Routine Capsular Closure Outperforms Incomplete Capsular Closure Following Hip Arthroscopy: A Meta-Analysis and Expected-Value Decision Analysis

To determine the optimal treatment decision for capsular management after primary hip arthroscopy for femoroacetabular impingement syndrome. An expected-value decision analysis was performed, (1) Organizing the decision problem, (2) determining outcome probabilities, (3) determining outcome utilities, (4) performing fold-back analyses, (5) performing sensitivity analyses. A decision tree was constructed (complete capsule closure vs incomplete closure) and a meta-analysis was conducted. Utilizing the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) framework, a systematic review was conducted to determine outcome probabilities. The protocol for this systematic review and meta-analysis was registered with PROSPERO (ID CRD42023458012). Sixty-five patients with hip pain were evaluated for demographics, Hip Activity Level (HAL) and surgical outcome preferences. Statistical fold-back analysis was calculated to determine the optimal treatment strategy. One-way sensitivity analysis evaluated the impact of varying outcome likelihoods in decision-making. Fold-back analysis showed the expected value for hip capsule complete closure was 8.60; the expected value for incomplete closure was 8.06. One-way sensitivity analysis of moderate complication shows that incomplete closure is favored when moderate complication probability following hip arthroscopy exceeds 16%. Meta-analysis of 17 studies and 3191 hips revealed the probability of a well outcome was greater for complete capsule closure 90.3% (95% CI 88.9%-92.0%) compared to capsule incomplete closure 83.2% (95% CI 80.9%-85.3%) (p < .000001). Fifty of sixty-five surveyed participants [mean age = 42.9 (SD 11.9), female = 66%] met inclusion criteria. The current meta-analysis and expected-value decision analysis demonstrated hip capsule complete closure as the superior capsular management technique based on greater expected value than incomplete capsular closure. This study demonstrated increased proportion of well outcomes with decreased rates of moderate (requiring revision hip arthroscopy) and major (requiring early conversion to Total Hip Arthroplasty [THA]) complications. III, meta-analysis of Level I-III studies with high heterogeneity.