Capsular management strategies in hip arthroscopy for femoroacetabular impingement syndrome: A multilevel meta-analysis.

Abstract

To compare three capsular management strategies in hip arthroscopy (capsule preservation [CP], capsule repair [CR] and capsule unrepaired [CU]) for femoroacetabular impingement syndrome (FAIS). We hypothesized that CP and CR would provide superior outcomes compared with CU. A systematic search of PubMed, Embase, CENTRAL and Epistemonikos was conducted up to 31 May 2025. Outcomes of CP, CR and CU were compared using a frequentist multilevel random-effects meta-analysis with restricted maximum likelihood estimation and Hartung-Knapp adjustment. Ultimately, 47 primary studies met the inclusion criteria and were included in the meta-analysis. A total of 7366 hips (7276 patients) were included across the 47 studies. These were distributed into three capsular management groups: (I) CP: 1352 hips, (II) CR: 5043 hips and (III) CU: 971 hips. CR showed the greatest improvement in modified Harris Hip Score with a mean change of 24.00 (95% confidence interval [CI]: 20.86-27.14), while CP achieved the highest MCID rate at 12 months post-operatively with a mean of 9.30 (95% CI: 7.47-11.14). No other consistent statistically significant differences were observed between groups across post-operative scores, change scores or complication rates. CP and CR both demonstrated superior outcomes compared to CU in selected functional parameters. All three strategies showed comparable results in pain reduction, revision rate, conversion to total hip arthroplasty and overall complication incidence. CR and CP yield superior outcomes compared to leaving the CU. Surgeons should close or preserve the capsule, while future trials will clarify the optimal strategy. Level II (systematic review and meta-analysis of predominantly Level III studies, with additional contributions from Levels I and II studies).