Objectives. The purpose of this study was to compare the thickness of the hip capsule in patients with surgical hip disease, either with cam-femoroacetabular impingement (FAI) or non-FAI hip pathology, with that of asymptomatic control hips. Methods. A total of 56 hips in 55 patients underwent a 3Tesla MRI of the hip. These included 40 patients with 41 hips with arthroscopically proven hip disease (16 with cam-FAI; nine men, seven women; mean age 39 years, 22 to 58) and 25 with non-FAI chondrolabral pathology (four men, 21 women; mean age 40 years, 18 to 63) as well as 15 asymptomatic volunteers, whose hips served as controls (ten men, five women; mean age 62 years, 33 to 77). The maximal capsule thickness was measured anteriorly and superiorly, and compared within and between the three groups with a gender subanalysis using student’s t-test. The correlation between alpha angle and capsule thickness was determined using Pearson’s correlation coefficient. Results. Superiorly, the hip capsule was significantly greater in cam- (p = 0.028) and non-FAI (p = 0.048) surgical groups compared with the asymptomatic group. Within groups, the superior capsule thickness was significantly greater than the anterior in cam- (p < 0.001) and non-FAI (p < 0.001) surgical groups, but not in the control group. There was no significant correlation between the alpha angle and capsule thickness. There were no gender differences identified in the thickness of the hip capsule. Conclusion. The thickness of the capsule does not differ between cam- and non-FAI diseased hips, and thus may not be specific for a particular aetiology of hip disease. The capsule is, however, thicker in diseased surgical hips compared with asymptomatic control hips. Cite this article: K. S. Rakhra, A. A. Bonura, R. Nairn, M. E. Schweitzer, N. M. Kolanko, P. E. Beaule. Is the hip capsule thicker in diseased hips? Bone Joint Res 2016;5:586–593. DOI: 10.1302/2046-3758.511.2000495

Aims. The hip’s capsular ligaments passively restrain extreme range of movement (ROM) by wrapping around the native femoral head/neck. We determined the effect of hip resurfacing arthroplasty (HRA), dual-mobility total hip arthroplasty (DM-THA), conventional THA, and surgical approach on ligament function. Materials and Methods. Eight paired cadaveric hip joints were skeletonized but retained the hip capsule. Capsular ROM restraint during controlled internal rotation (IR) and external rotation (ER) was measured before and after HRA, DM-THA, and conventional THA, with a posterior (right hips) and anterior capsulotomy (left hips). Results. Hip resurfacing provided a near-native ROM with between 5° to 17° increase in IR/ER ROM compared with the native hip for the different positions tested, which was a 9% to 33% increase. DM-THA generated a 9° to 61° (18% to 121%) increase in ROM. Conventional THA generated a 52° to 100° (94% to 199%) increase in ROM. Thus, for conventional THA, the capsule function that exerts a limit on ROM is lost. It is restored to some extent by DM-THA, and almost fully restored by hip resurfacing. In positions of low flexion/extension, the posterior capsulotomy provided more normal function than the anterior, possibly because the capsule was shortened during posterior repair. However, in deep flexion positions, the anterior capsulotomy functioned better. Conclusion. Native head-size and capsular repair preserves capsular function after arthroplasty. The anterior and posterior approach differentially affect postoperative biomechanical function of the capsular ligaments. Cite this article: Bone Joint J 2019;101-B:426–434

We report the presence of estrogen receptor (ER) in the ligamentum capitis femoris (LCF) and hip capsule. We took 15 LCF and hip capsule biopsies from 15 patients undergoing hip surgery for the Developmental Dysplasia of the hip (DDH) and 15 hip capsules and LCF’s from intrauterine ex fetuses. The mean age of the babies was 10.3 months (6–18 months) at the time of surgery. Total 60 specimens were grouped into two as the DDH group and the control group and each of these groups were further divided into two to generate the groups for the LCF and hip capsules. Full thickness 1 x 1 cm anterior capsule and LCF portions were taken as biopsy specimens. An immunohistochemical study using monoclonal antibody against to estrogen receptors was performed to identify estrogen target cells in the hip capsule and LCF. The positive rates of ER staining in the control group were % 1.6 ± 0.2 for the LCF and % 1.3 ± 0.2 for the hip capsule, in the DDH group positive rates of ER staining were %2.5 ± 0.3 for the LCF and % 2.0 ± 0.3 for the hip capsule. The positive rates of ER staining in LCF and hip capsule of the control group were significantly lower than that in the DDH group in both groups we found ER’s to be significantly lower in the hip capsule than in LCF. The presence of estrogen receptors in the LCF and hip capsule supports the effect of estrogen in etiology of the DDH

The human hip capsule is a heterogeneous structure contributing greatly to the stability of this joint. A posterior approach to the hip necessarily sacrifices the ischio-femoral ligament but the decision to release the ilio-femoral and pubo-femoral ligaments remains at the discretion of the surgeon. This mechanical study aims to demonstrate that these anterior capsular structures, when left intact, may limit the external rotational range of motion when the variables of femoral offset, leg length and neck version are adjusted at the time of surgery. A dry bone pelvis-femur model was prepared and registered with the Stryker iNstride Hip Navigation software. A cemented 28 HDPE contemporary cup was inserted at 45° inclination with 20° of anteversion and a revision modular stem implanted in the femoral medullary canal. Artificial ilio-femoral and pubo-femoral ligaments were then prepared from plastinated rubber fabric and mounted in their anatomical positions. Using this model, a range of restoration body sizes was sequentially introduced to vary the offset. The rotational range of motion was then assessed. Repeat measurements were made using + 10mm length bodies across the same offset range. Finally, assessments of rotational range of motion were made using the 19mm body alone while varying neck lengths and degrees of version were trialled. All measurements of external rotation were taken in a position of 0° hip flexion and 0° abduction, as determined using the Stryker iNstride Hip Navigation System. As femoral offset was increased using our model, there was a progressive loss of external rotation. This consistent restriction of external rotation was further accentuated when +10mm length bodies were trialled across the same range of offsets. When a standard 19mm restoration body was placed and a range of heads trialled, it was again found that increasing neck length consistently correlated with a reduction in external rotation. Varying the restoration neck version with a standard head, it was found that increasing retroversion correlated with an increase in the external rotational range of motion. The findings of this mechanical study suggest a progressive limitation of hip external rotation with increasing femoral offset and leg length when the anterior capsular structures are intact. Such findings are of importance in pre-operative planning as they suggest that increases in these variables may significantly limit a patient’s range of external rotation unless the anterior hip capsule is released. Such considerations must of course be balanced against the potential to destabilise the hip if too extensive a soft tissue release is performed. The artificial model used in this study is intended to approximate the human hip and its ligaments. The absolute values for rotational range of motion measured using the Stryker hip navigation system are less significant than the overall trend which they suggest. A patient-based study is now planned to further test these findings

Aims. Developmental dysplasia of the hip (DDH) is a complex musculoskeletal disease that occurs mostly in children. This study aimed to investigate the molecular changes in the hip joint capsule of patients with DDH. Methods. High-throughput sequencing was used to identify genes that were differentially expressed in hip joint capsules between healthy controls and DDH patients. Biological assays including cell cycle, viability, apoptosis, immunofluorescence, reverse transcription polymerase chain reaction (RT-PCR), and western blotting were performed to determine the roles of the differentially expressed genes in DDH pathology. Results. More than 1,000 genes were differentially expressed in hip joint capsules between healthy controls and DDH. Both gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses revealed that extracellular matrix (ECM) modifications, muscle system processes, and cell proliferation were markedly influenced by the differentially expressed genes. Expression of Collagen Type I Alpha 1 Chain (COL1A1), COL3A1, matrix metalloproteinase-1 (MMP1), MMP3, MMP9, and MMP13 was downregulated in DDH, with the loss of collagen fibres in the joint capsule. Expression of transforming growth factor beta 1 (TGF-β1) was downregulated, while that of TGF-β2, Mothers against decapentaplegic homolog 3 (SMAD3), and WNT11 were upregulated in DDH, and alpha smooth muscle actin (αSMA), a key myofibroblast marker, showed marginal increase. In vitro studies showed that fibroblast proliferation was suppressed in DDH, which was associated with cell cycle arrest in G0/G1 and G2/M phases. Cell cycle regulators including Cyclin B1 (CCNB1), Cyclin E2 (CCNE2), Cyclin A2 (CCNA2), Cyclin-dependent kinase 1 (CDK1), E2F1, cell division cycle 6 (CDC6), and CDC7 were downregulated in DDH. Conclusion. DDH is associated with the loss of collagen fibres and fibroblasts, which may cause loose joint capsule formation. However, the degree of differentiation of fibroblasts to myofibroblasts needs further study. Cite this article: Bone Joint Res 2021;10(9):558–570

Aims

Surgical approaches that claim to be minimally invasive, such as the direct anterior approach (DAA), are reported to have a clinical advantage, but are technically challenging and may create more injury to the soft-tissues during joint exposure. Our aim was to quantify the effect of soft-tissue releases on the joint torque and femoral mobility during joint exposure for hip resurfacing performed via the DAA.

We aimed to determine if there are mechanoreceptors in hip joint capsule and ligamentum capitis femoris of the patients with developmental dysplasia of the hip. We took capsule and ligamentum capitis femoris biopsies from 20 hips of 20 patients who were operated because of developmental dysplasia of the hip. Meanage was 10.2 months (ranges 6-20 months) on the time of surgery. There were 12 girls and 8 boys. Teratologic and secondary hip dislocations were not included in this study. 0.5x 0.5 cm full thickness anterior capsule and liga-mentum capitis femoris portions were taken for biopsy specimen. Specimens were stained with hemotoxylin eosin and examined immunohistochemically using poly-clonal antibodyagainst S-100 Protein. In both analysis no mechanoreceptors was found in any samples of capsule and ligamentum capitis femoris. Conclusion: We think that there is a possibility that developmental dysplasia of the hip can be caused from a defect in formation of mechanoreceptors on localized capsule and ligamentum capitis femoris and we emphasize the need for further studies on the subject

Hip arthroscopy rates continue to increase. As a result, there is growing interest in capsular management techniques. Without careful preservation and surgical techniques, failure of the repair result in capsular deficiency, contributing to iatrogenic instability and persistent post-operative pain. In this setting, capsular reconstruction may be indicated, however there is a paucity of objective evidence comparing surgical techniques to identify the optimal method. Therefore, the objective of this study was to evaluate the biomechanical effect of capsulectomy and two different capsular reconstruction techniques (iliotibial band [ITB] autograft and Achilles tendon allograft) on hip joint kinematics in both rotation and abduction/adduction. Eight paired fresh-frozen hemi-pelvises 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 connected to a joint-motion simulator, while the pelvis was secured to a custom-designed fixture allowing adjustment 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. Pairs were divided into ITB or Achilles capsular reconstruction. After specimen preparation, three conditions were tested: (1) intact, (2) after capsulectomy, and (3) capsular reconstruction (ITB or Achilles). All conditions were tested in 0°, 45°, and 90° of flexion. Internal rotation (IR) and external rotation (ER) as well abduction (ABD) and adduction (ADD) moments of 3 N·m were applied to the femur via the load cell at each position. Rotational range of motion and joint kinematics were recorded. When a rotational force was applied the total magnitude of internal/external rotation was significantly affected by the condition of the capsule, independent of the type of reconstruction that was performed (p=0.001). The internal/external rotation increased significantly by approximately 8° following the capsulectomy (p<0.001) and this was not resolved by either of the reconstructions; there remained a significant difference between the intact and reconstruction conditions (p=0.035). The total anterior/posterior translation was significantly affected by the condition of the capsule (p=0.034). There was a significant increase from 6.7 (6.0) mm when the capsule was intact to 9.0 (6.7) mm following the capsulectomy (p=0.002). Both of the reconstructions (8.6 [5.6] mm) reduced the anterior/posterior translation closer to the intact state. There was no difference between the two reconstructions. When an abduction/adduction force was applied there was a significant increase in the medial-lateral translation between the intact and capsulectomy states (p=0.047). Across all three flexion angles the integrity of the native hip capsule played a significant role in rotational stability, where capsulectomy significantly increased rotational ROM. Hip capsule reconstruction did not restore rotational stability and also increased rotational ROM compared to the intact state a statistically significant amount. However, hip capsule reconstruction restored coronal and sagittal plane stability to approach that of the native hip. There was no difference in stability between ITB and Achilles reconstructions across all testing conditions

Femoroacetabular impingement (FAI) – enlarged, aspherical femoral head deformity (cam-type) or retroversion/overcoverage of the acetabulum (pincer-type) – is a leading cause for early hip osteoarthritis. Although anteverting/reverse periacetabular osteotomy (PAO) to address FAI aims to preserve the native hip and restore joint function, it is still unclear how it affects joint mobility and stability. This in vitro cadaveric study examined the effects of surgical anteverting PAO on range of motion and capsular mechanics in hips with acetabular retroversion. Twelve cadaveric hips (n = 12, m:f = 9:3; age = 41 ± 9 years; BMI = 23 ± 4 kg/m2) were included in this study. Each hip was CT imaged and indicated acetabular retroversion (i.e., crossover sign, posterior wall sign, ischial wall sign, retroversion index > 20%, axial plane acetabular version < 15°); and showed no other abnormalities on CT data. Each hip was denuded to the bone-and-capsule and mounted onto a 6-DOF robot tester (TX90, Stäubli), equipped with a universal force-torque sensor (Omega85, ATI). The robot positioned each hip in five sagittal angles: Extension, Neutral 0°, Flexion 30°, Flexion 60°, Flexion 90°; and performed hip internal-external rotations and abduction-adduction motions to 5 Nm in each position. After the intact stage was tested, each hip underwent an anteverting PAO, anteverting the acetabulum and securing the fragment with long bone screws. The capsular ligaments were preserved during the surgery and each hip was retested postoperatively in the robot. Postoperative CT imaging confirmed that the acetabular fragment was properly positioned with adequate version and head coverage. Paired sample t-tests compared the differences in range of motion before and after PAO (CI = 95%; SPSS v.24, IBM). Preoperatively, the intact hips with acetabular retroversion demonstrated constrained internal-external rotations and abduction-adduction motions. The PAO reoriented the acetabular fragment and medialized the hip joint centre, which tightened the iliofemoral ligament and slackenend the pubofemoral ligament. Postoperatively, internal rotation increased in the deep hip flexion positions of Flexion 60° (∆IR = +7°, p = 0.001) and Flexion 90° (∆IR = +8°, p = 0.001); while also demonstrating marginal decreases in external rotation in all positions. In addition, adduction increased in the deep flexion positions of Flexion 60° (∆ADD = +11°, p = 0.002) and Flexion 90° (∆ADD = +12°, p = 0.001); but also showed marginal increases in abduction in all positions. The anteverting PAO restored anterosuperior acetabular clearance and increased internal rotation (28–33%) and adduction motions (29–31%) in deep hip flexion. Restricted movements and positive impingement tests typically experienced in these positions with acetabular retroversion are associated with clinical symptoms of FAI (i.e., FADIR). However, PAO altered capsular tensions by further tightening the anterolateral hip capsule which resulted in a limited external rotation and a stiffer and tighter hip. Capsular tightness may still be secondary to acetabular retroversion, thus capsular management may be warranted for larger corrections or rotational osteotomies. In efforts to optimize surgical management and clinical outcomes, anteverting PAO is a viable option to address FAI due to acetabular retroversion or overcoverage

The occurrence of impingement can lead to instability, accelerated wear, and unexplained pain after THA. While implant and bony impingement were widely investigated, importance of soft tissue impingement was unclear. In the THA through posterior approach, it is known that posterior soft tissue repair can decrease the risk of dislocation. However, it is not known whether anterior soft tissue impingement by anterior hip capsule will influence hip ROM. The purpose of this study is to quantitatively measure the effect of anterior capsule resection on hip ROM in vivo during posterior approach THA using hip navigation system. From June 2011, 26 hips (25 patients) that underwent primary THA using Stryker CT-based hip navigation system were the subjects. All were female osteoarthritis patients and the average age at the operation was 59 (47–76) years. Intraoperatively, acetabular cup and femoral stem placement were performed through posterior approach under the navigation system. After reduction of the joint, we measured hip ROM using the same navigation system. We measured them before and after the resection of anterior hip capsule and compared the difference. After the resection of anterior hip capsule, the average increases of ROM were 0.7±3.5 degrees for flexion, 2.3±2.3 degrees for extension, 1.1±2.3 degrees for abduction and 2.1±2.9 degrees for external rotation at flexion 0 degree compared with ROM before the resection. However, it significantly increased 7.5±5.1 degrees for internal rotation at flexion 90 degree (range; −3–20, paired t-test p<0.001) and 6.1±5.5 degrees for internal rotation at flexion 45 degree (range; −4–18, p<0.001). In this study, we used navigation system for assessment of soft tissue impingement. We found that during posterior approach THA, resection of anterior hip capsule brought about significant increase of ROM, especially in the direction of flexion with internal rotation. We also found that this procedure did not change ROM of flexion, extension, abduction and external rotation. These results indicated that, during THA through posterior approach, resection of anterior hip capsule could reduce the risk of posterior instability without increasing the risk of anterior instability

Introduction and Objective. The human body is designed to walk in an efficient way. As energy can be stored in elastic structures, it is no surprise that the strongest elastic structure of the human body, the iliofemoral ligament (IFL), is located in the lower limb. Numerous popular surgical hip interventions, however, affect the structural integrity of the hip capsule and there is a growing evidence that surgical repair of the capsule improves the surgical outcome. Though, the exact contribution of the iliofemoral ligament in energy efficient hip function remains unelucidated. Therefore, the objective of this study was to evaluate the influence of the IFL on energy efficient ambulation. Materials and Methods. In order to assess the potential passive contribution of the IFL to energy efficient ambulation, we simulated walking using the large public dataset (n=50) from Schreiber in a the AnyBody musculoskeletal modeling environment with and without the inclusion of the IFL. The work required from the psoas, iliacus, sartorius, quadriceps and gluteal muscles was evaluated in both situations. Considering the large uncertainty on ligament properties a parameter study was included. Results. A significant reduction in the active component of all hip flexors was observed when the IFL is intact. The required muscle work was found to be reduced by as much as 48% (CI: 29–62%), 61% (CI: 35–84%) and 38% (CI: 2–69%) for the psoas, iliacus, and sartorius muscle respectively. The IFL inclusion has no major effect on the required work from the quadriceps and the gluteal muscle group. The energy storage in the IFL is largest at maximal hip extension and the contribution to forward motion is the largest at the start of the swing phase. Conclusions. The iliofemoral ligament seems to be a crucial structure in energy efficient walking. The findings support need for meticulous reconstruction of the capsule ligament in case of surgical damage

Introduction. Dual Mobility (DM) implants have gained popularity for the treatment and prevention of hip dislocation, with increased stability provided by a large diameter mobile liner. However, distal regions of the liner can impinge on soft-tissues like hip capsule and iliopsoas, leading to anterior hip pain. Additionally, soft-tissue impingement may trap the mobile liner, leading to excessive loading of the liner rim, from engagement with the femoral stem, and subsequent intra-prosthetic dislocation. The hypothesis of this study was that reducing the liner profile below the equator (contoured design) can mitigate soft-tissue impingement without compromising inner-head pull-out resistance and overall hip joint stability (Fig. 1). Methods. The interaction of conventional and contoured liners with anterior soft-tissues was evaluated in 10 cadaveric hips (5 specimens; 2 male, 3 female; age 65 ± 10 yrs; liner diameter 42–48mm) via visual observation and fluoroscopic imaging. A metal wire was sutured to the deep fibers of the iliopsoas tendon/muscle, and metal wires were embedded in the mobile liners for fluoroscopic visualization (Fig. 2). All soft-tissue except the anterior hip capsule and iliopsoas was removed, and a rope was attached to the iliopsoas to apply tension along its natural orientation. Resistance to inner-head pull-out was evaluated via Finite Element Analysis (FEA) by simulating a full cycle of insertion of the inner head into the mobile liner and subsequent pullout. The femoral head, acetabular shell, and stem were modeled as rigid, while the mobile liner was modeled as plastically deformable. Hip joint stability was evaluated by dynamic simulations in for two dislocation modes: (A) Posterior dislocation (at 90° hip flexion) with internal hip rotation; (B) Posterior dislocation (starting at 90° flexion) with combined hip flexion and adduction. A 44 mm diameter conventional and a 44 mm contoured liner were evaluated during these tests. Results. The cadaver experiments showed that distal portion of conventional liners impinge on anterior hip capsule and iliopsoas at low flexion angles (<30°). Additionally, when the hip moved from flexion into extension, the liner motion was blocked between posterior neck engagement, and anterior soft-tissue impingement. In all hips, the soft-tissue impingement / tenting was significantly reduced with contoured liners (Fig. 7). The change in tenting could be visualized as change in distance between the iliopsoas wire, and the contoured/conventional liners on sequential fluoroscopic images. The maximum reduction in iliopsoas tenting for a given specimen ranged from 1.8 mm to 5.5 mm. Additionally, the contoured and conventional liners had identical inner-head pull-out resistance (901N vs. 909N), jump distance (9.4 mm mode-A, 11.7 mm mode-B) and impingement-free range of motion (47° mode-A, 29° mode-B). Conclusion. This study showed that distal portions of conventional DM liners can impinge against iliopsoas and hip capsule in low flexion leading to functional impediment of liner motion. Additionally, reducing the liner profile below the equator led to significant reduction in soft-tissue impingement/tenting without affecting mechanical performance. Thus, a contoured dual mobility liner design may reduce the risk of anterior hip pain and intra-prosthetic dislocation resulting from soft-tissue impingement and liner entrapment. To view tables/figures, please contact authors directly

The iliocapsularis muscle is a little known muscle that originates in part from the inferior border of the anterior-inferior iliac spine, but the main origin arises from an elongated attachment of the anteromedial hip capsule and inserts just distal to the lesser trochanter. Nevertheless, this muscle is an important landmark for exposure of the anteromedial hip capsule and psoas tendon interval during performance of the Bernese periacetabular osteotomy. Speculations about the function of this muscle as a tightener of the hip capsule and femoral head stabilisator have grown when an apparent hypertrophy of this muscle was encountered in patients with dysplasia of the hip. The aim of this study was to compare the morphology of the iliocapsularis muscle between patients with decreased (developmental dysplasia of the hip) and increased acetabular coverage (pincer-type of femoroac-etabular impingement) using Arthro-MRIs. Dysplasia of the hip (Group I) was defined as an LCE angle of less than 25° with a minimal acetabular index of 14° and pincer type of FAI (Group II) was defined as and LCE angle exceeding 39° on conventional radiographs. This resulted in 37 hips in Group I and 45 hips in Group II. The morphology of the iliocapsularis muscle was measured on axial slices of Arthro-MRIs. The parameters were muscle thickness, width and cross section at 4cm distal of the spina iliaca anterior inferior and also distal of the femoral head. Additionally, the volume of the muscle from its origins to the cross section distal of the femoral head was computed. All parameters were significantly increased in Group I compared to Group II (p< 0.05). In Group I the mean thickness was 20 ± 4.5 (range, 12 – 29) mm, width 25 ± 5.2 (range, 17 – 37), and cross section 281 ± 10.7 (range, 139 – 591) mm2 compared to Group II with a mean thickness of 17 ± 4.4 (range, 10 – 27) mm, width 22 ± 5.0 (range, 11 – 31), and cross section 235 ± 10.3 (range, 90 – 535) mm2. The muscle volume in Group I was 6.8 ± 2.9 (range, 2.2 – 13.0) cm3 compared to Group II with 8.7 ± 3.7 (range, 3.4 – 18.1) cm3. The results differed more when corrected for gender with the largest differences found for women. In hip dysplasia the anterior acetabular coverage is decreased. Because of the iliocapsularis muscle’s origination on the hip capsule, contrition of the muscle theoretically can tighten the anterior hip capsule, thus helping to stabilized the femoral head within the dysplastic acetabular. Although the true function of the iliocapsularis muscle remains unknown, constant use of this muscle in attempting to stabilize the femoral head in hip dysplasia theoretically would explain the apparent hypertrophy of this muscle

INTRODUCTION. Interest in tissue-preserving or minimally invasive total hip arthroplasty (THA) is increasing with focus toward decreased hospital stay, enhanced rehabilitation, and quicker recovery for patients. Two tissue-preserving techniques, the anterior and superior approaches to THA, have excellent clinical results, but little is known about their relative impact on soft tissue. The purpose of this study was to evaluate the type and extent of tissue damage after THA with each approach, focusing on abductors, short external rotators, and the hip capsule. METHODS. Total hip arthroplasty was performed on bilateral hips of eleven fresh-frozen cadavers (22 hips). They were randomized to anterior THA performed on one side and superior THA performed on the other, in the senior authors' standard technique. Two independent examiners graded the location and extent of tissue injury by performing postsurgical dissections. Muscle bellies, tendons, and capsular attachments were graded as intact, split, damaged (insignificant, minimal, moderate, or extensive damage), or detached based on direct visual inspection of each structure. Tissue injury was analyzed with either a chi-squared (≥5 qualifying structures) or Fisher's exact test (<5 qualifying structures). P values <0.05 were significant. RESULTS. The abductor muscles or tendons were intact or insignificantly damaged in 63.6% of anterior approach specimens compared with 84.1% of the superior specimens (p= 0.03). Specifically, the gluteus minimus tendon had moderate or extensive damage in 63.6% of anterior specimens compared with none of the superior specimens (p <0.01). Short external rotators (SERs) group, defined as both the muscle and tendon of the piriformis, conjoint, obturator externus, and quadratus, were intact or insignificantly damaged in 63.6% of anterior approach specimens compared with 80.5% of the SER group of superior specimens (p = 0.02). The femoral attachments of the anterior, posterior, and superior capsules were extensively damaged or detached in 90.9%, 81.8%, and 100% of anterior approach specimens respectively compared with 0%, 9.1% and 9.1% of superior approach specimens respectively (all p <0.01). CONCLUSION. In a cadaveric study examining superior and anterior approaches to THA, the superior approach demonstrated significantly less soft-tissue destruction than the anterior approach, specifically to the gluteus minimus tendon, short external rotators, and the hip capsule

Introduction. Current methodologies for designing and validating existing THA systems can be expensive and time-consuming. A validated mathematical model provides an alternative solution with immediate predictions of contact mechanics and an understanding of potential adverse effects. The objective of this study is to demonstrate the value of a validated forward solution mathematical model of the hip that can offer kinematic results similar to fluoroscopy and forces similar to telemetric implants. Methods. This model is a forward solution dynamic model of the hip that incorporates the muscles at the hip, the hip capsule, and the ability to modify implant position, orientation, and surgical technique. Muscle forces are simulated to drive the motion, and a unique contact detection algorithm allows for virtual implantation of components in any orientation. Patient-specific data was input into the model for a telemetric subject and for a fluoroscopic subject. Results. For both stance and swing phase, the model predicted similar patterns and magnitudes compared to telemetry (forces) and fluoroscopy (kinematics). During stance phase, the model predicts 2.5 xBW of maximum hip force while telemetry predicts 2.3 xBW, yielding 8.7% error (Figure 1a). During swing phase, the model predicts 1.1 xBW maximum hip force, similar to telemetry (Figure 1b). During stance phase, the model predicts 1.3mm of hip separation (sliding) compared to 1.6mm for fluoroscopy, yielding 18.8% error (Figure 1c). During swing phase, the model predicts 1.9mm of separation compared to 1.7mm for fluoroscopy, yielding 11.8% error (Figure 1d). The model was also used to assess component placement, version, and optimal positioning compared to live surgery, producing very promising results. Conclusion. The model has proven accurate in predicting kinematics and forces. Therefore, forward solution mathematical modeling can be used to efficiently evaluate new component designs, positioning and technique differences, patient-specific scenarios, and any specific contribution towards THA outcomes that cannot be controlled in vivo. For any figures or tables, please contact the authors directly

The hip joint capsule passively restrains extreme range of motion protecting against impingement, dislocation and possibly edge loading. These functions would be advantageous following total hip arthroplasty (THA) however the degree of capsular excision, preservation and/or repair greatly varies between surgeons/approaches. Therefore, we asked: how does THA affect capsular ligamentous biomechanics? Which factors have the biggest influence?. For this laboratory based, cadaveric model, THA was performed through the acetabular medial wall, thus preserving the entire hip capsule. A previously published testing rig was used to measure capsular function by internally and externally rotating the hip in each of five hip positions (standing, sitting, gait heel strike, and two impingement risk positions, full flexion with adduction & extension with abduction). N=8 hips were tested both before and after THA allowing for repeated measurements between the native and replaced hip. The ROM before the capsule engaged increased following THA (p<0.05), indicating reduced biomechanical function. Internal rotation was affected more than external rotation. Increasing neck length restored the ROM more towards the native condition. Increasing head size also had a small positive effect, but less than neck length. Following THA, the capsular ligaments were no longer able to wrap around the smaller femoral head thereby limiting their ability to restrain excessive hip movement. The anterior capsule is affected less than the posterior, and may benefit from being preserved length. A repair to the posterior capsule should compensate for the reduced THA head size in order to restore function

Hip impingement causes clinical problems for both the native hip, where labral or chondral damage can cause severe pain, and in the replaced hip, where subluxation can cause squeaking/metallosis through edge loading, or can cause dislocation. There is much research into bony/prosthetic hard impingements showing that anatomical variation/component mal-positioning can increase the risk of impingement. However, there is a lack of basic science describing the role of the hip capsule and its intertwined ligaments in restraining range of motion, ROM, and so it is unclear if careful preservation/repair of the capsular ligaments would offer clinical benefits to young adults, or could also help prevent edge loading in addition to reducing the postoperative dislocation rate in older adults. This in-vitro study quantifies the ROM where the capsule passively stabilises the hip and compares this to hip kinematics during daily activities at risk for hip subluxation. Ten cadaveric left hips were skeletonised preserving the joint capsule and mounted in a testing rig that allowed application of loads, torques and rotations in all six-degrees of freedom (Figure 1). At 27 positions encompassing a complete hip ROM, the passive rotation resistance of each hip was recorded. The gradient of the torque-rotation profiles was used to quantify where the capsule is taut/slack and after resecting the capsule, where labral impingement occur. The ROM measurements were compared against hip kinematics from daily activities. The capsule tightly restrains the hip in full flexion/extension with large slack regions in mid-flexion. Whilst ligament recruitment varies throughout hip ROM, the magnitude of restraint provided is constant (0.82 ± 0.31 Nm/degree). This restraint acts to prevent or reduce loading of the labrum in the native hip (Figure 2). The measured passive rotational stability envelope is less than clinical ROM measurements indicating the capsule does provide restraint to the joint within a relevant ROM. Activities such as pivoting, stooping, shoe tying and rolling over in bed all would recruit the capsular ligaments in a stabilising role. The fine-tuned anatomy of the hip capsule provides a consistent contribution to hip rotational restraint within a functionally relevant ROM for normal activities protecting the hip against impingement. Capsulotomy should be kept to a minimum and routinely repaired in the native hip to maintain natural hip mechanics. Restoring its native function following hip replacement surgery may provide a method to prevent subluxation and edge loading in the replaced hip

Introduction. The large diameter mobile polyethylene liner of the dual mobility implant provides increased resistance to hip dislocation. However, a problem specific to the dual mobility system is intra-prosthetic dislocation (IPD), secondary to loss of the retentive rim, causing the inner head to dissociate from the polyethylene liner. We hypothesized that impingement of the polyethylene liner with the surrounding soft-tissue inhibits liner motion, thereby facilitating load transfer from the femoral neck to the liner and leading to loss of retentive rim over time. This mechanism of soft-tissue impingement with the liner was evaluated via cadaver experiments, and retrievals were used to assess polyethylene rim damage. Methods. Total hip arthroplasty was performed on 10 cadaver hips using 3D printed dual mobility components. A metal wire was sutured to the posterior surface (underside) of the iliopsoas, and metal wires were embedded into grooves on the outer surface of the liner and inner head to identify these structures under fluoroscopy. Tension was applied to the iliopsoas to move the femur from maximum hyperextension to 90° of flexion for the purpose of visualizing the iliopsoas and capsule interaction with the mobile liner. The interaction of the mobile liner with the iliopsoas was studied using fluoroscopy and direct visual observation. Fifteen retrieved dual mobility liners were assessed for rim edge and rim chamfer damage. Rim edge damage was defined as any evidence of contact, and rim chamfer damage was classified into six categories: impact ribs on the chamfer surface, loss of machining marks, scratching or pitting, rim deformation causing a raised lip, a rounded rim edge, or embedded metal debris. Results. Manipulation of the cadaver specimens through full range of motion showed liner impingement with the iliopsoas tendon in low flexion angles, which impeded liner motion. At high flexion angles (beyond 30°), the iliopsoas tendon moved away from the liner and impingement was not observed. The fluoroscopy tests using the embedded metal wires confirmed what was observed during manual manipulation of the specimen. When observing the hip during maximum hyperextension, 0°, 15°, and 30° of flexion, there was obvious tenting of the iliopsoas. All retrieved components showed damage on the rim and the chamfer surface. The most common damage seen was scratching/ pitting. There was no association between presence of damage and time in vivo controlling for age and Body Mass Index (p≥0.255). Discussion. The cadaver studies showed that the mobile liner motion could be impeded by impingement with the iliopsoas tendon and hip capsule. Visual and fluoroscopic observation showed impingement of iliopsoas and hip capsule with the distal portion of the mobile liner, particularly during low flexion angles. All retrieved liners showed damage despite their limited time in vivo and despite being retrieved for reasons other than IPD. This suggests that soft-tissue impingement may inhibit liner motion routinely in vivo, resulting in load transfer from the femoral neck on to the rim of the liner. This may be an important mechanism for IPD

Purpose. While changes in lower limb alignment and pelvic inclination after total hip arthroplasty (THA) using certain surgical approaches have been studied, the effect of preserving the joint capsule is still unclear. We retrospectively investigated changes in lower limb alignment, length and pelvic inclination before and after surgery, and the risk of postoperative dislocation in patients who underwent capsule preserving THA using the anterolateral-supine (ALS) approach. Methods. Between July 2016 and March 2018, 112 hips (non-capsule preservation group: 42 hips, and capsule preservation group: 70 hips) from patients with hip osteoarthritis who underwent THA were included in this study. Patients who underwent spinal fusion and total knee arthroplasty on the same side as that of the THA were excluded. Using computed tomography, we measured lower limb elongation, external rotation of the knee, and femoral neck/stem anteversion before operation and three to five days after operation. We examined the pelvic inclination using vertical/transverse ratio of the pelvic cavity measured by X-ray of the anteroposterior pelvic region in the standing position before and six to 12 months after operation. All operations were performed using the ALS approach and taper wedge stem. Results. No dislocation was found in both groups. Lower limb elongation was 14.5±6.3 (mean±SD) mm in the non-capsule preservation group and 9.4±8.8 mm in the capsule preservation group. A significant reduction was found in the capsule preservation group (p<0.05). Changes in knee external rotation was 7.2±10.5 degrees in the non-capsule preservation group and 3.5±10.3 degrees in the capsule preservation group. A trend toward decreased knee external rotation in the capsule preservation group (p=0.07) was observed. There was no difference in femoral neck/stem anteversion and vertical/transverse ratio of the pelvic cavity between both groups. Discussion. Patients in the capsule preservation group tended to have reduced external rotation of lower limb, which might prevent postoperative anterior dislocation due to preservation of anterior structures. The capsule preservation group had significantly reduced lower limb elongation, suggesting that preservation of the hip joint capsule ligament contributes to joint stability. There was no significant difference in the pelvic inclination between both groups. Long-term changes will be assessed by regular follow up after operation

Background. An increased incidence of periprosthetic osteolysis, resulting in loss of biologic fixation, has been recently reported in contemporary THAs with low-carbide metal-on-metal compared to metal-on-polyethylene couple bearings. A hypersensitivity reaction due to Co and Cr debris is reported as a potential cause for failure of THAs with high-carbide bearings, but there are no evidence-based data for this reaction in low-carbide metal-on-metal bearings. Questions/purposes. We investigated whether there were differences in immunologic hypersensitivity reactions in retrievals from revised THAs with COP versus MOM bearing couples. Patients and Methods. We compared newly formed capsule and periprosthetic interface membranes retrieved from revision surgery due to aseptic failure in 20 patients with low-carbide bearings and 13 patients with ceramic-on-polyethylene bearings. For control tissue we obtained samples from the hip capsule during the primary THA implantation in 13 patients with low-carbide bearings and seven with ceramic-on-polyethylene. We examined the tissues with conventional histologic and immunohistochemical methods. Results. Compared to the controls and the tissue from patients with ceramic-on-polyethylene bearings, the tissues from patients with low-carbide metal-on-metal bearings were associated with (1) extensive necrosis and fibrin exudation in the newly formed hip capsule and (2) diffuse and perivascular lymphocytic infiltration of a higher degree than in the ceramic-on-polyethylene hips in conventional histologic examination and (3) more T than B cells. Conclusions. The conventional histologic and immunohistochemical findings in tissues retrieved from failed THAs with low-carbide metal-on-metal bearings are consistent with a link between hypersensitivity and osteolysis with low-carbide bearing couple THA