Review Question - QID 218190

The patient has capsular deficiency following arthroscopic treatment for FAI which would likely present with pain with hip extension and ER.

Femoroacetabular impingement (FAI) typically occurs as a result of abnormal contact between the femoral head-neck junction and the acetabular rim secondary to predisposing CAM and/or pincer lesions. Surgical management of FAI is typically performed arthroscopically, yielding favorable outcomes, however, revision rates have been reported to be around 5-10%. The most common reasons for revision include under-resection, over-resection, capsular deficiency, cartilage injuries, and unaddressed dysplasia. Capsular deficiency can be due to the capsule not being repaired, unaddressed capsular laxity, or failure of capsular repair due to overaggressive rehabilitation or trauma. The iliofemoral ligament is the strongest hip capsular ligament providing restraint against excessive external rotation and extension. The iliofemoral ligament is incised during the capsulotomy and capsular closure is generally recommended after interportal and T-capsulotomies to avoid postoperative capsular deficiency. Patients with postoperative capsular deficiency typically present with pain that is different than their preoperative symptoms, gross instability, pain or apprehension with hip extension and ER, positive dial test, or loss of recoil with log roll. The treatment for postoperative capsular defects is capsular repair or reconstruction with autograft or allograft.

Byrd and Jones reviewed a case series that included 200 patients who underwent hip arthroscopy for at least one year to assess the effectiveness of arthroscopic intervention for managing symptomatic FAI in athletes. The results showed a significant postoperative improvement in Harris Hip Scores. They also found that 95% of professional athletes and 85% of intercollegiate athletes were able to return to their previous level of competition. Complications were relatively rare, with only 5 transient neurapraxias (all resolved) and 1 case of heterotopic ossification.

Lynch et al provide an overview of different hip injuries that occur in athletic populations. They go into detail describing the "sports hip triad," which consists of adductor strains, osteitis pubis, and athletic pubalgia, and discuss the diagnostic algorithm best used in these injuries. Athletic hip conditions can be debilitating and often require a timely diagnosis to provide appropriate intervention.

Wylie et al. provided a review of the natural history of structural abnormalities in the hip and the relationship with OA. Conditions like cam-type femoroacetabular impingement, hip dysplasia, and the consequences of pediatric hip disease can increase the risk of early OA in the hip. However, they do note that not all individuals with abnormal hip anatomy go on to develop early OA. Outcomes following arthroscopic and open hip procedures have shown that they can improve pain and function. Yet there is limited evidence regarding long-term outcomes following hip preservation to indicate that these procedures can delay the need for a THA.

Neeple et al. conducted a cohort study to investigate whether clinical characteristics and radiographic parameters could predict intra-articular hip disease patterns in patients undergoing hip arthroscopy. They retrospectively reviewed 355 hips in 338 patients, finding that labral tears were present in 90.1% of hips, while acetabular cartilage lesions were present in 67.3%. Male sex, older age, Tönnis osteoarthritis grade, and an alpha angle greater than 50° on frog lateral radiographs were independently associated with an increased risk for severe acetabular chondromalacia. Insidious onset of pain was associated with acetabular chondromalacia. Cam-type FAI was linked to more severe labral disease. However, acetabular dysplasia and pincer-type FAI were not significantly associated with acetabular chondral disease in multivariate analysis.

Figure A is a Dunn view of the left hip demonstrating no residual CAM or Pincer lesion. Figure B is a T2-weighted fat-saturated coronal MRI demonstrating a superior capsular defect with extracapsular fluid extravasation.

Incorrect Answers
Answer 1: Pain with FADIR would be more consistent with residual impingement than a capsular defect.
Answer 2: Pain with resisted hip flexion is more likely to be due to iliopsoas tendonitis than a capsular defect.
Answer 3: Pain with passive hip flexion in neutral is more likely due to subspine impingement than a capsular defect
Answer 5: Loss of motion would be more consistent with capsular adhesions than a capsular defect.