Preliminary pain and function after labral reconstruction during femoroacetabular impingement surgery

Secondary Hip Labral Reconstruction Yields Inferior Minimum 2-Year Functional Outcomes to Primary Reconstruction Despite Comparable Intraoperative Labral Characteristics

PURPOSE

To compare intraoperative labral characteristics and minimum 2-year functional outcomes of allograft labral reconstruction in primary versus revision hip arthroscopy across multiple orthopaedic centers.

METHODS

A retrospective multicenter hip arthroscopy registry was queried for patients with completed labral reconstruction surgeries from January 2014 to March 2023 with completed 2-year international Hip Outcome Tool-12 (iHOT-12) reports. Age, sex, and major intraoperative variables also were collected. Patients were placed in cohorts based on whether their arthroscopic allograft labral reconstruction was a primary procedure or secondary procedure (reconstruction following failed hip arthroscopy). One-way analysis of variance was performed on continuous variables. χ2 test was performed on categorical variables. Achievement of minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), and Substantial Clinical Benefit (SCB) also was assessed.

RESULTS

In total, 77 patients met the inclusion and exclusion criteria and had complete information. The primary reconstruction group (n = 50) was significantly older than the secondary reconstruction group (n = 27) (47.5 ± 10.5 vs 39.1 ± 8.8 years; P = .001). In both cohorts, most patients had labral bruising, advanced labral degeneration, and/or grade III complexity of labral tearing. There was no difference in any recorded intraoperative findings (P = .160, P = .783, P = .357, respectively). Each cohort experienced significant improvement in iHOT-12 scores (P < .0001). However, patients undergoing secondary labral reconstruction reported inferior iHOT-12 scores (60.1 ± 29.2 vs 74.8 ± 27.0; P = .030). Patients undergoing primary reconstruction were more likely to reach MCID, PASS, and nearly normal SCB (92 vs 66.7%, P = .024; 68.0 vs 40.7%, P = .021; 76.0 vs 48.1%, P = .014, respectively).

CONCLUSIONS

Primary and secondary allograft labral reconstruction show clinical improvement, but primary reconstruction demonstrates better outcomes and greater percentage of patients reaching MCID, PASS, and nearly normal SCB than reconstruction in the revision setting.

LEVEL OF EVIDENCE

Level III, retrospective comparative prognostic case-control study.

Indirect Head of the Rectus Femoris Tendon as a Graft for Segmental Hip Labral Reconstruction: An Anatomic, Radiographical, and Biomechanical Study in Comparison With Iliotibial Labral Reconstruction

BACKGROUND

The indirect head of the rectus femoris (IHRF) tendon has been used as an autograft for segmental labral reconstruction. However, the biomechanical properties and anatomic characteristics of the IHRF, as they relate to surgical applications, have yet to be investigated.

PURPOSE

To (1) quantitatively and qualitatively describe the anatomy of IHRF and its relationship with surrounding arthroscopically relevant landmarks; (2) detail radiographic findings pertinent to IHRF; (3) biomechanically assess segmental labral reconstruction with IHRF, including restoration of the suction seal and contact pressures in comparison with iliotibial band (ITB) reconstruction; and (4) assess potential donor-site morbidity caused by graft harvesting.

STUDY DESIGN

Descriptive laboratory study.

METHODS

A cadaveric study was performed using 8 fresh-frozen human cadaveric full pelvises and 7 hemipelvises. Three-dimensional anatomic measurements were collected using a 3-dimensional coordinate digitizer. Radiographic analysis was accomplished by securing radiopaque markers of different sizes to the evaluated anatomic structures of the assigned hip.Suction seal and contact pressure testing were performed over 3 trials on 6 pelvises under 4 different testing conditions for each specimen: intact, labral tear, segmental labral reconstruction with ITB, and segmental labral reconstruction with IHRF. After IHRF tendon harvest, each full pelvis had both the intact and contralateral hip tested under tension along its anatomic direction to assess potential site morbidity, such as tendon failure or bony avulsion.

RESULTS

The centroid and posterior apex of the indirect rectus femoris attachment are respectively located 10.3 ± 2.6 mm and 21.0 ± 6.5 mm posteriorly, 2.5 ± 7.8 mm and 0.7 ± 8.0 mm superiorly, and 5.0 ± 2.8 mm and 22.2 ± 4.4 mm laterally to the 12:30 labral position. Radiographically, the mean distance of the IHRF to the following landmarks was determined as follows: anterior inferior iliac spine (8.8 ± 2.5 mm), direct head of the rectus femoris (8.0 ± 3.9 mm), 12-o'clock labral position (14.1 ± 2.8 mm), and 3-o'clock labral position (36.5 ± 4.4 mm). During suction seal testing, both the ITB and the IHRF reconstruction groups had significantly lower peak loads and lower energy to peak loads compared with both intact and tear groups (P = .01 to .02 for all comparisons). There were no significant differences between the reconstruction groups for peak loads, energy, and displacement at peak load. In 60° of flexion, there were no differences in normalized contact pressure and contact area between ITB or IHRF reconstruction groups (P > .99). There were no significant differences between intact and harvested specimen groups in donor-site morbidity testing.

CONCLUSION

The IHRF tendon is within close anatomic proximity to arthroscopic acetabular landmarks. In the cadaveric model, harvesting of the IHRF tendon as an autograft does not lead to significant donor-site morbidity in the remaining tendon. Segmental labral reconstruction performed with the IHRF tendon exhibits similar biomechanical outcomes compared with that performed with ITB.

CLINICAL RELEVANCE

This study demonstrates the viability of segmental labral reconstruction with an IHRF tendon and provides a detailed anatomic description of the tendon in the context of an arthroscopic labral reconstruction. Clinicians can use this information during the selection of a graft and as a guide during an arthroscopic graft harvest.

Tissue Regrowth and Its Vascularization Through Bone Marrow Stimulation: Microfracture at the Acetabular Rim for Irreparable Labral Tear in a Porcine Model

BACKGROUND

The treatment of irreparable acetabular labral tear remains a great challenge. Whether fibrocartilage-like tissue can regrow with sufficient volume to fill the labral defect area through bone marrow stimulation remains unknown.

PURPOSE

To characterize the healing process and vascularization course of the regrown tissue after microfracture at the acetabular rim for irreparable labral tears in a porcine model.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Twelve pigs randomly underwent unilateral microfracture at the acetabular rim after the resection of a 10 mm-long section of labrum from 10 to 1 o'clock. Pigs were randomly sacrificed at 6 and 12 weeks postoperatively. The regrown tissues were harvested for macroscopic evaluation and histologic assessment. The regrown tissue was zoned into 2 halves to observe the vascular distribution: the capsular half (zone I) and the articular half (zone II). Each zone was divided into 2 parts: the peripheral part (IA and IIA) and the part attached to the acetabulum (IB and IIB).

RESULTS

At 6 weeks, all regrown tissue was hypotrophic with <50% filling of the labral defect. Fibrochondrocytes were concentrated at the interface between the acetabulum and the regrown tissue. The vascularization was equal among each part within the regrown tissue. As compared with regrown tissue at 12 weeks, proteoglycan and collagen type 1 and 2 were more evident within the regrown tissue at 6 weeks. At 12 weeks, tissue disintegration occurred in all regrown tissue with <25% filling of the labral defect area. The vascular structure could barely be observed, with few fibrochondrocytes found at the area adjacent to the acetabulum.

CONCLUSION

Fibrocartilage-like tissue did regrow with well-distributed vascular ingrowth of each part of the regrown tissue through bone marrow stimulation at the early stage. However, insufficient volume of the regrown tissue led to loss of the hip suction seal and subsequent tissue disintegration.

CLINICAL RELEVANCE

Microfracture at the rim of the acetabulum alone could not restore the morphology and function of the acetabular labrum. Nonetheless, microfracture at the acetabular rim might be a viable adjunct to labral reconstruction, as the well-distributed vascularization through bone marrow stimulation might overcome the obstacle of poor vascular ingrowth of the articular half of the autograft.

Graft Options for Hip Labral Reconstruction

➢

Arthroscopic hip labral reconstruction is a complex procedure which is growing in use as indications, techniques, and surgical expertise advance.

➢

Graft selection is an important component of labral reconstruction based on relative advantages and disadvantages of available types of autografts and allografts.

➢

The ideal graft should mimic the native acetabular labrum form and function while also being affordable, readily available, and associated with low morbidity.

➢

High rates of patient satisfaction and positive patient-reported outcomes have been reported after labral reconstruction using several graft types.

Primary Arthroscopic Labral Management: Labral Repair and Complete Labral Reconstruction Both Offer Durable, Promising Results at Minimum 5-Year Follow-up

BACKGROUND

Increased understanding of the acetabular labrum's role in hip joint biomechanics has led to a greater focus on the conservation and restoration of normal labral anatomic characteristics; however, labral repair is often not possible in the setting of severe intrasubstance damage or deficiency.

PURPOSE

To compare 5-year postoperative patient-reported outcomes between hips treated with primary complete arthroscopic labral reconstruction and those treated with primary labral repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All hips that underwent primary labral repair or reconstruction by the senior surgeon between January 2015 and December 2015 were included. Hips that had undergone a previous intra-articular procedure were excluded. Visual analog scales and patient-reported outcome (PRO) instruments were completed by patients within 1 week before surgery as a baseline measurement, between 22 and 26 months postoperatively for 2-year outcomes, and between 58 and 62 months for 5-year outcomes. PRO scores collected included the modified Harris Hip Score (mHHS), the 12-Item International Hip Outcome Tool, and the visual analog scale for pain and satisfaction. Pain and satisfaction were assessed using visual analog scales.

RESULTS

A total of 68 primary labral repairs and 62 primary complete labral reconstructions were included in the final analysis. Patients in the reconstruction cohort were older (38.3 vs 29.9 years; P < .001), had a higher incidence of severe labral tearing (62.90% vs 5.88%; P < .001), required a greater number of concomitant procedures (P < .001), and were more likely to have Beck grade III or IV chondral damage (12.94% vs 1.47%; P < .001). Both groups demonstrated statistically significant increases in outcome scores at minimum 5-year follow-up. Patients who underwent labral reconstruction had a significantly greater increase in mHHS from the preoperative assessment to latest follow-up compared with patients undergoing labral repair (27.43 vs 17.13; P = .04). No statistically significant differences between the 2 cohorts were found in achievement of minimal clinically important difference, Patient Acceptable Symptom State, maximum outcome improvement, and substantial clinical benefit at latest follow-up (P > .05). In total, 2 patients in the repair cohort and 3 patients in the reconstruction cohort required revision arthroscopy (P = .574). Further, 1 patient from each group converted to arthroplasty (P = .947).

CONCLUSION

The results of this study suggest that primary complete labral reconstruction is a viable surgical option for hips with moderate to severe labral pathology. At minimum 5-year follow-up, labral reconstruction produced similar outcomes to labral repair despite less favorable preoperative patient characteristics in the reconstruction cohort.

Does labral treatment technique influence the outcome of FAI surgery? A matched-pair study of labral reconstruction versus repair and debridement with a follow-up of 10 years

The aim of this study was to analyze the long-term clinical outcomes of labral reconstruction in patients undergoing femoro-acetabular impingement (FAI) surgery and compare them with labral repair and debridement. This is a single-center, single-surgeon, retrospective match-paired study from a prospectively collected hip preservation database. All patients underwent a hip surgical dislocation for FAI surgery. Eight patients underwent labral reconstruction with the ligamentum teres and were matched on sex, age and body mass index with 24 labral repair and 24 labral debridement (1:3). Failure was defined as conversion to total hip replacement (THR) and patient-reported outcome measures (PROMs) were collected. Mean follow-up was 9.8 years ±2.6 (5.2–13.9). There was a significant improvement in postoperative PROMs in the three groups regarding the WOMAC total, WOMAC function, HOOS-QoL, HOOS-ADL and HOOS-SRA (P < 0.05). There was no statistical difference between the three groups regarding postoperative PROMs and change in PROMs (P > 0.05). A total of 10 hips underwent joint replacement surgery at a mean time of 7.9 ± 3.5 years (2.4–12). There was no statistically significant difference between the three groups regarding the conversion rate to THR (P = 0.64) or time between surgery and conversion to THR (P = 0.15). Compared to a match-pair group of labral repair and debridement, labral reconstruction with ligamentum teres provides similar survival with conversion to a THR as an endpoint, as well as similar improvement in PROMs. Labral treatment can be safely adapted at the nature of the labral lesion with a treatment ‘à la carte’.

Microfracture of Acetabular Rim After Segmental Labral Resection to Restore the Morphology and Function of Labrum: A Retrospective Study of More than 2 Years Follow-up

Objective

To report on the clinical outcome of patients undergoing combined arthroscopic treatment of labral resection and microfracture at the rim of acetabulum at a minimum 2‐year follow‐up.

Methods

The retrospective study included 38 patients undergoing hip arthroscopy for irreparable labral injury from 24 February 2014 to 26 February 2018. Thirteen patients were excluded owing to patient refusal of participation and concomitant diseases like synovial chondromatosis and dysplasia hip. The study group consisted of patients undergoing combined arthroscopic labral resection and microfracture at the rim of acetabulum (MICRO Group: 20 patients), arthroscopic labral resection alone (RESEC Group: five patients). Postoperative three‐dimensional (3D) double‐echo steady‐state (DESS) sequence with radial imaging at 3 Tesla were obtained and fluoroscopic image of the involved hip under distraction were used to observe the restoration of vacuum effect. Patient‐reported outcome scores (PROs) including the Harris Hip Score (HHS), Visual Analogue Score (VAS), Hip Outcome Score Activities of Daily Living Subscale (HOS‐ADL), Hip Outcome Score Sport‐Specific Subscale (HOS‐SSS) were collected and compared between two groups.

Results

All patients were followed up for at least 6 months. The follow‐up time of RESEC group is longer than MICRO group (46.6 months vs 23.9 months, P < 0.05). The 3D DESS imaging demonstrated intermediate signal intensity at the relative area where the labrum resected followed by microfracture at the acetabular rim in MICRO group. Meanwhile, regrowth of labrum‐like tissue was not observed in MRI imaging of the RESEC group. Furthermore, vacuum effect was more apparent in MICRO group compared with RESEC group. All PROs in both groups showed a statistically significant improvement at follow‐up compared with preoperative levels. RESEC group: HHS (73.0 vs 93.8, P < 0.05); HOS‐ADL (51.5 vs 89.1, P < 0.05); HOS‐SSS (47.8 vs 88.3, P < 0.05); VAS (6.4 vs 2.0, P < 0.05). MICRO group: HHS (70.5 vs 91.5, P < 0.05); HOS‐ADL (52.4 vs 87.0, P < 0.05); HOS‐SSS (48.1 vs 86.5, P < 0.05); VAS (6.3 vs 1.6, P < 0.05). One patient of MICRO group had transient neurapraxias of the pudendal nerve that resolved completely by 3 months. There showed no statistically significant difference between groups regarding the preoperative and postoperative PROs.

Conclusion

Compared to labral resection, combined arthroscopic labral resection and microfracture at the rim of acetabulum is able to fulfill the labral defect area with the potential to restore the seal effect of labrum as an effective and safe option for irreparable segmental labral tears.

[Arthroscopic labrum reconstruction for femoroacetabular impingement syndrome: 12 cases report]

To investigate the surgical effect of hip arthroscopic labrum reconstruction. A retrospective study was performed on the clinical data of 12 patients who underwent hip arthroscopic labrum reconstruction in our department from September 2017 to February 2021 and were followed up for 5-46 months, with an average of 21.5 months. All the patients had a hip joint space of more than 2 mm, and Tonnis grade less than level Ⅱ. These 12 patients underwent arthroscopic debridement of hyperplastic synovium, femoral head and neck and/or acetabular osteoplasty, and labrum reconstruction using autograft iliotibial band or gracilis tendon. After the surgery, we conducted follow-up and data collection, recorded the satisfaction of the patients and occurrence of complications, as well as the cartilage lesion of hip joint observed under the arthroscopy. We compared the alpha angle of Dunn X-ray film, center-edge angle (CE angle) of AP X-ray film, modified Harris hip score (mHHS score), hip outcome score (HOS), international hip outcome tool 12 score (iHOT12 Score), and visual analogue scale (VAS scale) before and after the arthroscopic operation, to assess clinical symptom relief and joint function recovery. The 12 patients were followed up for 5-46 (21.5±12.8) months. The VAS scale were (5.3±2.5) and (2.5±1.4) before and after the surgery, showing significant decrease (P=0.018). The mHHS score were (60.6±22.2) and (83.1±5.8) before and after the surgery, showing significant increase (P=0.003). The patient satisfaction was high (7.8±2.0) (range: 0-10). None of the 12 patients had serious complications, revision surgery, or total hip replacement at the end of the last follow-up. Autologous tendon transplantation for reconstruction of acetabular labrum under arthroscopy can improve the clinical symptoms and joint function of patients with femoroacetabular impingement (FAI), which is a safe and effective treatment.

Acetabular labral reconstruction with medial meniscal allograft: preliminary results of a new surgical technique

PURPOSE

Reconstruction of the acetabular labrum during femoroacetabular impingement (FAI) surgery is accepted when the labrum is deficient and irreparable. Here we describe a novel technique using fresh-frozen medial meniscal allograft for labral reconstruction during surgical hip dislocation for correction of pincer FAI due to acetabular overcoverage.

METHODS

The results from seven hips (six patients) that underwent this procedure with 1 year minimum follow-up, and radiographs are presented.

RESULTS

Six of the seven hips had improvements in pain, hip flexion, hip abduction, and Merle d'Aubigné-Postel scores. Only one patient with pre-existing osteoarthritis underwent reoperation with conversion to total hip arthroplasty. All digastric trochanteric osteotomies healed, and there were no cases of femoral head osteonecrosis or progression of Tönnis grades.

CONCLUSIONS

The medial meniscus is a morphologically and clinically suitable option for labral reconstruction and effectively restores the hip fluid seal.

Why Does Hip Arthroscopy Fail? Indications and PEARLS for Revision Success

The surgical treatment of femoroacetabular impingement has been shown to have successful early and mid-term clinical outcomes. Despite these favorable clinical outcomes that have been published in the literature, there is a subgroup of patients that present with continued or recurrent symptoms after surgical treatment. Not only has there been an increase in the number of hip arthroscopy procedures, but also there has been a corresponding increase in the number of revision hip arthroscopy and hip preservation surgeries. Previous studies have reported residual deformity to be the most common reason for revision hip arthroscopy. However, chondral, labral, and capsular considerations also are important when addressing patients not only in the primary but also, the revision setting. In this review, we outline the evaluation and treatment of the patient that presents with continued hip and groin pain after undergoing a hip.

Graft Options in Hip Labral Reconstruction

PURPOSE OF REVIEW

The last decade has seen a boom in hip arthroscopy with refined indications. Improved understanding of pathoanatomy and disease progression has allowed for the development of advanced techniques. Labral reconstruction has been developed to substitute a non-functional or absent labrum. It has become an important technique in the armamentarium of high-volume arthroscopic hip surgeons.

RECENT FINDINGS

Basic science studies have improved understanding of hip biomechanics in the presence and absence of a labrum with a labral reconstruction allowing for reconstitution of normalcy. Current techniques have shown success with autograft and allograft tissue options. While autograft tissue allows for easy access intra-operatively and maintains patient biology, donor site morbidity is possible. Allografts negate donor site morbidity and allow for an abundance of tissue but can be resource-intensive and face availability concerns. Recent studies support outcomes of labral reconstructions using both autograft and allograft. Promising results have also allowed for performing labral reconstruction in a primary setting. Labral reconstruction can be successfully performed using both autograft and allograft. Patient biology should be respected, and native hip biomechanics restored. The literature is plentiful for appropriate surgical decision-making allowing the surgeon with multiple graft choices depending on training, experience, and resources.

Indications and Outcomes for Arthroscopic Hip Labral Reconstruction With Autografts: A Systematic Review

Background: The acetabular labrum plays a major role in hip function and stability. The gold standard treatment for labral tears is labral repair, but in cases where tissue is not amenable to repair, reconstruction has been demonstrated to provide superior outcomes compared to debridement. Many types of grafts have been used for reconstruction with good to excellent outcomes. Autograft options include iliotibial band (ITB), semitendinosus, and indirect head of the rectus femoris tendon, while allografts have included fascia lata and gracilis tendon allografts.

Questions/Purposes: As allografts are not always readily available and have some inherent disadvantages, the aims of this systematic review were to assess (1) indications for labral reconstruction and (2) summarize outcomes, complications, and reoperation rates after arthroscopic labral reconstruction with autografts.

Methods: A systematic review of the literature was performed using six databases (PubMed, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Scopus, and Google Scholar) to identify studies reporting outcomes for arthroscopic labral reconstruction utilizing autografts, with a minimum follow-up of 1 year. Study design, patient demographics, autograft choice, complications, donor site morbidity, reoperation rates, conversion to arthroplasty, and patient reported outcomes were extracted and reported.

Results: Seven studies were identified for inclusion with a total of 402 patients (173 females, age range 16–72, follow-up range 12–120 months). The most commonly reported functional outcome score was the modified Harris Hip Score (mHHS), which was reported in six of seven studies. Preoperative mHHS ranged from 56 to 67.3 and improved postoperatively to a range of 81.4–97.8. Conversion to total hip arthroplasty and reoperation rates ranged from 0 to 13.2% and 0 to 11%, respectively. The most common indication for labral reconstruction was an irreparable labrum. Autografts utilized included ITB, hamstring tendons, indirect head of rectus femoris, and capsular tissue.

Conclusions: Arthroscopic autograft reconstruction of the acetabular labrum results in significant improvement in the short- and mid-term patient reported outcomes, for properly selected patients presenting with pain and functional limitation in the hip due to an irreparable labral injury.

Is Labral Size Predictive of Failure With Repair in Hip Arthroscopy?

PURPOSE

To assess whether labral size is predictive of labral repair failure or shows an association with patient outcomes after hip arthroscopy.

METHODS

We performed a retrospective chart review of patients who underwent arthroscopic hip labral repair. Labral size was measured in 4 quadrants with an arthroscopic probe. The average size across torn labral segments was assessed for failure as determined by the change in patient-reported outcomes, the rate at which subjects achieved the minimal clinically important difference and patient acceptable symptomatic state, and the need for additional surgery. Outcomes were evaluated for any continuous correlation as well as significant differences between the middle 50% of labral sizes and classes of labral sizes derived from upper and lower quartile and decile ranges. Included hips were those from patients aged between 18 and 55 years with 2-year postoperative follow-up and lateral center-edge angles between 25° and 40°.

RESULTS

The study included 571 hips. Labral width did not show a significant difference between hips requiring revision and those not requiring revision (P = .4054). No significant correlation was found between labral width and the change in the International Hip Outcome Tool 12 score (R² = 0.05780), modified Harris Hip Score (R² = 0.19826), or Nonarthritic Hip Score (R² = 0.23543) from preoperatively to 2 years postoperatively. Hips with labral sizes in the upper decile of our cohort showed significantly decreased improvement in the International Hip Outcome Tool 12 score (P = .0287) and Nonarthritic Hip Score (P = .0490) compared with the middle 50% of labral sizes. No statistically significant difference was found in the rate at which the groups achieved the minimal clinically important difference or patient acceptable symptomatic state.

CONCLUSIONS

Hypertrophic labra in the largest 10th percentile showed lower postoperative outcome scores. However, no detectable clinical benefit was found in terms of patient-perceived clinical difference or acceptable symptomatic state. For most patients, labral size does not appear to significantly alter patient outcomes or the need for arthroplasty.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Diagnosis and treatment of labral tear

Objective:

To review the literature regarding diagnosis and treatment of labral tear.

Data sources:

A systematic search was performed in PubMed using various search terms and their combinations including hip, labrum, acetabular labral tear, arthroscopy, diagnosis, and anatomy.

Study selection:

For each included study, information regarding anatomy, function, etiology, diagnosis, and management of acetabular labral tear was extracted.

Results:

Five hundred and sixty abstracts about anatomy, function, etiology, diagnosis, and management of acetabular labral tear were reviewed and 66 selected for full-text review. The mechanism of labral tear has been well explained while the long-term outcomes of various treatment remains unknown.

Conclusions:

Labral tear is generally secondary to femoroacetabular impingement, trauma, dysplasia, capsular laxity, and degeneration. Patients with labral tear complain about anterior hip or groin pain most commonly with a most consistent physical examination called positive anterior hip impingement test. Magnetic resonance arthrography is a reliable radiographic examination with arthroscopy being the gold standard. Conservative treatment consists of rest, non-steroidal anti-inflammatory medication, pain medications, modification of activities, physical therapy, and intra-articular injection. When fail to respond to conservative treatment, surgical treatment including labral debridement, labral repair, and labral reconstruction is often indicated.

The Hip Labrum Reconstruction: Indications and Outcomes-an Updated Systematic Review

PURPOSE OF REVIEW

To present an updated systematic review of the indications and outcomes of open and arthroscopic labral reconstruction. Due to the increasing popularity and recognition, the arthroscopic procedure has gained in recent years, the aim was to assess for changes in indications, graft selection, and improvement in outcomes within the last 5 years.

RECENT FINDINGS

A total of nine eligible studies (six case series, one cohort, and two retrospective comparative studies) with a total of 234 patients (265 hips), and an average 12/16 (non-comparative studies) and 20/24 (comparative studies) quality on the MINORS score were included in this review. All patients underwent labral reconstruction, whether as primary surgery or revision (76% vs 24% respectively). There were 244 hips assessed at final follow- up (92%) with a reported mean range of 12 and 61 months. There were more graft variabilities found in this study compared with the previous review (iliotibial band allograft, gracilis tendon autograft, indirect head of rectus femoris autograft, semitendinosus allograft, peroneus brevis allograft, labrum allograft, ligamentum capitus femoris). Surgical approaches differed (open 7.9% (previously 18.7%), arthroscopic 86% (previously 81. 3 %), arthroscopic assisted mini-open technique (AAMOT) (6%)). Overall, improvement was observed in the patient-reported outcomes and functional scores, with variability in their statistical significance. The failure rate or conversion to total hip arthroplasty (THA) decreased compared with the previous review (20% vs 9.5% [conversion to THA was 5.7% and revision surgery rate was 3. 8%]). Indications for labrum reconstruction remained similar (i.e., young, active patients with no or minimal arthritis (Tonnis 0-1), irreparable or ossified labrum, and hypotrophic < 2 mm or dysfunctional hypertrophic labrum > 8 mm). According to recent evidence, hip labrum reconstruction is a new technique that showed short- and mid-term improvement in patient-reported outcomes and functional scores postoperatively. The primary indication for reconstruction remained similar over time. The failure rates and/or conversion to THA appear to have decreased over time. Long-term follow-up with higher quality studies was not available in the literature based on this review. Level of evidence 2.

Arthroscopic Reconstruction of the Irreparable Acetabular Labrum: A Match-controlled Study

PURPOSE

To report clinical outcomes of arthroscopic labral reconstruction in the hip at minimum 2-year follow-up in comparison to a pair-matched labral repair group.

METHODS

Patients were included in this study if they underwent labral reconstruction during hip arthroscopy and had minimum 2-year follow-up data available. Exclusion criteria were active workers' compensation claims or previous ipsilateral hip surgery or conditions. Reconstruction patients were matched 1:2 to patients that underwent arthroscopic labral repair but otherwise met all inclusion and exclusion criteria. Matching criteria were age within 5 years, sex, body mass index within 5, same capsular treatment, and whether there was chondral damage of Outerbridge grade II or greater. Three patient-reported outcome (PRO) measures and visual analog scale (VAS) for pain were recorded preoperatively and at a minimum of 2 years postoperatively. International Hip Outcome Tool and patient satisfaction were also collected at latest follow-up.

RESULTS

Thirty-four reconstruction patients were matched to 68 repair patients. There were no significant differences in age (P = .941), sex (P > .999), body mass index (P = .935), or any other demographics between groups. A statistically significant increase was seen in PROs for both the reconstruction group (Modified Harris Hip Score, P = .002; Hip Outcome Score - Sports Subscale, P<.001; Non-arthritic Hip Score, P<.001) and the repair group (Modified Harris Hip Score, P<.001; Hip Outcome Score - Sports Subscale, P < .001; Non-arthritic Hip Score, P<.001) at minimum 2-year follow-up. Significant decrease was shown for VAS for both groups (reconstruction VAS, P<.001; repair, P<.001) at minimum 2-year follow-up. There were no significant differences in rates of postoperative complications (P>.999), secondary arthroscopy (P>.999), or conversion to total hip arthroplasty (P = .728) between groups.

CONCLUSIONS

Arthroscopic labral reconstruction is associated with significant improvement in PROs and a low incidence of secondary surgery within 2-year follow-up. Improvements in PROs, VAS, patient satisfaction, and incidence of secondary procedures were comparable to a match control treated with labral repair. Although there were no differences shown in the 2 groups with respect to complication rate, secondary arthroscopy, or conversion to total hip arthroplasty, the study was not powered to compare these outcome parameters. Based on this evidence, either labral repair or reconstruction may be selected depending upon the clinical scenario.

LEVEL OF EVIDENCE

Level III; retrospective comparative study.

Graft choices for acetabular labral reconstruction

The acetabular labrum plays a key role in maintaining hip function and minimizing hip degeneration. Once thought to be a rare pathology, advances in imaging have led to an increase in the number of diagnosed labral tears. While still a relatively new field, labral reconstruction surgery is an option for tears that are irreparable or require revision after primary repair. Various autograft and allograft options exist when considering labral reconstruction. The first labral reconstruction surgery was described using the ligamentum teres capitis, and has since evolved, incorporating more graft sources and reconstructive techniques. The purpose of this review is to assess and describe the different graft sources and technique currently implemented by hip surgeons. Moreover, this review attempts to determine whether a single labral reconstructive graft type is superior to the others. Techniques using the Ligamentum teres capitis autograft, ITB autograft, gracilis autograft, quadriceps tendon autograft, capsular autograft, semitendinosus allograft, indirect head of the rectus femoris autograft, peroneus brevis tendon allograft and Tensor fascia lata allograft were found. Scoring was available on 5 out of the 9 graft types. The advantages and disadvantages of each graft source is described as a comparative tool. No single graft type has shown increased benefit in acetabular labral reconstruction. The lack of uniform outcome measurements hinders comparison of reported outcomes. Surgeons should make an informed decision based on their experience as well as the patient's history and needs when choosing which graft type would be best suited for their patients.

Primary Circumferential Acetabular Labral Reconstruction: Achieving Outcomes Similar to Primary Labral Repair Despite More Challenging Patient Characteristics

BACKGROUND

Treatment of acetabular labral tears with moderate or severe intrasubstance damage or segmental defects remains a substantial challenge. Circumferential labral reconstruction with iliotibial band allograft is a relatively new technique that has been proposed to restore stability and eliminate high-stress junction points.

PURPOSE

To compare outcomes between hips treated with primary allograft circumferential labral reconstruction and primary labral repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All consecutive hips between 2014 and 2015 that underwent primary reconstruction or primary repair by the senior surgeon were included and compared. Hips that had a prior intra-articular procedure were excluded. Patient-reported outcome (PRO) scores and visual analog scales were completed by patients within 1 week before surgery and between 22 and 26 months postoperatively. PROs included the modified Harris Hip Score, the International Hip Outcome Tool, and the 12-Item Short Form Health Survey for physical health. Pain and satisfaction were assessed with visual analog scales. Crude and inverse probability of treatment weighting comparisons of PROs between groups were performed.

RESULTS

A total of 162 hips met the inclusion criteria for this study, including 99 labral repairs and 63 complete labral reconstructions. Patients who underwent labral reconstruction were, on average, older (43.4 vs 29.5 years; P < .01), had a slightly higher body mass index (24.6 vs 23.0; P < .01), had hips with a higher Tönnis grade (grade 1 or 2: 25% vs 9%; P < .01), had higher preoperative pain scores (49.9 vs 41.5; P = .01), and had hips with more severe pathology (68% vs 5%; P < .01) as compared with patients with labral repair hips. Five (5%) labral repair hips and 5 (8%) labral reconstruction hips failed treatment ( P = .48). Among hips that did not fail (n = 94 repairs, n = 58 reconstructions), all demonstrated statistically significant improvements in PROs, and there was no statistical difference in PROs between groups after weighting ( P > .05).

CONCLUSION

Primary circumferential labral reconstruction is a viable treatment option with promising short-term outcomes for hips that demonstrate moderate or severe labral damage. Despite less favorable preoperative characteristics, labral reconstruction offers similar outcomes when compared with labral repair in hips with less severe pathology.

Arthroscopic acetabular labral reconstruction with rectus femoris tendon autograft: Our experiences and early results

Background

The native labrum has been shown to play a critical role in the maintenance of overall health of the cartilage of the hip. Disruption of the labral seal could be detrimental to the overall nutrition of the cartilage, leading to its premature degeneration.

Purpose

This study sought to investigate patients undergoing labral reconstruction with indirect head of rectus femoris autograft, to determine the subjective improvement in pain they experienced, the complications and reoperation rates including conversion to Total hip replacement(THR).

Method

We retrospectively reviewed all 7 patients who underwent labral reconstruction using indirect head of the rectus femoris tendon autograft between January 2013 to October 2015. We assessed improvement in pain and function, complications, and subsequent surgery. The minimum follow-up was 12 months (average, 15 months; range, 12-18 months).

Results

All patients reported subjective improvement in preoperative pain and function. The mean modified Harris Hip Score (mHHS) improved significantly from 56 (54-60) preoperatively to 93 (90-97)) at mean latest follow-up. The mean change of mHHS was 36 (30-43) and mean postoperative patient satisfaction score was 9.1. We observed no radiological progression of arthritis as well as no patient had revision procedure including total hip replacement.

Conclusion

Acetabular labrum reconstruction for irreparable labral tears in young patients with no significant arthritis, using indirect head of the rectus femoris tendon autograft is a new technique that shows improvement in pain and function post-operatively. Long-term follow-up results with higher quality studies will be necessary to further define the role of labral reconstruction in hip preservation surgery.

Labral debridement, repair and reconstruction: current concepts

Proper treatment of labral pathology is under debate. The treatments currently available to hip surgeons are: conservative treatment, labral debridement, repair and reconstruction while concomitantly addressing bony dysmorphisms. The data available to assist surgeons to make the correct treatment decisions are inconclusive. In this current concepts review, the technical aspects and currently available literature to assist in the decision-making process with these treatment modalities are reviewed. The exact indications for each procedure are still up for debate and ongoing research will better define the ideal patients for each procedure. The purpose of this narrative review was to discuss the current research on debridement, repair and reconstruction as well as the techniques that are currently reported in the literature.

Prevalence and Consistency in Surgical Outcome Reporting for Femoroacetabular Impingement Syndrome: A Scoping Review

PURPOSE

The purposes of this review were (1) to collate and synthesize research studies reporting any outcome measure on both open and arthroscopic surgical treatment of femoroacetabular impingement (FAI) syndrome and (2) to report the prevalence and consistency of outcomes across the included studies.

METHODS

A computer-assisted literature search of the MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Embase databases was conducted using keywords related to FAI syndrome and both open and arthroscopic surgical outcomes, resulting in 2,614 studies, with 163 studies involving 14,824 subjects meeting the inclusion criteria. Two authors independently reviewed study inclusion and data extraction with independent verification. The prevalence of reported outcomes was calculated and verified by separate authors.

RESULTS

Between 2004 and 2016, there has been a 2,600% increase in the publication of surgical outcome studies. Patients had a mean duration of symptoms of 27.7 ± 21.5 months before surgery. Arthroscopy was the surgical treatment used in 71% of studies. The mean final follow-up period after surgery was 32.2 ± 17.3 months. Follow-up time frames were reported in 78% of studies. Ten different patient-reported outcome measures were reported. The alpha angle was reported to be measured 42% less frequently as a surgical outcome than as a surgical indication. Surgical complications were addressed in only 53% of studies and failures in 69%. Labral pathology (91% of studies reporting) and chondral pathology (61%) were the primary coexisting pathologies reported. Clinical signs, as defined by the Warwick Agreement on FAI syndrome, were reported in fewer than 25% of studies.

CONCLUSIONS

Most FAI syndrome patients have longstanding pain and potential coexisting pathology. Patient-reported outcome measures and diagnostic imaging are the most frequently reported outcomes. Measures of hip strength and range of motion are under-reported. It is unclear whether the inconsistency in reporting is because of lack of measurement or lack of reporting of specific outcomes in these studies. Current surgical outcomes are limited to mid-term surgical follow-up time frames and inconsistent outcome reporting.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through IV studies.

Arthroscopic Reconstruction of Segmental Defects of the Hip Labrum: Results in 22 Patients With Mean 2-Year Follow-Up

PURPOSE

To report mean 2-year patient-reported outcomes (PROs) and the incidence of revision hip arthroscopy or conversion to total hip arthroplasty (THA) in patients who had undergone arthroscopic reconstruction of the hip labrum for segmental defects.

METHODS

Data were prospectively collected and retrospectively reviewed on all patients who had undergone hip arthroscopy from April 2008 to April 2013. All patients who underwent arthroscopic labral reconstruction with either a semitendinosus allograft or a gracilis autograft with mean 2-year follow-up were part of the inclusion criteria. The following outcomes were recorded: modified Harris hip score, nonarthritic athletic hip score, hip outcome score-sports-specific subscale, hip outcome score-activities of daily living subscale, visual analog scale, for pain, patient satisfaction, revision hip arthroscopies, and conversion to THA. A 2-tailed Student's t-test was used to assess for statistically significant differences between the mean of preoperative and postoperative PROs. P values less than .05 were considered statistically significant.

RESULTS

A total of 22 patients (14 females, 8 males) met the inclusion criteria. There was 100% follow-up. The mean age of the study population was 32.2 years. Twelve patients had reconstruction as part of a revision procedure and 10 patients had a reconstruction at the time of primary arthroscopy. Concomitant arthroscopic procedures included acetabuloplasty and femoroplasty. There was statistically significant improvement in all PROs (P = .013 to < .001). The mean changes for the modified Harris hip score, nonarthritic athletic hip score, hip outcome score-sports-specific subscale, and hip outcome score-activities of daily living subscale were 11.0 ± 19.5, 22.2 ± 15.0, 23.1 ± 30.9, and 19.1 ± 17.5 points, respectively. The mean improvement in the visual analog scale was 3.33 ± 2.92 points (P < .001), and the mean patient satisfaction was 6.73 out of 10 points. One patient required conversion to THA for presumed progression of osteoarthritis and 2 patients required a revision procedure for adhesions.

CONCLUSIONS

This arthroscopic technique for labral reconstruction was associated with a significant improvement in PROs and function. Conversion to THA with the procedure was 4.5%.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Acetabular Labral Debridement/Segmental Resection Versus Reconstruction in the Comprehensive Treatment of Symptomatic Femoroacetabular Impingement: A Systematic Review

PURPOSE

To perform a systematic review comparing outcomes of labral debridement/segmental resection with labral reconstruction as part of a comprehensive treatment strategy for femoroacetabular impingement.

METHODS

A systematic review was conducted according to established PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines using defined inclusion and exclusion criteria. The study groups were divided into labral debridement/segmental resection (group 1) and labral reconstruction (group 2). Multiple search engines were queried (PubMed, Medline) for this analysis.

RESULTS

After an exhaustive search of the available literature, 20 publications were included. Twelve studies explored outcomes after labral debridement/resection in a total of 400 hips, whereas 7 studies reported on outcomes after labral reconstruction in a total of 275 hips. One additional matched-pair control study compared labral resection (22 hips) with reconstruction (11 hips). The surgical intervention was a revision in 0% to 100% for group 1 versus 5% to 55% for group 2. A direct anterior approach was not performed in group 2, and cam-type impingement appeared to make up a larger percentage of group 1. The Tönnis grade ranged from 0 to 1 for group 1 versus 0.3 to 1.1 for group 2. Joint replacements were performed in 0% to 30% and 0% to 25%, respectively. The modified Harris Hip Score was the most widely used patient-reported outcome measure and suggested that labral reconstruction was not inferior to labral debridement/segmental resection.

CONCLUSIONS

Clinical outcomes after labral debridement/segmental resection versus labral reconstruction were found to be comparable. In the setting of unsalvageable labral pathology, labral reconstruction was used more frequently as a revision option whereas debridement may be more commonly used in the index setting.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I, III, and IV studies.

Arthroscopic Technique for Acetabular Labral Reconstruction Using Iliotibial Band Autograft

The dynamic function of the acetabular labrum makes it an important structure for both hip stability and motion. Because of this, injuries to the labrum can cause significant dysfunction, leading to altered hip kinematics. Labral repair is the gold standard for symptomatic labral tears to keep as much labral tissue as possible; however, in cases where the labrum has been injured to such a degree that it is either deficient or repair is not possible, arthroscopic labral reconstruction is preferred. This article describes our preferred approach for reconstruction of the acetabular labrum using iliotibial band autograft.

The acetabular labrum

The acetabular labrum is a soft-tissue structure which lines the acetabular rim of the hip joint. Its role in hip joint biomechanics and joint health has been of particular interest over the past decade. In normal hip joint biomechanics, the labrum is crucial in retaining a layer of pressurised intra-articular fluid for joint lubrication and load support/distribution. Its seal around the femoral head is further regarded as a contributing to hip stability through its suction effect. The labrum itself is also important in increasing contact area thereby reducing contact stress. Given the labrum’s role in normal hip joint biomechanics, surgical techniques for managing labral damage are continuously evolving as our understanding of its anatomy and function continue to progress. The current paper aims to review the anatomy and biomechanical function of the labrum and how they are affected by differing surgical techniques.

Take home message: The acetabular labrum plays a critical role in hip function and maintaining and restoring its function during surgical intervention remain an essential goal.

Cite this article: Bone Joint J 2016;98-B:730–5.

Open Surgical Treatment for Femoroacetabular Impingement in Patients over Thirty Years: Two Years Follow-up Results

Purpose

We report short term results of open surgical treatment for symptomatic femoroacetabular impingement (FAI) in patients over the age of 30 years.

Materials and Methods

Between May 2011 and June 2012, thirteen FAI hips (11 patients) with hip pain persisting longer than 6 months were treated by either surgical hip dislocation (SHD) or anterior mini-open. They were followed up for longer than 2 years. The 11 patients included 7 females and 4 males with a mean age of 45 (range, 33-60) years. They were clinically evaluated for modified Harris hip score (MHHS) and University of California at Los Angeles (UCLA) activity level. Their lateral center-edge angle, acetabular index, and alpha angle were measured and compared.

Results

Acetabuloplasties were performed for seven cases. Femoral osteochondroplasty was performed for all thirteen cases. At minimum follow-up of two year (range, 24-29 months), all patients had substantial relief in preoperative pain with improvement in range of motion. The median MHHS was significantly (P<0.05) improved from 61 points preoperatively to 87 points at the last follow-up. The median UCLA activity level was 7 (range, 5-8) at last follow-up. Radiological indices improved. Two cases showed mild residual pain attributable to adhesion between capsule and reshaped femoral head-neck area.

Conclusion

Open surgical treatment of FAI was a reliable and effective treatment method in symptomatic FAIs for patients over the age of 30 years without advanced arthritic change of hip joint at short term follow-up.

Arthroscopic Hip Labral Reconstruction and Augmentation Using Knotless Anchors

Biomechanical stability is the primary function of the acetabular labrum. It provides a hip suction seal and optimal joint function. Labral tears are a common reason for hip arthroscopy, to improve patient function and to prevent long-term degenerative arthropathy. Arthroscopic labral repair has shown significantly better outcomes in return to premorbid activity levels when compared with labral debridement. Injury to the acetabular labrum is a challenge and can lead to long-term complications. In this scenario, arthroscopic labral reconstruction has shown good results regarding patient subjective and objective outcomes. We describe a technique for complete arthroscopic labral reconstruction using tensor fascia lata allograft.

Clinical and radiographical results of labral reconstruction

Treatment of femoroacetabular impingement (FAI) includes correction of underlying bony deformities. Labrum preservation is recommended whenever possible. In hips, where the labrum is missing or damaged beyond preservation, labral reconstruction is an option to restore labral seal. Between 2008 and 2011, 84 hips underwent treatment for FAI by means of a surgical hip dislocation. In 13 of these hips (11 patients), the severely damaged or missing labrum was reconstructed with ligamentum capitis femoris. Pre- and postoperative radiographic and clinical data were analysed with a mean follow-up of 38 months (range: 19–65 months). Clinical outcome was determined with Oxford hip score (OHS) and overall satisfaction, rest and load pain with a visual analogue scale (VAS; 0–100). Clinical outcome was compared with a control group where labral refixation was performed. Mean OHS improved significantly (P ≤ 0.001) from 29 (SD 8) to 44 (SD 4). Overall satisfaction with the hip increased significantly (P = 0.002) from 44 (SD 35) to 87 (SD 15). Mean VAS for rest pain decreased significantly (P = 0.0004) from 45 (SD 35) to 5 (SD 7) as well as for load pain (P = 0.0007) from 59 (SD 26) to 16 (SD 19). There were no significant differences between the two groups. Reconstruction of the acetabular labrum with ligamentum capitis femoris yields good clinical results. Technical superiority of open labral reconstruction may explain the unexpected, excellent outcome.

Management of Labral and Chondral Disease in Hip Preservation Surgery

The techniques utilized for the management of articular cartilage and labrum injuries during hip preservation surgery have changed dramatically recently. Conservative treatment may involve image-guided injection of cortisone or viscosupplementation in conjunction with oral NSAIDs and physical therapy. Damage to the labrum runs a broad spectrum, and the treatments are individualized, but span from debridement to repair and reconstruction. The overarching goal of labral treatment is to restore the native functions of the labrum to allow for more normal biomechanical function. Similarly, cartilage injuries can be managed a number of different ways, including with debridement, microfracture or drilling, cartilage transplants, and higher level restorative techniques. These cartilage restoration techniques have evolved rapidly as well, and may include the use of scaffolds, allograft cartilage cells, and other stem-cell-related procedures.

The Horsens-Aarhus Femoro Acetabular Impingement (HAFAI) cohort: outcome of arthroscopic treatment for femoroacetabular impingement. Protocol for a prospective cohort study

INTRODUCTION

During the past decade, it has become increasingly more common to offer hip arthroscopic surgery when treating people with femoroacetabular impingement (FAI). Nevertheless, the latest reviews conclude that it still remains to be properly investigated how surgery affects the patients. Specifically, detailed information on the functional, muscular and mechanical impact of surgery in larger groups is lacking. Furthermore, the long-term outcome of the surgery is still to be investigated.

METHODS AND ANALYSIS

In this prospective cohort study, a total of 60 patients with FAI scheduled for arthroscopic surgery will be followed and tested preoperatively, and again after 3, 6, 9 and 12 months. Assessment includes isokinetic dynamometry evaluating hip flexion and extension; evaluation of functional capacity in a three-dimensional motion laboratory; pain assessment; self-reported function, quality of life, expectation and satisfaction with the surgery; recording of previous and present sporting activities and accelerometry. In addition, data on surgical procedure, rehabilitation progress, adverse events and failure will be recorded. Patients will be compared with an age-matched and gender-matched reference group of 30 persons with no hip, knee, ankle or back problems. Long-term follow-up of this cohort may evaluate possible reoperations and development of hip osteoarthritis. Furthermore, analysis on how subgroups respond to the treatment could be performed together with identification of possible "non-responders".

ETHICS AND DISSEMINATION

The study is approved by the Central Denmark Region Committee on Biomedical Research Ethics (Journal No 1-10-72-239-14). The results from this study will be presented at national and international congresses and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT02306525.

The Hyperflexible Hip: Managing Hip Pain in the Dancer and Gymnast

Context:

Dance, gymnastics, figure skating, and competitive cheerleading require a high degree of hip range of motion. Athletes who participate in these sports use their hips in a mechanically complex manner.

Evidence Acquisition:

A search of the entire PubMed database (through December 2013) and additional searches of the reference lists of pertinent articles.

Study Design:

Systematic review.

Level of Evidence:

Level 3.

Results:

Whether innate or acquired, dancers and gymnasts have some hypermobility that allows their hips to be placed in potentially impinging or unstable positions required for their given activity. Such extremes of motion can result in both intra-articular and extra-articular impingement as well as compensatory osseous and muscular pathology. In addition, dancers and gymnasts are susceptible to impingement-induced instability. Dancers with innate generalized hyperlaxity are at increased risk of injury because of their activities and may require longer recovery times to return to play. Both nonoperative and operative treatments (arthroscopic and open) have an important role in returning flexibility athletes to their preoperative levels of sport and dance.

Conclusion:

Because of the extreme hip motion required and the compensatory soft tissue laxity in dancers and gymnasts, these athletes may develop instability, impingement, or combinations of both. This frequently occurs in the setting of subtle pathoanatomy or in patients with normal bony anatomy. With appropriate surgical indications and the correct operative technique, the treating surgeon can anticipate high levels of return to play for the gymnast and dancer with hip pain.

Labral Reconstruction: When to Perform and How

Over the past decade, the understanding of the anatomy and function of the hip joint has continuously evolved, and surgical treatment options for the hip have significantly progressed. Originally, surgical treatment of the hip primarily involved resection of damaged tissue. Procedures that maintain and preserve proper hip anatomy, such as labral repair and femoroacetabular impingement correction, have shown superior results, in terms of pain reduction, increased function, and ability to return to activities. Labral reconstruction is a treatment option that uses a graft to reconstruct the native labrum. The technique and outcomes of labral reconstruction have been described relatively recently, and labral reconstruction is a cutting edge procedure that has shown promising early outcomes. The aim of this article is to review the current literature on hip labral reconstruction. We will review the indications for labral reconstruction, surgical technique and graft options, and surgical outcomes that have been described to date. Labral reconstruction provides an alternative treatment option for challenging intra-articular hip problems. Labral reconstruction restores the original anatomy of the hip and has the potential to preserve the longevity of the hip joint. This technique is an important tool in the orthopedic surgeon’s arsenal for hip joint treatment and preservation.

Reporting of non-hip score outcomes following femoroacetabular impingement surgery: a systematic review

This systematic review was designed to evaluate the reporting of non-hip score outcomes following surgical management of femoroacetabular impingement (FAI). MEDLINE, EMBASE and PubMed were searched and screened in duplicate for studies involving non-hip score outcomes following the surgical management of FAI. A full-text review of eligible studies was conducted and references were searched using pre-determined inclusion and exclusion criteria. Thirty-three studies involving 3198 patients were included in this review. The most common non-hip score outcomes reported included: patient satisfaction (72.7%), symptom improvement (24.7%), pain improvement (12.4%), hip range of motion (12.3%) and return to sport (6.8%). The most frequently reported standardized hip outcome scores used were the modified Harris Hip Score (mHHS) (41.2%), Non-Arthritic Hip Score (NAHS) (29.4%), Hip Outcome Score—Activities of Daily Living (HOS-ADL) (26.5%), the Western Ontario McMaster Universities Index of Osteoarthritis (WOMAC) (17.6%), the HOS Sport-Specific Subscale (SSS) (17.6%). The most commonly reported non-hip score outcomes are patient satisfaction, symptom improvement and pain improvement. Patients report high levels of satisfaction when surveyed post-operatively. A discrepancy exists between what outcomes the literature suggests should be reported and what outcomes are actually reported. Return to sport is often held as a major patient-important outcome yet it is seldom reported in studies assessing the efficacy of FAI surgery. Second, despite emerging evidence that outcome measures such as the HOS or IHOT evaluate the FAI patient population precisely, other standardized hip score outcomes (mHHS and NAHS) are still more commonly reported.

Arthroscopic surgery for global versus focal pincer femoroacetabular impingement: are the outcomes different?

To determine outcomes from arthroscopic surgery for global pincer femoroacetabular impingement (FAI), a large multicenter prospective study investigating arthroscopic surgical outcomes was performed with minimum 2-year follow-up. Global (center-edge angle 40+ degrees) and Focal (center-edge angle 25-39 degrees) cohorts were based on pre-operative radiographs. Pre-operative and intra-operative findings, surgical procedures, post-operative nonarthritic hip score (NAHS) and satisfaction (5-point Likert scale), complications and conversion arthroplasties were compared. A nested case-control study was also performed. The Global cohort consisted of 15 patients (18 hips) of mean age 37.2 years. Pre-operative NAHS was 51.5 and 74.1 at 24+ months post-surgery. The change in NAHS was significant (P = 0.01). Mean satisfaction was 4.2. There was one total hip arthroplasty (THA) conversion (5.6%), no revision surgeries or complications. The Focal cohort consisted of 125 patients (129 hips) of mean age 39.8 years. Pre-operative NAHS was 54.8 and 77.8 at 24+ months post-surgery. The change in NAHS was significant (P < 0.0001). Mean satisfaction was 4.2. There were eight THA conversions (6.2%), three complications (2.3%) and two revision surgeries (1.5%). Cohort comparisons revealed no statistically significant difference in NAHS (P = 0.30), satisfaction (P = 0.92) or THA conversion rate (P = 0.91). The nested case-control study found mean post-operative change in NAHS was +22.2 and +20.4, respectively, at 24+ months (P = 0.76). Arthroscopic treatment of global pincer FAI is a safe and effective procedure. With outcomes comparable to those observed in the arthroscopic treatment of lesser focal deformities, arthroscopic surgery provides a less invasive option for the treatment of global pincer FAI.

The lesser trochanter as a cause of hip impingement: pathophysiology and treatment options

Impingement of the lesser trochanter on the ischium or the posterior acetabular rim is not a frequent pathology, but has recently received increased recognition. We have seen 14 cases over a period of 14 years, but concentrate on eight hips showing complex deformities revealing similar characteristics. All eight hips had a residual Perthes or a Perthes-like disease with an elliptically deformed femoral head, but a congurent joint a short or absent femoral neck, a high riding greater trochanter, and a reduced vertical distance between the head and the lesser trochanter. Impingement took place between the lesser trochanter and the ischium or the posteroinferior acetabular border, but was hardly recognisable due to the predominant intraarticular impingement of the nonspherical femoral head and the extraarticular impingement of the greater trochanter. In three cases the impingement showed reproducible subluxation of the hip. While in our hips, excision was the preferred treatment for impingement due to an oversized lesser trochanter, distal advancement was used in the hips with the Perthes morphology; the surgical time was not longer. The overall clinical results in this group however were dominated by a substantial increase in the range of motion (ROM), dependent mainly on the achieved contour of the femoral head and the relative lengthening of the neck. Strength of active hip flexion was normal. Recurrent subluxation disappeared and no complications were recorded.

The hip labrum reconstruction: indications and outcomes--a systematic review

PURPOSE

With further understanding of the function and the importance of the hip labrum, greater attention has been paid to preserve and repair the damaged labrum. Hip labrum reconstruction has been described to optimize hip preservation when the labrum is deficient. This systematic review aimed to explore and identify the reported indications and outcomes in patients who undergo labral reconstruction of the hip joint.

METHODS

The electronic databases EMBASE, MEDLINE, and PubMed were searched for all available dates up to July 2013. Further hand search of the reference sections of the included studies was done. Two reviewers searched, screened, and evaluated the included studies for data quality using the Methodological Index for Non-Randomized Studies (MINORS) Scale. Data were also abstracted in duplicate, and agreement and descriptive statistics are presented.

RESULTS

There were 5 eligible studies (3 case series, 1 prospective cohort, and 1 retrospective chart review) with a total of 128 patients, and an average 11/16 quality on the MINORS score included in this review. All patients were diagnosed with femoroacetabular impingement and underwent labral reconstruction. Ninety-four patients were assessed at follow-up (73.4 % survivorship) between a reported mean range of 10 and 49 months. There was variability between the studies with regard to the graft types utilized (ilio-tibial band, Gracilis tendon, Ligamentum teres), surgical approaches [open (18.7 %) vs. arthroscopic (81.3 %)], and the reported outcome measures. Overall, improvement was observed in the patient-reported outcomes and functional scores (mHHS, HOS, UCLA, NASH, and SF-12). The failure rate or conversion to THA rate in all available patients was 20 %. The most common indication for labrum reconstruction was a young, active patient with minimal arthritis and non-salvageable or deficient labrum. Other indications included instability, pain, and hypotrophic dysfunctional labrum.

CONCLUSION

Based on the current available evidence, hip labrum reconstruction is a new technique that shows short-term improvement in patient-reported outcomes and functional scores post-operatively. The main indication for reconstruction was a deficient labrum due to previous surgical excision or irreparable tears in young patients with no significant arthritis. Long-term follow-up results with higher quality studies are still lacking based on this review.

What's New in Femoroacetabular Impingement Surgery: Will We Be Better in 2023?

Context:

Femoroacetabular impingement (FAI) has been described as a common cause of hip pain in young adults. This leads to abnormal hip joint mechanics and contact pressures. The associated pathomechanics can lead to the development of early osteoarthritis. Better understanding of the anatomy and pathophysiology, biomechanics, and diagnostic and therapeutic advances has led to improved clinical outcomes. A growing body of evidence has set the foundation for future progress in the treatment of this commonly encountered condition.

Evidence Acquisition:

The PubMed database was searched for English-language articles pertaining to FAI over the past 15 years (1998-2013).

Study Design:

Retrospective literature review.

Level of Evidence:

Level 4.

Results:

The authors evaluated and discussed the current evidence regarding the anatomy, physiology, biomechanics, imaging, and clinical outcomes of surgical intervention for FAI. Based on this information, future directions for improving the diagnosis and management of FAI are proposed.

Conclusion:

There remains a diverse approach to the diagnosis and management of cam- and/or pincer-type FAI. Recent advances in clinical diagnosis, imaging, indications, and arthroscopic techniques have led to improved outcomes and have set the foundation for future progress in the management of this condition.

Strength of Recommendation Taxonomy (SORT):

B

Arthroscopic labralization of the hip: an alternative to labral reconstruction

Labralization, which may be performed by open or arthroscopic means, may be an attractive alternative to hip labral reconstruction. By preserving the articular cartilage in the region of labral deficit with meticulous rim trimming, the resultant undermined free chondral margin ("pseudolabrum") may immediately restore a fluid seal function and may theoretically enhance hip preservation. Arthroscopic hip labralization is a relatively simple and fast procedure without graft harvest morbidity. It may be performed in patients tolerating rim reduction with encouraging preliminary outcomes.

Arthroscopic labral reconstruction is superior to segmental resection for irreparable labral tears in the hip: a matched-pair controlled study with minimum 2-year follow-up

BACKGROUND

The acetabular labrum is an important structure that plays a significant role in proper biomechanical function of the hip joint. When the labrum is significantly deficient, arthroscopic reconstruction could provide a potential solution for the nonfunctional labrum.

PURPOSE

To compare the clinical outcomes of arthroscopic labral reconstruction (RECON) with those of arthroscopic segmental labral resection (RESEC) in patients with femoroacetabular impingement (FAI) of the hip.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between April 2010 and March 2011, all prospectively gathered data for patients with FAI who underwent arthroscopic acetabular labral reconstruction or segmental resection with a minimum 2-year follow-up were reviewed. Eleven cases in the RECON group were matched to 22 cases in the RESEC group according to the preoperative Non-Arthritic Hip Score (NAHS) and sex. The patient-reported outcome scores (PROs) used included the NAHS, the Hip Outcome Score (HOS), and the modified Harris Hip Score (mHHS). Statistical analyses were performed to compare the change in PROs in both groups.

RESULTS

There was no statistically significant difference between groups regarding the preoperative NAHS (P = .697), any of the other preoperative PROs, or demographic and radiographic data. The mean change in the NAHS was 24.8 ± 16.0 in the RECON group and 12.5 ± 16.0 in the RESEC group. The mean change in the HOS-activities of daily living (HOS-ADL) was 21.7 ± 16.5 in the RECON group and 9.5 ± 15.5 in the RESEC group. Comparison of the amount of change between groups showed greater improvement in the NAHS and HOS-ADL for the RECON group (P = .046 and .045, respectively). There was no statistically significant difference in the mean changes in the rest of the PROs, although there were trends in all in favor of the RECON group. All PROs in both groups showed a statistically significant improvement at follow-up compared with preoperative levels.

CONCLUSION

Arthroscopic labral reconstruction is an effective and safe procedure that provides good short-term clinical outcomes in hips with insufficient and nonfunctional labra in the setting of FAI.

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.

Management of labral tears of the hip in young patients

Our understanding of labral tears in young patients has evolved significantly in recent years. Successful outcome depends on addressing all bony impingement to improve the intra-articular environment, and prevent further damage to the labrum and articular cartilage. Improved clinical outcomes are associated with labral repair; in cases of a deficient labrum, arthroscopic reconstruction techniques have been developed, with promising clinical outcomes. This article reviews the anatomy of the acetabular labrum, and discusses the pathogenesis of labral tears as well as various treatment options, including arthroscopic labral repair and reconstruction.

Treatment of femoroacetabular impingement: a systematic review

The purpose of this review is to determine if there is a difference in outcomes after: (1) nonsurgical vs surgical treatment of FAI; (2a) surgical dislocation with greater trochanteric osteotomy, (2b) anterior mini-open, (2c) arthroscopic plus mini-open, and (2d) arthroscopic surgery for FAI; (3) difference in complication and re-operation rates; and (4a) labral refixation and (4b) labral debridement for labral injuries. A systematic review of multiple databases was performed after PROSPERO registration and using PRISMA guidelines. Level I-IV evidence clinical studies with minimum 2-year follow-up were included. Data were compared using 2-sample and 2-proportion Z-test calculators. Study methodological quality was analyzed using Modified Coleman Methodology Score (MCMS). Recommendations were made using SORT (Strength Of Recommendation Taxonomy). Twenty-nine studies were included (2369 subjects; 2507 hips). MCMS was poor. Mean subject age was 34.4+/-8.4 years and mean follow-up was 3.1+/-0.9 years. Statistically significant differences were observed following both nonsurgical and surgical treatment, with greater (P < 0.05) improvements following surgery (SORT B), without consistent significant differences observed between different surgical techniques (SORT C). There was a greater (P < 0.05) reoperation and complication rate following surgical dislocation vs mini-open and arthroscopic techniques (SORT A). Clinical outcomes were significantly better (P < 0.05) following labral refixation vs debridement (SORT B). Outcomes of operative treatment of femoroacetabular impingement are significantly better than nonsurgical management. Surgical treatment significantly improves outcomes, with no consistent significant differences exhibited between open and arthroscopic techniques. Open surgical dislocation has significantly greater reoperation and complication rates vs mini-open and arthroscopic techniques. Outcomes of labral refixation are significantly better than debridement in patients with labral injuries.

Acetabular labral reconstruction with an iliotibial band autograft: outcome and survivorship analysis at minimum 3-year follow-up

BACKGROUND

Injury to the acetabular labrum results from multiple causes including femoroacetabular impingement, dysplasia, and acute trauma. The patient's labrum can be reconstructed utilizing an iliotibial band autograft that is tubularized and fixed to the acetabular rim, substituting for the patient's own labrum. Purpose/

HYPOTHESIS

The purpose of this study was to evaluate the midterm results of this technique with a follow-up from 3 to 6 years after reconstruction. The hypothesis was that midterm results would show excellent patient-reported outcomes and high patient satisfaction with outcome.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective review of a prospectively collected registry was undertaken that identified 75 patients (76 hips) who underwent arthroscopic labral reconstruction using an iliotibial band autograft by a single surgeon from February 2005 to August 2008. Modified Harris Hip Score (mHHS), Hip Outcome Score (HOS), and patient satisfaction level (on a scale of 1-10) were recorded preoperatively and postoperatively annually. Survivorship analysis curves were created to evaluate the effectiveness of this technique.

RESULTS

Among 76 hips, 19 progressed to total hip arthroplasty at an average of 28 months from the procedure. Mean survivor time (no arthroplasty) was 59.1 months (95% CI, 53.9-64.4). Follow-up on the surviving hips was available for 49 patients (86%) with a mean follow-up time of 49 months (range, 36-70 months). The mHHS significantly increased from a preoperative mean of 58.9 to the most recent follow-up score averaging 83 (P = .0001); HOS values in the sports and the activities of daily living subscales also increased significantly (P = .0001 and P = .001, respectively). Median patient satisfaction with outcome was 8. A joint space of ≤2 mm was found to be a poor prognostic factor for survival of the hip.

CONCLUSION

Arthroscopic labral reconstruction using an iliotibial band autograft resulted in a survivorship of 56 months. Of the 76% of patients who did not require total hip arthroplasty, improvement in function and high satisfaction with outcome were reported. Joint space of ≤2 mm is a contraindication for acetabular labral reconstruction.

Nonarthroplasty hip surgery for early osteoarthritis

The most favorable mechanical environment for the hip is one that is free of both instability and impingement, creating a concentric articulation with optimum femoral head coverage by the acetabulum. Anatomic variations such as acetabular dysplasia with associated instability, and femoroacetabular impingement with abnormal constraint, will lead to abnormal joint mechanics, articular damage, and osteoarthritis. Surgical techniques such as periacetabular osteotomies, and femoral and acetabular osteoplasties enable correction of anatomic variations that cause mechanical damage to the hip joint, thereby potentially preventing or delaying development of osteoarthritis and subsequent need for joint replacement.

Use of the quadriceps tendon in arthroscopic acetabular labral reconstruction: potential and benefits as an autograft option

The acetabular labrum serves many integral functions within the hip joint. As a result, novel surgical techniques that aim to preserve or reconstruct the labrum have entered the spotlight. We have performed labral reconstruction using the quadriceps tendon as an autograft for a patient with a moderate labral defect. The purpose of this report is to propose this novel donor site as a viable alternative for labral reconstruction using an autograft; the potential benefits over currently popular methods are discussed.

Arthroscopic hip labral reconstruction with a gracilis autograft versus labral refixation: 2-year minimum outcomes

BACKGROUND

There is high interest but very little evidence to support labral reconstruction of the hip. Purpose/

HYPOTHESIS

The purpose of this study was to determine the clinical effectiveness of arthroscopic hip labral reconstruction using gracilis autograft in the multistep surgeries for femoroacetabular impingement (FAI). The hypothesis was that patients undergoing arthroscopic hip labral reconstruction with gracilis autograft would have improvement in symptoms and function attributable to this procedure.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A comparative retrospective review at a large medical facility was performed of patients who underwent labral reconstruction with a gracilis autograft (RECON group) and those who underwent labral refixation (REFIX group) between October 2008 and November 2009. Inclusion criteria were adult patients having undergone arthroscopic surgery for symptomatic cam-pincer FAI without advanced radiographic osteoarthritis, who had both acetabular and femoral osteoplasties with a minimum 2-year follow-up. Patient satisfaction and preoperative and postoperative nonarthritic hip scores (NAHS) were obtained. Predictive modeling, linear regression, and a nested case-control study were performed.

RESULTS

A total of 54 patients met the inclusion criteria. The RECON group (n = 8; mean age, 34.6 years; range, 18-58 years) with an average 30-month follow-up (range, 24-37 months) and 100% participation reported a high level of patient satisfaction (7 high, 1 moderate). The mean NAHS improved by 50.5 points (P = .008) in the RECON group and 22.5 points (P < .0001) in the REFIX group; however, the preoperative NAHS was lower (P < .05) in the RECON group than in the REFIX group. Only the surgery group (RECON vs REFIX) and the preoperative NAHS were significantly associated with the NAHS at follow-up. The predictive model and linear regression revealed a 15.0- and 14.6-point increase, respectively, in the postoperative NAHS in the RECON group compared with the REFIX group. There were no major complications, revision surgeries, or conversion arthroplasties after labral reconstruction.

CONCLUSION

Arthroscopic hip labral reconstruction with gracilis tendon autograft is a safe and effective procedure. Patients undergoing labral reconstruction may not necessarily have outcomes inferior to those of patients undergoing labral refixation despite more severe initial labral insufficiency.