Evidence and Approach for Management of Labral Deficiency: The Role for Labral Reconstruction

The revision hip arthroscopy complex: capsular deficiency, labral deficiency, femoral over-resection and adhesions can result in good survivorship with revision hip arthroscopy

To evaluate the patient-reported outcomes (PROs) and survivorship of combined arthroscopic hip labral reconstruction/augmentation, capsular reconstruction, femoral neck remplissage and lysis of adhesions. Patients ≥18 years old who underwent this combination of procedures during revision hip arthroscopy and were eligible for minimum 2-year follow-up were identified. PRO scores including Hip Outcome Score (HOS)-Activities of Daily Living scale, HOS-Sports scale, modified Harris Hip Score, Short Form 12, and Western Ontario & McMaster Universities Osteoarthritis Index, patient satisfaction and failure rates were analyzed. Seven patients (5 females and 2 males) with average age of 45.0 ± 5.2 (range: 40-54 years) met inclusion criteria. Patients had a median of 1 (range: 1-3) prior hip surgery at an outside institution. All patients had previously undergone femoral osteoplasty, and 85% (6/7) of patients had a labral repair performed. Four patients had no capsule closure performed in their prior procedures. Six patients were available for minimum 2-year follow-up. Two patients converted to total hip arthroplasty: one patient with four prior hip arthroscopies and the other had advanced osteoarthritis with outerbridge grade 3/4 defects requiring microfracture. Mean patient satisfaction was 7 (range: 2-9). At mean follow-up of 3 years, most patients who underwent the combination of labral reconstruction, capsular reconstruction, femoral neck remplissage and lysis of adhesions during revision hip arthroscopy demonstrated improved PROs. This salvage procedure has the potential to restore hip function in patients who have failed an initial hip arthroscopy procedure. In patients with these pathologies present and concomitant joint space narrowing, a total hip arthroplasty may be a more appropriate salvage option.

Midterm Outcomes After Hip Labral Augmentation in Revision Hip Arthroscopy

BACKGROUND

Labral augmentation has emerged as an essential procedure to address a deficient or irreparable labrum while preserving native labral tissue and restoring the hip suction seal mechanism.

PURPOSE

To evaluate midterm outcomes of arthroscopic hip labral augmentation for labral insufficiency after previous hip arthroscopy.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients were identified from a prospectively collected database who underwent arthroscopic hip labral augmentation between January 2011 and January 2017 with a minimum 3-year follow-up. Pre- and postoperative patient-reported outcome scores were compared and included the 12-Item Short Form Health Survey physical and mental component summaries, Western Ontario and McMaster Universities Osteoarthritis Index, modified Harris Hip Score (mHHS), and Hip Outcome Score (HOS) (Activities of Daily Living [ADL] and Sport). Postoperative Tegner Activity Scale and patient satisfaction (1-10) scores were also evaluated. The minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) between the preoperative and minimum 3-year follow-up scores were calculated.

RESULTS

A total of 88 patients (39 men, 49 women) underwent revision hip arthroscopy with labral augmentation. The average age was 32.8 ± 11 years. Of these, 77 patients (88%) were available for the minimum 3-year follow-up. The survivorship (absence of conversion to total hip arthroplasty) at 3 years and 5 years was 93% at both time points, with a mean survival time of 8.5 years (95% CI, 8.0-8.9). Eleven patients (14%) required revision arthroscopic surgery for continued pain. Revisions occurred at a mean of 2.6 ± 1.4 years after augmentation. The mean follow-up was 5.2 ± 1.2 years (range, 3-9 years). For patients not requiring subsequent surgery (n = 61), all patient-reported outcome measures significantly improved, which included a 20-point increase in HOS-ADL (MCID, 82%; PASS, 72%) and mHHS (MCID, 78%; PASS, 70%). The median postoperative Tegner score was 4 (range, 1-10). The median postoperative patient satisfaction score was 9 out of 10 (range, 1-10).

CONCLUSION

Arthroscopic hip labral augmentation is a successful treatment option for patients with labral insufficiency after previous hip arthroscopy, demonstrating improved patient-reported outcomes and survivorship of 93% at 3 years and 5 years. This technique provides a valuable labral preservation option when addressing hip labral pathology when viable native labral tissue remains.

Hip Labral Reconstruction: Techniques and Outcomes

PURPOSE OF REVIEW

With increased understanding of the biomechanical function of the acetabular labrum, more attention has been directed towards surgical techniques that preserve or restore normal joint anatomy. While labral repair has been shown to produce superior outcomes to labral debridement, repair is not always possible in the setting of severe labral intrasubstance tearing or deficiency. These patients were previously left without suitable arthroscopic treatment options.

RECENT FINDINGS

Labral reconstruction is an emerging procedure that has been shown to offer promising outcomes for traditionally difficult-to-treat hip pathology. Short- and mid-term follow-up studies have consistently demonstrated significant improvement in patient-reported outcomes, function, and patient satisfaction postoperatively, often despite less favorable preoperative characteristics. Labral reconstruction is a viable arthroscopic treatment option that has been shown to reliably produce clinically meaningful results in patients with severe labral pathology that is not amenable to repair/refixation or augmentation.

Return to Sports and Minimum 2-Year Outcomes of Primary Arthroscopic Hip Labral Reconstruction for Irreparable Tears in High-Level Athletes With a Propensity-Matched Benchmarking Against a Labral Repair Control Group

BACKGROUND

Labral reconstruction has shown promise for the treatment of irreparable labral tears in high-level athletes. The literature is scarce regarding outcomes and timing of return to sports (RTS) in these patients.

PURPOSE

(1) To report minimum 2-year patient-reported outcome (PRO) scores and RTS characteristics for high-level athletes undergoing primary labral reconstruction for irreparable labral tears and (2) to compare clinical results with a matched control group of athletes undergoing labral repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed for high school, college, and professional athletes who underwent a primary arthroscopic labral reconstruction between January 2010 and June 2018. Minimum 2-year PROs were compared for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and Hip Outcome Score-Sport Specific Subscale (HOS-SSS), as well as the visual analog scale (VAS) pain score, patient satisfaction, and RTS. The percentages of patients achieving the Patient Acceptable Symptom State (PASS) and minimal clinically important difference (MCID) for the mHHS (PASS, >74 points; MCID, >8 points) and HOS-SSS (PASS, >75 points; MCID, >6 points) were also recorded. These patients were propensity score matched in a 1:3 ratio to other high-level athletes undergoing labral repair.

RESULTS

A total of 17 high-level athletes with primary arthroscopic labral reconstruction were included with a median follow-up time of 37.1 months (95% CI, 37.2-60.3 months). They demonstrated significant improvement from preoperatively to the latest follow-up for mHHS, NAHS, HOS-SSS, and VAS for pain (P < .05). Further, patients achieved PASS/MCID for mHHS at high rates (PASS, 84.2%; MCID, 68.4%). Athletes were able to return to sport-specific training at a median of 3.33 months (95% CI, 3.07-4.71 months) and RTS at a median of 6.2 months (95% CI, 5.08-11.98 months). Fourteen (82.4%) of reconstructions and 29 (82.8%) of repairs either returned to sport or decided not to do so for reasons unrelated to the hip. PROs, RTS rate, and PASS/MCID rates were similar between the labral reconstruction group and a control labral repair group (P > .05).

CONCLUSION

Primary arthroscopic labral reconstruction for irreparable labral tears was associated with significant improvement in PROs and high rates of RTS in high-level athletes. These results were comparable with those of a control group of athletes undergoing labral repair.

Development and Prospect of Intra-Articular Injection in the Treatment of Osteoarthritis: A Review

Osteoarthritis (OA) is a common degenerative disease that affects the vast majority of the elderly and may eventually embark on the road of the total knee arthroplasty (TKA), although controversy still exists in the medical community about the best therapies for osteoarthritis. Compared with physical therapy, oral analgesics and other non-operative treatments, intra-articular injection is more safe and effective. Moreover, intra-articular injection is much less invasive and has fewer adverse reactions than surgical treatment. This article reviews mechanism, benefits and adverse reactions of corticosteroids (CS), hyaluronic acid (HA), platelet-rich plasma (PRP), mesenchymal stem cell (MSCs), stromal vascular fraction (SVF) and other new therapies (for example: gene therapy). The application prospect of intra-articular injection was analyzed according to the recent progress in drug research.

First 100 segmental labral reconstructions compared to the most recent 100: the role of surgeon experience in decreasing conversion to total hip arthroplasty

PURPOSE

The purpose of this study was to determine if conversion to total hip arthroplasty and patient-reported outcomes were similar in the first 100 patients who underwent segmental labral reconstruction with iliotibial band autograft compared to the most recent 100 patients.

METHODS

Patients who underwent hip segmental labral reconstruction with autologous iliotibial band were evaluated preoperatively and postoperatively with a minimum 2-year follow-up. The first consecutive 100 patients (Group 1) and the most recent 100 patients (Group 2) were retrospectively compared. Conversion to total hip arthroplasty, necessity of a revision hip arthroscopy, and patient-reported outcome scores were compared.

RESULTS

Overall follow-up rate (> 2 years) was 94% (Group 1 vs. Group 2, 91% vs. 96%, n.s.). Mean age of Group 1 (37 ± 12) was significantly higher than that of Group 2 (34 ± 12) (p = 0.03). In Group 2, 69 surgeries out of 100 were revision hip arthroscopies, which was significantly higher rate than Group 1 (48/100) (p = 0.003). Group 1 had significantly higher rate of conversion to THA [23% (23/100) vs. 5% (5/100), p = 0.001]. Revision hip arthroscopy was performed in 11/76 (15%) in Group 1 and in 8/95 (9%) in Group 2 (n.s.). Patient-reported outcomes scores were similar between two groups (all n.s.). Higher age and joint space ≤ 2 mm were significant risk factors of total hip arthroplasty conversion.

CONCLUSION

This study showed that, with experience, fewer conversions to total hip arthroplasty were seen; however, revision rate and outcomes were similar.

LEVEL OF EVIDENCE

IV.

Return to Sport and Athletic Function in an Active Population After Primary Arthroscopic Labral Reconstruction of the Hip

Background:

Labral reconstruction has been advocated as an alternative to debridement for the treatment of irreparable labral tears, showing favorable short-term results. However, literature is scarce regarding outcomes and return to sport in the nonelite athletic population.

Purpose:

To report minimum 1-year clinical outcomes and the rate of return to sport in athletic patients who underwent primary hip arthroscopy with labral reconstruction in the setting of femoroacetabular impingement syndrome and irreparable labral tears.

Study Design:

Case series; Level of evidence, 4.

Methods:

Data were prospectively collected and retrospectively analyzed for patients who underwent an arthroscopic labral reconstruction between August 2012 and December 2017. Patients were included if they identified as an athlete (high school, college, recreational, or amateur); had follow-up on the following patient-reported outcomes (PROs): modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score–Sport Specific Subscale (HOS-SSS), and visual analog scale (VAS); and completed a return-to-sport survey at 1 year postoperatively. Patients were excluded if they underwent any previous ipsilateral hip surgery, had dysplasia, or had prior hip conditions. The proportions of patients who achieved the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) for mHHS and HOS-SSS were calculated. Statistical significance was set at P = .05.

Results:

There were 32 (14 females) athletes who underwent primary arthroscopic labral reconstruction during the study period. The mean age and body mass index of the group were 40.3 years (range, 15.5-58.7 years) and 27.9 kg/m² (range, 19.6-40.1 kg/m²), respectively. The mean follow-up was 26.4 months (range, 12-64.2 months). All patients demonstrated significant improvement in mHHS, NAHS, HOS-SSS, and VAS (P < .001) at latest follow-up. Additionally, 84.4% achieved MCID and 81.3% achieved PASS for mHHS, and 87.5% achieved MCID and 75% achieved PASS for HOS-SSS. VAS pain scores decreased from 4.4 to 1.8, and the satisfaction with surgery was 7.9 out of 10. The rate of return to sport was 78%.

Conclusion:

At minimum 1-year follow-up, primary arthroscopic labral reconstruction, in the setting of femoroacetabular impingement syndrome and irreparable labral tears, was associated with significant improvement in PROs in athletic populations. Return to sport within 1 year of surgery was 78%.

Limitations of arthroscopy for managing coxa profunda

Coxa profunda is a complex entity that can result in femoro-acetabular impingement (FAI). A meticulous evaluation of the type of acetabular overcoverage is essential to determine which treatment is best suited to each individual patient. Focal overcoverage with no posterior impingement can be treated by arthroscopic recontouring of the disproportionate acetabular wall. Any femoral deformities should be managed during the same procedure. General overcoverage, with predominant postero-inferior impingement, requires open surgery to obtain access to the entire acetabular rim. Rim resection should be sparing, to avoid removing an excessive proportion of the joint surface, yet sufficient to eliminate the impingement. In the event of protrusio acetabuli, which is the extreme form of coxa profunda, reverse peri-acetabular osteotomy should be considered, particularly if the acetabular roof angle is reversed. In some patients, chiefly those with coxa vara, valgus femoral osteotomy should be considered as a means of redirecting the loads towards the acetabular roof, thereby diminishing the forces that tend to drive the femoral head deeper into the socket.

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.

Acetabular Labral Reconstruction: Development of a Tool to Predict Outcomes

BACKGROUND

Acetabular labral reconstruction has demonstrated good results for labral lesions not amenable to labral repair.

PURPOSE

To determine the predictors of outcomes at a minimum 2 years after labral reconstruction.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients included in the study underwent labral reconstruction with a minimum 2-year follow-up. The primary outcome variable was the Hip Outcome Score-Activities of Daily Living (HOS-ADL). Secondary outcome measures included the 12-item Short Form Health Survey physical component summary (SF-12 PCS) and patient satisfaction with surgical outcomes. Preoperative and intraoperative variables assessed included demographics, prior surgery, chronicity of symptoms, radiographic measurements, preoperative outcome scores, and findings at arthroscopic surgery. Predictors were assessed using logistic regression with restricted cubic splines. Bivariate statistics assessed risk factors for reoperation including revision arthroscopic surgery and total hip arthroplasty (THA).

RESULTS

Three hundred seventeen of 368 labral reconstructions were available for follow-up (86.1%). Of these, 42 were converted to THA (13.2%) and 35 required revision arthroscopic surgery after labral reconstruction (11.0%). Factors associated with THA included older age, ≥2 previous surgeries, ≤2 mm of joint space, and lateral center edge angle (LCEA) <25°. Factors associated with revision included female sex, ≥2 previous surgeries, and LCEA <25°. Six patients refused to participate (1.9%), leaving 234 with a minimum follow-up of 2 years (mean, 3.7 years [range, 2.0-11.3 years]). These patients had significant improvement in HOS-ADL (71 to 90; P < .001), HOS-Sport (47 to 75; P < .001), Western Ontario and McMaster Universities Osteoarthritis Index (27 to 9; P < .001), modified Harris Hip Score (65 to 85; P < .001), and SF-12 PCS scores (41.6 to 53.1; P < .001). Median postoperative satisfaction was 9. Predictors of improvement for the HOS-ADL included higher preoperative HOS-ADL scores ( P < .001), joint space >2 mm ( P = .004), and no prior surgery ( P = .039). Predictors of improvement for the SF-12 PCS included higher preoperative SF-12 PCS scores ( P < .001), subacute chronicity (3 months to 1 year) of symptoms ( P = .013), and joint space >2 mm ( P = .046). Joint space >2 mm ( P < .001) and higher preoperative SF-12 scores (PCS: P = .034; mental component summary: P = .039) predicted higher satisfaction.

CONCLUSION

At a minimum 2 years' follow-up, patients who did not undergo conversion to THA (13.2%) or require revision (11.0%), reported significant improvement in outcome scores and high satisfaction with outcomes. Predictors of revision or THA included ≥2 previous surgeries, low LCEA, female sex for revision, and narrowed joint space for THA. Higher preoperative outcome scores were the most significant predictors of improvement after labral reconstruction. Lower preoperative scores, joint space narrowing, and history of surgery were predictive of an inferior result and decreased postoperative satisfaction.

Revision Hip Arthroscopy After Labral Reconstruction Using Iliotibial Band Autograft: Surgical Findings and Comparison of Outcomes With Labral Reconstructions Not Requiring Revision

PURPOSE

To determine the causes of revision hip arthroscopy in patients who underwent labral reconstruction and to compare outcomes of these patients with patients who did not require a revision following reconstruction.

METHODS

Patients who underwent revision hip arthroscopy after previous labral reconstruction from 2006 to 2014 were included. Patients with less than 2-year follow-up, preoperative joint space of ≤2 mm, or who underwent other reconstructive procedures at the time of labral reconstruction were excluded. Each patient was matched by year of surgery, age, gender, and the number of previous surgeries with 2 patients that underwent labral reconstruction but did not require a revision following the reconstruction. Preoperatively and at a minimum 2-year follow-up, outcome scores were collected including the Hip Outcome Score-Activities of Daily Living (HOS-ADL) and HOS-Sports Scale, modified Harris Hip Score, Western Ontario and McMaster Universities Index (WOMAC), the 12-Item Short Form Health Survey (SF-12) Physical Component Summary, and the patient satisfaction outcome were collected. Differences between the preoperative and the postoperative outcomes score of each patient in the 2 groups was assessed using the paired t test. The Mann-Whitney U test was used to compare the 2 groups.

RESULTS

From 347 patients who underwent iliotibial band autograft labrum reconstruction from 2006 to 2014, 28 hips (8%) in 26 patients (18 females and 8 males) had revision arthroscopy after labral reconstruction. The mean age was 32 years (range: 16-64). The mean number of hip surgeries prior to the labral reconstruction was 1.9 ± 1.2. The average time from the last labral reconstruction procedure to revision labral reconstruction was 27 months (range: 5-59). Procedures performed at revision included lysis of adhesions (100%), additional femoroacetabular impingement (FAI) correction (50%), ligamentum teres debridement (50%), psoas release (29%), labral augmentation or reconstruction (14%), and others. Following revision surgery after previous labral reconstruction, 4 patients (14%) underwent total hip arthroplasty and 2 (7%) patients required a subsequent revision arthroscopy (age 67 and 23) at 15 months and 16 months. The average follow-up time was 3.6 years ± 1 year after revision following labral reconstruction and after labral reconstruction in the nonrevision group. No significant difference was detected in the outcome scores and postoperative satisfaction between the 2 groups. The HOS-ADL improved 16 points in the nonrevision group and 19 points in the revision group.

CONCLUSIONS

Patients who underwent revision surgery after labral reconstruction were mostly female, with 2 or more surgeries prior to reconstruction, and 14% required THA and 7% had recurrent scarring. In those who did not fail, outcomes significantly improved and were similar with patients who did not need revision. Adhesions and residual FAI were the most common findings during revision labral reconstruction.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Bilateral Hip Arthroscopy: Direct Comparison of Primary Acetabular Labral Repair and Primary Acetabular Labral Reconstruction

PURPOSE

Directly compare primary acetabular labral repair versus primary acetabular labral reconstruction using a self-controlled cohort study design.

METHODS

Patients who underwent primary labral repair in one hip and primary labral reconstruction using iliotibial band allograft in the other hip by a single surgeon between August 2009 and November 2014 were identified. One patient with inflammatory arthritis was excluded. Patient-reported outcome data included change in Modified Harris Hip Score (MHHS), Lower Extremity Functional Scale (LEFS), average pain using a 10-point visual analog scale (VAS), and patient satisfaction (1: very dissatisfied, 10: very satisfied). Failure was defined as subsequent intra-articular hip surgery. Data were analyzed using McNemar's and Wilcoxon Signed Rank tests.

RESULTS

Overall, 29 patients (58 hips) were included in the analysis. There were 23 females and 6 males. The average age at time of surgery was 32.6 years (range: 14.9-51.6 years). Follow-up was obtained from all 29 patients (100%) at a mean of 56 months (range = 27-85 months) postoperative for repaired hips and 40 months (range = 22-61 months) postoperative for reconstructed hips. No labral reconstruction hips failed, and 9 (31%) labral repair hips failed (P < .01). Among those that did not fail treatment, there was no difference in MHHS change (32.2 ± 15.4 vs 29.6 ± 15.4; P = .63), LEFS change (26.6 ± 16.5 vs 23.9 ± 17.8; P = .61), VAS pain change (-3.2 ± 2.4 vs -3.6 ± 2.1; P = .47), or satisfaction (8.6 ± 2.0 vs 8.7 ± 2.4; P = .59) between the repair and reconstruction groups, respectively.

CONCLUSIONS

In this cohort of patients, hips that underwent primary labral repair were more likely to fail treatment than hips that underwent labral reconstruction (31% vs 0%, respectively). Among hips that did not fail treatment, patient-reported outcome scores were similar between groups. Excellent clinical results can be obtained with both forms of labral-preserving treatment but were more predictably observed with primary labral reconstruction in this cohort. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Labral Gracilis Tendon Allograft Reconstruction and Cartilage Regeneration Scaffold for an Uncontained Acetabular Cartilage Defect of the Hip

Hip cartilage injuries are very common, with rates as high as 50% having been reported in some series; abnormal femoral acetabular contact can result in a full-thickness cartilage defect or labral lesion. The prevalence of labral lesions can be as high as 55%. This Technical Note describes an arthroscopic technique to reconstruct an uncontained, full-thickness, focal cartilage defect of the acetabulum, with reconstruction of the missing labrum using a gracilis allograft and use of a biological liquid scaffold for cartilage reconstruction. Capsulotomy, acetabuloplasty, and microfracture with marrow bleeding should be performed simultaneously with the gracilis allograft preparation. The graft is inserted and anchored to reconstruct the missing labrum and to re-create a contained defect. Suction and drying of the joint surfaces are performed while the mixture of BST-CarGel (Piramal Healthcare, Laval, Quebec, Canada) and blood is prepared. A drop-by-drop technique is then used to reconstruct the cartilage defect.