Innervation of the hip joint capsular complex: A systematic review of histological and immunohistochemical studies and their clinical implications for contemporary treatment strategies in total hip arthroplasty

Abstract

The hip joint capsule contributes to the stability of the hip joint and lower extremity, yet this structure is incised and often removed during total hip arthroplasty (THA). Increasing incidence of osteoarthritis is accompanied by a dramatic rise in THAs over the last few decades. Consequently, to improve this treatment, THA with capsular repair has evolved. This partial restoration of physiological hip stability has resulted in a substantial reduction in post-operative dislocation rates compared to conventional THA without capsular repair. A further reason for the success of this procedure is thought to be the preservation of the innervation of the capsule. A systematic review of studies investigating the innervation of the hip joint capsular complex and pseudocapsule with histological techniques was performed, as this is not well established. The literature was sought from databases Amed, Embase and Medline via OVID, PubMed, ScienceDirect, Scopus and Web of Science; excluding articles without a histological component and those involving animals. A total of 21 articles on the topic were identified. The literature indicates two primary outcomes and potential clinical implications of the innervation of the capsule. Firstly, a role in the mechanics of the hip joint, as mechanoreceptors may be present in the capsule. However, the nomenclature used to describe the distribution of the innervation is inconsistent. Furthermore, the current literature is unable to reliably confirm the proprioceptive role of the capsule, as no immunohistochemical study to date has reported type I-III mechanoreceptors in the capsule. Secondly, the capsule may play a role in pain perception, as the density of innervation appears to be altered in painful individuals. Also, increasing age may indicate requirements for different strategies to surgically manage the hip capsule. However, this requires further study, as well as the role of innervation according to sex, specific pathology and other morphometric variables. Increased understanding may highlight the requirement for capsular repair following THA, how this technique may be developed and the contribution of the capsule to joint function and stability.

Fig 1. PRISMA flowchart of systematic review process.

Systematic review process, including databases, keywords, number of papers retrieved, inclusion and exclusion criteria and results from backwards and forwards searching [37].

Fig 2. Diagram demonstrating the general agreement of innervation by mechanoreceptors I-V across the hip joint capsule.

(A) Anterior view of the left side, representing increased expression laterally and superior-laterally. (B) posterior view of the left side, showing increased expression laterally. Darker regions depict areas where the literature demonstrates greater agreement of higher density of innervation. Lighter areas are regions of general agreement of little to no innervation. D = distal, I = inferior, L = lateral, M = medial, P = proximal, S = superior. ASIS = anterior superior iliac spine, AIIS = anterior inferior iliac spine.