Routine Capsular Closure Outperforms Incomplete Capsular Closure After Hip Arthroscopy: A Meta-analysis and Expected-Value Decision Analysis

McLeod K Phillips; Taylor Abouhaif; Timothy L Waters; Garrett Bullock; Andrew J Recker; Anthony P Fiegen; Nicholas A Trasolini; Allston J Stubbs; Brian R Waterman

doi:10.1016/j.arthro.2024.11.080

Routine Capsular Closure Outperforms Incomplete Capsular Closure After Hip Arthroscopy: A Meta-analysis and Expected-Value Decision Analysis

Arthroscopy. 2024 Dec 9:S0749-8063(24)01010-7. doi: 10.1016/j.arthro.2024.11.080. Online ahead of print.

Authors

McLeod K Phillips¹, Taylor Abouhaif², Timothy L Waters³, Garrett Bullock⁴, Andrew J Recker⁵, Anthony P Fiegen⁶, Nicholas A Trasolini⁵, Allston J Stubbs⁵, Brian R Waterman⁵

Affiliations

¹ Department of Orthopedic Surgery, Morristown Medical Center, Morristown, New Jersey, U.S.A.. Electronic address: mickleodk@gmail.com.
² Wake Forest University School of Medicine, Winston-Salem, North Carolina, U.S.A.
³ Department of Orthopaedic Surgery, Medical College of Georgia, Augusta, Georgia, U.S.A.
⁴ Department of Orthopaedic Surgery and Rehabilitation, Wake Forest University School of Medicine, Winston-Salem, North Carolina, U.S.A.; Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, University of Oxford, United Kingdom.
⁵ Department of Orthopaedic Surgery and Rehabilitation, Wake Forest University School of Medicine, Winston-Salem, North Carolina, U.S.A.
⁶ Orthopedic Institute, Sioux Falls, South Dakota, U.S.A.

PMID: 39662851
DOI: 10.1016/j.arthro.2024.11.080

Abstract

Purpose: To determine the optimal treatment decision for capsular management after primary hip arthroscopy for femoroacetabular impingement syndrome.

Methods: An expected-value decision analysis was performed (1) organizing the decision problem, (2) determining outcome probabilities, (3) determining outcome utilities, (4) performing fold-back analyses, and (5) performing sensitivity analyses. A decision tree was constructed (complete capsule closure vs incomplete closure) and a meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework, a systematic review was conducted to determine outcome probabilities. The protocol for this systematic review and meta-analysis was registered with PROSPERO (ID CRD42023458012). Sixty-five patients with hip pain were evaluated for demographics, hip activity level, and surgical outcome preferences. Statistical fold-back analysis was calculated to determine the optimal treatment strategy. One-way sensitivity analysis evaluated the impact of varying outcome likelihoods in decision making.

Results: Fold-back analysis showed the expected value for hip capsule complete closure was 8.60; the expected value for incomplete closure was 8.06. One-way sensitivity analysis of moderate complication showed that incomplete closure is favored when moderate complication probability after hip arthroscopy exceeds 16%. A meta-analysis of 17 studies and 3,191 hips revealed the probability of a well outcome was greater for complete capsule closure 90.3% (95% confidence interval 88.9%-92.0%) compared with capsule incomplete closure 83.2% (95% confidence interval 80.9%-85.3%) (P < .000001). Fifty of sixty-five surveyed participants (mean age = 42.9 years, standard deviation 11.9; female = 66%) met inclusion criteria.

Conclusions: The current meta-analysis and expected-value decision analysis showed hip capsule complete closure as the superior capsular management technique on the basis of greater expected value than incomplete capsular closure. This study revealed increased proportion of well outcomes with decreased rates of moderate (requiring revision hip arthroscopy) and major (requiring early conversion to total hip arthroplasty) complications.

Level of evidence: Level III, meta-analysis of Level I-III studies with high heterogeneity.

Publication types

Review