Routine Capsular Closure With Hip Arthroscopic Surgery Results in Superior Outcomes: A Systematic Review and Meta-analysis.

BACKGROUND: In hip arthroscopic surgery, capsulotomy is performed to improve visualization and allow instrumentation of the joint. Traditionally, the defect has been left unrepaired; however, increasing evidence suggests that this may contribute to persistent pain and iatrogenic capsular instability. Nevertheless, the clinical benefit of performing routine capsular repair remains controversial. PURPOSE/HYPOTHESIS: We conducted a systematic review and meta-analysis to investigate the effects of routine capsular closure on patient-reported outcomes (PROs), hypothesizing that superior PROs would be observed with routine capsular closure. STUDY DESIGN: Meta-analysis and systematic review; Level of evidence, 4. METHODS: A systematic review and meta-analysis was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The terms "hip,""arthroscopy,""capsule,""capsular,""repair," and "closure" were used to query Ovid MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), CINAHL (Cumulative Index to Nursing and Allied Health Literature), SPORTDiscus, and PubMed. Articles with PROs stratified by capsular management were included. Multivariate mixed-effects metaregression models were implemented with study-level random-effects and fixed-effects moderators for capsular closure versus no repair and after controlling for surgical indication and preoperative PROs. The effect of repair on both the postoperative score and the change in scores was evaluated via the Harris Hip Score (HHS)/modified HHS (mHHS), Hip Outcome Score (HOS)-Activities of Daily Living (ADL), and HOS-Sport Specific Subscale (SSS), with a supplemental analysis of additional outcomes. RESULTS: Of 432 initial articles, 36 were eligible for analysis, with results for 5132 hip arthroscopic procedures. The capsule was repaired in 3427 arthroscopic procedures and unrepaired in 1705. Capsular repair was associated with significantly higher postoperative HHS/mHHS (2.011; SE, 0.743 [95% CI, 0.554-3.467]; P = .007), HOS-ADL (3.635; SE, 0.873 [95% CI, 1.923-5.346]; P < .001), and HOS-SSS (4.137; SE, 1.205 [95% CI, 1.775-6.499]; P < .001) scores as well as significantly superior improvement on the HHS/mHHS (2.571; SE, 0.878 [95% CI, 0.849-4.292]; P = .003), HOS-ADL (3.315; SE, 1.131 [95% CI, 1.099-5.531]; P = .003), and HOS-SSS (3.605; SE, 1.689 [95% CI, 0.295-6.915]; P = .033). CONCLUSION: This meta-analysis is the largest to date evaluating the effect of capsular closure on PROs and demonstrates significantly higher mean postoperative scores and significantly superior improvement with repair, while controlling for the effects of preoperative score and surgical indication. The true magnitude of the benefit of capsular repair may be clarified by large prospective randomized studies using PRO measures specifically targeted and validated for hip arthroscopic surgery/preservation.

A comparison of postoperative pain between anterior cruciate ligament reconstruction and repair.

PURPOSE: To determine if patients who underwent ACL repair experienced less short-term postoperative pain versus patients who underwent ACL reconstruction. METHODS: Electronic charts were retrospectively reviewed of patients who underwent ACL surgery from November 2014 through April 2019 by a single surgeon. Patients were divided into two groups based on whether they underwent ACL repair or ACL reconstruction. A two-tailed equal variance t-test was used to evaluate visual analog scale (VAS) pain scores at the first postoperative visit. A chi-squared test of independence was used to evaluate narcotic prescription refills at the first postoperative visit. RESULTS: 36 ACL repair patients and 71 ACL reconstruction patients were included. The mean visual analog scale (VAS) pain score at the first postoperative visit (12.9 ± 3.7 days post-op) for ACL repair patients (2.81 ± 1.79) was significantly lower (p = .004) compared to ACL reconstruction patients (4.07 ± 2.26). The number of narcotic prescription refills at the first postoperative visit was significantly lower (p = .027, ARR = 21.4%, NNT = 4.67) in the ACL repair group (7 of 36, 19.4%) compared to the ACL reconstruction group (29 of 71, 40.8%). CONCLUSION: Patients who underwent ACL repair experienced less short-term postoperative pain and were prescribed fewer narcotics compared to patients who underwent ACL reconstruction.

Outcome of reconstructive surgery for intestinal fistula in the open abdomen.

OBJECTIVE: To determine factors which influence the outcome of surgical techniques to close enterocutaneous fistulas within the open abdomen. SUMMARY BACKGROUND DATA: Enterocutaneous fistulation within an open abdominal wound is associated with considerable morbidity and mortality. The factors that influence the outcome of reconstructive surgery are unclear. METHODS: Sixty-one patients undergoing 63 operations to close enterocutaneous fistulas associated with open abdominal wounds were referred to a national center for further management. Once sepsis had been eradicated, nutritional status restored and local conditions in the abdomen judged to be suitable, fistulas were resected and the abdominal wall reconstructed by suture repair with and without component separation, or by suture repair in combination with absorbable or nonabsorbable prosthetic mesh. Patients were followed up for 16 to 84 months postoperatively. RESULTS: There were 3 postoperative deaths (4.8%). Major complications, including postoperative respiratory and surgical site infection occurred in 52 of 63 (82.5%) procedures. Refistulation occurred in 7 cases (11.1%) but was more common when the abdominal wall was reconstructed with prosthetic mesh (7 of 29, 24.1%) than with sutures (0 of 34, 0%). Porcine collagen mesh was associated with a particularly high rate of refistulation (5 of 12, 41.7%). CONCLUSIONS: Simultaneous reconstruction of the intestinal tract and abdominal wall remains associated with a high complication rate, justifying the management of such patients in specialized units. Simultaneous reconstruction of the abdominal wall with prosthetic mesh is associated with a particularly high incidence of recurrent postoperative fistulation and should be avoided if possible.