knee testing platform (Little Rock AR) and subjected to a 10 Nm varus and valgus torque and a 1.5 Nm internal and external rotational torque. The angle at which these moments occurred was recorded, and each test was repeated for 0, 30, 60, and 90 degrees of flexion. After tests were performed on retrieved TKA specimens, a fellowship trained orthopedic surgeon vented the knee capsule by making an incision with a number 10 scalpel blade in a horizontal nature to provide a landmark for anatomic reapproximation. Tests were repeated as before, after which the surgeon performed a standard arthrotomy and repaired it using #0 suture and a neutral alignment. Sutures were cut and the repair was repeated using upward 5 mm shift and downward 5 mm shift of the medial side of the arthrotomy during the repair. All tests were repeated after each repair technique. Any increase or decrease in laxity after capsule repair was referenced to the TKA laxity tested prior to an arthrotomy being performed. Results:. Simply venting the capsule did increase laxity of the TKA in midflexion to varus torque by 3 degrees under the same torque. Otherwise, when the medial limb of the arthrotomy was shifted up during closure by 5 mm, the knee joint tended to be stiffer in flexion compared to the neutral repair measurements under varus torque, while it was closer to the measurements of the neutral or anatomic closure when the medial limb was shifted down during closure. These changes seemed to be seen in flexion more than full extension. Discussion and Conclusion:. Small changes were measured in the stiffness of the joint after venting the capsule and under different degrees of non-anatomic closure. The results stress the fact that the capsule can be measurably tightened during arthrotomy repair and may impact post-operative rehabilitation or range of motion

The Latarjet procedure is a well described method to stabilize anterior shoulder instability. There are concerns of high complication rates, one of these being a painful shoulder without instability due to screw irritation. The arthroscopic changes in the shoulder at time of screw removal compared to those pre-Latarjet have not been described in the literature. We conducted a retrospective review of arthroscopic videos between 2015 and 2022 of 17 patients at the time of their Latarjet screw removal and where available (n=13) compared them to arthroscopic findings at time of index Latarjet. Instability was an exclusion criterion. X-rays prior to screw removal were assessed independently by two observers blinded to patient details for lysis of the graft. Arthroscopic assessment of the anatomy and pathological changes were made by two shoulder surgeons via mutual consensus. An intraclass correlation coefficient (ICC) was analyzed as a measure for the inter-observer reliability for the radiographs. Our cohort had an average age of 21.5±7.7 years and an average period of 16.2±13.1 months between pre- and post-arthroscopy. At screw removal all patients had an inflamed subscapularis muscle with 88% associated musculotendinous tears and 59% had a pathological posterior labrum. Worsening in the condition of subscapularis muscle (93%), humeral (31%) and glenoid (31%) cartilage was found when compared to pre-Latarjet arthroscopes. Three failures of capsular repair were seen, two of these when only one anchor was used. X-ray review demonstrated 79% of patients had graft lysis. Excellent inter-rater reliability was observed with an ICC value of 0.82. Our results show a high rate of pathological change in the subscapularis muscle, glenoid labrum and articular cartilage in the stable but painful Latarjet. 79% of patients had graft lysis with prominent screws on X-ray

Surgical management of cam-type femoroacetabular impingement (FAI) aims to preserve the native hip, restore joint function, and delay the onset of osteoarthritis. However, it is unclear how surgery affects joint mechanics and hip joint stability. The aim was to examine the contributions of each surgical stage (i.e., intact cam hip, capsulotomy, cam resection, capsular repair) towards hip joint centre of rotation and microinstability. Twelve fresh, frozen cadaveric hips (n = 12 males, age = 44 ± 9 years, BMI = 23 ± 3 kg/m2) were skeletonized to the capsule and included in this study. All hips indicated cam morphology on CT data (axial α = 63 ± 6°, radial α = 74 ± 4°) and were mounted onto a six-DOF industrial robot (TX90, Stäubli). The robot positioned each hip in four sagittal angles: 1) Extension, 2) Neutral 0°, 3) Flexion 30°, and 4) Flexion 90°, and performed internal and external hip rotations until a 5-Nm torque was reached in each direction, while recording the hip joint centre's neutral path of translation. After the (i) intact hip was tested, each hip underwent a series of surgical stages and was retested after each stage: (ii) T-capsulotomy (incised lateral iliofemoral capsular ligament), (iii) cam resection (removed morphology), and (iv) capsular repair (sutured portal incisions). Eccentricity of the hip joint centre was quantified by the microinstability index (MI = difference in rotational foci / femoral head radius). Repeated measures ANOVA and post-hoc paired t-tests compared the within-subject differences in hip joint centre and microinstability index, between the testing stages (CI = 95%, SPSS v.24, IBM). At the Extension and Neutral positions, the hip joint centre rotated concentrically after each surgical stage. At Flexion 30°, the hip joint centre shifted inferolaterally during external rotation after capsulotomy (p = 0.009), while at Flexion 90°, the hip joint centre further shifted inferolaterally during external rotation (p = 0.005) and slightly medially during internal rotation after cam resection, compared to the intact stages. Consequently, microinstability increased after the capsulotomy at Flexion 30° (MI = +0.05, p = 0.003) and substantially after cam resection at Flexion 90° (MI = +0.07, p = 0.007). Capsular repair was able to slightly restrain the rotational centre and decrease microinstability at the Flexion 30° and 90° positions (MI = −0.03 and −0.04, respectively). Hip microinstability occurred at higher amplitudes of flexion, with the cam resection providing more intracapsular volume and further lateralizing the hip joint during external rotation. Removing the cam deformity and impingement with the chondrolabral junction also medialized the hip during internal rotation, which can restore more favourable joint loading mechanics and stability. These findings support the pathomechanics of cam FAI and suggest that iatrogenic microinstability may be due to excessive motions, prior to post-operative restoration of static (capsular) and dynamic (muscle) stability. In efforts to limit microinstability, proper nonsurgical management and rehabilitation are essential, while activities that involve larger amplitudes of hip flexion and external rotation should be avoided immediately after surgery

Patients with neuromuscular disease and imbalance present a particularly challenging clinical situation for the orthopaedic hip surgeon. The cause of the neuromuscular imbalance may be intrinsic or extrinsic. Intrinsic disorders include those in which the hip is in development, such as cerebral palsy, polio, CVA, and other spinal cord injuries and disease. This can result in subluxation and dislocation of the hip in growing children, and subsequent pain, and difficulty in sitting and perineal care. Extrinsic factors involve previously stable hips and play a secondary role in the development of osteoarthritis and contractures in later life. Examples of extrinsic factors are Parkinson's disease, dyskinesis, athetosis, and multiple sclerosis. Goals of treatment in adults with pain and dysfunction in the setting of neuromuscular imbalance are to treat contractures and to perform salvage procedures to improve function and eliminate pain. Treatment of patients with neuromuscular imbalance may include resection arthroplasty (Girdlestone), arthrodesis, or total hip arthroplasty. Resection arthroplasty is typically reserved for patients that are non-ambulatory, or hips that are felt to be so unstable that arthroplasty would definitely fail due to instability. In modern times arthrodesis has limited use as it negatively impacts function and self-care in patients with neuromuscular disorders. Total hip arthroplasty has the ability to treat pain, relieve contractures, and provide improved function. Due to the increased risk of instability, special considerations must be made during primary total hip arthroplasty in this patient cohort. Risk of instability may be addressed by surgical approach, head size, or use of alternative bearing constructs. Posterior approach may have increased risk of posterior dislocation in this patient group, particularly if a posterior capsular repair is not possible due to the flexion contractures and sitting position in many patients. Surgeons familiar with the approaches may utilise the anterolateral or direct anterior approach judicially. Release of the adductors may be performed in conjunction with primary total hip arthroplasty to help with post-operative range of motion and to decrease risk of instability. In a standard bearing, the selected head size should be the largest that can be utilised for the particular cup size. Rigorous testing of intra-operative impingement, component rotation, and instability is required. If instability cannot be adequately addressed by a standard bearing, the next option is a dual mobility bearing. Multiple studies have shown improved stability with the use of these bearings, but they are also at risk for instability, intraprosthetic dislocation, and fretting and corrosion of the modular connections. Another option is a constrained liner. However, this results in reduced range of motion, and an increased risk for mechanical complications of the construct. The use of a constrained liner in a primary situation should be limited to the most severe instability cases, and the patient should be counseled with the associated risks. If total hip arthroplasty results in repeated instability, revision surgery or Girdlestone arthroplasty may be considered

Mini-posterior technique advantages: Familiar anatomy; Widely applicable; Predictable (and thus preventable) sources of errors; Demonstrated functional advantages over the 2-incision THA in recent prospective randomised trials and in direct comparison studies. Familiar anatomy: A substantial number of surgeons routinely use the posterior approach; With careful attention to skin incision placement and leg positioning intraoperatively it is relatively easy for most surgeons to shorten the skin incision; With the addition of specialised retractors, offset reamers and offset cup and stem inserters many THA can be done with a skin incision of 10cm or less; Easily converted to standard posterior approach if intraoperative concerns arise; Formal posterior capsular repair substantially lowers historical risk of dislocation. Widely applicable: With relatively little variation this approach can be used for a broad range of THA patients; Several variations of the mini-posterior technique exist (Sculco, Dorr, Swanson, Goldstein); Dorr technique has been used in my practice and we have studied it extensively in direct comparison studies against the 2-incision technique

Polyethylene and femoral head exchange for wear or osteolysis is a common operation. The difficulty lies in the facts that wear and osteolysis are difficult to measure, wear does not always correlate with osteolysis, catastrophic failure (wear through, loosening, or fracture) is difficult to predict, and these problems are usually asymptomatic. I currently recommend this procedure when complete wear through of the polyethylene is present or impending, when the patient has obvious wear and symptoms, or if there is a rapidly enlarging osteolytic lesion. The surgical goals focus on management of debris generation and management of the osteolytic lesion. A third goal becomes avoidance of the know complications of this procedure. Management of debris generation basically involves modernising the head and polyethylene. Management of the osteolytic lesion includes debridement and when possible grafting. By far the most common complication after this procedure is dislocation. Prevention of dislocation should be accomplished by patient education, use of larger heads when possible, and capsular repair. Prerequisites to perform this procedure are a replacement liner of adequate thickness that can be locked or cemented in place. The acetabular component must be stable. Lastly the component must be properly oriented to minimise both wear and dislocation. Metal-on-metal liner conversion to metal-on-poly is becoming more common. Since patient satisfaction with THA is high, MoM patients may unknowingly minimise their symptoms because they are minor compared to the symptoms before surgery. The patient history should include specific questions about groin pain, swelling, hip noise, and asking the patient if they notice their hip on a daily basis. Patient symptoms, osteolysis and a pseudotumor are indications for modular conversion. Radiographically stable, well-oriented components that can accept a polyethylene liner are requirements for a successful conversion

Polyethylene and femoral head exchange for wear or osteolysis is a common operation. The difficulty lies in the facts that wear and osteolysis are difficult to measure, wear does not always correlate with osteolysis, catastrophic failure (wear through, loosening, or fracture) is difficult to predict, and these problems are usually asymptomatic. I currently recommend this procedure when complete wear through of the polyethylene is present or impending, when the patient has obvious wear and symptoms, or if there is a rapidly enlarging osteolytic lesion. The surgical goals focus on management of debris generation and management of the osteolytic lesion. A third goal becomes avoidance of the know complications of this procedure. Management of debris generation basically involves modernising the head and polyethylene. Management of the osteolytic lesion includes debridement and when possible grafting. By far the most common complication after this procedure is dislocation. Prevention of dislocation should be accomplished by patient education, use of larger heads when possible, and capsular repair. Prerequisites to perform this procedure are a replacement liner of adequate thickness that can be locked or cemented in place. The acetabular component must be stable. Lastly the component must be properly oriented to minimise both wear and dislocation. Metal-on-metal liner exchanges. Metal-on-metal liner conversion to metal-on-poly is becoming more common. Since patient satisfaction with THA is high, MoM patients may unknowingly minimise their symptoms because they are minor compared to the symptoms before surgery. The patient history should include specific questions about groin pain, swelling, hip noise, and asking the patient if they notice their hip on a daily basis. Patient symptoms, osteolysis and a pseudotumour are indications for modular conversion. Radiographically stable, well-oriented components that can accept a polyethylene liner are requirements for a successful conversion

The excitement and enthusiasm that accompanies the introduction of many new technologies and techniques can be self-sustaining, meaning that the appeal of doing something new or different (not necessarily doing something better) becomes the prime driver. Such is likely the case today with the direct anterior approach to total hip arthroplasty. Can THA be done successfully through a direct anterior approach? Certainly the answer is yes; and with experience it can be done in relatively broad groups of patients with an acceptable risk of complications. Is it a better way to do THA than other approaches? Well probably not in 2012. Contemporary THA done with a variety of approaches and coupled with advanced anesthetic, pain management and rapid rehabilitation protocols has been shown to be safe and effective with both short hospital stays (48 hours) and even outpatient surgery in selected patients. No substantial clinical advantage has been shown to date with a direct anterior approach. The sometimes extraordinary claims associated with the direct anterior approach are accompanied by relatively ordinary data. The purported benefits of direct anterior related to more rapid recovery, better function, or a lower dislocation risk just have not proved to be demonstrable in broad groups of patients. In regard to recovery there are now several studies suggesting no difference at 2 hours; 2 days; 2 weeks or 2 years after surgery; and likely no difference at 2 months either. In regard to function there are now multiple gait analysis studies with no demonstrable benefit at 2 weeks or 6 weeks. In regard to lower risk of dislocation if we pool the data from big published studies Sariali (1.5%) Matta (0.6%) Jewett (1%) and Woolson (0%) the mean is 0.88%. Interestingly, contemporary posterior approach THA with formal capsular repair also has <1% dislocation rate when we look at published data from White (0.5%) Pagnano (0.3%) and Dorr (0%). The direct anterior does come at a cost including: longer operative times; additional equipment and/or personnel; unique complications; and in some techniques the need for intra-operative fluoroscopy with attendant exposure to radiation for the surgeon and staff. It is clear in 2012 that the direct anterior approach is just another technique for performing a very successful procedure, namely total hip arthroplasty. With advanced anesthetic, pain management, and rapid rehabilitation protocols it will be extremely difficult to prove any marginal benefit associated with THA surgical technique. To summarize the available data on direct anterior THA it is not unreasonable to conclude that “the extraordinary claims are accompanied by very ordinary data.”