How capsular management strategies impact outcomes: A systematic review and meta -analysis of comparative studies

Purpose: To objectively evaluate the effect different management strategies have on the following post-surgical outcomes. Methods: The PubMed, Embase and Cochrane Library databases were reviewed for articles published between January 1st, 2000 to September 18, 2019 that reported on studies comparing techniques for handling the capsule during hip arthroscopy. After applying the inclusion and exclusion criteria, our final analysis included 10 studies. In total, these articles included 1556 hips. The following capsular management strategies were implemented: complete repair (n= 444; 28.53%), partial repair (n= 32; 2.06%), plication (n= 223; 14.33%) and release/no-repair (n = 857; 55.08%). A meta-analysis was performed on outcomes presented in three or more studies using sufficient pooled statistical analysis data. Results: Our meta-analysis demonstrated an improvement in the HOS-SS with capsular repair without being statistically significant (95%CI [-6.71, 8.21], p = 0.06). However, a significant improvement in the mHHS was detected with capsular repair (95%CI [-1.37, 9.39], p = 0.03). Of the Four studies evaluating HOS-ADL, two reported improved outcomes with capsular repair (p < 0.05 for both) while the other two reported no significant difference. While mixed results were demonstrated for reoperation rates, no difference was found across capsular management strategies regarding radiological outcomes, NAHS (all p-values > 0.05) pain (p > 0.05), flexion (p > 0.05), and patient satisfaction (p > 0.05). Conclusion: Capsular repair has the potential to improve patient reported outcomes after hip arthroscopy. While there was no consensus in literature, studies consistently reported similar or superior outcomes in the capsular repair cohorts compared to capsular release. Further randomized controlled studies need to be conducted for better evaluation of outcomes.