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Effect of Capsulotomy on Hip Stability—A Consideration During Hip Arthroscopy C

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Effect of Capsulotomy on Hip Stability—A Consideration During Hip Arthroscopy C An Original Study Effectf o Capsulotomy on Hip Stability— A Consideration During Hip Arthroscopy Christopher O. Bayne, MD, Robert Stanley, BS, Peter Simon, MS, Alejandro Espinoza-Orias, PhD, Michael J. Salata, MD, Charles A. Bush-Joseph, MD, Nozomu Inoue, MD, PhD, and Shane J. Nho, MD, MS Abstract We conducted a study to further understand the effect P = .02). After capsulotomy, there was a qualitative of capsulotomy on hip joint stability using an in vitro ca- observation of increased distal, lateral, and anterior daver model. Thirteen fresh-frozen cadaveric hip speci- translation of the femoral head in neutral position, and mens were subjected to an external rotation torque of a qualitative observation of increased medial, posterior, 0.588 Nm. The experimental kinematics, post-process and distal translation of the femoral head in flexion. translation, and rotation data for each specimen were Qualitatively, after capsulotomy, hips tested in neutral tested under 4 conditions: neutral flexion with capsule position demonstrated more translation than rotation, intact; neutral flexion with transverse capsulotomy; maxi- whereas hips tested in flexion demonstrated more rota- mum flexion with capsule intact; and maximum flexion tion than translation. with transverse capsulotomy. A segmented 3-dimension- Capsulotomy appears to permit increased rotation in al model of the femur was used to evaluate femoral head maximum flexion. Hips tested in neutral trended toward translation after application of external rotation torque. more translation than rotation, whereas hips in flexion In maximum flexion, hips with intact capsules rotated trended toward more rotation than translation. less than hips with capsulotomy in the y (abduction)AJO Judicious capsular management is indicated during and z (external rotation) planes (y-plane, P = .01; z-plane, arthroscopic hip procedures. ip arthroscopy is an increasingly popular procedure positions of extension and external rotation of the hip and with steadily expanding utility and broadening in- loose in flexion and internal rotation.2 Martin and colleagues1 HDOdications. For arthroscopic NOT procedures of the hip, a found thatCOPY the iliofemoral ligament was determined to resist capsulotomy is often performed, as it helps the surgeon achieve anterior translation of the femoral head from within the ac- intra-articular visualization, facilitates instrument exchange, etabulum, with its lateral arm limiting internal rotation in and enhances maneuverability within a highly constrained extension. The pubofemoral ligament was shown to control joint. As such, an appropriate capsulotomy is a necessity for external rotation in extension. The ischiofemoral ligament was arthroscopic procedures in the central compartment. In ad- found to be the most significant resistor of internal rotation dition, capsulotomy improves visualization of the peripheral forces of the hip as well as resistor to adduction forces. compartment for the treatment of cam lesions and other extra- Using this in vitro model, we conducted a study to further articular pathology. Consequently, interest in the contribution understand the effect of a transverse capsulotomy (often per- of capsular structures to hip stability has increased. formed during hip arthroscopy) on the rotational and trans- The role of the hip joint capsule on hip joint stability or lational kinematics of the hip. We hypothesized that increased kinematics is relatively unknown. Martin and colleagues1 rotational and translational femoroacetabular motion would conducted the initial biomechanics study of the role of the be observed after capsulotomy. iliofemoral, ischiofemoral, and pubofemoral ligaments. The triangular iliofemoral ligament (Y ligament of Bigelow) is the Materials and Methods strongest of the capsular ligaments. It arises from the anterior We obtained 13 fresh-frozen cadaveric hip specimens consist- inferior iliac spine of the pelvis and extends distally and later- ing of the hemipelvis, the femur, and the overlying soft-tissues. ally along the femoral neck to attach to the intertrochanteric All specimens were screened by computed tomography (CT) line of the anterior femur. The iliofemoral ligament is taut in examination to assess acetabular and femoral version and to Authors’ Disclosure Statement: Dr. Nho is a consultant for Stryker and Pivot Medical. The other authors report no actual or potential conflict of interest in relation to this article. 160 The American Journal of Orthopedics® April 2014 www.amjorthopedics.com An Original Study confirm the absence of bony pathology. Two inclusion criteria loading apparatus described by Provencher and colleagues.3 The were hip center-edge angle 25° or less and Tönnis grade 1 or apparatus allowed for adjustment of flexion, extension, and axial less. Two exclusion criteria were hip center-edge angle more rotation of the femur around a static ilium and acetabulum.3 than 25° and Tönnis grade more than 1. After thawing for 24 Six reflective markers were rigidly attached to the speci- hours, all muscle and soft-tissue were removed from each speci- mens to allow for 3-dimensional (3-D) position tracking. A men by careful dissection, leaving the hip capsule and labrum motion-tracking system (Eagle4 cameras and EVaRT analy- intact. The femur was transected at the junction of the proximal sis software; Motion Analysis Corp., Santa Rosa, California) and distal thirds to allow for potting in polymethylmethacry- was used to record the experimental kinematics, post-process late (PMMA) in a cylindrical polyvinyl chloride mold. The iliac translation, and rotation data. The loading apparatus holding wing of the hemipelvis was placed in a 4 × 4-in mold to allow each specimen was mounted on an x-y displacement table for potting in PMMA. The acetabular seal was vented placing (modified Provencher frame; Figure 1).3 An external rotation a 20-gauge needle between the labrum and the bony acetabu- torque of 0.588 Nm was applied by static load and held while lum. Each specimen was placed into a modified version of the data were recorded for 10 seconds for each loading condition. This torque magnitude was chosen because pilot testing dem- onstrated that 0.588 Nm was sufficient to cause full external rotation of the femur without causing impingement of the greater trochanter on the acetabulum at terminal rotation. Each hip was tested under 4 conditions: neutral flexion with capsule intact; neutral flexion with transverse capsulotomy; maximum flexion with capsule intact; and maximum flexion with transverse capsulotomy. The transverse capsulotomy was performed on the anterior aspect of the femoral neck, 1 cm from the acetabular rim. It was continued distally, parallel to the labrum, involving the entire iliofemoral ligament. The 3-D position of the markers in space was analyzed AJOusing Euler angle calculation in order to obtain translational and rotational parameters. CT scan was obtained of each speci- men, and a virtual model was segmented using Mimics soft- ware (Materialise, Leuven, Belgium). In the model, the femo- ral and pelvic bones were separately extracted at the neutral position. These were superimposed over the images of each Figure 1. Motion tracking system with loading apparatus mounted onDO x-y displacement table. NOTdifferent positionCOPY using voxel-based registration to evaluate A B C X (Flexion) Y (Abduction) Z (External Rotation) 12 1.0 25.0 0.9 22.5 10 0.8 20.0 0.7 17.5 8 0.6 15.0 Degrees Degrees Degrees 6 0.5 12.5 0.4 10.0 4 0.3 7.5 0.2 5.0 2 0.1 2.5 0 0.0 0 Intact Capsulotomy Intact Capsulotomy Intact Capsulotomy Figure 2. Rotation in neutral flexion. (A) Rotation in the x (flexion) plane. (B) Rotation in the y (abduction) plane. (C) Rotation in the z (external rotation) plane. www.amjorthopedics.com April 2014 The American Journal of Orthopedics® 161 Effect of Capsulotomy on Hip Stability—A Consideration During Hip Arthroscopy C. O. Bayne et al A B C X (Flexion) Y (Abduction) Z (External Rotation) 10 1.8 22.5 1.6 20.0 8 1.4 17.5 1.2 15.0 6 1.0 12.5 Degrees Degrees Degrees 0.8 10.0 4 0.6 7.5 2 0.4 5.0 0.2 2.5 0 0.0 0 Intact Capsulotomy Intact Capsulotomy Intact Capsulotomy Figure 3. Rotation in maximum flexion. (A) Rotation in the x (flexion) plane. (B) Rotation in the y (abduction) plane. (C) Rotation in the z (external rotation) plane. femoral head translation after application of the external rota- However, after capsulotomy, hips tested in flexion leaned to- tion torque. Differences between experimental groups were ward distal, posterior, and medial translation (Figure 4). assessed with both analysis of variance and AJOnonparametric To better understand these qualitative observations, we analysis. Level of significance was set atP < .05. plotted the mean displacement of all specimens in each test- ing condition. Again, there was no statistically significant Results difference in displacement of the femoral head after applied We compared femoroacetabular motion caused by applied torque. Only qualitative directional tendencies were observed. external rotation torque for each testing condition in terms of In general, specimens tested in neutral rotation were likely translation and rotation. The vector components of the rotation to demonstrate anterior displacement of the femoral head observedDO for each applied torque NOT were analyzed in the x, y, both beforeCOPY and after capsulotomy (0.17 mm anterior before, and z axes. These equated to flexion, abduction, and external 0.22 mm anterior after). This anterior displacement
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