Review Article

Microinstability of the Hip—Gaining

Acceptance

Abstract
Marc R. Safran, MD The hip has generally been considered an inherently stable joint.
However, the femoral head moves relative to the acetabulum.
Although the bones are primarily important in hip stability, the
importance of the soft tissues has recently been demonstrated.
Symptomatic microinstability of the hip is defined as extraphysiologic
hip motion that causes pain with or without symptoms of hip joint
unsteadiness and may be the result of bony deficiency and/or soft-
tissue damage or loss. Recent work has helped improve the ability to
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identify microinstability patients preoperatively. Initial management

begins with activity modification and strengthening of the
periarticular musculature. Failing nonsurgical management, surgical
intervention can be beneficial, focusing on treatment of the
underlying cause of microinstability, as well as associated intra-
From the Department of Orthopaedic articular pathology. Bony deficiency may be treated with a
Surgery, and the Department of redirectional osteotomy, whereas those with adequate bony
Sports Medicine, Stanford University, coverage may be treated with capsular plication, capsular
Redwood City, CA.
reconstruction, and/or labral reconstruction.
Dr. Safran or an immediate family
member has received royalties from
DJ Orthopaedics, Smith & Nephew,
and Stryker; is a member of a
speakers’ bureau or has made paid
presentations on behalf of ConMed
Linvatec, Medacta, and Smith &
T here has been increasing aware-
ness of microinstability of the
hip, although it remains a contro-
clinically, confirms that hip micro-
instability is a real entity, even without
bony deficiency (ie, hip dysplasia).
Nephew; serves as a paid consultant
to ConMed Linvatec, Cool Systems, versial topic. It has commonly been This manuscript reviews the recent
and Medacta; serves as an unpaid held that the hip is one of the most growing literature supporting the
consultant to Cool Systems, Cradle inherently stable joints in the body concept of hip microinstability, fo-
Medical, Ferring Pharmaceuticals, cusing on the relevant contributions
as a result of bony congruity and
Biomimedica, and Eleven Blade
Solutions; has stock or stock options stout supporting structures. Litera- of the anatomy to hip stability, the
held in Cool Systems, Cradle Medical, ture review of the 20th century lacks dynamics of hip motion, causes of hip
Biomimedica, and Eleven Blade discussion of hip microinstability, microinstability, evaluation of the
Solutions; has received research or patient with microinstability, and
institutional support from Ferring
even after a hip dislocation, whereas
Pharmaceuticals and Smith & recurrent dislocations were also quite treatment options.
Nephew; and serves as a board rare. Part of the lack of general
member, owner, officer, or committee acceptance of hip microinstability
member of the International Society of Contributors to Hip Stability
Arthroscopy, Knee Surgery, and as a clinical issue is the fact that the
Orthopaedic Sports Medicine and the hip has an apparent high degree of Microinstability of the hip is defined
International Society for the Hip. bony conformity and is deep within a as extraphysiologic hip motion that
J Am Acad Orthop Surg 2019;27: dense soft-tissue envelop in which causes pain with or without symp-
12-22 small amounts of increased motion toms of hip joint unsteadiness and
DOI: 10.5435/JAAOS-D-17-00664 (that may cause symptoms and/or may be the result of bony deficiency
intra-articular damage) may be hard and/or soft-tissue damage or loss.1
Copyright 2018 by the American
Academy of Orthopaedic Surgeons. to detect or quantify. Nonetheless, Many factors contribute to the sta-
mounting evidence, preclinically and bility of the hip.

12 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Marc R. Safran, MD

Bony Stability Figure 1

Although the hip has generally been
considered a highly constrained ball
in socket joint, most studies have
suggested that it is really a gimbal
joint. Furthermore, under physiologic
loads, the weight-bearing surface un-
dergoes deformation—flattening and
widening—allowing for translation.
The acetabulum is a quasi-hemisphere
that covers approximately 170° of the
femoral head. The acetabular labrum
increases the acetabular volume by
approximately 20% and the surface
area by 25%.2 The acetabulum is
anteverted 15° to 20° and has 45°
lateral tilt. When considering the hip
and stability, the importance of the
proximal femur is often discounted.
Approximately 130° of superior in-
clination of the femoral neck from
the shaft (ie, neck-shaft angle) and
approximately 10° of anteversion
exist; both play a notbale role in the
stability of the hip. This combination
of femoral and acetabular ante-
version and lateral inclination pro- Schematic showing the microinstability cycle that demonstrates the
vide good bony coverage posteriorly pathophysiology of symptomatic microinstability. Generally, femoral head
and thus inherent stability, allowing motion exists within the acetabulum. This phenomenon stresses the labrum and
capsuloligamentous structures. With continued extremes of motion and forces,
for more hip flexion and abduction the labrum may breakdown and/or the capsuloligamentous structures stretch
than extension and adduction. As a out. This phenomenon leads to more femoral head motion, which stresses the
result, greater reliance exists on soft- capsuloligamentous structures and labrum further. Eventually, patients will
tissue structures for anterior stabil- develop pain and through disuse, the muscular contributions to stability will
diminish, as the muscles weaken.
ity, especially in femoral adduction,
extension, and external rotation. In
hip dysplasia, with decreased ace- Table 1
tabular depth, increased anteversion, Hip Instability Examination Tests
increased acetabular roof inclina- Test Comment
tion, and increased femoral ante-
version, less bony stability exists, Anterior apprehension/HEER Sensitivity of 71% and specificity of 85%
which allows more anterior and Abduction-extension-external Sensitivity of 81% and specificity of 89%
rotation
superior/lateral femoral head migra-
tion, increasing the reliance on the Prone external rotation Sensitivity of 33% and specificity of 98%
soft tissues for stability. If all 3 tests mentioned earlier are 95% likelihood of microinstability
positive confirmed at surgery
Beighton signs Generalized ligamentous laxity. Does not
Ligaments necessarily correlate with hip
microinstability
There are four main capsu-
Log roll Assess iliofemoral ligament laxity
loligamentous structures and 1 non-
Axial distraction Distraction stability
capsular ligament in the hip. The
noncapsular ligament, ligamentum Posterior apprehension For posterior instability
teres (LT), has a unique pyramidal HEER = hyperextension external rotation
and somewhat flattened shape. This

January 1, 2019, Vol 27, No 1 13

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Microinstability of the Hip

Table 2 Table 3
Imaging Findings for Hip Stability Intraoperative Findings of Hip
Instability
Plain radiographs
Center edge angle less than 20° or 25° Ease of distractibility
Lateral center edge angle less than 20° to 25° Labrum
Acetabular roof inclination greater than 10° Labral-chondral separation
Femoral head subluxation Straight anteriorly
Broken Shenton line Straight laterally
Cliff sign Chondral damage
Distal femoral neck sclerosis Acetabulum
Splits radiograph for vacuum sign and/or femoral head subluxation Wearing down pattern
Femoro-epiphyseal acetabular roof index 1 to 3 mm from the rim
MRI Straight anteriorly
Capsular integrity/defect Straight laterally
Thin anterior lateral capsule (,3 mm) Femoral head
Wide anterior capsular recess (.5 mm) Central
Accumulation of contrast in the posterior-inferior joint in $2 planes Ligamentum teres
Tear
Hypertrophy
ligament takes its origin from the limits hip external rotation in hip
transverse acetabular ligament and flexion, whereas both internal and
posterior-inferior acetabular fossa external rotations are limited by the
ments of the hip joint, helping main-
and inserts into the fovea capitis of ILFL in hip extension.
tain the negative intra-articular pressure
the femoral head. Hip flexion, ad- The PFL originates on the anterior
within the joint and creating a suction
duction, and external rotation result acetabulum and spirals inferiorly and
effect.9-11 This has been confirmed in
in tightening of the LT and have been posteriorly around the femoral head,
the lab, as 60% less force was required
shown to be secondary restraints in before blending with the other two
to distract the femoral head in the
that position.3,4 Furthermore, hyper- longitudinal capsular ligaments. The
presence of a labral tear.9,12,13
trophy or tearing of the LT has been PFL limits external rotation, espe-
seen in the setting of hip dysplasia and cially in hip extension. The ISFL
Dynamic Stabilizing Factors
hip instability.5,6 starts at the ischial acetabular margin
The iliofemoral (ILFL), pubofemoral and inserts at the base of the greater Dynamic factors include adhesion-
(PFL), and ischiofemoral (ISFL) liga- trochanter posteriorly. The ISFL cohesion, negative intra-articular pres-
ments are longitudinal thickening of limits posterior translation and hip sure, and muscular forces of the 17
the capsule that spiral around the internal rotation (iem in both flexion muscles that cross the hip that provide
femoral head and insert on the ace- and extension). compression of the femoral head into
tabulum directly, except for the PFL. The zona orbicularis is a capsular the acetabular concavity. In addition,
Sixty percent of the hip capsule com- thickening that encircles the femoral the iliopsoas musculotendinous unit
prises the hip capsuloligamentous neck, at the narrowest point of the may provide additional stability to
thickenings.7 The ILFL is the strongest capsule, and is important in limiting resist anterior femoral head translation
ligament in the body and is also called femoral head distraction.8 based on its anatomic location. Most of
the Y Ligament of Bigelow because of these individual factors have not been
its inverted Y shape with a single studied for their role specifically in the
proximal attachment at the base of Labrum hip joint; however, they provide sta-
the anterior inferior iliac spine. The As mentioned earlier, the intact bility in other joints, such as the shoul-
ILFL inserts on the anterior promi- labrum increases the surface area and der, and may function similarly in the
nence of the greater trochanter lat- volume of the acetabulum. This phe- hip.
erally and at the level of the lesser nomenon contributes to hip stability
trochanter on the anterior femur for and the distribution of joint stresses Femoral Head Motion
the medial attachment. The lateral during loading. Furthermore, the Although the bony anatomy has long
arm of the ILFL is a primary restraint labrum functions as a seal between been considered the primary factor in
for many hip motions.4 The ILFL the central and peripheral compart- the stability of the hip, recent studies

14 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Marc R. Safran, MD

have demonstrated that the center of Figure 2

the femoral head (ie, centroid) moves
relative to the center of the acetabu-
lum. We have shown that the femoral
head moves on average 3.4 mm in the
medial-lateral plane, 1.5 mm in the
anterior-posterior plane, and 1.5 mm
in the proximal-distal plane as the
hip is taken through the extremes
of motion in a cadaver model.14
Charbonnier et al15 demonstrated
the femoral head subluxates an
average 2 mm when comparing MRIs
of asymptomatic professional ballet
dancers in the supine position versus an
MRI while in the splits position.
Recently, Mitchell and coinvestigators
described the splits radiograph that is
an AP pelvis radiograph with the legs
abducted in the splits position.16 They
found that 89% of 47 professional
ballet dancers had lateral subluxation
of their femoral head (ie, average Photograph showing the flexion, abduction and external rotation (FABERE) test.
1.4 mm), and 36% had a vacuum sign, With the patient supine, the leg being examined is brought into a “figure-of-4”
position. The distance from the lateral knee joint line to the table may give a clue
also indicating that microinstability of as to laxity (or stiffness). The clinician uses his fist as a measure. A distance less
the hip exists. More recently, dynamic than 3 inches from the lateral knee to the table may be a clue to laxity of the hip
in vivo femoral head motion relative joint.
to the acetabulum has been demon-
strated using biplanar fluoroscopy,
with translations between 0.69 and have generally divided patients into nation of these bony abnormalities
4.1 mm.17 six categories based on the underlying may result in anterior hip instability
Thus, femoral head centroid moves cause of instability or microinstability: and early degenerative changes because
relative to the acetabulum. Femoral (1) notable bony abnormalities or of these abnormal hip joint forces.
head motion may also be guided, and developmental dysplasia of the hip, (2) Connective tissue disorders are
limited, by the soft tissues, including connective tissue disorders, (3) post- often genetic disorders of soft-
the ligaments about the hip, labrum, traumatic, (4) microtraumatic (ie, usu- tissue elasticity/stiffness. Collagen
and muscles.14,18 Myers et al and ally associated with athletics), (5) disorders, such as Ehlers-Danlos
others demonstrated that the ILFL iatrogenic, and (6) idiopathic.1,6 syndrome, Marfan syndrome, or
plays a notable role in limiting hip Notable bony abnormalities may be Down syndrome, are associated with
external rotation and anterior femoral developmental, such as acetabular joint instability, including the hip. Lesser
head translation, whereas the acetab- dysplasia or posttraumatic (discussed degrees of connective tissue disorders
ular labrum is a secondary stabilizer later), which result in microinstability include benign hypermobility disorders.
for these motions.4,19 Repeated ex- because of the lack of bony support, Posttraumatic hip instability is rel-
tremes of femoral head motion may stressing the soft tissues (ie, labrum atively uncommon. However, the
lead to breakdown of the soft tissues, and ligaments) that may result in pathology of a hip dislocation in-
such as a labral tear, or stretch out the breakdown over time. Typical ana- cludes tearing of the ILFL and often a
ligaments of the hip, and continue in a tomic changes in developmental dys- posterior labral-chondral separation
downward spiral (Figure 1). plasia of the hip include a misshapen and tearing of the LT. There may also
femoral head, a shallow acetabulum be posterior acetabular rim fractures.
Causes with loss of anterolateral coverage, Because most hip dislocations are
increased acetabular lateral tilt, and posterior, if there is no associated
Atraumatic hip microinstability may excessive anteversion of the acetabu- bony damage, recurrent instability is
be caused by a variety of factors. We lum and proximal femur. The combi- uncommon; however, in those with

January 1, 2019, Vol 27, No 1 15

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Microinstability of the Hip

Figure 3 hip arthroscopy, making a capsu-

lotomy between the anterior and
anterolateral portals (ie, interportal
capsulotomy). Cutting the ILFL in-
creases femoral head translation,
especially in neutral flexion-
extension, and rotation (especially
in flexion), as well as increasing
hip range of motion and joint lax-
ity.19,20 Furthermore, the more of
the ILFL that is cut, the more easily
the hip can be distracted.21 Some
also extend the interportal capsu-
lotomy distally, in a “T” fashion
(T-capsulotomy). Making the inter-
portal capsulotomy cuts the ILFL by
necessity.7 The T-capsulotomy also
results in increased hip external
rotation compared with an intact
state and interportal capsulotomy.22
These capsulotomies, with or with-
out iliopsoas tenotomy, have been
Photograph showing the anterior apprehension test. The anterior apprehension associated with hip dislocations
test, also known as the hyperextension, external rotation test, is performed with postoperatively and likely lesser
the patient supine at the end of the examination table, with their buttocks just at
the edge of the table. The patient holds one knee toward their chest, whereas the
degrees of instability (ie, micro-
extremity to be examined is passively allowed to fall into hyperextension. The instability).6,23 Furthermore, Frank,
extremity being examined is then externally rotated by the clinician, which et al demonstrated that patients
stresses the anterior capsule and labrum, and should reproduce the patient’s who had closure of the whole
anterior pain or apprehension. Posterior pain with this maneuver may be the
result of posterior impingement. We have found that the anterior apprehension
T-capsulotomy did better than those
test has a sensitivity of 71% and specificity of 85% (Hoppe et al25). who just had closure of the longi-
tudinal portion (leaving the inter-
portal capsulotomy open).24 This
associated fracture, acetabular retro- potential cause of hip microtraumatic has been hypothesized to be the result
version with posterior wall insuffi- instability or even complete disloca- of reducing hip microinstability.
ciency, or extensive soft-tissue damage, tion. Pincer-type FAI was initially
posttraumatic recurrent instability may described as causing the contrecoup
exist. damage from a subluxation type Diagnosis
Microtrauma can occur from mechanism of the femoral head—neck
repeated extreme range of motion. junction levering on the over- The diagnosis of hip microinstability
External rotation of the lower extrem- covering anterior acetabulum. Re- can be difficult, especially if the
ity results in anterior translation of cently, several authors have reported patient does not have notable bony
the femoral head relative to the ace- that cam- or pincer-type FAI is abnormalities or connective tissue
tabulum, which may result in ante- associated with low-velocity hip disorder. The signs and symptoms
rior labral tears, and stretching of the subluxation or dislocation in most of may be quite subtle, and there is no
anterior capsuloligamentous struc- their cases. Thus, FAI anatomy with definitive preoperative diagnostic
tures. This condition is seen in ballet the hip at end range of motion can test, physical examination finding, or
dancers who continuously train to try load the acetabular labrum and imaging modality that is pathogno-
to get increased turnout of their leg, stretch the hip capsule, resulting in monic for hip microinstability, simi-
stretching the ILFL and stressing the instability—microtraumatic or true lar to the case of shoulder. Recent
anterior labrum, as well as in golfers, dislocation. research has identified some physical
who apply an axial load and rotate. More recently, iatrogenic hip insta- examination maneuvers and imaging
In addition, femoroacetabular im- bility has been identified after hip findings that may provide a clue to
pingement (FAI) may also be a arthroscopy. Many surgeons perform the clinician (Tables 1 and 2). In

16 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Marc R. Safran, MD

addition to having a high index of Figure 4

suspicion, intraoperative findings
have been associated with hip mi-
croinstability to help confirm the
diagnosis (Table 3).

History
Patients with hip microinstability rarely
complain that their hip is actually
unstable or coming out of the socket.
Usually patients complain of pain deep
in the joint, such as the C sign, or deep
in the inguinal crease or groin.1,6 They
may complain of pain or apprehen-
sion, or giving way with certain
activities. This is particularly true with
rotational activities with an axial load
(ie, specifically external rotation), or
with hyperextension, such as when
their leg is behind them when walking.
Most patients will note an insidious
onset of hip pain, with gradual wors-
Photograph showing the abduction-extension-external rotation test. The abduction-
ening, although they may have had an extension-external rotation test is performed with the patient in the lateral decubitus
injury the initiated the pain. position, and the leg to be examined is abducted about 30°, extended, and then
In the author’s practice, many pa- externally rotated. Then, an anteriorly directed force is applied to the posterior
tients who have failed hip arthros- greater trochanter. This should reproduce the patient’s symptoms. We have
found this test to have a sensitivity and specificity of 81% and 89%, respectively
copy have microinstability—either (Hoppe et al25).
iatrogenic (ie, from cutting the ILFL
or removal of the labrum) or had
mentous laxity. Hip strength and of 85%, whereas the abduction-
microinstability before the first sur-
range of motion should be tested, as extension-external rotation test
gery that was not addressed.
well as evaluation of other joints to rule has a sensitivity of 81% and a
out referred pain. Excessive hip internal specificity of 89%, and the prone
Physical Examination or external rotation (.60° in either external rotation test is sensitive
A thorough and complete physical direction) and/or lateral knee joint line 33% of the time but has a specificity
examination is important when the distance from the examination table of of 98%.25 If all three of these tests
diagnosis of hip microinstability is less than 3 inches with the leg in the are positive on clinical examination,
suspected because this is a dynamic figure-of-4 position may be suggestive there is a 95% likelihood that the
issue, and imaging is a static modality of hip joint laxity (Figure 2). patient will have intraoperative
to evaluate the hip. The goal of the Six specific provocative maneuvers confirmation of hip microinstability.
examination should be to reproduce are commonly described to evaluate
the patient’s symptoms, whether hip stability: the anterior apprehen-
Imaging
pain or apprehension, with range of sion test (Figure 3), the abduction-
motion, palpation and/or provoca- extension-external rotation test Radiographs
tive tests. (Figure 4), the prone external rota- Plain radiographs should include a
Although we have not found gener- tion test (Figure 5), the log roll test high-quality supine AP pelvis radio-
alized ligamentous laxity to correlate (Figure 6), the axial distraction test graph, a good lateral radiograph (ie,
with hip microinstability, certainly (Figure 7), and the posterior appre- not a frog lateral but a cross-table or
individuals with diffuse ligamentous hension test6 (Figure 8; Table 1). We Dunn view), and a false-profile view.
laxity have a greater likelihood of recently studied three of these tests.25 Radiographs should be studied for
having hip laxity and possibly, mi- This study demonstrated that the evidence of hip dysplasia, FAI, pre-
croinstability. As such, we test anterior apprehension test has a vious surgery, previous trauma, and
Beighton signs of generalized liga- sensitivity of 71% and a specificity degenerative changes. Acetabular

January 1, 2019, Vol 27, No 1 17

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Microinstability of the Hip

Figure 5 assessed on AP pelvis radiographs,

as greater than 10° is suggestive of
acetabular dysplasia, and angles of
more than 14° to 16° have been
associated with poorer outcomes of
hip arthroscopy, as has femoral
neck-shaft angle of greater than
139°. AP pelvis radiographs should
also be assessed for acetabular
retroversion, as suggested by the
posterior wall sign and/or ischial
spine sign (Figure 9).
Some recent studies report radio-
graphic findings consistent with hip
microinstability (Table 2). We
describe the cliff sign, where there is
loss of sphericity of the femoral head
(Figure 10). In a study of 96 patients,
74% of those with a cliff sign had
hip microinstability, whereas only
7% of those who had no cliff sign
had microinstability.26 For the 20
Photograph showing the prone external rotation test. The prone external rotation women younger than 32 years who
test is performed with the patient prone, and thus, their hip is in neutral flexion- had a cliff sign, 100% had capsular
extension. The hip is then externally rotated, and the examiner applies an
anterior directed force to the posterior trochanter. Pain or apprehension felt
laxity. It has also been noted that
anteriorly is consistent with the diagnosis of hip instability, and we found that this patients with sclerosis distal on the
test to be sensitive 33% of the time but have a 98% specificity (Hoppe et al25). femoral neck likely have impingement
due to supraphysiologic motion,
possibly against the anterior inferior
Figure 6 iliac spine, as a sign of potential hip
microinstability. Other radiographic
signs include extrusion of the femo-
ral head, and a broken Shenton line,
usually seen in patients with
dysplasia.
Wyatt et al27 recently described
the femoro-epiphyseal acetabular
roof index as a clue to instability
for those with borderline dyspla-
sia.26 They evaluated that the angle
comprised two lines formed from
(1) the acetabular roof inclination and
(2) the femoral head physeal scar. A
Photograph showing the log roll test. The log roll test is performed while the positive value, indicating the roof is
patient is laying supine on the examination table. With the patient relaxed, supine at a steeper angle than the physeal
and knee in extension, the examiner internally rotates the foot fully and then scar, was consistent with instability.
removes their hand from the foot. The foot will passively rotate back in to external
rotation. If external rotation is greater than the contralateral side, and more
specifically, less than 20° foot-table angle, anterior hip laxity may be present. MRI
Magnetic resonance arthrography
(MRA) can be particularly helpful.
dysplasia is defined as a lateral and on the false-profile view of Postoperative instability may result
center edge angle of Wiberg of less Lequesne. Furthermore, the ace- in capsular defects, with dye extrav-
than 20° to 25° on the AP pelvis tabular roof inclination needs to be asation from the joint, which may

18 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Marc R. Safran, MD

Figure 7 Figure 8

AP pelvis radiograph of a patient

with just the left hip demonstrating a
posterior wall sign and ischial spine
sign. The posterior wall sign is
present when the posterior
acetabular wall (white line) is medial
to the center of the femoral head
(white dot) and is suggestive of
posterior wall insufficiency as a
Photograph showing the axial distraction test. The axial distraction test is also result of acetabular retroversion.
performed with the patient supine on the examination table. The examiner places The dashed line with block white
their knee up against the patient’s ischium while the patient’s hip and knee are arrow highlights the left hip ischial
flexed approximately 30°. With the patient relaxed as best as possible, the spine, which also is a clue to
examiner applies an axial load. The examiner evaluates whether the hip toggles, retroversion of the acetabulum.
whether it causes apprehension, and whether it generates pain. The right hip shows the center of the
femoral head (black dot) is at the
level of the posterior wall (white
arrow).
be a clue to hip instability.28,29 Fur- posterior-inferior joint on two or
thermore, Magerkurth et al28 iden- more planes.27
tified features on MRA in patients patient’s perineum against the post,
with hip laxity. Those investigators before applying fine traction. This
injected as much fluid into the hip as Intraoperative does not happen in patients without
patients would tolerate. They studied Intraoperatively, hip microinstability microinstability.
the area lateral to the zona orbicu- can be confirmed by (1) ease of dis- Evaluation of the location and
laris on axial sections. These authors tractibility and (2) location and pat- pattern of pathology in the joint can
found the space between the femoral tern of intra-articular pathology be helpful in determining whether hip
neck and capsule, the anterior hip (Table 3). Different fracture tables microinstability is present. Patients
joint recess, measured more than 5 mm have different pitch to the screw with microinstability have labral
in patients with laxity, whereas stable mechanism of traction. However, on damage straight anteriorly, or straight
patients did not have this wide recess. the fracture table (ie, Maquet Hip laterally, compared with patients with
Second, they found that the adjacent Interventions Table) used in our FAI, where the damage is most fre-
hip joint capsule anteriorly, but lateral center, hips with microinstability quently anterolateral.30 Furthermore,
to the zona orbicularis, was thin—less required less than 11 turns (44 mm) the damage initially is a labral-chondral
than 3 mm. In our evaluation of hip under general anesthesia with separation. There usually is associated
microinstability, we also found that paralysis to distract the femoral chondral wear, that is shallow (1 to
capsular thinning of less than 3 mm head 8 to 10 mm. The traction is 3 mm) and has a pattern of being worn
was associated with hip micro- applied after the patient is posi- down, as opposed to the abutment,
instability in females.26 Lastly, tioned against the perineal post. softening, and delamination of FAI.
Wyatt et al27 describe instability on Some patients will distract one to Other less frequent findings include
MRA as having a crescent shaped several millimeters just with body central femoral head chondral damage
accumulation of gadolinium in the weight applied to initially bring the and tearing or hypertrophy of the LT.

January 1, 2019, Vol 27, No 1 19

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Microinstability of the Hip

Figure 9 Figure 10 lent intra-articular visualization with

lower morbidity, comparative studies of
open and arthroscopic management of
hip microinstability are lacking.
When treating hip microinstability,
it is important to address concomi-
tant intra-articular pathology and
the hip capsule. As the labrum is
an important secondary stabilizer,
labral tears should be repaired if
possible.13 If labral repair is not
possible, consideration should be
given to labral reconstruction as an
adjunct to hip stabilization.13,31
There have been reported cases of
Schematic demonstrating capsular hip dislocation after arthroscopic
AP pelvis radiograph of a woman plication used by the author. The
with hip instability demonstrating cliff capsulotomy/capsulectomy without
iliofemoral is above, and the
sign. Note the femoral head is out of closure,23,32 as well as instability
ischiofemoral below. Thus, a partial
round. This sudden loss of sphericity without dislocation after hip arthros-
capsulectomy is performed straight
we have called the Cliff sign. This laterally, in an area of the capsule copy.33,34 It is recommended that any
sign has been seen in patients with devoid of ligaments. The capsule is
hip instability. patient undergoing hip arthroscopy
then closed with sutures, functioning
with capsular redundancy and/or
like a rotator interval closure of the
shoulder—not overconstraining symptomatic capsular laxity be
either ligament. considered for capsule repair and/or
Treatment plication.35-37 In addition, capsular
repair and/or plication should be
As with most orthopaedic maladies,
ally, a significant number of patients strongly considered in patients with
treatment options for the management
with hip microinstability can improve generalized ligamentous laxity or an
of patients with hip microinstability
and return to regular activities without underlying connective tissue disorder
include conservative/nonsurgical and
surgery, just by doing rehabilitation. who are undergoing arthroscopic
surgical options. Unfortunately, little
treatment of labral tears, cartilage
literature exists to guide management
damage, or FAI.6,36,38,39 Wylie re-
of this relatively new diagnosis. Surgical Management ported excellent outcomes in
For those patients who have no symptomatic patients undergoing
Nonsurgical Management improvement in symptoms after an hip capsular plication after failed hip
Initial management of the patient 8- to 12-week course of nonsurgical arthroscopy.34 For those patients
with hip microinstability is based on treatment, surgical intervention may who have capsular defects, open or
modifiable factors. Physical therapy be considered. In cases of notable arthroscopic capsular reconstruction
to strengthen the periarticular mus- bony deformity such as marked ace- should be considered if the defect
cles is of paramount importance— tabular dysplasia or acetabular retro- cannot be closed primarily.31
particularly the iliopsoas, gluteal version, open redirectional osteotomies Arthroscopic techniques to treat
musculature, and the adductors and of the acetabulum and/or proximal hip capsular redundancy and reduce
rotators, in addition to the core femur may be required. In the absence capsular volume include thermal
musculature. Activity modification of such bony abnormalities, much of capsulorrhaphy and suture plication.
to reduce symptomatic activities the literature would suggest that treat- Arthroscopic thermal capsulorrhaphy
should be adopted. Nonsteroidal anti- ment options should focus on the of the hip was first reported by
inflammatory medications can help labrum and/or hip capsuloligamentous Philippon40 in 12 patients with
with the pain, especially in helping the complex. Several techniques have been hip instability. All their patients re-
patient perform the strengthening described to reduce hip capsular volume, ported improvement at 6-week and
activities. No studies published report both by open and arthroscopic 6-month follow-up visits. The hip
the outcomes of nonsurgical manage- approaches, successfully treating atrau- capsular volume was reduced with
ment of hip microinstability, though matic hip microinstability. Although the use of thermal energy causing
the authors’ experience and anecdot- arthroscopy has the advantage of excel- tissue shrinkage. The concern of

20 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Marc R. Safran, MD

chondrolysis and thermal necrosis of traumatic and atraumatic instability. Clin

the capsule led to the development
Summary Sports Med 2011;30:349-367.

and acceptance of arthroscopic hip 2. Tan V, Seldes R, Katz M, et al:

Symptomatic hip microinstability is Contribution of acetabular labrum to
suture capsular plication for the articulating surface area and femoral head
increasingly being recognized as a
management of hip microinstability coverage in adult hip joints: An anatomic
potential cause of pain and disability in study in cadavera. Am J Orthop 2001;30:
due to capsular laxity. Although
young patients. More recent research 809-812.
more technically demanding, this
studies have confirmed the importance 3. Martin H, Savage A, Braly B, et al: The
technique allows control of plication
of the periarticular soft tissues in the function of the hip capsular ligaments: A
tension and can easily be used during quantitative report. Arthroscopy 2008;24:
stability of the hip. The etiology of hip 188-195.
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microinstability includes bony abnor-
FAI procedures. Several authors 4. van Arkel RJ, Amis AA, Cobb JP, et al: The
malities, residual laxity after traumatic capsular ligaments provide more hip
have reported success with a variety
dislocation, connective tissue disorders rotational restraint than the acetabular
of arthroscopic suture plication labrum and the ligamentum teres: An
resulting in ligamentous laxity, repeti-
techniques.38,39,41 Larson et al38 experimental study. Bone Joint J 2015;
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January 1, 2019, Vol 27, No 1 21

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Microinstability of the Hip

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22 Journal of the American Academy of Orthopaedic Surgeons

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