Enhanced anterior capsular repair: A very low dislocation rate in a population at risk with standard implants

Levonti Ohanisian; Whisper Grayson; Emma Watson; David Watson

doi:10.1016/j.jor.2025.07.016

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67 (); 344-348

doi:

10.1016/j.jor.2025.07.016

Enhanced anterior capsular repair: A very low dislocation rate in a population at risk with standard implants

Levonti Ohanisian^a, Whisper Grayson^b,, Emma Watson^c, David Watson^a

a Department of Orthopaedic Surgery, University of South Florida, Tampa, FL, USA

b Department of Orthopaedic Surgery & Rehabilitation, Loyola University Medical Center, Maywood, IL, USA

c University of Florida, Gainesville, FL, USA

⁎Corresponding author: Whisper Grayson. whisper.grayson@luhs.org

Received: 2025-7-8, Accepted: 2025-7-20, Published: 2025-7-21

Professor P K Surendran Memorial Education Foundation

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Femoral neck fractures (FNFs) treated with total hip arthroplasty (THA) are at high risk for dislocation. While several techniques have been studied in attempts to address this increased risk, there is a scarcity of literature describing the efficacy of capsular management through anterior approach-based surgeries. In this study, we describe our institutional experience with an enhanced capsular repair (ECR) technique, where the capsule is sutured to the gluteus minimus. We hypothesize that this technique will enhance stability and decrease dislocation rate.

Seventy-nine patients who underwent primary THA for FNF between January 1, 2017–March 30, 2022, with a minimum of one-year follow-up were identified. These patients underwent an anterior approach-based operation where the ECR was performed. All operations were performed by a single fellowship trained arthroplasty surgeon. Primary outcomes included dislocation, revision surgery, and infection rates. Ambulatory status, radiographic parameters, and the Charlson Comorbidity Index (CCI) were also obtained.

A total of 79 patients were included with zero dislocations observed. There were two revisions for aseptic loosening and traumatic periprosthetic fracture. Two superficial surgical site infections were successfully treated non-operatively. The average CCI was 3.89 and the average head size was 34 mm. The radiographic parameters postoperatively demonstrated an average abduction angle of 41.6° and average leg length change of +2.33 mm.

We found that performing an ECR after an anterior approach THA for FNF achieved adequate stability with the use of conventional implants. No significant leg lengthening or changes to ambulatory status were observed post-operatively.

Keywords

Total hip arthroplasty

Anterior approach

Hip dislocation

Enhanced capsular repair

Femoral neck fracture

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1 Background

Total hip arthroplasty (THA) following femoral neck fractures (FNFs) are considered high risk for complications, most notably dislocation.^1–3 Dislocation rates as high as 12 % following THA for an acute FNF have been reported in the literature with variability existing between the different approaches.⁴ These patients often need to undergo revision surgery, leading to significant patient morbidity and strain on the healthcare system.³^,⁵^,⁶

Historically, this increased risk of dislocation with THA has had multiple proposed solutions for achieving additional stability. One popular proposition is a dual mobility construct. Studies have shown a significant decrease in dislocation rates with the use of a dual mobility cup in THA for FNFs.^7–10 However, the dual mobility cup can be associated with increased costs, up to $1000 more than conventional implants, as well as increased rates of aseptic loosening.⁶^,⁸^,¹¹ Other proposed solutions have included increasing the femoral head size, a technique that also increases the potential for aseptic loosening.¹⁰ Despite these advancements, the rate of dislocation following THA for FNFs remains high.^7–10

Capsular closure has been described in the literature as a technique used to enhance stability for THA after FNFs.¹² While well-described for the posterior approach, there is a paucity of literature evaluating capsular repair after THA for FNF through an anterior approach. Additionally, there is no literature describing techniques for enhanced capsular closure techniques through an anterior approach. In this study, we seek to contribute to this paucity of literature by describing an enhanced capsular repair technique for THA through an anterior approach. In this technique, the surgeon sutures the capsule to the gluteus minimus, providing additional support to the implant. We hypothesize that this technique will enhance stability for THA performed for FNFs and decrease dislocation rates despite the use of conventional implants.

2 Material and methods

2.1

2.1 Patient selection

Following Institutional Review Board (IRB) approval, a retrospective chart review of primary THAs for acute FNFs was performed. Current Procedural Terminology (CPT) code 27,130 was used for initial patient extraction, following by chart review to ensure inclusion and exclusion criteria were met. Inclusion criteria included all patients ≥18 years of age who underwent a primary THA for acute FNF between January 1st, 2017 and March 30th, 2022. Exclusion criteria included patients with less than one-year follow-up and patients undergoing revision THA. All operations were performed by a single high-volume fellowship trained arthroplasty surgeon who performed this closure for all THAs.

2.2

2.2 Variables of interest

Baseline demographics including age, gender, race/ethnicity, body mass index (BMI), tobacco use, hypertension, diabetes mellitus, immunocompromised status, and Charlson Comorbidity Index (CCI) were collected via chart review. Post-operative outcomes assessed included hip dislocation, implant loosening, revision surgery, superficial surgical site infection (defined as an infection treated with oral antibiotics and/or superficial tissue debridement), prosthetic joint infection, follow-up time, and ambulatory status. Intraoperative implant descriptions including head size and type of offset (standard versus high offset) were noted. Radiographical measurements were made on immediate post-operative anteroposterior pelvic radiographs and included offset, abduction angle, and leg length discrepancy.

2.3

2.3 Surgical technique

All patients underwent THA for acute FNF through an anteriorly based approach, either through a direct anterior (DA) or Watson-Jones approach (Figure 1). Smith and Nephew anthology stem and R3 cup were utilized exclusively. The short external rotators were preserved in all cases. Cup positioning was judged intraoperatively based on the transverse acetabular ligament. Fluoroscopy was utilized to confirm appropriate stem size at the time of trialing. Head size was selected based on the largest available monolithic head for the given cup size. Offset was selected based off contralateral hip templating and intraoperative assessment of tissue tension. After final placement of THA components and acceptable leg length and stability had been achieved, copious irrigation was utilized, and vancomycin powder placed. Attention was then turned to performing an enhanced capsular repair for additional stability. The two leaflets of the capsule were identified and multiple interrupted 0-vicryl sutures were used in a figure of 8 pattern for capsular closure. Once this was achieved, the tendinous portion of the gluteus minimus was identified. Interrupted 0-vicryl sutures in a figure of 8 pattern were used from the capsule to the gluteus minimus tendon with the hip in an internally rotated position (Figure 2). The remainder of the wound was then closed in the usual fashion utilizing a barbed suture for fascial and deep closure, followed by 2-0 vicryl and 3-0 monocryl suture for subcutaneous and skin layers. All patients were weight bearing as tolerated after the procedure with no precautionary measures or restrictions placed.

3 Results

A total of 79 patients met the study criteria during the enrollment period (January 1st, 2017 to March 30th, 2022). These patients underwent a primary THA for acute FNF with an enhanced capsular repair performed during closure. The average age was 69.8 years-old (std dev, 10.3) and 35.4 % of the patients were male. Common comorbidities included hypertension (74.7 %) and diabetes (22.8 %), with an average Charlson Comorbidity Index of 3.9 (std dev, 2.1). Most of the patients denied any tobacco use history (53.2 %), compared to current (16.5 %) or former (30.4 %) use (Table 1).

Table 1 Enhanced capsular repair (ECR) cohort – demographics (n = 79).

	ECR Cohort n = 79
Average Age	69.8 (10.3)
Gender (% Male)	35.4 % (28)
Race/EthnicityCaucasianAfrican AmericanHispanicOther	82.3 % (65)10.1 % (8)6.3 % (5)1.3 % (1)
Average BMI	25.1 (4.5)
Tobacco UseCurrentFormerNever	16.5 % (13)30.4 % (24)53.2 % (42)
Hypertension (% Yes)	74.7 % (59)
Diabetic (% Yes)	22.8 % (18)
Immunocompromised (% Yes)	8.9 % (7)
Average Charlson Comorbidity Index	3.9 (2.1)

There were no dislocations observed. Complications were witnessed in two patients. Two revisions were performed for an aseptic loosening and a traumatic periprosthetic fracture. There were subsequently superficial site infections in those same two patients that were successfully treated non-operatively. The average follow-up time was 24.3 months. The average leg length change was +2.33 mm (range: −14 mm to +16.8 mm) (Table 2). All patients were able to weight bear as tolerated at final follow-up.

Table 2 Enhanced capsular repair cohort – post-operative outcomes (n = 79).

	ECR Cohort n = 79
Hip Dislocation	0
Implant Loosening	1
Revision Surgery	2
Superficial Surgical Site Infection	2
Prosthetic Joint Infection	0
Average Follow-up Time (months)	24.3
Average Post-operative Leg Length Discrepancy (mm)	+2.33

With regards to the intraoperative implants utilized, a majority (77.5 %) of the patients received a standard offset stem, with 22.8 % receiving a high offset stem. Average offset was 102.6 mm, average head size was 34 mm, and the average abduction angle was 41.6° (Table 3).

Table 3 Intraoperative implant descriptions (n = 79).

	ECR Cohort n = 79
Average Offset (mm)	102.6
Type of Offset Stem UsedStandardHigh Offset	77.2 % (61)22.8 % (18)
Average Head Size (mm)	34
Average Abduction Angle (degrees)	41.6

4 Discussion

With an increasingly aging population, the incidence of FNFs continues to crescendo.¹³ THA has continued to grow in popularity with multiple studies citing improved results and cost-efficacy compared to hemiarthroplasty or osteosynthesis.^14–18 Historically, FNFs treated with THA are considered a high-risk group for complications such dislocation as well as readmission.¹⁴ Several techniques have been attempted to address this increased risk including anterior based approaches, dual mobility constructs, and larger femoral heads.¹⁴^,¹⁹^,²⁰ In our study, we found a low complication rate and zero dislocations observed in a cohort of patients who underwent THA for FNF with an enhanced capsular repair. To our knowledge, this is the largest study to date evaluating the use of capsular repair following anterior THA for FNF.

This study aligns with current literature by seeking to find ways of reducing dislocation rates following THA. Other techniques attempted in prior studies include capsular preservation and repair. Previous literature has described the benefits of capsular repair in THA through an anteriorly based approach in regards to associated complications, mainly dislocation, for both elective THA and THA performed for FNF.^21–23 A systematic review has also demonstrated lower dislocation rates with capsular repair for elective THA when using a posterolateral approach.²⁴^,²⁵

Despite these previous studies, there is a scarcity of literature describing the efficacy of capsular management for FNFs through an anteriorly based operation. Arac et al. described their experience with 32 patients who underwent an anteriorly based THA after FNF.²¹ They reported anterior capsular closure in all cases and report zero dislocations at one year follow-up.²¹ In this study, Arac et al. used cemented acetabular cups in 12 cases and femoral cemented components in 27 of the 32 cases. No specific details on the implants used were given.²¹ They argue that a capsular closure enhances stability to the hip joint leading to lower dislocation rates.²¹ Our results support this study, contributing to the argument that the proposed enhanced capsular repair should be considered during THA for the treatment of patients with a FNF. Furthermore, when compared to historical dislocation rates as high as 12 % in patients undergoing a primary THA for FNF, our study's results demonstrated a reduced dislocation risk with ECR.⁴

Additionally, the overall low complication rate and uninhibited ambulatory status of our patients lends support to the notion that a THA in this at-risk patient population can safely be performed with standard implants. Thus, avoiding the need for specialized implants and increased costs with the average cost of dual mobility implants ranging from $250 to $2000.²⁶ The described ECR with tagging the capsule to the leading edge of minimus further tensions the capsule, prevents capsular retraction and helps to minimize dead space in the deep wound. By tensioning the capsule with the hip internally rotated, external rotation at the hip is somewhat normalized to pre-release levels limiting early anterior instability while maintaining normal cup anteversion. This is supported by a study conducted by Schwartz et al. whose randomized control trial evaluating capsular management in DAA THA found no significant differences in postoperative range of motion with capsule repair compared to a capsulectomy.²⁷

Overall, the complication rate in our study was low (2.5 %), consisting of two revision surgeries for aseptic loosening and periprosthetic fracture, each subsequently complicated by a superficial surgical site infection that was managed non-operatively. This is low compared to an average reported complication rate of 6.9 % following THA.²⁸ Current literature reports average rates of 1.5 % for postoperative periprosthetic fractures, 3.2 % for wound complications, and 0.8 % for aseptic loosening following primary THA.²⁸ Thus, our complications are not significantly different from prior studies, with low concern for this technique imparting any increased risk in adverse outcomes.

While enhanced capsular repair has been supported in the literature as a technique capable of reducing dislocation rates, it is not without potential limitations. Some studies have reported no significant difference in dislocation risk, along with the limitation of prolonged operating room time.²⁴ Additional studies are needed to fully assess the advantages and limitations of this technique.

The results of this study must be considered within its limitations, including the inherent biases present with the retrospective study design. Additionally, this study only includes operations performed by a single surgeon, thus limiting the generalizability. Next, a primary endpoint of one-year was chosen for hip dislocation based on clinical data suggesting that most dislocations due to insufficiency occur within this timeframe.²⁹ Nonetheless, hip dislocations can present at any time. We acknowledge that some complications may have presented outside of the follow-up window or patients may have presented to another institution. Finally, functional hip outcome scores were not reported; however, ambulatory status was reported. Future studies are warranted to further evaluate the dislocation rates of patients undergoing enhanced capsular repair during THA for FNF compared to patients without this surgical technique.

5 Conclusion

This study found no dislocations following THA for FNF at one-year through anterior based approaches with an enhanced capsular repair. This surgical technique is easily applicable and holds the potential to improve patient outcomes by limiting hip dislocation rates without the use of specialized implants. Further large-scale study is warranted.

CRediT authorship contribution statement

Levonti Ohanisian: Investigation, Methodology, Writing – original draft, Writing – review & editing. Whisper Grayson: Investigation, Methodology, Data curation, Writing – original draft, Writing – review & editing. Emma Watson: Investigation, Methodology, Writing – review & editing. David Watson: Conceptualization, Investigation, Supervision, Writing – review & editing.

Consent

Institutional Review Board approval was submitted and received for this study, and the manuscript is not submitted elsewhere for publication consideration.

Ethical review committee statement

The study has been performed in accordance with the ethical standards in the 1964 Declaration of Helsinki and has been carried out in accordance with relevant regulations of the US Health Insurance Portability and Accountability Act (HIPAA).

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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