Previous Arthroscopic Hip Surgery Increases Axial Distractibility Compared to the Native Contralateral Hip and May Suggest Instability

Published:September 24, 2021DOI:


      To compare intraoperative hip joint distractibility between hips that previously underwent arthroscopic surgery and the contralateral hip with no history of surgical manipulation.


      Patients undergoing revision hip arthroscopy between April 2019 and December 2020, who previously underwent arthroscopic hip surgery for femoroacetabular impingement syndrome, were prospectively enrolled. Exclusion criteria were any contralateral hip surgery. Before instrumentation, fluoroscopic images of both hips were obtained at 25 lbs traction intervals up to 100 lbs. Total joint space was measured at each traction interval. Distraction was calculated as the difference between the baseline joint space and the total joint space at each subsequent traction interval. Wilcoxon signed ranks tests and McNemar tests were used to compare distraction between revision and native contralateral hips.


      Forty-seven patients were included. Mean distraction of operative hips was significantly greater than mean distraction of nonoperative hips at traction intervals of 50 lbs (2.13 vs 1.04 mm, P = .002), 75 lbs (6.39 vs 3.70 mm, P < .001), and 100 lbs (8.24 vs 5.39, P < .001). Mean total joint space of operative hips was significantly greater than mean total joint space of nonoperative hips at traction intervals of 50 lbs (6.60 vs 5.39 mm, P < .001), 75 lbs (10.86 vs 8.05 mm, P < .001), and 100 lbs (12.73 vs 9.73, P < .001). A greater percentage of operative hips achieved all distraction thresholds, in 2-mm intervals up to 10-mm, at each traction interval.


      In the majority of patients undergoing revision hip arthroscopy, previous arthroscopic hip surgery increases axial distractibility of the hip joint compared with the native contralateral hip at axial traction forces of 50-100 lbs. Increased axial distractibility following hip arthroscopy may be suggestive of hip instability and can be assessed on a stress examination with the patient under anesthesia.

      Level of Evidence

      III, case–control study.
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        • Safran M.R.
        Microinstability of the hip—gaining acceptance.
        J Am Acad Orthop Surg. 2019; 27: 12-22
        • Yeung M.
        • Memon M.
        • Simunovic N.
        • Belzile E.
        • Philippon M.J.
        • Ayeni O.R.
        Gross instability after hip arthroscopy: An analysis of case reports evaluating surgical and patient factors.
        Arthroscopy. 2016; 32: 1196-1204.e1
        • Kalisvaart M.M.
        • Safran M.R.
        Microinstability of the hip—it does exist: Etiology, diagnosis and treatment.
        J Hip Preserv Surg. 2015; 2: 123-135
        • Johannsen A.M.
        • Behn A.W.
        • Shibata K.
        • Ejnisman L.
        • Thio T.
        • Safran M.R.
        The role of anterior capsular laxity in hip microinstability: A novel biomechanical model.
        Am J Sports Med. 2019; 47: 1151-1158
        • O’Neill D.C.
        • Mortensen A.J.
        • Cannamela P.C.
        • Aoki S.K.
        Clinical and radiographic presentation of capsular iatrogenic hip instability after previous hip arthroscopy.
        Am J Sports Med. 2020; 48: 2927-2932
        • Khair M.M.
        • Grzybowski J.S.
        • Kuhns B.D.
        • Wuerz T.H.
        • Shewman E.
        • Nho S.J.
        The effect of capsulotomy and capsular repair on hip distraction: A cadaveric investigation.
        Arthroscopy. 2017; 33: 559-565
        • Fagotti L.
        • Kemler B.R.
        • Utsunomiya H.
        • et al.
        Effects of capsular reconstruction with an iliotibial band allograft on distractive stability of the hip joint: A biomechanical study.
        Am J Sports Med. 2018; 46: 3429-3436
        • Weber A.E.
        • Neal W.H.
        • Mayer E.N.
        • et al.
        Vertical extension of the t-capsulotomy incision in hip arthroscopic surgery does not affect the force required for hip distraction: Effect of capsulotomy size, type, and subsequent repair.
        Am J Sports Med. 2018; 46: 3127-3133
        • Wuerz T.H.
        • Song S.H.
        • Grzybowski J.S.
        • et al.
        Capsulotomy size affects hip joint kinematic stability.
        Arthroscopy. 2016; 32: 1571-1580
        • Nepple J.J.
        • Philippon M.J.
        • Campbell K.J.
        • et al.
        The hip fluid seal—part II: The effect of an acetabular labral tear, repair, resection, and reconstruction on hip stability to distraction.
        Knee Surg Sport Traumatol Arthrosc. 2014; 22: 730-736
        • Crawford M.J.
        • Dy C.J.
        • Alexander J.W.
        • et al.
        The 2007 Frank Stinchfield Award. The biomechanics of the hip labrum and the stability of the hip.
        Clin Orthop Relat Res. 2007; 465: 16-22
        • Kapron A.L.
        • Karns M.R.
        • Aoki S.K.
        • et al.
        Patient-specific parameters associated with traction in primary and revision hip arthroscopic surgery.
        Orthop J Sport Med. 2018; 6 (2325967118807707)
        • Makhni E.C.
        • Ramkumar P.N.
        • Cvetanovich G.
        • Nho S.J.
        Approach to the patient with failed hip arthroscopy for labral tears and femoroacetabular impingement.
        J Am Acad Orthop Surg. 2020; 28: 538-545
        • Cvetanovich G.L.
        • Chalmers P.N.
        • Levy D.M.
        • et al.
        Hip arthroscopy surgical volume trends and 30-day postoperative complications.
        Arthroscopy. 2016; 32: 1286-1292
        • Kovalenko B.
        • Bremjit P.
        • Fernando N.
        Classifications in brief: Tonnis classification of hip osteoarthritis.
        Clin Orthop Relat Res. 2018; 476: 1680-1684
        • Wylie J.D.
        • Kapron A.L.
        • Peters C.L.
        • Aoki S.K.
        • Maak T.G.
        Relationship between the lateral center-edge angle and 3-dimensional acetabular coverage.
        Orthop J Sport Med. 2017; 5
        • Hanson J.A.
        • Kapron A.L.
        • Swenson K.M.
        • Maak T.G.
        • Peters C.L.
        • Aoki S.K.
        Discrepancies in measuring acetabular coverage: Revisiting the anterior and lateral center edge angles.
        J Hip Preserv Surg. 2015; 2: 280-286
        • Atkins P.R.
        • Shin Y.
        • Agrawal P.
        • et al.
        Which two-dimensional radiographic measurements of cam femoroacetabular impingement best describe the three-dimensional shape of the proximal femur?.
        Clin Orthop Relat Res. 2019; 477: 242-253
        • Bockhorn L.N.
        • Vera A.M.
        • Dong D.
        • Delgado D.A.
        • Varner K.E.
        • Harris J.D.
        Interrater and intrarater reliability of the Beighton score: A systematic review.
        Orthop J Sport Med. 2021; 9
        • O’Neill D.C.
        • Mortensen A.J.
        • Tomasevich K.M.
        • et al.
        Joint venting prior to hip distraction minimizes traction forces during hip arthroscopy.
        Arthroscopy. 2021; 37: 2164-2170
        • Aoki S.K.
        • Karns M.R.
        • Hananouchi T.
        • Todd D.C.
        Hip arthroscopy capsular closure: The figure of eight technique.
        Arthrosc Tech. 2017; 6: e505-e509
        • Featherall J.
        • Tomasevich K.M.
        • O’Neill D.C.
        • Mortensen A.J.
        • Aoki S.K.
        Arthroscopic hip capsule reconstruction for anterior hip capsule insufficiency in the revision setting.
        Arthrosc Tech. 2021; 10: e1339-e1344
        • Koo T.K.
        • Li M.Y.
        A guideline of selecting and reporting intraclass correlation coefficients for reliability research.
        J Chiropr Med. 2016; 15: 155-163
        • Dumont G.D.
        Hip instability: Current concepts and treatment options.
        Clin Sports Med. 2016; 35: 435-447
        • Riff A.J.
        • Kunze K.N.
        • Movassaghi K.
        • et al.
        Systematic review of hip arthroscopy for femoroacetabular impingement: The importance of labral repair and capsular closure.
        Arthroscopy. 2019; 35: 646-656.e3
        • Philippon M.J.
        • Schenker M.L.
        • Briggs K.K.
        • Kuppersmith D.A.
        • Maxwell R.B.
        • Stubbs A.J.
        Revision hip arthroscopy.
        Am J Sports Med. 2007; 35: 1918-1921
        • Bolia I.K.
        • Fagotti L.
        • Briggs K.K.
        • Philippon M.J.
        Midterm outcomes following repair of capsulotomy versus nonrepair in patients undergoing hip arthroscopy for femoroacetabular impingement with labral repair.
        Arthroscopy. 2019; 35: 1828-1834
        • Frank R.M.
        • Lee S.
        • Bush-Joseph C.A.
        • Kelly B.T.
        • Salata M.J.
        • Nho S.J.
        Improved outcomes after hip arthroscopic surgery in patients undergoing t-capsulotomy with complete repair versus partial repair for femoroacetabular impingement: A comparative matched-pair analysis.
        Am J Sports Med. 2014; 42: 2634-2642
        • Economopoulos K.J.
        • Chhabra A.
        • Kweon C.
        Prospective randomized comparison of capsular management techniques during hip arthroscopy.
        Am J Sports Med. 2020; 48: 395-402
        • Wylie J.D.
        • Beckmann J.T.
        • Maak T.G.
        • Aoki S.K.
        Arthroscopic capsular repair for symptomatic hip instability after previous hip arthroscopic surgery.
        Am J Sports Med. 2016; 44: 39-45
        • Kalisvaart M.M.
        • Safran M.R.
        Hip instability treated with arthroscopic capsular plication.
        Knee Surgery, Sport Traumatol Arthrosc. 2017; 25: 24-30
        • Filan D.
        • Carton P.
        Routine interportal capsular repair does not lead to superior clinical outcome following arthroscopic femoroacetabular impingement correction with labral repair.
        Arthroscopy. 2020; 36: 1323-1334
        • Ortiz-Declet V.
        • Mu B.
        • Chen A.W.
        • et al.
        Should the capsule be repaired or plicated after hip arthroscopy for labral tears associated with femoroacetabular impingement or instability? A systematic review.
        Arthroscopy. 2018; 34: 303-318
        • Röling M.A.
        • Mathijssen N.M.
        • Blom I.
        • Lagrand T.
        • Minderman D.
        • Bloem R.M.
        Traction force for peroperative hip dislocation in hip arthroscopy.
        Hip Int. 2019; 30: 333-338
        • Ellenrieder M.
        • Tischer T.
        • Bader R.
        • Kreuz P.C.
        • Mittelmeier W.
        Patient-specific factors influencing the traction forces in hip arthroscopy.
        Arch Orthop Trauma Surg. 2017; 137: 81-87
        • Dienst M.
        • Seil R.
        • Gödde S.
        • et al.
        Effects of traction, distension, and joint position on distraction of the hip joint: An experimental study in cadavers.
        Arthroscopy. 2002; 18: 865-871
        • Lertwanich P.
        • Plakseychuk A.
        • Kramer S.
        • et al.
        Biomechanical evaluation contribution of the acetabular labrum to hip stability.
        Knee Surg Sport Traumatol Arthrosc. 2016; 24: 2338-2345
        • Vahedi H.
        • Aalirezaie A.
        • Azboy I.
        • Daryoush T.
        • Shahi A.
        • Parvizi J.
        Acetabular labral tears are common in asymptomatic contralateral hips with femoroacetabular impingement.
        Clin Orthop Relat Res. 2019; 477: 974-979