Labral base refixation in the hip: rationale and technique for an anatomic approach to labral repair

Morphologic Changes and Outcomes After Arthroscopic Acetabular Labral Repair Evaluated Using Postoperative Computed Tomography Arthrography

PURPOSE

To investigate smaller sized labra after acetabular labral repair comparing preoperative and postoperative computed tomography arthrography (CTA) and to assess the correlation between the anatomic changes and clinical outcomes.

METHODS

The design and protocol of this retrospective study were approved by the institutional review board of our hospital. The inclusion criteria included age older than 18 years and hip pain associated with mechanical symptoms. Patients with previous hip surgery, avascular necrosis, rheumatologic disorders, or advanced arthritis were excluded. All tears with femoroacetabular impingement were treated with bumpectomy or acetabuloplasty and repaired using arthroscopic suture anchors. We evaluated clinical outcomes using the modified Harris Hip Score (mHHS) and the morphologic changes and radiologic outcomes (labral retear and leakage of dye) using CTA at a minimum 2-year follow-up. The paired t test was performed to detect changes in labral height, labral width, and mHHS.

RESULTS

Forty labral tears in 40 patients (mean age, 32.1 ± 9.2 years) underwent labral repair, with femoroplasty in 20 hips and acetabuloplasty in 17 hips, and no patients required capsular repair after capsulotomy. No leakage of contrast dye was detected during the follow-up CTA procedure. No labral retears were observed after labral refixation at the postoperative CTA evaluation. However, the mean width and height of the labrum changed from 8.1 mm and 4.9 mm, respectively, preoperatively to 6.7 mm and 4.4 mm, respectively, at the postoperative follow-up (decreasing by 19% and 11%, respectively; both P < .001). In addition, the mean mHHS for the 36 patients in the complete repair group improved from 61 ± 16.0 to 90 ± 9.6 (P = .01). Four hips showed incomplete repairs.

CONCLUSIONS

Repaired labra are well maintained after capsulotomy based on follow-up CTA after arthroscopic labral repair. In addition, decreased height and width of the labra do not affect the clinical outcomes.

LEVEL OF EVIDENCE

Level IV, therapeutic study (case series [no, or historical, control group]).

Hip arthroscopy results in improved patient reported outcomes compared to non-operative management of waitlisted patients

Hip arthroscopy (HA) is an established treatment option to address intra-articular pathology of the hip. However, some clinicians encourage non-operative management (NOM). Non-operative management may include active measures such as physiotherapy and intra-articular steroid injections, or NOM may involve so called watchful waiting with no active intervention. These approaches, along with surgery have been detailed recently in the Warwick Agreement, a Consensus Statement regarding diagnosis and treatment of Femoroacetabular Impingement Syndrome The aim of this study is to compare the change in clinical outcome scores of waitlisted patients with intra-articular hip pathology who receive no active treatment with matched controls that have undergone HA. Patients less than 60 years of age were identified from a HA waiting list in a single hospital in the Australian public hospital system. Patient reported outcomes (PRO) were collected whilst patients waited for surgery. During this waiting period no specific treatment was offered. A separate group of patients who had previously undergone HA were matched based on age, sex, body mass index and baseline non-arthritic hip scores (NAHS). The groups were compared using the NAHS as the primary outcome measures. Modified Harris Hip Scores were also collected and compared. Thirty-six patients were included in each group, with a mean follow up of 19 months (12–36). There were no significant differences in age, sex, BMI and NAHS between groups at baseline. At final follow up, mean NAHS scores after HA were significantly higher than scores after NOM, 82.1 (36.4–100.0) versus 48.9 (11.3–78.8), respectively (P < 0.001) with a large effect size for mean change in scores between groups (d = 1.77, 95% CI 1.21–2.30). Mean mHHS after HA were significantly higher than scores after NOM, 84.3 (15.4–100.0) versus 48.1 (21.0–66.0) respectively (P < 0.001), with a large effect size for mean change in scores between groups (d = 1.92, 95% CI 1.34–2.46). HA may lead to significant improvements in PRO when compared to non-operative management of waitlisted patients with intra-articular pathology of the hip at 18 months follow-up.

Arthroscopic labral repair versus labral debridement in patients with femoroacetabular impingement: a minimum 2.5 year follow-up study

PURPOSE

To compare the clinical results of labral repair with labral debridement in patients undergoing arthroscopy for femoroacetabular impingement.

METHODS

Between July 2008 and December 2011, 67 patients (73 hips) underwent arthroscopic treatment for femoroacetabular impingement. The repair group consisted of 33 patients; 18 hips with pincer only, 1 with CAM only and 15 with combined impingement. The debridement group contained 34 patients; 6 with pincer only, 5 with CAM only and 28 with combined type. The mean age in the repair group was 33.5 years (range, 30-61) and in the debridement group was 39.5 years (range, 18-59 y). At the time of last follow-up, patient's hip function was evaluated with ROM of the hip; daily Hip Outcome scores (dHOS) and Visual Analogue Score (VAS).

RESULTS

The mean follow-up was 45.2 month in the repair group and 47.2 month in debridement group. Daily hip outcome scores were significantly improved from preoperatively to last follow-up in both groups (p&lt;0.05). However, there were no statistical significant difference in dHOS between repair and debridement groups (p&gt;0.05) at last follow-up. 2 patients in the repair group and 1 patient in the debridement group had undergone total hip replacement at an average of 16 months (range, 4-32 m) after arthroscopic treatment. Hip joint instability occurred in 1 patient in the repair group due to aggressive capsular resection. This was treated by a periacetabular osteotomy.

CONCLUSIONS

No difference in hip functional outcomes was observed between labral debridement and labral repair in arthroscopic treatment of femoroacetabular impingement.

Hip labral repair: options and outcomes

The importance of the acetabular labrum has been increasingly recognized, playing a critical role in both normal anatomy and abnormal pathology of the hip joint. The labrum increases acetabular surface area and volume, providing a stable and durable articulation. The fibrocartilaginous composition affords a tissue capable of a lifetime of normal function in the absence of significant osseous pathology. In the setting of femoroacetabular impingement (FAI) or dysplasia, bony biomechanics may cause labral injury, which may translate to patient symptoms. Long-term consequences of labral tears may include joint degeneration. Labral preservation surgery emphasizes retention of the form and function of the labrum, prioritizing labral repair (in the presence of reparable tissue) and reconstruction (in the absence of reparable tissue) over debridement. Patient-reported outcomes have consistently demonstrated significantly better results following labral repair versus debridement. In conjunction with correction of osseous abnormalities, labral surgery can improve short-term outcomes and potentially reduce the risk of long-term osteoarthritis.

Injectable autologous chondrocyte transplantation for full thickness acetabular cartilage defects: early clinical results

INTRODUCTION

Acetabular cartilage lesions are frequently seen in young patients with hip pain and have been identified as an important prognostic factor. New therapies have complemented abrasion and microfracture procedures. The aim of the study is to evaluate the early outcome of patients with arthroscopic injectable autologous chondrocyte transplantations (ACT) for full thickness acetabular cartilage defects.

METHODS

A two-step procedure ACT was performed in patients with full thickness acetabular cartilage defects measuring ≥2 cm(2). The patients were closely followed with clinical examination, pre- and postoperative scores until the latest available follow-up of 3, 6, 12, and 24 months.

RESULTS

20 consecutive cases (4 female, 16 male, mean age 33 years) were included. No patients were lost at final follow-up. The average defect size was 5.05 (range 2-6) cm(2). The average follow-up was 12.05 (range 6-24) months. Three months postoperatively the preoperative scores improved significantly from a mean mHHS of 63-81 points (p = 0.009), iHOT33 of 44-66 % (p = 0.028) and subjective hip assessment (Subjective Hip Value, SHV) of 60-87 % (p = 0.007). After 12 months the results improved significantly to a mean mHHS of 93 points (p = 0.017), an iHOT33 of 79 % (p = 0.007) and an SHV of 82 % (p = 0.048) compared with the preoperative scores.

DISCUSSION

The injectable matrix associated ACT is a reliable procedure, yielding promising early results with a significant increase of all scores evaluated in patients with full thickness acetabular cartilage defects.

Clinical Outcomes of Hip Arthroscopic Surgery: A Prospective Survival Analysis of Primary and Revision Surgeries in a Large Mixed Cohort

BACKGROUND

With the rapid increase in hip preservation procedures, revision hip arthroscopic surgery and conversion to total hip arthroplasty (THA) or hip resurfacing (HR) after primary hip arthroscopic surgery have become a large focus in the recent literature.

PURPOSE

The primary purpose was to perform a survival analysis in a large mixed cohort of patients undergoing hip arthroscopic surgery at a high-volume tertiary referral center for hip preservation with a minimum 2-year follow-up. The secondary purpose was to compare clinical outcomes of primary versus revision hip arthroscopic surgery.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

From February 2008 to June 2012, data were prospectively collected on all patients undergoing primary or revision hip arthroscopic surgery. Patients were assessed preoperatively and postoperatively with the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), and Hip Outcome Score-Sport-Specific Subscale (HOS-SSS). Pain was estimated on a visual analog scale (VAS). Patient satisfaction was measured with the question "How satisfied are you with your surgery results?" (1 = not at all, 10 = the best it could be).

RESULTS

There were a total of 1155 arthroscopic procedures performed, including 1040 primary arthroscopic procedures (926 patients) and 115 revision arthroscopic procedures (106 patients). Of these, 931 primary arthroscopic procedures (89.5%) in 824 patients (89.0%) and 107 revision arthroscopic procedures (93.0%) in 97 patients (91.5%) were available for follow-up and included in our study. The mean change in patient-reported outcome (PRO) scores at 2-year follow-up in the primary arthroscopic surgery group was 17.4 for the mHHS, 19.7 for the HOS-ADL, 23.8 for the HOS-SSS, 21.3 for the NAHS, and -3.0 for the VAS, and the mean change in the revision arthroscopic surgery group was 13.4, 10.9, 16.1, 15.4, and -2.7, respectively. All scores improved significantly compared with preoperatively (P < .001). PRO scores were higher at all time points for the primary group compared with the revision group (P < .05). Mean satisfaction was 7.7 and 7.2 for the primary and revision groups, respectively. Of 931 primary arthroscopic procedures, 52 (5.6%) converted to THA/HR. Of 107 revision arthroscopic procedures, 12 (11.2%) converted to THA/HR. The relative risk of THA/HR was 2.0 after revision procedures compared with primary procedures. The cumulative incidence of competing risks of conversion to THA/HR and revision hip arthroscopic surgery after primary hip arthroscopic surgery was 2.6% and 5.8%, respectively. The overall complication rate was 4.3%.

CONCLUSION

Patients showed significant improvement in all PRO, VAS, and satisfaction scores at 2 years after hip arthroscopic surgery. Patients who underwent primary arthroscopic surgery showed higher PRO scores and a trend toward greater improvement in the VAS score compared with patients who underwent revision arthroscopic surgery. The relative risk of THA/HR was 2.0 after revision procedures compared with primary procedures.

Anatomic Labral Repair in the Hip Using a Knotless Tensionable Suture Anchor

To perform a proper labral repair, most surgeons use anchors to secure the labrum to the acetabular bone. We aim to describe a technique for labral repair with a knotless tensionable suture anchor. This technique uses a looped suture configuration, allowing selective tensioning of the repair to maintain the anatomic suction seal of the hip. The use of this technique is easily reproducible and reduces the surgical time compared with previous techniques.

Safe Angle of Anchor Insertion for Labral Repair During Hip Arthroscopy

PURPOSE

To compare the use of the distal anterolateral accessory (DALA) portal with the anterolateral (AL) and midanterior (MA) portals during arthroscopic hip labral repair.

METHODS

Standard AL, MA, and DALA portals were created on 6 cadaveric hip specimens. Four 2.4-mm pins were placed in the acetabular rim to the depth of a standard anchor using a drill guide. Pins were placed in the 12 to 3 o'clock positions. The specimens then underwent computed tomographic scans with the pins left in place, and the distance from the pin to the articular surface was calculated at different depths of insertion.

RESULTS

In the anterior location, the average starting distance for the DALA pin was 2.05 mm and for the MA pin it was 2.51 mm from the articular surface (P = .29). Statistically significant differences between the DALA and MA pins were found at depths of 6 mm (P = .04) and 9 mm (P = .03). In the superior location, the average starting distance for the DALA pin was 2.40 mm and for the AL pin it was 2.62 mm from the articular surface (P = .34). Statistically significant differences between the DALA and AL pins were found at depths of 6 mm (P = .02), 9 mm (P = .01), 12 mm (P = .01), 15 mm (P = .04), and 18 mm (P = .04).

CONCLUSIONS

The DALA portal allows pins to be placed at a greater distance from the articular surface than the MA and AL portals when using a straight drill guide. This may decrease the incidence of intra-articular penetration during arthroscopic hip labral repair.

CLINICAL RELEVANCE

Intra-articular penetration of a drill bit or anchor is an iatrogenic complication that can occur during labral repair. By using the DALA portal instead of the AL and MA, the anchor can be safely placed on the acetabular rim and directly away from the articular surface, decreasing the chance for this complication.

Editorial Commentary: Confirming Intuitive Thoughts in Hip Preservation

In a biomechanical laboratory study of 63 bovine hip labra examining suture configuration, passer size, and radiofrequency treatment, superior biomechanical properties were found for vertical and oblique sutures compared with horizontal sutures, smaller puncture holes were better compared with large bore holes in the labra, and radiofrequency strengthened labra only when horizontal suture configuration was used. The authors appropriately acknowledge that suture anchor type, presence or absence of knots, and bone quality based on patient demographics and considering various regions of the acetabular rim are additional important factors. Although the authors wisely advocate caution in extrapolation to in vivo behavior, this study represents an important addition to our understanding of the importance of suture configuration in labral repair in the hip. Given the findings of this study and the present state of the art, the current winning formula appears to be labral base refixation with vertical or oblique mattress configuration, performed with small diameter suture passage devices.

Editorial Commentary: Please Simplify Hip Arthroscopy

Hip arthroscopy is a challenging technical procedure for which basic science principles have not been thoroughly discerned with respect to the procedures we perform. In this commentary, a plea is made to continue to expand the science behind what we do, but in as simple a fashion as possible such that more surgeons are willing to learn perfect hip arthroscopy.

Biomechanical Performance of Hip Labral Repair Techniques

PURPOSE

To determine the strength of various suture techniques and the impact of suture passer size on cyclically loaded hip labra.

METHODS

We assigned 63 bovine hip labra to 9 simple knotless suture technique groups using OrthoCord suture: (1) penetrating grasper (2.6 mm)-placed horizontal mattress, (2) penetrating grasper-placed vertical mattress, (3) SutureLasso (1.8 mm)-placed vertical mattress, (4) penetrating grasper-placed oblique repair, (5) penetrating grasper-placed vertical mattress plus radiofrequency, (6) SutureLasso-placed horizontal mattress, (7) SutureLasso-placed oblique mattress, (8) SutureLasso-placed horizontal mattress plus radiofrequency, and (9) SutureLasso-placed oblique mattress plus radiofrequency. After 20 cycles of uniaxial tensile loading (5 to 80 N), destructive testing was performed.

RESULTS

Penetrating grasper-placed horizontal mattress sutures showed lower ultimate failure loads than vertical and oblique mattress sutures (P < .05). Penetrating grasper-placed vertical mattress sutures had higher peak-to-peak displacement than SutureLasso-placed vertical mattress sutures (P = .04). SutureLasso-placed oblique mattress sutures had a higher ultimate load (P < .01) and stiffness (P = .04) than SutureLasso-placed horizontal mattress sutures. SutureLasso-placed horizontal mattress sutures had lower cyclic elongation than penetrating grasper-placed horizontal mattress sutures (P = .01) and lower ultimate load (P < .01) and stiffness than SutureLasso-placed vertical mattress sutures (P < .01). Horizontal mattress sutures with radiofrequency had a higher ultimate load (P = .02), stiffness, and cyclic elongation (P < .01) than without radiofrequency.

CONCLUSIONS

A horizontal mattress hip labrum stitch shows a lower ultimate failure load than vertical or oblique mattress stitches. Smaller-diameter suture-passing devices show less cyclic displacement and elongation than larger-diameter devices. Radiofrequency labral treatment does not alter vertical stitch strength but does alter horizontal mattress stitch strength.

CLINICAL RELEVANCE

Vertical and oblique stitches are stronger than horizontal stitches. A 1.8-mm passing device shows a better cyclic loading performance than a 2.6-mm device.

Management of the Acetabular Labrum

The options for labral treatment are debridement, repair, and reconstruction. Debridement of labral tissue is indicated when there is peripheral tearing of the labrum that does not compromise the functionality of the labrum at its base or if the labrum is not playing an important role in the patient's pathology. Labral repair is performed when the base of the labrum is unstable at its attachment at the acetabular rim and the tissue is of otherwise good quality. Labral reconstruction is an option for labral tissue compromised beyond repair, segmental labral defect, or previous failed repair.

New perspectives on femoroacetabular impingement syndrome

Femoroacetabular impingement (FAI) is characterized by an abnormality in the shape of the femoral head-neck or acetabulum that results in impingement between these two structures. Arthroscopic treatment has become the preferred method of management of FAI owing to its minimally invasive approach. Surgical correction involves resection of impinging osseous structures as well as concurrent management of the associated chondral and labral pathology. Research from the past 5 years has shown that repair of the labrum results in a better anatomic correction and improved outcomes compared with labral debridement. Research is underway to improve cartilage assessment by using innovative imaging techniques and biochemical tests to inform predictions of prognosis. Several ongoing randomized controlled trials, including the Femoroacetabular Impingement Trial (FAIT) and the Femoroacetabular Impingement Randomized Controlled Trial (FIRST), will provide critical information regarding the diagnosis, management and prognosis of patients undergoing arthroscopic management of FAI.

Does Primary Hip Arthroscopy Result in Improved Clinical Outcomes?: 2-Year Clinical Follow-up on a Mixed Group of 738 Consecutive Primary Hip Arthroscopies Performed at a High-Volume Referral Center

BACKGROUND

Hip arthroscopy has gained increasing popularity over the past decade. The need to develop metrics to evaluate success and complications in primary hip arthroscopy is an important goal.

PURPOSE

To evaluate 2-year patient-related outcome (PRO) scores and patient satisfaction scores for a single surgeon at a high-volume referral center for all primary hip arthroscopy procedures performed.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

During the study period between April 2008 and October 2011, data were collected on all patients who underwent primary hip arthroscopy. All patients were assessed pre- and postoperatively with 4 PRO measures: the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), and Hip Outcome Score-Sport-Specific Subscale (HOS-SSS). Pain was estimated on the visual analog scale (VAS), and satisfaction was measured on a scale from 0 to 10. The number of patients who underwent revision arthroscopy, total hip arthroplasty (THA), or a resurfacing procedure during the study period was also reported.

RESULTS

A total of 595 patients were included in the study. The score improvement from preoperative to 2-year follow-up was 61.29 to 82.02 for mHHS, 62.79 to 83.05 for HOS-ADL, 40.96 to 70.07 for HOS-SSS, 57.97 to 80.41 for NAHS, and 5.86 to 2.97 for VAS. All scores were statistically significantly different (P < .0001). Overall patient satisfaction was 7.86 ± 2.3 (range, 1-10). Forty-seven (7.7%) patients underwent revision hip arthroscopy, and 54 (9.1%) patients underwent either THA or the hip resurfacing procedure during the study period. The multivariate regression analysis showed that increased age at time of surgery was a significant risk factor for conversion to THA, revision arthroscopy, and change in NAHS <10 points. Acute injury, acetabuloplasty, iliopsoas release, and patient sex were significant for 2 of these 3 types of failure.

CONCLUSION

Primary hip arthroscopy for all procedures performed in aggregate had excellent clinical outcomes and patient satisfaction scores at short-term follow-up in this study. More studies must be conducted to determine the definition of a successful outcome. There was a 6.1% minor complication rate, which was consistent with previous studies. Patients should be counseled regarding the potential progression of degenerative change leading to arthroplasty as well as the potential for revision surgery.

Eversion-Inversion Labral Repair and Reconstruction Technique for Optimal Suction Seal

Labral tears are a significant cause of hip pain and are currently the most common indication for hip arthroscopy. Compared with labral debridement, labral repair has significantly better outcomes in terms of both daily activities and athletic pursuits in the setting of femoral acetabular impingement. The classic techniques described in the literature for labral repair all use loop or pass-through intrasubstance labral sutures to achieve a functional hip seal. This hip seal is important for hip stability and optimal joint biomechanics, as well as in the prevention of long-term osteoarthritis. We describe a novel eversion-inversion intrasubstance suturing technique for labral repair and reconstruction that can assist in restoration of the native labrum position by re-creating an optimal seal around the femoral head.

Acetabular Labral Base Repair Versus Circumferential Suture Repair: A Matched-Paired Comparison of Clinical Outcomes

PURPOSE

To determine whether an acetabular labral repair technique would be superior to another repair technique based on clinical outcomes measured by patient-reported outcome (PRO) scores.

METHODS

We identified 465 patients who underwent labral base repair or circumferential suture repair from February 2008 to February 2012. The type of repair performed was based on labral size and tear type. The 2 groups were pair matched for age within 5 years, sex, crossover sign within 15%, coxa profunda, Workers' Compensation status, and microfracture (femur, acetabulum, or none). Data were prospectively collected and retrospectively reviewed. PROs included a visual analog scale score and the modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score-Activities of Daily Living, and Hip Outcome Score-Sports-Specific Subscale.

RESULTS

One hundred ten patients met the inclusion criteria for labral base repair and were pair matched on a 1:1 basis with 110 patients who underwent circumferential suture repair. The mean follow-up period was 30 months for both groups, with a range of 19.2 to 60 months for the labral base repair group and 19.2 to 67 months for the circumferential suture repair group. Radiographic data were similar between groups with respect to the lateral center-edge angle (P = .906), acetabular inclination (P = .329), anterior center-edge angle (P = .208), alpha angle (P = .387), and joint space width (P = .388). All preoperative PRO scores were statistically similar. Both groups showed significant improvements in all PROs. There were no statistical differences in postoperative PRO scores at latest follow-up (modified Harris Hip Score, P = .215; Hip Outcome Score-Activities of Daily Living, P = .839; Hip Outcome Score-Sports-Specific Subscale, P = .561; Non-Arthritic Hip Score, P = .333; visual analog scale score, P = .373; and satisfaction, P = .483). There were similar rates of revision (n = 10 for both groups) and conversion to arthroplasty (n = 2 for both groups).

CONCLUSIONS

On the basis of PRO scores at 2 years' follow-up, there is no difference in outcomes based on the type of labral repair performed.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Extracapsular approach for arthroscopic treatment of femoroacetabular impingement: clinical and radiographic results and complications

OBJECTIVES

To evaluate the clinical and radiographic results and complications relating to patients undergoing arthroscopic treatment for femoroacetabular impingement by means of an extracapsular approach.

METHODS

Between January 2011 and March 2012, 49 patients (50 hips) underwent arthroscopic treatment for femoroacetabular impingement, performed by the hip surgery team of the Orthopedic Hospital of Passo Fundo, Rio Grande do Sul. Forty patients (41 hips) fulfilled all the requirements for this study. The mean follow-up was 29.1 months. The patients were assessed clinically by means of the Harris Hip score, as modified by Byrd (MHHS), the Non-Arthritic Hip score (NAHS) and the internal rotation of the hip. Their hips were also evaluated radiographically, with measurement of the CE angle, dimensions of the joint space, alpha angle, neck-head index, degree of arthrosis and presence of heterotopic ossification of the hip.

RESULTS

Out of the 41 hips treated, 31 (75.6%) presented good or excellent clinical results. There was a mean postoperative increase of 22.1 points for the MHHS, 21.5 for the NAHS and 16.4̊ for the internal rotation of the hip (p < 0.001). Regarding the radiographic evaluation, correction to normal values was observed for the alpha angle and neck-head index, with a mean postoperative decrease of 32.9̊ and mean increase of 0.10, respectively (p < 0.001).

CONCLUSION

Arthroscopic treatment of femoroacetabular impingement by means of an extracapsular approach presented satisfactory clinical and radiographic results over a mean follow-up of 29.1 months, with few complications.

Clinical Outcomes After Arthroscopic Hip Labral Repair Using Looped Versus Pierced Suture Techniques

BACKGROUND

With an improved understanding of the importance of the labrum, labral repair is replacing labral debridement as a component of hip arthroscopy for femoroacetabular impingement. Labral repair can be performed by passing suture limbs either around (looped) or through (pierced) the labral tissue.

PURPOSE

To determine whether there is any clinical difference between these different labral repair techniques.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A prospective data registry was queried for patients who underwent primary hip arthroscopy with labral repair from 2009 to 2011. Patients older than 18 years who had undergone labral repair were included in the study. Exclusion criteria included previous hip surgery, avascular necrosis, joint space less than 2 mm, and labral reconstruction or augmentation. Patients were grouped based upon the 3 labral repair techniques: looped, pierced, or combined. Statistical equivalence testing was performed to evaluate the primary outcome measure, the Hip Outcome Score-activities of daily living subscale (HOS-ADL). Other measures included the HOS-sport subscale (HOS-Sport), modified Harris hip score (mHHS), Short Form-12 (SF-12), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and patient satisfaction with outcome (1-10 scale; 10 = very satisfied).

RESULTS

Preoperative scores improved in the looped group (HOS-ADL, from 68 to 91; mHHS, from 64 to 83; HOS-Sport, from 51 to 81; and WOMAC, from 23 to 9), the pierced group (HOS-ADL, from 64 to 89; mHHS, from 62 to 83; HOS-Sport, from 46 to 77; and WOMAC, from 34 to 12), and the combined group (HOS-ADL, from 64 to 89; mHHS, from 63 to 83; HOS-Sport, from 52 to 79; and WOMAC, from 26 to 12). Median patient satisfaction in all groups was 9.0. The 3 labral repair groups were shown to be statistically and clinically equivalent (P < .05) with respect to the validated HOS-ADL to within a clinically irrelevant threshold at mean 36-month follow-up. In addition, there were no differences in secondary outcome measures or in the revision rate (looped, 7% [14/209], pierced, 8% [5/65], and combined, 6% [5/83]).

CONCLUSION

This study showed equivalent HOS-ADL outcomes between looped, pierced, and combined labral repairs. Secondary outcome measures, including failure and revision rates, were not significantly different among the groups. Thus, suture type did not influence outcomes.

Arthroscopic acetabuloplasty and labral refixation without labral detachment

BACKGROUND

Arthroscopic acetabuloplasty was initially described with detachment of the labrum to access the acetabular rim for resection, followed by labral refixation. Recent technical improvements have made it possible to perform acetabuloplasty and labral refixation without labral detachment when the chondrolabral junction is intact.

PURPOSE

To compare outcomes for patients undergoing arthroscopic acetabuloplasty and labral refixation without labral detachment (study group), as well as compare this with a group of patients who underwent acetabuloplasty with labral refixation and labral detachment (control group) with a minimum 2-year follow-up.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

During the study period, data were prospectively collected on all patients treated with hip arthroscopy. Inclusion criteria for the study group were acetabuloplasty and labral refixation without detachment, performed in cases with an intact chondrolabral junction. Patients were then compared with a control group of patients who had acetabuloplasty with labral detachment and refixation. All patients were assessed pre- and postoperatively using 4 patient-reported outcome (PRO) measures and a visual analog scale (VAS) for pain, as well as monitored for revision surgery.

RESULTS

In the study group, the preoperative to postoperative score changed from 64.2 to 86.6 for modified Harris Hip Score (mHHS), 60.5 to 83.8 for Nonarthritic Hip Score (NAHS), 65.3 to 87.3 for Hip Outcome Score-Activity of Daily Living (HOS-ADL), 45 to 75.1 for Hip Outcome Score-Sport-Specific Subscale (HOS-SSS), and 5.7 to 2.6 for VAS. In the control group, the preoperative to postoperative score changed from 61.2 to 84.4 for mHHS, 59 to 84 for NAHS, 62.7 to 86.2 for HOS-ADL, 40.1 to 74.1 for HOS-SSS, and 6.3 to 2.8 for VAS. There was no difference between preoperative and postoperative PRO scores. The preoperative VAS score was lower in the study group than in the control group (P=.04). The control group demonstrated larger mean preoperative anterior center edge angles (ACEA) (33.8° vs 29.5°) and mean alpha angles (60.5° vs 53.5°) than the study group (P<.05). There was no statistically significant difference in the change in PRO or VAS scores between groups. Both groups demonstrated significant improvement from preoperative to 2-year follow-up for all 4 PRO scores (P<.05) and decrease in VAS (P<.05). One patient in the study group converted to total hip arthroplasty. Seven patients underwent revision hip arthroscopy in the study group, and 8 patients in the control group underwent revision hip arthroscopy. There was no difference in revision rates between groups.

CONCLUSION

Treatment of pincer- and combined-type impingement with arthroscopic acetabuloplasty and labral refixation without detachment, when possible, resulted in similar patient outcomes compared with acetabuloplasty with labral detachment. We may conclude that in cases where the chondrolabral junction remains intact, acetabuloplasty and labral refixation without detachment is a viable option.

Arthroscopic labral repair of the hip, using a through-labral double-stranded single-pass suture technique

The normal labrum is crucial to the biomechanical function of the hip joint, not only increasing the surface area and depth of the acetabulum but also maintaining a suction seal to assist in normal synovial fluid flow from the peripheral to the central compartment. Simple loop suture repairs of the labrum may evert the labrum, thus losing the optimal seal, as well as causing abrasion of the articular cartilage. Vertical mattress suture and labral base fixation techniques aim to leave the free edge of the labrum intact and undisturbed, therefore improving the contact of the labrum to the femoral head and neck to improve the seal of the acetabulum. We aim to describe a double-stranded single-pass vertical mattress suture technique that may allow greater versatility to the surgeon in repairing thinner labrums while still achieving a free and continuous free edge.

Arthroscopic technique for treatment of combined pathology associated with femoroacetabular impingement syndrome using traction sutures and a minimal capsulotomy

The use of hip arthroscopy is gaining popularity for diagnostic and therapeutic purposes. With our increasing understanding of hip biomechanics and pathophysiology, our techniques for treatment are evolving as well. The main aim is to preserve the joint and prolong the degenerative process associated with femoroacetabular impingement (FAI). In general, combined pathology is encountered when a diagnosis of FAI is established. In our experience, we have seen large number of patients with a combination of cam and pincer lesions with or without associated labral tears. It is optimal to address all symptomatic pathology with one surgical intervention. The described technique shows the feasibility of dealing with the hip FAI pathology by using traction sutures on the capsule through a 2-portal technique.

A comprehensive five-phase rehabilitation programme after hip arthroscopy for femoroacetabular impingement

PURPOSE

Recent advancements in the understanding of hip biomechanics have led to the development of techniques to remove bony impingement and repair and/or preserve the labrum during hip arthroscopy. Although much attention in the literature is devoted to diagnosis and treatment, there is little information about post-operative rehabilitation. Therefore, the purpose of this review is to (1) provide a five-phase rehabilitation protocol following arthroscopic treatment for FAI and (2) report clinical and functional outcomes of patients following this protocol at minimum 1-year follow-up, in order to provide the surgeon and therapist with a protocol that is supported by clinical data.

METHODS

All consecutive patients undergoing hip arthroscopy and subsequent five-phase rehabilitation protocol at a single institution from 1 April 2011 to 1 April 2012 were analysed. Inclusion criteria were as follows: no prior ipsilateral hip surgery, completion of the five-phase rehabilitation protocol, minimum 1-year follow-up, and documented outcome scores. Prospective outcomes were assessed with modified Harris hip score (MHHS) and hip outcome score (HOS).

RESULTS

Fifty-two patients (19 male and 33 female) met the inclusion criteria with a median age of 42 (range 16-59) years. Mean MHHS, HOS-ADL, and HOS-sport scores at a mean 12.5 (range 12-15) months were 80.1 ± 19.9 (0-100), 83.6 ± 19.2 (13.2-100), and 70.3 ± 27.0 (0-100), respectively.

CONCLUSION

This five-phase rehabilitation programme provides a framework where progression from surgery to increasing post-operative activity level can take place in a predictable manner. Patients following this rehabilitation protocol after hip arthroscopy demonstrated satisfactory clinical and functional outcomes, validating its implementation.

The acetabular labrum regulates fluid circulation of the hip joint during functional activities

BACKGROUND

An assessment of the effect of surgical repair or reconstruction on the function of the hip labrum is critical to the advancement of hip preservation surgery; however, validated models of the hip that allow the quantification of labral function in functional joint positions have yet to be developed.

PURPOSE

To evaluate (1) whether intra-articular pressures within the hip are regulated by fluid transport between the labrum and femoral head and (2) whether the sealing capacity of the labrum varies with joint posture.

STUDY DESIGN

Descriptive laboratory study.

METHODS

The sealing ability of the hip labrum was measured during fluid infusion into the central compartments of 8 cadaveric specimens. Additionally, the pathway of fluid transfer from the central to the peripheral compartment was assessed via direct visualization in 3 specimens. The effect of joint posture on the sealing capacity of the labrum was determined by placing all 8 specimens in 10 functional postures. The relationship between pressure resistance and 3-dimensional motion of the femoral head within the acetabulum was quantified using motion analysis and computer modeling.

RESULTS

Resistance to fluid transport from the central compartment of the hip was directly controlled by the labrum during loading. Maximum pressure resistance was affected by joint posture (P = .001). Specifically, positions that increased external rotation of the joint (pivoting) provided an improved seal, while positions that increased flexion combined with internal rotation (stooping) augmented the ease of fluid transport from the central to the peripheral compartment. Maximum pressure resistance was associated with the distance between the labrum and femoral head during pivoting.

CONCLUSION

This study demonstrated that the transfer of fluid from the central compartment of the hip occurs at the junction of the labrum and femoral head. Joint position was shown to strongly affect the sealing function of the labrum and was attributable to the distance between the labrum and femoral head in certain positions.

CLINICAL RELEVANCE

Altering the relationship between the labrum and femoral head may disrupt the sealing ability of the labrum, potentially leaving the joint at risk for pathological changes with time.

Arthroscopic labral base repair in the hip: clinical results of a described technique

PURPOSE

The purpose of this study was to evaluate the clinical outcomes of a cohort of patients who underwent labral repair by use of a previously published labral base repair suture technique for the treatment of acetabular labral tears and pincer-type femoroacetabular impingement (FAI).

METHODS

Patients who received hip arthroscopy for symptomatic intra-articular hip disorders and underwent the previously described labral base repair technique were included in the study group. Patients who had Tönnis arthritis grade 2 or greater, had Legg-Calves-Perthes disease, or underwent simple looped stitch repair were excluded. The patient-reported outcome scores included the modified Harris Hip Score, the Non-Arthritic Hip Score, the Hip Outcome Score-Activities of Daily Living, and the Hip Outcome Score-Sport-Specific Subscale obtained preoperatively and at 2 years' and 3 years' follow-up. Any complications, revision surgeries, and conversions to total hip arthroplasty were noted.

RESULTS

Of the patients, 54 (82%) were available for follow-up. The mean length of follow-up for this cohort was 2.4 years (range, 1.7 to 4.1 years). At final follow-up, there was significant improvement in all 4 patient-reported outcome scores (modified Harris Hip Score, 63.7 to 89.9; Non-Arthritic Hip Score, 60.9 to 87.9; Hip Outcome Score-Activities of Daily Living, 66.9 to 91.0; and Hip Outcome Score-Sport-Specific Subscale, 46.5 to 79.2) (P < .0001). A good or excellent result was achieved in 46 patients (85.2%). There was significant improvement in pain as measured by the change in visual analog scale score from 6.5 to 2.3 (P < .0001), and the patient satisfaction rating was 8.56 ± 2.01. There were no perioperative complications. Revision surgery was required in 3 patients (5.6%), and 2 patients (3.7%) required conversion to total hip arthroplasty.

CONCLUSIONS

The clinical results of this labral base repair technique showed favorable clinical improvements based on 4 patient-reported outcome questionnaires, visual analog scale, and patient satisfaction. More clinical, biomechanical, and histologic studies are needed to determine the optimal repair technique.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Combined hip arthroscopy and periacetabular osteotomy: indications, advantages, technique, and complications

Evaluation and treatment of concomitant intra-articular pathology may be beneficial before periacetabular osteotomy (PAO) is performed. Hip arthroscopy before PAO allows the surgeon to perform full inspection of the hip joint and can be used to treat hip pathology before osteotomy. The indications for hip arthroscopy before PAO are presented in this article. The combined surgical procedure is described, along with potential complications. The advantages and disadvantages of this technique are outlined.

Arthroscopic capsular plication and labral preservation in borderline hip dysplasia: two-year clinical outcomes of a surgical approach to a challenging problem

BACKGROUND

The role of hip arthroscopy in the treatment of patients with dysplasia is unclear because of the spectrum of dysplasia that exists. Patients with borderline dysplasia are generally not candidates for periacetabular osteotomy because of the invasive nature of the procedure. However, arthroscopy in dysplasia has had mixed results and has the potential to exacerbate instability.

HYPOTHESIS

Patients with borderline dysplasia will demonstrate postoperative improvement, high satisfaction rates, and low reoperation rates after a surgical approach that includes arthroscopic labral repair augmented by capsular plication with inferior shift.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between April 2008 and November 2010, patients less than 40 years old who underwent hip arthroscopy for symptomatic intra-articular hip disorders, with a lateral center-edge (CE) angle ≥18° and ≤25°, were included in this study. Patients with Tönnis grade 2 or greater, severe hip dysplasia (CE ≤17°), and Legg-Calve-Perthes disease were excluded. Patient-reported outcome scores, including the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sport-Specific Subscale (HOS-SSS), Hip Outcome Score-Activity of Daily Living (HOS-ADL), and visual analog scale (VAS) for pain were obtained in all patients preoperatively and at 1, 2, and 3 years postoperatively. Revision surgery and complications were recorded for each group.

RESULTS

A total of 26 patients met the criteria to be included in the study. Of these, 22 (85%) patients were available for follow-up. The mean (± standard deviation) length of follow-up for this cohort was 27.5 ± 5.5 months (range, 17-39 months) and the average age was 20 years (range, 14-39 years). The mean lateral CE angle was 22.2° (range, 18°-25°) and the mean Tönnis angle was 5.8° (range, 0°-17°). There was significant improvement in all patient-reported outcome scores (mHHS, NAHS, HOS-SSS, and HOS-ADL) (P < .0001). There was a significant improvement in VAS scores from 5.8 to 2.9 (P < .0001). Overall patient satisfaction was 8.4 out of 10. Seventeen patients had good/excellent results (77%). Two patients required revision arthroscopy.

CONCLUSION

Patients with borderline dysplasia have often fallen into a gray area between arthroscopy and periacetabular osteotomy, and viable treatment options have remained scarce. The current study demonstrates favorable results at 2-year follow-up for an arthroscopic approach that includes labral repair augmented by capsular plication with inferior shift.

Arthroscopy of the hip: factors affecting outcome

Hip arthroscopy is a rapidly progressing field that has advanced in function and survivorship over the past decade. As increasing literature is published on outcomes of hip arthroscopy, a retrospective review has allowed for the identification of factors that affect survivorship. Within this review, the authors present the factors identified to date that affect survivorship after hip arthroscopy while raising questions about the future direction of the field.

Arthroscopic acetabular rim resection in the treatment of femoroacetabular impingement

Appropriate identification and precise resection of the pincer lesion are integral parts of the arthroscopic surgical treatment of femoroacetabular impingement. Preoperative radiographic planning of the bone resection, as well as executing the plan intraoperatively using both fluoroscopic and arthroscopic cues, is critical to adequately removing the pincer lesion. We present our surgical technique of removing the impinging bone by defining the focal acetabular rim overcoverage, accessing the pincer lesion with labral detachment, and then performing acetabular rim resection.

Arthroscopic labral repair in the treatment of femoroacetabular impingement

Labral repair has become an essential technique in the arthroscopic surgical management of femoroacetabular impingement. Several clinical studies suggest that labral repair results in superior patient outcomes in comparison to labral debridement alone. The repair procedure requires accurate evaluation of labral tissue quality, precise placement of sutures and anchors, and careful re-tensioning of the labrum. We present our preferred technique for labral repair.

Surgical dislocation of the hip versus arthroscopic treatment of femoroacetabular impingement: a prospective matched-pair study with average 2-year follow-up

PURPOSE

The purpose of this study was to prospectively compare outcomes of patients receiving surgical hip dislocation and those undergoing arthroscopic treatment for femoroacetabular impingement (FAI), using a matched-pair analysis.

METHODS

Between January 2008 and August 2011, patients aged 30 years or younger with a diagnosis of FAI treated with surgical dislocation or arthroscopy were included. Patients were excluded with Tönnis grade 2 or greater, dysplasia, Legg-Calve-Perthes disease, and previous hip surgery. Patients treated with surgical dislocation were pair-matched to patients treated arthroscopically in a 1:2 ratio. Patient-reported outcomes were prospectively obtained in all patients preoperatively and postoperatively at 3 months, at 1 year, at 2 years, and at latest follow-up. Alpha angles were measured preoperatively and postoperatively for both groups. Revision surgery and complications were recorded for each group.

RESULTS

Ten patients were included in the surgical dislocation group, and 20 pair-matched patients were included in the arthroscopic group. We obtained 100% follow-up at a mean of 24.8 months in the open group and 25.5 months in the arthroscopic group. Preoperative scores were similar between the 2 groups; significant improvements were made postoperatively for both groups. When we compared the 2 groups, the change in Hip Outcome Score-Sport-Specific Subscale (42.8 v 23.5, P = .047) and 2-year Non-Arthritic Hip Score (94.2 v 85.7, P = .01) were significantly higher in the arthroscopic group. Both groups showed a significant decrease in the alpha angle postoperatively (P = .775).

CONCLUSIONS

Favorable results were shown with both approaches, with significant improvement in all patient-reported outcome measures and high patient satisfaction ratings. However, arthroscopic treatment of FAI showed greater improvement in the Hip Outcome Score-Sport-Specific Subscale and a higher absolute Non-Arthritic Hip Score at an average 2-year follow-up.

LEVEL OF EVIDENCE

Level II, prospective matched-pair comparative study.

Arthroscopic technique for chondrolabral capsular preservation during labral repair and acetabular osteoplasty

Traditional techniques for acetabular osteoplasty in femoral acetabular impingement have required surgical detachment of the labrum at the chondrolabral junction. Such approaches compromise labral blood flow and contribute to a limited ability for healing at the chondrolabral junction. In this technical note and accompanying video, we present a technique for preservation of the chondrolabral junction during labral repair and acetabular osteoplasty. We elevate the chondrolabral complex subperiosteally off the acetabular rim, and the acetabular shelf is then contoured under fluoroscopic guidance. The labrum is then repaired and reconstituted to a new anatomic footprint. We find this technique to be advantageous because it preserves the blood flow to the labrum, thereby maximizing healing potential. Outcome studies are warranted to further elucidate the functional and outcome benefits of this surgical technique.

Outcomes of endoscopic gluteus medius repair with minimum 2-year follow-up

BACKGROUND

Gluteus medius tears may be present in as many as 25% of late middle-aged women and 10% of middle-aged men, and they are often misdiagnosed. Outcomes of endoscopic repair of gluteus medius tears have seldom been reported.

PURPOSE

To report the early outcomes of endoscopic repair of partial- and full-thickness gluteus medius tears.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between April 2009 and January 2010, data were prospectively collected for all patients undergoing endoscopic gluteus medius repair by one of the authors. Inclusion criteria for the study were patients undergoing repair for either high-grade, partial-, or full-thickness tears. Only patients with endoscopic evidence of a gluteus medius tear were treated surgically. In the case of an articular-side tear, a transtendinous repair technique was used, whereas in the presence of a full-thickness tear, the tendon was refixated to the bone directly.

RESULTS

A total of 15 patients met the inclusion criteria. The cohort included 14 women and 1 man, with an average age of 58 years (range, 44-74 years). Endoscopically, 6 cases were found to be partial-thickness tears. Nine were either full-thickness tears or near-full-thickness tears, which were completed for the repair. Follow-up was obtained on all patients at an average of 27.9 months postoperatively (range, 24-37 months). Fourteen of the 15 patients showed postoperative improvement in all 4 hip-specific scores used to assess outcome, with an average improvement of more than 30 points for all scores. Satisfaction with the surgery results was reported to be from good to excellent (scores of 7-10 out of 10) in 14 of 15 patients.

CONCLUSION

This study demonstrates that endoscopic surgical repair, whether performed through a transtendinous or full-thickness technique, can be an effective treatment of gluteus medius tears at a minimum follow-up of 2 years. Longer term follow-up studies are necessary to determine whether these therapeutic and functional gains are maintained.

Arthroscopic technique for treatment of femoroacetabular impingement

With an increasing understanding of femoroacetabular impingement (FAI) and advancement of the surgical treatment in patients with FAI, various techniques have been published. Successful outcome after arthroscopic hip surgery depends on appropriately reshaping the bony architecture to allow for improved range of motion before impingement symptoms occur, with special attention to preserve the labrum and restore its function. We present our surgical technique for the arthroscopic treatment of FAI.

Histologic assessment of acetabular labrum healing

PURPOSE

The purpose of this study was to histologically examine the human healing response of arthroscopically repaired acetabular labrum tears.

METHODS

Biopsy specimens were retrieved from 6 patients during total hip arthroplasty after clinical failure of the index arthroscopic procedure. All patients were diagnosed as having femoroacetabular impingement with a concomitant labral tear. In all cases severe chondral damage was observed during arthroscopy (Beck grades 3 to 4). Despite successful technical repair of the labral tear, chondral damage in these patients was so advanced that the clinical progress after the procedure was unsatisfactory and arthroplasty of the joint was required. Biopsy specimens of the repaired acetabular labra were harvested during the arthroplasty surgery and processed for standard histologic evaluation.

RESULTS

Macroscopically and histologically, all repaired labra kept their triangular shape more or less and appeared to have healed. All harvested biopsy specimens displayed a typical fibrocartilaginous appearance with limited vascular supply. Calcifications were present in only 1 biopsy specimen. In 3 cases neovascularization of the labral tissue was noticed in the proximity of the sutures. In the superficial and deep parts of the labral body, small clefts were observed in all cases.

CONCLUSIONS

In this study the histologic aspects of arthroscopically repaired human labral tears were addressed. It was shown that human labral tears show healing potential after surgical repair. The surfaces of the labral tissues were intact, and neither remnants of the tear nor the presence of fibrovascular scar tissue was observed. However, some small clefts in the superior and deep parts of the repaired structures were noticed in all cases.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Investigation of the preservation of the fluid seal effect in the repaired, partially resected, and reconstructed acetabular labrum in a cadaveric hip model

BACKGROUND

Debate exists on whether hip labral tears should be surgically repaired, partially resected, or reconstructed. Furthermore, limited data exist regarding the fluid seal properties of hip labrum repair and/or reconstruction with iliotibial band autograft when compared with the labrum-intact condition. Hypothesis/

PURPOSE

The purpose of this study was to investigate the fluid seal properties of hip labral repair and reconstruction techniques. We hypothesized that hip labral repair preserves the acetabular labral fluid seal greater than labral tear, partial-resection, and reconstruction conditions.

STUDY DESIGN

Controlled laboratory study.

METHODS

Six human cadaveric hemipelvises were dissected of all soft tissue, leaving the hip capsule intact. Fluid efflux was measured under 5 conditions using a custom fluid infusion device: (1) hip labrum intact, (2) labral tear, (3) labral repair with suture anchors, (4) partial labral resection, and (5) labral reconstruction using ipsilateral iliotibial band autograft. Joint fluid expression was measured as flow rate under 3 different pressure settings (2, 3, and 4 psi). Statistical differences between conditions were assessed using 2-way, repeated-measures analysis of variance. The Student-Newman-Keuls (SNK) multiple comparison test was used to determine differences between levels.

RESULTS

There was a significant increase in fluid efflux with a simulated labral tear (0.54 ± 0.3 mL/sec) when compared with the intact hip labrum condition (0.006 ± 0.008 mL/sec, P < .05). The labrum-repaired condition (0.21 ± 0.2 mL/sec) demonstrated significantly less fluid efflux when compared with the labral-tear condition. Hip labral repair significantly prevented greater fluid efflux when compared with partial labral resection (0.60 ± 0.4 mL/sec) and reconstruction with iliotibial band autograft (0.54 ± 0.3 mL/sec; P < .05). Labral repair did not preserve fluid efflux as effectively as in the labrum-intact condition (0.21 ± 0.2 > 0.006 ± 0.008 mL/sec; P < .05). There was no difference observed in fluid efflux between the labral reconstruction, tear, or resection conditions (P > .05).

CONCLUSION

In this human cadaveric model, hip labral repair outperforms partial labral resection and reconstruction in preserving the joint fluid seal; however labral repair does not restore fluid seal characteristics as effectively as in the labrum-intact condition.

CLINICAL RELEVANCE

Further prospective studies are needed to determine whether hip labral repair outperforms partial labral resection and/or reconstruction in clinical practice.

Complications of arthroscopic surgery of the hip

Over recent years hip arthroscopic surgery has evolved into one of the most rapidly expanding fields in orthopaedic surgery. Complications are largely transient and incidences between 0.5% and 6.4% have been reported. However, major complications can and do occur. This article analyses the reported complications and makes recommendations based on the literature review and personal experience on how to minimise them.

Tears of the ligamentum teres: prevalence in hip arthroscopy using 2 classification systems

BACKGROUND

The ligamentum teres (LT) anatomy has been known for many years. While its functionality remains debatable, it is well recognized that the LT can be a source of pain in the hip joint. In 1997, a landmark publication by Gray and Villar established a classification for LT tears and increased the awareness of LT disorders. However, the incidence of LT tears and the various tear types is unknown.

PURPOSE

The authors report the prevalence of LT tears in a population of patients who underwent hip arthroscopy, using both the Gray and Villar classification and a new descriptive classification.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between February 2008 and January 2011, 616 hip arthroscopies were performed by the senior author. After excluding revision surgeries, a total of 558 surgeries (502 patients) were included in the study. Data were collected regarding patients' demographics, mechanism of injury, range of motion, magnetic resonance results, and intraoperative findings. Preoperative hip-specific questionnaire scores and pain level were recorded as well. Ligamentum teres tears were classified according to Gray and Villar's classification, and were also categorized using a descriptive grading system as follows: 0, no tear; 1, <50% tear; 2, >50% tear; or 3, 100% tear.

RESULTS

A total of 284 (51%) of the 558 surgeries in this cohort revealed LT tears. According to the descriptive grading system, 22% were grade 1, 24% were grade 2, and 5% were grade 3. According to the Gray and Villar classification 3.7% had full rupture, 43% had a partial tear, and 4.5% had a degenerative tear. Patients with LT tears were significantly older and had worse preoperative functional scores; they did, however, have a greater range of motion. Intraoperatively, an association with larger labral tear size and acetabular chondral damage was found. Magnetic resonance arthrography was found to have low accuracy and sensitivity in detection of LT tears. No correlation to the pain level was found.

CONCLUSION

Ligamentum teres tears had a higher prevalence in this study than was published in the past, most probably attributable to a lower threshold used in defining a tear. The incidence is defined both using the Gray and Villar classification, as well as a new descriptive classification system that categorizes the LT according to amount of tearing.

Defining a safety margin for labral suture anchor insertion using the acetabular rim angle

BACKGROUND

Suture anchors are commonly used to reattach a torn labrum to the acetabular rim. The acetabular rim anatomy is not uniform, and the safety margin for inserting suture anchors is unknown. The acetabular rim angle is an anatomic measurement that is indicative of the safety margin for inserting suture anchors.

PURPOSE

To investigate the acetabular rim angle as a function of clock position, to evaluate the effect of drill depth on the acetabular rim angle, and to evaluate the effect of rim trimming on the acetabular rim angle.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Three-dimensional acetabular models were reconstructed from computed tomography scans of 20 nonpaired cadaveric hip specimens, and the acetabular rim angle, which quantifies the angle between the subchondral margin and the outer cortex of the acetabulum, was measured from the 8- to 4-o'clock positions. At each position, the acetabular rim angle was measured for 5 drill depths (10, 12.5, 15, 20, and 25 mm) to simulate different lengths of suture anchors or drill bit depths on the acetabular rim angle. To simulate rim trimming, the acetabular rim angle was measured at the points that would become the suture anchor insertion points after 2.5- and 5-mm rim trimming.

RESULTS

Clock position, drill depth, and rim trimming all had significant effects on the acetabular rim angle (P < .0001). The acetabular rim angle was largest at the 2-o'clock and smallest at the 3-o'clock position. Greater drill depths provided smaller acetabular rim angles, whereas rim trimming provided larger acetabular rim angles.

CONCLUSION

The acetabular rim angle varied significantly as a function of the location on the acetabular rim. A shorter drill depth and a greater amount of rim trimming provided a larger acetabular rim angle.

CLINICAL RELEVANCE

Surgeons should be aware of the acetabular rim variations, especially in the anterosuperior quadrant, as well as the effects of drill depth and rim trimming, when selecting the optimal insertion angle for suture anchor placement to avoid articular cartilage penetration. The acetabular safety angle was smallest at the 3-o'clock position. Therefore, extra care must be taken when drilling or inserting anchors around the 3-o'clock position.

Open surgical dislocation versus arthroscopy for femoroacetabular impingement: a comparison of clinical outcomes

PURPOSE

Over the last decade, the surgical treatment of femoroacetabular impingement (FAI) has evolved as surgical techniques through arthroscopy, open surgical dislocation, and combined approaches have been developed. The purpose of this systematic review was to evaluate and compare the clinical results of available surgical approaches for FAI.

METHODS

A review of the literature was performed through the PubMed database and related articles' reference lists. Inclusion criteria were (1) all patients treated for FAI, (2) Level I, II, III, or IV study design, and (3) written in the English language. Case reports and studies involving patients with acetabular dysplasia were excluded.

RESULTS

Overall, 1,299 articles fit our keyword search criteria. Of these, 26 articles reported clinical outcomes, using 3 surgical modalities: open surgical dislocation, arthroscopic, and combined approaches. In compiling the data in these articles, we analyzed the outcomes of a total 1,462 hips in 1,409 patients. The most published surgical method was arthroscopy, which included 62% of the patients. Labral repair was performed more frequently in open surgical dislocation (45%) and combined approach (41%) procedures than in arthroscopies (23%). Mean improvement in the modified Harris hip score after surgery was 26.4 for arthroscopy, 20.5 for open surgical dislocation, and 12.3 for the combined approach. A higher rate of return to sport was reported for arthroscopy in professional athletes than for open surgical dislocation. Overall complication rates were 1.7% for the arthroscopic group, 9.2% for the open surgical dislocation group, and 16% in the combined approach group.

CONCLUSIONS

All 3 surgical approaches led to consistent improvements in patient outcomes. Because a wide variety of subjective hip questionnaires were used, direct comparisons could not be made in many cases, and none of the approaches could be clearly shown to be superior to the others. However, it seems that, overall, the arthroscopic method had the lowest complication and fastest rehabilitation rate.