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

Hip Labral Repair versus Reconstruction: Meta-analysis

The purpose of this meta-analysis is to compare the postoperative outcomes and complications of labral repair with those of labral reconstruction. An electronic search strategy was conducted from 1986 until August 2023 using the following databases: PubMed, Cochrane, and Google Scholar (pages 1-20). The primary objectives included the postoperative clinical outcomes determined by the number of patients who reached minimal clinical important difference (MCID) on the visual analog scale (VAS), modified Harris hip score (mHHS), Hip Outcome Score-Sports Subscale (HOS-SS), Hip Outcome Score-Activities of Daily Life (HOS-ADL), and International Hip Outcome Tool-12 (iHOT-12). In addition, analysis of the rate of revision arthroscopy, the rate of conversion to total hip arthroplasty (THA), the postoperative VAS, mHHS, HOS-SS, HOS-ADL, iHOT-12, nonarthritic hip score (NAHS), patient satisfaction, lower extremity function scale (LEFS), and the SF-12 (12-item shortform) was also performed. Any differences arising between the investigators were resolved by discussion. Seventeen studies were relevant to the inclusion criteria and were included in this meta-analysis. A higher rate of patients who reached MCID in the mHHS (P=0.02) as well as a higher rate of revision arthroscopy was observed for labral repair (P=0.03). The remaining studied outcomes were comparable. Despite the greater predictability of success in the reconstruction group, conduct of additional studies will be required for evaluation of the benefits of such findings. In addition, labral reconstruction is more technically demanding than a labral repair.

Predictors of Clinical Outcomes After Hip Arthroscopy: 10-Year Follow-up Analysis of 1038 Patients

BACKGROUND

Although hip arthroscopy has been shown to have beneficial outcomes, there is a paucity of literature examining predictive factors of 10-year clinical outcomes.

PURPOSE

(1) To identify predictive factors of 10-year outcomes of hip arthroscopy and (2) to compare these factors with those found in 2-year and 5-year studies.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed on all patients undergoing hip arthroscopy between February 2008 and June 2012. Patients were included if they had a minimum 10-year follow-up on 2 patient-reported outcome measures: Nonarthritic Hip Score (NAHS) and modified Harris Hip Score. Exclusion criteria included previous ipsilateral hip conditions. Using bivariate and multivariate analyses, that authors analyzed the effects of 37 pre- and intraoperative variables on the NAHS, modified Harris Hip Score, and conversion to total hip arthroplasty.

RESULTS

Of the 883 patients who met the inclusion criteria, 734 (83.1%) had follow-up data. The mean follow-up time was 124.4 months (range, 120.0-153.1 months). Six variables were significant predictors of NAHS in both multivariate and bivariate analyses: revision status, body mass index (BMI), duration of symptoms, preoperative NAHS, age at onset of symptoms, and need for acetabular microfracture. Positive predictors of 10-year survivorship included acute injury and gluteus medius repair, while negative predictors included revision arthroscopy, Tönnis grade, acetabular inclination, iliopsoas fractional lengthening, and notchplasty.

CONCLUSION

Multiple predictive factors including age, BMI, revision status, and preoperative outcome scores were identified for long-term survivorship and functional outcomes. These may prove useful to clinicians in refining indications and guiding patients on expected outcomes of hip arthroscopy.

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.

Similar Clinical Outcomes for Arthroscopic Labral Reconstruction in Irreparable Cases Using the Indirect Head of the Rectus Femoris Tendon With an All-Inside Technique for Small Defects and the Iliotibial Band for Large Defects

PURPOSE

To evaluate the clinical outcomes and satisfaction rate of patients who underwent arthroscopic labral reconstruction for an irreparable labral tear with a minimum follow-up period of 2 years. Additionally, this study aimed to compare 2 different reconstructive techniques for small and large labral defects: the indirect head of the rectus femoris tendon (IHRFT) autograft with an all-inside technique used to repair small defects (≤3 hours) and the iliotibial band (ITB) autograft for large defects (>3 hours).

METHODS

A total of 24 hips treated with the IHRFT were compared with 24 hips treated with the ITB. All patients underwent clinical evaluation before surgery and during the most recent follow-up (42 ± 18 months). The evaluation included patient satisfaction, the modified Harris Hip Score, the Non-Arthritic Hip Score, the Hip Outcome Score, the Hip Outcome Score-sport subscale, the 12-item International Hip Outcome Tool, and the visual analog scale pain score.

RESULTS

All clinical scores were significantly improved (P < .001) at the latest follow-up in both groups. The final satisfaction was 7.1 ± 2.8 and 8.8 ± 1.6 for the IHRFT and ITB groups, respectively (P = .006). There was a significant difference in age (41.2 ± 6.0 years for the IHRFT group and 33 ± 8.5 for the ITB group; P = .004) and in surgery time (147.3 ± 39.4 minutes for the ITB group and 105.3 ± 25.7 for the IHRFT group; P < .001). One patient (4.2%) in the IHRFT group underwent total hip arthroplasty after 21.3 months (P = .999).

CONCLUSIONS

At the 2-year follow-up, treating small defects using IHRFT and larger defects using ITB resulted in good patient-reported outcome measures with a low rate of complications and failures. The ITB group reported a higher level of satisfaction at the final follow-up.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Labral repair, reconstruction, and augmentation improve postoperative outcomes in patients with irreparable or hypoplastic labra: A systematic review

PURPOSE

To review the postoperative outcomes of arthroscopic surgical options in treating irreparable and hypoplastic labrum of the hip.

METHODS

Three online databases (PubMed, MEDLINE, and EMBASE) were searched from database inception to June 27, 2023 to identify literature on treatment strategies for hypoplastic/irreparable acetabular labrum. Data pertaining to classification of irreparable tears or labral hypoplasia, indication for surgery, description of treatment, radiographic findings, and clinical outcomes were recorded and described. The methodological quality of included studies was assessed by the Methodological Index for Non-Randomized Studies (MINORS) criteria.

RESULTS

Seven level IV case series, eleven level III retrospective cohort studies, and two level II prospective cohort studies comprising 1937 patients were included for analysis. Studies were divided into an irreparable labral group comprising 1002 patients and a hypoplastic labral group comprising 935 patients. Treatments included repair, augmentation, or reconstruction. In the irreparable group, 12 studies recorded improvement of modified Harris Hip Score (mHHS) with preoperative scores ranging from 50.3 to 67.3 and postoperative scores ranging from 76.2 to 95.0. The rate of conversion to total hip arthroplasty (THA) and rate of revision arthroscopy were 6.6% and 5.9%, respectively across all studies. In the hypoplastic group, two studies that focused on repair noted no statistical difference in mHHS for repair in hypoplastic labrum vs repair in non-hypoplastic labrum. One study showed that there was a difference in post-operative mHHS for labral repair for hypoplastic vs non-hypoplastic labrum, with repair in non-hypoplastic labrum showing superior mHHS (p ​< ​0.001).

CONCLUSION

The findings of this review suggest that treatment of irreparable labra with reconstruction or augmentation results in improved patient-reported outcome measures (PROMs). For the hypoplastic labrum, primary repair also results in improvement in PROMs. Future studies focusing on the hypoplastic labra alone with an appropriate control group, rather than irreparable labral tears, are needed to properly assess patient outcomes and guide surgical indications.

No Difference in Most Reported Outcome Measures for Allograft Versus Autograft for Hip Labral Reconstruction: A Systematic Review of Comparative Studies

PURPOSE

To systematically review studies comparing outcomes of allograft versus autograft for hip labral reconstruction.

METHODS

A systematic review following guidelines established by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) was performed in 3 databases using the terms "labrum," "hip," "acetabulum," "reconstruction," "augmentation," "allograft," and "autograft." Data on study characteristics, patient demographic characteristics, follow-up time, patient-reported outcomes (PROs), rates of revision surgery, and rates of conversion to total hip arthroplasty (THA) were collected.

RESULTS

Three studies were included, with Methodological Index for Non-randomized Studies (MINORS) scores ranging from 17 to 23. Among 92 patients receiving allografts, the mean ages ranged from 30.6 to 34.8 years; mean follow-up times, from 34.6 to 66.1 months; revision rates, from 0% to 23.6%; and conversion-to-THA rates, from 0% to 20%. Among 185 patients receiving autografts, the mean ages ranged from 34.6 to 35.9 years; mean follow-up times, from 32.7 to 80.8 months; revision rates, from 0% to 7.3%; and conversion-to-THA rates, from 0% to 6.7%. One study reported significantly higher revision rates in the allograft group. All studies reported no statistically significant differences in postoperative PROs, and all postoperative PROs significantly improved compared with preoperative PROs. Rates of achievement of the minimal clinically important difference and patient acceptable symptomatic state, reported by 1 study, were statistically similar between the 2 groups and ranged from 55.6% to 100% for the allograft group and from 53.8% to 84.6% for the autograft group.

CONCLUSIONS

There were no significant differences between allograft and autograft patients in terms of postoperative PROs; however, all PRO measures were slightly higher in allograft patients. Both revision and conversion-to-THA rates were higher in allograft patients in 2 studies, with the level of significance being reached in terms of revision in 1 study. The third study reported zero revisions and conversions to THA in allograft and autograft patients.

LEVEL OF EVIDENCE

Level III, systematic review of Level II and III studies.

Can the Acetabular Labrum Be Reconstructed With a Meniscal Allograft? An In Vivo Pig Model

BACKGROUND

No single graft type has been shown to have a benefit in acetabular labral reconstruction. The native labrum and lateral meniscus share many similarities, suggesting that the meniscus may be a promising source of graft material in labral reconstruction.

QUESTIONS/PURPOSES

Using a pig model, we sought to evaluate the healing process of fresh-frozen meniscus allograft for acetabular reconstruction by assessing (1) MRI and macroscopic observations of the meniscus allograft; (2) histologic appearance and immunohistologic evaluation of the meniscus allograft, native meniscus, and labrum; (3) microscopic assessment of the native labrum and meniscus via scanning electron microscopy; and (4) biomechanical assessment of tensile properties.

METHODS

Twelve skeletally mature male miniature Bama pigs (24 hips) were randomly divided into two groups: labral defect group (control) and lateral meniscus allograft group. The selection of Bama pig specimens was based on the similarity of their acetabular labrum to that of the human acetabular labrum, characterized by the presence of fibrocartilage-like tissue lacking blood vessels. The pigs underwent bilateral hip surgery. Briefly, a 1.5-cm-long section was resected in the anterior dorsal labrum, which was left untreated or reconstructed using an allogeneic lateral meniscus. The pigs were euthanized at 12 and 24 weeks postoperatively, and then evaluated by macroscopic observations and MRI measurement to assess the extent of coverage of the labral defect. We also performed a histologic analysis and immunohistologic evaluation to assess the composition and structure of meniscus allograft, native labrum, and meniscus, as well as scanning electron microscopy assessment of the microstructure of the native labrum and meniscus and biomechanical assessment of tensile properties.

RESULTS

Imaging measurement and macroscopic observations revealed that the resected area of the labrum was fully filled in the lateral meniscus allograft group, whereas in the control group, the labral defect remained at 24 weeks. The macroscopic scores of the meniscus allograft group (8.2 ± 0.8) were higher than those of the control groups (4.8 ± 1.0) (mean difference 3.3 [95% CI 1.6 to 5.0]; p < 0.001). Moreover, in the meniscus allograft group, histologic assessment identified fibrocartilage-like cell cluster formation at the interface between the graft and acetabulum; cells and fibers arranged perpendicularly to the acetabulum and tideline structure that were similar to those of native labrum could be observed at 24 weeks. Immunohistochemical results showed that the average optical density value of Type II collagen at the graft-acetabulum interface was increased in the meniscus allograft group at 24 weeks compared with at 12 weeks (0.259 ± 0.031 versus 0.228 ± 0.023, mean difference 0.032 [95% CI 0.003 to 0.061]; p = 0.013). Furthermore, the tensile modulus of the lateral meniscus allograft was near that of the native labrum at 24 weeks (54.7 ± 9.9 MPa versus 63.2 ± 11.3 MPa, mean difference -8.4 MPa [95% CI -38.3 to 21.4]; p = 0.212).

CONCLUSION

In a pig model, lateral meniscus allografts fully filled labral defects in labral reconstruction. Regeneration of a fibrocartilage transition zone at the graft-acetabulum interface was observed at 24 weeks.

CLINICAL RELEVANCE

The use of an autograft meniscus for labral reconstruction may be a viable option when labral tears are deemed irreparable. Before its clinical implementation, it is imperative to conduct a comparative study involving tendon grafts, which are extensively used in current clinical practice.

Labral Reconstruction via Capsular Augmentation Maintains Perfusion to the Acetabular Labrum and Locally Transferred Autograft: An in Vivo Laser Doppler Flowmetry Analysis

Background

The purpose of the present study was to examine the effects of arthroscopic labral repair with capsular augmentation on blood flow in vivo with use of laser Doppler flowmetry (LDF) to measure microvascular perfusion of the labrum and autograft tissue.

Methods

The present prospective case series included patients ≥18 years old who underwent arthroscopic acetabular labral repair with capsular augmentation; all procedures were performed by a single surgeon between 2018 and 2022. The LDF probe measured microvascular blood flow flux within 1 mm3 of the surrounding labral and capsular tissue of interest. Mean baseline measurements of flux were compared with readings immediately following capsular elevation and after completing labral augmentation. Blood flux changes were expressed as the percent change from the baseline measurements.

Results

The present study included 41 patients (24 men [58.5%] and 17 women [41.5%]) with a mean age (and standard deviation) of 31.3 ± 8.4 years, a mean BMI of 24.6 ± 3.4 kg/m2, a mean lateral center-edge of angle 35.3° ± 4.9°, a mean Tönnis angle of 5.8° ± 5.8°, and a mean arterial pressure of 93.7 ± 10.9 mm Hg. Following capsular elevation, the mean percent change in capsular blood flow flux was significantly different from baseline (-9.24% [95% confidence interval (CI), -18.1% to -0.04%]; p < 0.001). Following labral augmentation, the mean percent change in labral blood flow flux was significantly different from baseline both medially (-22.3% [95% CI, -32.7% to -11.9%]; p < 0.001) and laterally (-32.5% [95% CI, -41.5% to -23.6%]; p = 0.041). There was no significant difference between the changes in medial and lateral perfusion following repair (p = 0.136).

Conclusions

Labral repair with capsular augmentation sustains a reduced blood flow to the native labrum and capsular tissue at the time of fixation. The biological importance of this reduction is unknown, but these findings may serve as a benchmark for other labral preservation techniques and support future correlations with clinical outcomes.

Level of Evidence

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Allograft reconstruction of acetabular labrum has comparable outcomes to labral refixation

The acetabular labrum plays an important role in hip stability, intra-articular fluid pressurization and force distribution. For irreparable labral pathology, labral reconstruction is an increasingly adopted technique shown to decrease hip pain and improve function. We evaluated survivorship and clinical outcomes of allograft labral reconstruction using the mini-open anterior surgical approach. Twelve patients who underwent labral reconstruction using a semitendinosus tendon allograft (reconstruction group) were matched 1:3 based on age, gender, body mass index, year of surgery, preoperative Tönnis grade, previous hip surgery, residual hip pathology and extent of acetabular chondral lesion to a control group of 36 patients who underwent direct labral repair with anchors (refixation group). At a minimum follow-up of 2 years, patient-reported outcomes, radiological findings and failure rates were compared. The average age was 31.3 years (±13.6) for reconstruction and 34.7 (±10.2) for refixation. Both groups had similar preoperative symptomatic periods (P = 0.3), prevalence of residual hip pathology (P = 1.0) and prevalence of prior hip surgeries (P = 1.0). both groups had a significant improvement of modified Harris Hip scores and 36-Item Short-Form Health Survey physical scores. There was no statistically significant difference in conversion rates to total hip arthroplasty (25% versus 8.3%, P = 0.2); however, time to conversion was significantly longer in the reconstruction group (3.58 years ±1.04) compared to the refixation group (1.20 years± 0.93; P = 0.04). In conclusion, at a minimum of 2 years of follow-up, mini-open labrum reconstruction for severe insufficiency of acetabular labrum demonstrated comparable improvements in functional outcomes and significantly longer survivorship compared to labral refixation.

Treatment of Severe Pincer-Type Femoroacetabular Impingement With Arthroscopic Significant Acetabular Rim Correction and Circumferential Labral Reconstruction Improves Patient-Reported Outcome Measures

PURPOSE

To validate an arthroscopic approach for performing significant acetabular rim correction and circumferential labral reconstruction required to treat severe pincer-type femoroacetabular impingement.

METHODS

Using a minimum of 2-year follow-up, data from 48 hips, including 47 patients (11 male, 36 female; mean age of 42 years) having undergone significant arthroscopic acetabuloplasty for severe pincer impingement (center edge angle >45°) with concomitant circumferential allograft labral reconstruction were analyzed to determine improvements in patient-reported outcomes and degree of radiographic correction.

RESULTS

Findings demonstrated a 98% success rate, including substantial improvements on all radiographic measurements and patient-reported outcomes. Minimal clinically important differences were met with extremely strong measures of effect. The mean center edge angle improved from 49° to 36° (MΔ = 13.96, P ≤ .001, standard deviation [SD] = 55.97, confidence interval [CI] 12.17- 15.62, d = 2.33) and the mean Tönnis angle improved from -6° to 0° (MΔ = 6.2, P ≤ .001, SD = 2.76 CI -7.1 to -5.39, d = 2.29). Modified Hip Harris Scores improved by a mean of 34.45 points (P ≤ .001, SD = 20.64, 95% CI 28.45-40.44, d = 1.66). Lower extremity functional scale scores improved by a mean of 27.35 points (P ≤ .001, SD = 18.37, 95% CI 22.02-32.69, d =1.48). No complications were reported. One case converted to a total hip arthroplasty (2%).

CONCLUSIONS

Findings validated that the significant acetabular rim correction required to treat severe pincer morphology is safe and feasible via an arthroscopic approach. This, in addition to concomitant circumferential allograft labral reconstruction, resulted in improvement in patient-reported outcomes and radiographic measurements.

LEVEL OF EVIDENCE

Level IV, therapeutic case-series.

Propensity-Matched Patients Undergoing Revision Hip Arthroscopy Older Than the Age of 40 Years Had Greater Risk of Conversion to Total Hip Arthroplasty Compared With Their Primary Counterparts

PURPOSE

To report patient-reported outcomes (PROs) and survivorship following revision hip arthroscopy in patients aged ≥40 years and to compare these results with a propensity-matched primary hip arthroscopy control group.

METHODS

Data were prospectively collected and retrospectively reviewed for all patients who underwent revision hip arthroscopy between June 2008 and January 2019. Patients were included if they were ≥40 years of age at the time of surgery and had minimum 2-year follow-up for the modified Harris Hip Score, Nonarthritic Hip Score, Visual Analog Scale for pain, and the Hip Outcome Score-Sports Specific Subscale. Patients who had a previous hip condition, or those who lacked minimum 2-year follow-up, were excluded. The revision group was further analyzed by conducting a 1:1 propensity-matched sub-analysis to a primary hip arthroscopy control group based on age, sex, body mass index, and acetabular labrum articular disruption grade. Statistical significance was set at P < .05.

RESULTS

Eighty-nine hips (92.7% follow-up) were included, with 66.3% being females. The mean age, body mass index, and follow-up time were 49.4 ± 8.0 years, 26.6 ± 4.1, and 62.7 ± 38.5 months, respectively. Significant improvement in all PROs (P < .001) was reported, and 71.8%, 58 74.4%, and 65.2% achieved the minimal clinically important difference for the modified Harris Hip Score, Nonarthritic Hip Score, and Hip Outcome Score-Sports Specific Subscale, respectively. Eighty-seven revision hips were successfully propensity-matched to 87 primary hips. Both groups reported similar improvement for all PROs, but the relative risk of conversion to total hip arthroplasty was 2.63 times greater (95% confidence interval 1.20-5.79) for the revision group.

CONCLUSIONS

Patients aged ≥40 years who underwent revision hip arthroscopy reported significant improvement in all PROs at a mean follow-up of 62.7 months with favorable rates of achieving the minimal clinically important difference. When compared to the propensity-matched control group, both achieved similar rates of improvement, but the revision group was 2.63 times more likely to convert to total hip arthroplasty.

LEVEL OF EVIDENCE

III. case-control study.

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.

Hip Labral Reconstruction With a Polyurethane Scaffold: Restoration of Femoroacetabular Contact Biomechanics

Background:

Many advances have been made in hip labral repair and reconstruction and in the restoration of the suction seal.

Purpose/Hypothesis:

The purpose of this study was to evaluate the biomechanical effects of segmental labral reconstruction with a synthetic polyurethane scaffold (PS) in comparison with segmental labrectomy. Our hypothesis was that reconstruction with a icroporous polyurethane implant would normalize joint kinetics of the hip and restore the suction seal.

Study Design:

Controlled laboratory study.

Methods:

We used 10 hips from 5 fresh-frozen pelvises with an intact acetabular labrum without osteoarthritis. Using an intra-articular pressure measurement system, the contact area, contact pressure, and peak force were assessed for the following conditions: intact labrum, partial anterosuperior labrectomy, and PS reconstruction. For each condition, all specimens were analyzed in 4 positions (90° of flexion, 90° of flexion and internal rotation, 90° of flexion and external rotation, and 20° of extension) and underwent a labral seal test. The relative change from the intact condition was determined for all conditions and positions.

Results:

Compared with the intact labrum, labrectomy resulted in a significant decrease in the contact area (P < .001) and a significant increase in the peak force (P < .001) and contact pressure (P < .001) across all positions. Compared with labrectomy, PS reconstruction resulted in a significant increase in the contact area (P < .001) and a significant decrease in the contact pressure (P ≤ .02) and peak force (P < .001) across all positions. Compared with the intact labrum, PS reconstruction restored the contact area and peak force to normal values in all positions (P > .05), whereas the contact pressure was significantly decreased compared with labrectomy (P < .05) but did not return to normal values. The labral seal was lost in all specimens after labrectomy but was restored in 80% of the specimens after PS reconstruction.

Conclusion:

Femoroacetabular contact biomechanics significantly worsened after partial labrectomy; reconstruction using a PS restored the contact area and peak force to the intact state and improved the contact pressure increases seen after partial labrectomy. The contact area and peak force were normalized, and the labral seal was re-established in most cases.

Clinical Relevance:

This study provides biomechanical evidence for the use of a scaffold for labral reconstruction.

Minimum 5-Year Outcomes After Primary Segmental Labral Reconstruction for Irreparable Labral Tears in the Hip With Hamstring Grafts: With a Subanalysis Comparing Autograft Versus Allograft

BACKGROUND

Comparable short-term outcomes have been obtained using hamstring allografts versus autografts after primary segmental labral reconstruction (SLR). Midterm results have not yet been determined.

PURPOSE

(1) To evaluate minimum 5-year patient-reported outcome (PRO) scores in patients who underwent primary SLR with hamstring grafts in the setting of femoroacetabular impingement syndrome (FAIS) and irreparable labral tears and (2) to compare the outcomes of hamstring autografts versus allografts in a subanalysis using propensity-matched groups.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Prospectively collected data were retrospectively reviewed for patients who underwent primary hip arthroscopy between September 2010 and November 2015. Patients were included if they underwent SLR using hamstring autografts or allografts and had preoperative and minimum 5-year PROs. The exclusion criteria were previous ipsilateral hip surgery or conditions, dysplasia, or Tönnis grade >1. Patients with autograft SLR were propensity matched 1 to 1 based on age, sex, and body mass index (BMI) to patients who underwent SLR using hamstring allografts. The minimal clinically important difference (MCID) and the Patient Acceptable Symptom State (PASS) were calculated.

RESULTS

Overall, 48 patients (N = hips 48) were eligible to be included in this study, and 41 patients (n = 41 hips [85.4%]) had a minimum 5-year follow-up reporting significant improvements in all PROs. Within the entire cohort, 9.8% required a secondary arthroscopy, with a mean time of 19 ± 1.8 months, and survivorship was 82.9%. Of the 41 included patients, 15 underwent an SLR with a hamstring autograft and were matched to 15 patients with labral reconstruction using a hamstring allograft. Groups were similar for sex (P > .999), age (P = .775), and BMI (P = .486). The mean follow-up times were 80.8 ± 25.5 and 66.1 ± 8.3 months (P = .223) for the autograft and allograft groups, respectively. Baseline PROs, preoperative radiographic measurements, surgical findings, and intraoperative procedures were similar. The groups achieved significant and comparable improvements for all PROs (P < .0001), satisfaction (P = .187), and the rate of achieving the MCID and the PASS. However, a tendency for higher postoperative PROs favoring allograft reconstruction was found.

CONCLUSION

At a minimum 5-year follow-up, patients who underwent primary arthroscopic SLR in the context of FAIS and irreparable labra, with either autograft or allograft hamstring tendons, reported significant improvements and comparable postoperative scores for all PROs, patient satisfaction, MCID, and PASS.

Pre- and intraoperative decision-making challenges in hip arthroscopy for femoroacetabular impingement

There has been a marked increase in the number of hip arthroscopies performed over the past 16 years, primarily in the management of femoroacetabular impingement (FAI). Insights into the pathoanatomy of FAI, and high-level evidence supporting the clinical effectiveness of arthroscopy in the management of FAI, have fuelled this trend. Arthroscopic management of labral tears with repair may have superior results compared with debridement, and there is now emerging evidence to support reconstructive options where repair is not possible. In situations where an interportal capsulotomy is performed to facilitate access, data now support closure of the capsule in selective cases where there is an increased risk of postoperative instability. Preoperative planning is an integral component of bony corrective surgery in FAI, and this has evolved to include computer-planned resection. However, the benefit of this remains controversial. Hip instability is now widely accepted, and diagnostic criteria and treatment are becoming increasingly refined. Instability can also be present with FAI or develop as a result of FAI treatment. In this annotation, we outline major current controversies relating to decision-making in hip arthroscopy for FAI. Cite this article: Bone Joint J 2022;104-B(5):532-540.

Segmental and Circumferential Acetabular Labral Reconstruction Have Comparable Outcomes in the Treatment of Irreparable or Unsalvageable Labral Pathology: A Systematic Review

PURPOSE

To perform a systematic review comparing outcomes of segmental versus circumferential arthroscopic labral reconstruction as a treatment for symptomatic irreparable or unsalvageable acetabular labral pathology.

METHODS

A systematic review was conducted according to PRISMA guidelines using defined inclusion and exclusion criteria. The study groups were divided into segmental and circumferential labral reconstructions. Studies with <2 years follow up, overlapping patient populations, or indications for labral reconstruction other than irreparable or unsalvageable pathology were excluded.

RESULTS

The literature search resulted in nine included publications. Five studies presented data on segmental labral reconstruction (166 hips in 164 patients), and seven studies presented data on circumferential labral reconstruction (261 hips in 253 patients). All circumferential reconstruction studies used allograft only, while segmental studies used a combination of autograft and allograft. The range of conversion to total hip arthroplasty was 9.1% to 26.8% in the segmental studies and 3.1% to 9.9% in the circumferential studies. The modified Harris Hip Score (mHHS) was the only patient-reported outcome measure reported in three or more studies in both groups. The mean change from preoperative to postoperative mHHS ranged from 17.8 to 29 in the segmental group and from 20.4 to 31.7 in the circumferential group. Weighted estimates were not calculated due to significant heterogeneity for both the segmental and circumferential groups (I² = 63.9% and 72.9%, respectively).

CONCLUSIONS

Segmental and circumferential reconstructions are both reasonable options for arthroscopic treatment of irreparable or unsalvageable labral pathology. Articles in both groups demonstrated improvement in patient-reported outcomes (mHHS). Because of study heterogeneity, low level of evidence, and high risk of bias, the scores were unable to be directly compared. Although there are theoretical biomechanical and technical advantages of one technique over another, this systematic review did not demonstrate clinical superiority of either technique.

LEVEL OF EVIDENCE

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

Comparison of Acetabular Labral Reconstruction With 7-mm Tibialis Anterior Allograft and 5-mm Iliotibial Band Autograft at Minimum 2-Year Follow-up

BACKGROUND

Labral reconstruction has been described as a treatment option for irreparable labral tear. Labral graft size ranges from 5 to 7 mm² for reconstruction. A thicker labral graft could support mechanical stability and protect cartilage better. No study has compared the effect of graft thickness on clinical outcomes.

PURPOSE/HYPOTHESIS

The purpose of this study was to compare patient-reported outcomes between hips reconstructed with an autologous iliotibial band (AUITB; 5 mm²) graft and with an allogenic tibialis anterior (ALTA; 7 mm²) tendon graft. Our hypothesis was that hips reconstructed with a thicker allograft (7 mm²) would have better clinical outcomes than those with a smaller autograft (5 mm²).

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A total of 42 patients (aged 21 to 54 years) underwent arthroscopic hip segmental labral reconstruction during the study period of January 2016 to November 2018. Twenty patients had reconstruction with AUITB grafts (5 mm²) and 22 with ALTA grafts (7 mm²). Both groups had minimum 2 year follow-up. Patients were evaluated with patient-related outcome scores: modified Harris Hip Score, Nonarthritic Hip Score, and Hip Outcome Score-Sports Specific. Pain evaluation was performed using a visual analog scale.

RESULTS

There were significant differences in all studied variables when comparing pre- and postoperative scores. Yet, there were no differences in terms of patient-related outcome scores between the groups postoperatively. Postoperative visual analog scale scores averaged 2.1 for the AUITB group vs 1.9 for the ALTA group (P = .89); modified Harris Hip Score, 82.7 vs 83.3 (P = .77); Nonarthritic Hip Score, 81.1 vs 82.2 (P = .81); and Hip Outcome Score-Sports Specific, 81.6 vs 82.5 (P = .67).

CONCLUSION

No differences were found in terms of clinical outcomes between the 7-mm² ALTA graft and the 5-mm² AUITB graft. Both graft types and thicknesses might be considered comparable choices for primary reconstruction. Although a thicker-graft labral reconstruction seemed to have more ability to cover joint surface, clinical results did not show any superiority of a thicker graft whether it is autologous or allogenic.

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’.

Allograft Labral Reconstruction of the Hip: Expanding Evidence Supporting Greater Utilization in Hip Arthroscopy

Purpose of Review

The current review investigates outcomes and failure rates associated with arthroscopic circumferential allograft labral reconstruction of the hip, both as a revision and primary procedure in treating femoroacetabular hip impingement and labral-related pathology.

Recent Findings

Numerous studies within the last decade have demonstrated excellent patient-reported outcomes, high rates of return-to-play in athletes, and low failure rates in patients having undergone arthroscopic circumferential allograft labral reconstruction of the hip. Removal of chronically diseased and injured labral tissue can eliminate a significant pain-generator from the hip joint. Additionally, circumferential reconstruction of the labrum restores the hoop fiber strength and fluid seal akin to what would be seen with native, healthy labral tissue. Recent research has shown that arthroscopic circumferential allograft labral reconstruction may be used not only in the revision setting, but as a primary procedure. Circumferential labral reconstruction should be considered when a surgeon feels that the labrum is irreparable or has failed previous repair.

Summary

Arthroscopic circumferential allograft labral reconstruction of the hip can be utilized as treatment option not only in revision settings, but also in primary treatment for femoroacetabular impingement and labral pathology

Multicenter Outcomes After Primary Hip Arthroscopy: A Comparative Analysis of Two-Year Outcomes After Labral Repair, Segmental Labral Reconstruction, or Circumferential Labral Reconstruction

PURPOSE

(1) To report minimum 2-year follow-up patient-reported outcome measures in patients undergoing labral repair (LR), segmental labral reconstruction (SLR), or circumferential labral reconstruction (CLR) in the primary setting; and (2) to compare minimum 2-year follow-up patient-reported outcome measures among these groups.

METHODS

A retrospective review of a prospectively maintained multicenter database of patients undergoing hip arthroscopy was performed. Inclusion criteria were patients undergoing hip arthroscopy for treatment of labral tear and femoroacetabular impingement syndrome between January 2014 and October 2017, and completion of minimum 2-year postoperative outcome scores. Exclusion criteria were patients undergoing revision hip surgery, labral treatment limited to debridement, lateral center-edge angle <20°, osteoarthritis (Tönnis grade > 1), slipped capital femoral epiphysis, workers compensation status, and patients undergoing concomitant gluteus medius and/or minimus repair. Labral reconstruction patients were matched (1:3) with labral repair patients on age, sex, and body mass index. The labral reconstruction group was further stratified into SLR, and CLR groups. Patient demographic characteristics and clinical outcomes including Hip Outcome Score - Activities of Daily Living, Hip Outcome Score - Sport Subscale, modified Harris Hip Score, international Hip Outcome Tool, and visual analog scale for pain were analyzed, as well as achievement of the minimal clinical improvement difference (MCID). A P-value less than .05 indicated statistical significance.

RESULTS

A total of 416 patients were included (LR, n = 312; SLR, n = 53; CLR, n = 51). The age, body mass index, and sex of the matched cohort were 42.3 ± 11.2 years, 24.7 ± 3.7, and 55.0% female. At a minimum of 2-year after hip arthroscopic surgery, no differences were found in preoperative, postoperative, or the delta visual analog scale for pain, modified Harris Hip Score, Hip Outcome Score - Activities of Daily Living, Hip Outcome Score - Sport Subscale, or international Hip Outcome Tool. Subsequently, the proportion of patients achieving the MCID and the PASS at latest follow-up were analyzed. This analysis revealed that no significant differences in the rate of MCID or PASS achievement for any outcome measure existed based on labral treatment.

CONCLUSIONS

In this multicenter study on labral treatment in the primary setting, patients undergoing LR, SLR, and CLR demonstrated no difference in preoperative or postoperative scores, nor the proportion of patients achieving clinically significant outcome improvement.

LEVEL OF EVIDENCE

III; therapeutic outcome study with controls.

The Effect of Rim Preparation, Labral Augmentation, and Labral Reconstruction on the Suction Seal of the Hip

PURPOSE

To evaluate the biomechanical properties of the labral suction seal in the native labrum and after rim preparation, labral augmentation, and labral reconstruction.

METHODS

Eight hemi-pelvises were dissected to the level of labrum and mounted for biomechanical testing. Each specimen was tested in axial distraction starting with the native labrum and then sequentially following rim preparation from 12 to 3 o'clock, labral augmentation, and segmental labral reconstruction using the iliotibial band allograft. In each condition, the specimens were compressed to 250 N and then distracted at 10 mm/s with force and displacement continuously recorded. Each test was repeated 3 times, and the mean peak force, displacement at peak force, and work were calculated. Data were reported as a percentage of the intact values to account for sex and size differences. Statistical testing was performed via a repeated-measures analysis of variance with a post hoc Tukey analysis.

RESULTS

Peak loads occurred within 2.21 to 3.11 mm of displacement. The mean peak force, displacement at peak force, and work relative to the intact condition were the following: rim preparation (91.1% ± 8.5%, 94.4% ± 14.3%, 93.4% ± 23.5%, respectively), augmentation (66.1% ± 27.6%, 78.2% ± 16.3%, 55.7% ± 30.7%, respectively), and reconstruction (55.6% ± 25.7%, 64.7% ± 31.4%, 38.7% ± 27.2%, respectively). There was no significant difference in peak force following the rim preparation (P = .807), but peak force was significantly decreased after augmentation and reconstruction (P = .010 and P < .001, respectively). There was no significant difference in displacement at peak force following rim preparation or augmentation (P = .936 and P = .125, respectively), but displacement at peak force was significantly decreased after reconstruction (P = .005). The work from the suction seal was significantly less in both augmentation and reconstruction states compared to the intact labrum (P = .004 and P < .001, respectively) and rim preparation (P = .017 and P < .001, respectively).

CONCLUSIONS

The results show that the suction seal is not significantly changed following rim preparation. Relative to the rim preparation, labral augmentation may re-create the labral suction seal better than labral reconstruction.

CLINICAL RELEVANCE

This study provides a biomechanical basis for surgical decision making and clinical management of patients with labral tears of the hip.

Favorable Outcomes of Revision Hip Arthroscopy Irrespective of Whether Index Surgery was Performed by the Same Surgeon or a Different Surgeon

The purpose of this study was to compare minimum 2-year patient-reported outcomes (PROMs) after revision hip arthroscopy between two different patient cohorts who had undergone primary hip arthroscopy with the same surgeon (SS) and a different surgeon (DS). We hypothesized no difference in clinical outcomes between the groups despite differences in intraoperative findings based on the surgical decision making in a revision setting at a high-volume center.

Circumferential and Segmental Labral Reconstruction: A Systematic Review

The purposes of this study were to synthesize, report, and compare patient-reported outcomes (PROs) between arthroscopic segmental and circumferential labral reconstruction. A systematic review was performed in February 2019 using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) method. Inclusion criteria were levels I to IV evidence, articles in English, arthroscopic labral reconstruction, and PROs data. Exclusion criteria were labral treatment without reconstruction, open surgery, and less than 6-month follow-up. Eleven studies were identified. Nine studies (212 hips) reported outcomes of segmental reconstruction. Two studies (194 hips) reported outcomes of circumferential reconstruction. Significant improvement in PROs at short-term with either segmental or circumferential reconstruction was found. [Orthopedics. 2021;44(6):361-366.].

In search of labral restoration function with hip arthroscopy: outcomes of hip labral reconstruction versus labral repair: a systematic review

PURPOSE

To perform a systematic review comparing patient-reported outcomes (PROs) in patients who underwent hip arthroscopy with labral repair versus labral reconstruction in the setting of femoroacetabular impingement syndrome (FAIS) and labral tears.

METHODS

A systematic review of the PubMed, Embase, and Cochrane databases was performed in May 2020 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and checklist. Articles were included in the analysis if they compared PROs between a labral repair and labral reconstruction cohort. For all PROs, the standardised mean difference (SMD) was calculated to compare the effect size of labral repair and labral reconstruction.

RESULTS

10 comparative studies, with 582 reconstruction cases and 631 repair cases, were included in this analysis. The mean age for the reconstruction and the repair groups ranged from 27.0 years to 52.6 years and 27.5 years to 47.0 years, respectively. The mean follow-up for the reconstruction and the repair groups ranged from 24.0 months to 66.0 months and 24.0 months to 71.0 months, respectively. The modified Harris Hip Scores (mHHS) was favourable in 8 reconstruction studies (range 80.4-95.0) and 9 repair studies (range 84.1-93.0). Average NAHS scores for the repair and reconstruction cohorts ranged from 77.9-88.6 and 73.9-92.4, respectively. Additionally, the effect sizes regarding NAHS and mHHS scores were large (SMD > 0.8) in both the reconstruction and repair groups for the majority of studies. Finally, reconstruction patients underwent a subsequent total hip arthroplasty (THA) at a slightly higher rate.

CONCLUSIONS

In the setting of FAIS and labral tears, patients who underwent hip arthroscopy may expect significant improvement in PROs at short-term follow-up with either labral repair or labral reconstruction. Although, not statistically significant, the repair group trended towards higher scores and exhibited a lower risk of conversion to THA.

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.

Minimum 2-Year Functional Outcomes of Patients Undergoing Capsular Autograft Hip Labral Reconstruction

BACKGROUND

There is a paucity of literature on arthroscopic capsular autograft labral reconstruction.

PURPOSE

To report midterm functional outcomes for patients undergoing acetabular labral repair with capsular autograft labral reconstruction.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This is a retrospective case series of prospectively collected data on patients who underwent arthroscopic acetabular labral repair by the senior surgeon between March 2013 and August 2018. The inclusion criteria for this study were adult patients aged 18 years or older who underwent primary hip arthroscopy for arthroscopic capsular autograft labral reconstruction. Exclusion criteria were <2 years of postoperative follow-up, elective disenrollment from study before 2-year follow-up, or repeat ipsilateral hip surgery before 2-year follow-up. Intraoperatively, patients underwent capsular autograft hip labral reconstruction if they were found to have a labrum with hypoplastic tissue (width <5 mm), complex tearing, or frank degeneration of native tissue. Clinical outcome data consisted of patient-reported outcome measures.

RESULTS

A total of 97 hips (94 patients) met the inclusion criteria with a mean final follow-up of 28.2 months (95% CI, 26.0-30.4). Patients had a mean age of 39.0 years (95% CI, 36.8-41.2) with a mean body mass index of 25.8 (95% CI, 24.9-26.7). When compared with baseline (40.4 [95% CI, 36.7-44.2]), the mean international Hip-Outcome Tool-33 (iHOT-33) scores were significantly greater at 3-month (60.9 [95% CI, 56.8-64.9]; P < .001), 6-month (68.8 [95% CI, 64.7-72.9]; P < .001), 12-month (73.2 [95% CI, 68.9-77.5]; P < .001), and final (76.6 [95% CI, 72.4-80.8]; P < .001) follow-up. At 2-year follow-up, 76.3%, 65.5%, and 60.8% of patients' iHOT-33 scores exceeded clinically meaningful outcome thresholds for minimally clinically important difference (MCID), patient-acceptable symptomatic state, and substantial clinical benefit, respectively.

CONCLUSIONS

In this study of 97 hips undergoing arthroscopic labral repair with capsular autograft labral reconstruction, we found favorable outcomes that exceeded the MCID thresholds in the majority of patients at a mean 28.2 months' follow-up. Future studies should compare outcomes between this technique and other methods of autograft and allograft reconstruction to determine differences in patient-reported outcomes, donor-site morbidity, and complications.

Revision Hip Arthroscopy in the Native Hip: A Review of Contemporary Evaluation and Treatment Options

Hip arthroscopy is a reproducible and efficacious procedure for the treatment of femoroacetabular impingement syndrome (FAIS). Despite this efficacy, clinical failures are observed, clinical entities are challenging to treat, and revision hip arthroscopy may be required. The most common cause of symptom recurrence after a hip arthroscopy that leads to a revision arthroscopy is residual cam morphology as a result of inadequate femoral osteochondroplasty and restoration of head–neck offset, though several other revision etiologies including progressive chondral and labral pathologies also exist. In these cases, it is imperative to perform a comprehensive examination to identify the cause of a failed primary arthroscopy as to assess whether or not a revision hip arthroscopy procedure is indicated. When a secondary procedure is indicated, approaches may consist of revision labral repair, complete labral reconstruction, or labral augmentation depending on labral integrity. Gross instability or imaging-based evidence of microinstability may necessitate capsular augmentation or plication. If residual cam or pincer morphology is present, additional resection of the osseous abnormalities may be warranted. This review article discusses indications, the evaluation of patients with residual symptoms after primary hip arthroscopy, and the evaluation of outcomes following revision hip arthroscopy through an evidence-based discussion. We also present a case example of a revision hip arthroscopy procedure to highlight necessary intraoperative techniques during a revision hip arthroscopy.

Hip Labral Reconstruction with Capsular Autograft Augmentation

Multiple treatment options are available for patients presenting with a torn or deficient acetabular labrum. Biomechanical studies have demonstrated that the acetabular labrum may play a role in decreasing the risk of osteoarthritis and in maintaining long-term hip kinematics and stability. As such, repair or reconstruction of the labrum is often preferred over resection or debridement. In instances of a hypoplastic labrum, labral reconstruction or augmentation may be necessary even in a primary setting. Although reconstruction is a technique that should be in any hip arthroscopist's toolkit, allografts can be expensive and may not always be available when needed. In this Technical Note, we describe a labral augmentation with capsular autograft that diminishes donor-site morbidity associated with fascia lata autografts. This technique enables incorporation of healthy capsular tissue that allows for the recreation of the suction seal while avoiding some of the technically challenging aspects and costs of the conventional allograft labral reconstruction.

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.

Evaluation of outcome reporting trends for femoroacetabular impingement syndrome- a systematic review

PURPOSE

The aim of this systematic review was to evaluate the trends in the literature regarding surgical treatment for femoroacetabular impingement syndrome (FAIS) and to present which patient-reported outcome-measures (PROMs) and surgical approaches are included.

METHODS

This systematic review was conducted with the PRISMA guidelines. The literature search was performed on PubMed and Embase, covering studies from 1999 to 2020. Inclusion criteria were clinical studies with surgical treatment for FAIS, the use of PROMs as evaluation tool and studies in English. Exclusion criteria were studies with patients < 18 years, cohorts with < 8 patients, studies with primarily purpose to evaluate other diagnoses than FAIS and studies with radiographs as only outcomes without using PROMs. Data extracted were author, year, surgical intervention, type of study, level of evidence, demographics of included patients, and PROMs.

RESULTS

The initial search yielded 2,559 studies, of which 196 were included. There was an increase of 2,043% in the number of studies from the first to the last five years (2004-2008)-(2016-2020). There were 135 (69%) retrospective, 55 (28%) prospective and 6 (3%) Randomized Controlled Trials. Level of evidence ranged from I-IV where Level III was most common (44%). More than half of the studies (58%) originated from USA. Arthroscopic surgery was the most common surgical treatment (85%). Mean follow-up was 27.0 months (± 17 SD), (range 1.5-120 months). Between 1-10 PROMs were included, and the modified Harris Hip Score (mHHS) was most commonly used (61%).

CONCLUSION

There has been a continuous increase in the number of published studies regarding FAIS with the majority evaluating arthroscopic surgery. The mHHS remains being the most commonly used PROM.

Surgical Treatment of Labral Tears: Debridement, Repair, and Reconstruction

Advances in hip preservation surgery have to lead to increased utilization of hip arthroscopy. With this, there has also been a growth in the understanding of various hip conditions, therefore, leading to an increase in hip conditions amenable to arthroscopic intervention. The acetabular hip labrum has been at the forefront of arthroscopic advances in the hip. The labrum is important for hip stability, provision of the suction seal, and joint proprioception. Given the labrum's central role in hip biomechanics, there is increasing emphasis on labral preservation in the form of debridement and repair. In revision settings, advanced techniques such as labral augmentation and reconstruction may play a role in the management of labral pathology. Appropriate management of the hip labrum at the time of surgery can be an important mediator of the outcome. As such, an understanding of the evolving evidence base and surgical indications and techniques are integral to the treatment and management of labral pathology.

Technical Pearls for Arthroscopic Labral Augmentation of the Hip

Our recent understanding of the importance of the acetabular labral suction seal has placed preserving labral integrity as a guiding principle in hip preservation surgery. In cases with a hypoplastic labrum and intact chondrolabral junction, labral augmentation presents as a viable alternative and an often preferred treatment option over labral reconstruction. At this time, there are few studies that have described the technical pearls of performing labral augmentation of the hip. In this technique guide, we describe, in detail, the kite technique for the introduction, control, and acetabular fixation of a hip labral augmentation graft. Comparable to flying a kite with 2 fly lines and to the previously described kite technique for hip labral reconstruction, the kite technique for labral augmentation is based on the principle that the use of 2 control sutures in a pulley system creates an efficient method to accurately and reproducibly facilitate graft passage and fixation during arthroscopic labral augmentation procedures.

The Efficacy of Labral Reconstruction: A Systematic Review

Background:

With a greater understanding of the importance of the acetabular labrum in the function of the hip, labral repair is preferred over debridement. However, in some scenarios, preservation or repair of the labrum is not possible, and labral reconstruction procedures have been growing in popularity as an alternative to labral resection.

Purpose:

To provide an up-to-date analysis of the literature to determine the overall efficacy of labral reconstruction when compared with labral repair or resection.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

PubMed, Embase, and MEDLINE databases were searched for literature regarding labral reconstruction in the hip before July 21, 2020. The results were screened and evaluated by 2 reviewers, and a third reviewer resolved any discrepancies. The final studies were evaluated using the MINORS (Methodological Index for Non-randomized Studies) score.

Results:

There were 7 comparative studies that fit the inclusion criteria, with 228 hips from 197 patients. The mean follow-up was 34.6 months, and the mean age of all patients was 38.34 years. There were slightly more female patients than male patients (105 vs 92). Arthroscopic reconstruction was performed in 86% of studies (6/7); open surgical techniques, in 14% (1/7). A variety of grafts was used in the reconstructions. The indications for labral reconstruction and outcome measures varied in these publications. Nine patients were lost follow-up, and 6 patients converted to total hip replacement postlabral reconstruction. The assessment of these comparative studies illustrated statistically equivalent results between labral reconstruction and labral repair. Comparisons of labral reconstruction with labral resection also showed statistically equivalent postoperative patient-reported outcome scores; however, the rates of conversion to total hip arthroplasty were significantly higher in the population undergoing resection.

Conclusion:

The review of current available comparative literature, which consists entirely of level 3 studies, suggests that labral reconstruction does improve postoperative outcomes but does not demonstrate superiority over repair. There may, however, be benefit to performing labral reconstruction over resection owing to the higher rate of conversion to total hip arthroplasty in the labral resection group.

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.

Femoroacetabular Impingement and Management of Labral Tears in the Athlete

Femoroacetabular impingement and associated labral tearing is a common source of hip pain in athletes. This article reviews the hip joint anatomy and complex interplay between alterations on the femoral and acetabular sides, in addition to evaluation of soft tissue stabilizers and spinopelvic parameters. Symptom management with a focus on arthroscopic treatment of abnormal bony morphology and labral repair or reconstruction is discussed. In select patients with persistent pain who have failed conservative measures, hip arthroscopy with correction of bony impingement and labral repair or reconstruction has yielded good to excellent results in recreational and professional athletes.

Predictors of Clinical Outcomes After Hip Arthroscopy: 5-Year Follow-up Analysis of 1038 Patients

BACKGROUND

Although hip arthroscopy has been shown to have favorable results, there is a paucity of literature describing predictive factors of 5-year clinical outcomes.

PURPOSE

To identify predictive factors of midterm outcomes after hip arthroscopy in a cohort of 1038 patients whose outcomes at minimum 2-year follow-up were previously reported. In addition, to provide a comparison of short- and midterm predictive factors in outcome measures after hip arthroscopy.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed on all patients undergoing hip arthroscopy between February 2008 and June 2012. Patients were included if they had minimum 5-year follow-up on 2 patient-reported outcomes: Nonarthritic Hip Score (NAHS) and modified Harris Hip Score. Patients were excluded if they had any previous ipsilateral hip conditions. Using bivariate and multivariate analyses, we analyzed the effect of 36 pre- and intraoperative variables on the NAHS, modified Harris Hip Score, and conversion to total hip arthroplasty.

RESULTS

A total of 1038 patients met the inclusion criteria for the 2-year study, and 860 met our listed inclusion criteria for the 5-year study. The mean follow-up time was 62.0 months (range, 60.0-120.0 months). The bivariate analysis identified 10 variables (4 categorical and 6 continuous) that were predictive of 5-year postoperative NAHS. For the multivariate analysis, 7 variables were identified as being significant: preoperative NAHS, body mass index (BMI), age, lateral joint space, alpha angle, revision hip arthroscopy, and acetabular microfracture. These 7 variables were also predictive in the bivariate analysis. Age, BMI, revision hip arthroscopy, Tönnis grade, sex, trochanteric bursectomy, femoral head cartilage damage, and acetabular inclination were significant predictors of conversion to total hip arthroplasty.

CONCLUSION

This study reports favorable midterm clinical outcomes in the largest cohort of hip arthroscopies with minimum 5-year follow-up in the literature to date. Seven variables were identified as being significant predictors of postoperative NAHS in the bivariate and multivariate analyses: preoperative NAHS, BMI, age, lateral joint space, alpha angle, revision hip arthroscopy, and acetabular microfracture. Of these, preoperative NAHS, BMI, age, and revision hip arthroscopy were predictive of 2- and 5-year postoperative NAHS. These predictive factors may prove useful to clinicians in determining indications for hip arthroscopy and counseling patients on its expected outcomes.

Modified Pull-Through Technique for Hip Labral Reconstruction Using A Suture Suspension Bridge

Preservation of hip labral function is a primary goal in hip preservation surgery. Arthroscopic labral reconstruction in the hip is an alternative procedure for irreparable labrum in the nonarthritic hip population, with beneficial outcomes reported. Several challenges occur during labral reconstruction that make the procedure more difficult. The first is measuring the labral defect and matching the graft perfectly to the patient. The second is subsequent suture fixation and passage around the graft when it is loose within the joint. We propose a modification to the pull-through technique that both eliminates the inaccuracies in graft measurement and minimizes graft damage by eliminating the step of suture passage around the graft. This technique can be used for both segmental reconstruction or circumferential reconstruction of the hip labrum and can also accommodate knotless and knot-tied anchors. The advantages of this technique are increased procedure accuracy and efficiency.

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.

Acetabular Labral Reconstruction with Iliotibial Band Autograft: Outcome and Survivorship at a Minimum 10-Year Follow-up

BACKGROUND

Labral reconstruction has been shown to result in improved patient-reported outcomes (PROs) at mid-term follow-up in patients with a deficient labrum. The purpose of this study was to determine survivorship and PROs at a minimum 10-year follow-up.

METHODS

A retrospective evaluation of a prospectively collected single-surgeon database included 91 hips (89 patients) that underwent arthroscopic labral reconstruction with iliotibial band autograft between 2006 and 2008. The primary PRO was the Hip Outcome Score (HOS)-activities of daily living (ADL). The modified Harris hip score (mHHS), HOS-sports, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and patient satisfaction (on a scale of 1 to 10) were also collected at a 10-year minimum follow-up. Survivorship analysis curves were evaluated.

RESULTS

Eighty-two hips were evaluated at a 10-year minimum follow-up. Overall survivorship, with revision hip arthroscopy or total hip arthroplasty (THA) as the end point, was 70% at 5 years and 61% at 10 years, and the mean survival time was 9 years (95% confidence interval = 7.6 to 10 years). For the patients who did not undergo subsequent surgery, on average the mHHS increased from 60 preoperatively to 82 at the 10-year follow-up (p = 0.001), the HOS-ADL improved from 69 to 90 (p = 0.004), the HOS-sports improved from 43 to 76 (p = 0.001), and the median patient satisfaction was 10 of 10. Eighty percent of the patients achieved the minimal clinically important difference (MCID) in the HOS-ADL, and 87% obtained a patient acceptable symptom state (PASS).

CONCLUSIONS

Following arthroscopic labral reconstruction with iliotibial band autograft, 9% of the hips underwent revision arthroscopy and 27% underwent THA. At 10 years, the survival rate, with revision hip arthroscopy or THA as the end point, was 61%; however, for those with >2 mm of joint space, the current indication for labral reconstruction, the 10-year survival rate was 90%. Excellent PROs and patient satisfaction were reported by those who did not require revision or THA. With appropriate patient selection and prevention of postoperative adhesions, labral reconstruction results in excellent outcomes and high patient satisfaction that is sustained at a minimum 10-year follow-up.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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.

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.

Does hip preservation surgery prevent arthroplasty? Quantifying the rate of conversion to arthroplasty following hip preservation surgery

Hip arthroscopic surgery for femoroacetabular impingement and periacetabular osteotomy (PAO) for dysplasia is the most commonly used contemporary treatment for these conditions and has been shown to provide pain relief and restore function. What is less understood and perhaps of more interest to health economists, is the role of these procedures in preserving the hip joint and avoiding hip arthroplasty. The aim of this systematic review was to determine whether hip joint preservation surgery, indeed, preserves the hip joint by looking at conversion rates to total hip arthroplasty (THA). Two separate searches were undertaken, using PRISMA guidelines and utilizing PubMed and Open Athens search engines, identifying manuscripts that looked at conversion to THA following either hip arthroscopy (HA) or PAO. When considering HA, we found 64 eligible papers. Out of these studies, there were 59 430 hips with 5627 undergoing conversion to THA (9.47% [95% CI 9.23–9.71%]) with a mean conversion time of 24.42 months. Regarding PAO, there were 46 eligible papers including 4862 patients who underwent PAO with subsequent conversion to THA in 404 patients (8.31% [95% CI 7.54–9.12%]). with a mean conversion time of 70.11 months. Certain features were associated with increased conversion rates, including increasing age, worsening arthritis and joint space <2 mm. This study demonstrates that the mean conversion rates to be <10% for HA and PAO, during the mean follow-up periods of included manuscripts. Joint preserving surgery appears to defer or at least delay the need for THA.

Outcomes After Arthroscopic Hip Labral Reconstruction: A Systematic Review and Meta-analysis

BACKGROUND

The acetabular labrum is critical to maintenance of hip stability and has been found to play a key role in preservation of the hip fluid seal. For irreparable labral damage, arthroscopic labral reconstruction is an evolving technique that has been shown to decrease hip pain and restore function.

PURPOSE

To provide a comprehensive review of current literature for arthroscopic hip labral reconstruction, with a focus on determining if outcomes differ between autograft or allograft tissue.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

PubMed and Scopus online databases were searched with the key terms "hip,""labrum,""reconstruction," and "graft" in varying combinations. Procedures performed, complications, failures, and functional outcome measures were included in this analysis. The inverse variance method was used to calculate pooled estimates and 95% CIs.

RESULTS

Eight studies with 537 hips were included. Mean age was 37.4 years (95% CI, 34.5-40.4 years), and mean follow-up time was 29 months (95% CI, 26-33 months). Survivorship after autograft reconstruction ranged from 75.7% to 100%, as compared with 86.3% to 90.0% in the allograft cohort. In the autograft cohort, failures included 0% to 13.2% conversion to total hip arthroplasty and 0% to 11.0% revision hip arthroscopy. Failures in the allograft cohort included 0% to 12.9% total hip arthroplasty conversion, 0% to 10.0% revision arthroscopy, and 0% to 0.8% open revision surgery. Based on 6 studies, the modified Harris Hip Score improved by a mean 29.0 points after labral reconstruction (P < .0001).

CONCLUSION

Arthroscopic hip labral reconstruction results in clinically significant improvements in patient-reported outcomes. Our analysis indicates that there are no significant differences in outcomes based on graft type alone. A number of factors may determine graft choice, including patient preference, surgeon experience, operative time, morbidity, and cost. Proper patient selection based on age and severity of degenerative joint disease will also optimize outcomes after labral reconstruction.

Surgical Treatment of Labral Tears: Debridement, Repair, Reconstruction

PURPOSE OF REVIEW

With the rapid growth of hip arthroscopy over the past decade, new treatment paradigms as well as recognition of new disease states have sprung forth. The ability to perform complex arthroscopic procedures of the hip such as labral augmentation and reconstruction is essential for hip arthroscopists in the revision setting, with patient selection and indications for various labral treatments the key driver for improved short- and mid-term clinical outcomes.

RECENT FINDINGS

Current techniques have been developed to address disease states where the labrum is either unstable, torn, deficient, or otherwise incompetent. Many early reports focused on the description of these techniques with new literature reporting short- and mid-term outcomes. A few of these have demonstrated improved outcomes with a contemporary arthroscopy with emphasis on capsule preservation and repair. Studies have demonstrated that labral repair has improved outcomes over labral debridement, with results of labral reconstruction in a revision approaching those of labral repair. In addition, newer reports have shown significantly improved outcomes and survivorship with capsule repair and therefore should be included in every hip arthroscopy.

Minimum 5-Year Outcomes of Arthroscopic Hip Labral Reconstruction With Nested Matched-Pair Benchmarking Against a Labral Repair Control Group

BACKGROUND

Labral reconstruction has demonstrated short-term benefit for the treatment of irreparable labral tears. Nonetheless, there is a scarcity of evidence for midterm outcomes of this treatment.

HYPOTHESES

Arthroscopic segmental reconstruction in the setting of irreparable labral tears would show improvement in patient-reported outcomes (PROs) and high patient satisfaction at minimum 5-year follow-up. Second, primary labral reconstruction (PLRECON) would result in similar improvement in PROs at minimum 5-year follow-up when compared with a matched-pair primary labral repair (PLREPAIR) control group.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data from February 2008 to April 2013 were retrospectively reviewed. Patients were included if they underwent hip arthroscopy for segmental labral reconstruction in the setting of irreparable labral tear and femoroacetabular impingement, with minimum 5-year follow-up for modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, patient satisfaction, and visual analog scale for pain. Exclusion criteria were Tönnis osteoarthritis grade >1, prior hip conditions, or workers' compensation claims. PLRECON cases were matched in a 1:3 ratio to a PLREPAIR control group based on age ±5 years, sex, and body mass index ±5 kg/m².

RESULTS

Twenty-eight patients were eligible for the study, of which 23 (82.14%) had minimum 5-year follow-up. The authors found significant improvement from preoperative to latest follow-up in all outcome measures recorded: 17.8-point increase in modified Harris Hip Score (P = .002), 22-point increase in Nonarthritic Hip Score (P < .001), 25.4-point increase in Hip Outcome Score-Sports Specific Subscale (P = .003), and a 2.9-point decrease in visual analog scale pain ratings (P < .001). Mean patient satisfaction was 7.1 out of 10. In the nested matched-pair analysis, 17 patients who underwent PLRECON were matched to a control group of 51 patients who underwent PLREPAIR. PLRECON demonstrated comparable survivorship and comparable improvements in all PROs with the exception of patient satisfaction (6.7 vs 8.5, P = .04).

CONCLUSION

Hip arthroscopy with segmental labral reconstruction resulted in significant improvement in PROs at minimum 5-year follow-up. PLRECON reached comparable functional outcomes when compared with a benchmark PLREPAIR control group but demonstrated lower patient satisfaction at latest follow-up.

Clinical and Radiographic Predictors for Unsalvageable Labral Tear at the Time of Initial Hip Arthroscopic Management for Femoroacetabular Impingement

BACKGROUND

The acetabular labrum plays important roles in proprioception, nociception, synovial fluid seal effect, and static and dynamic joint stability and as a shock absorber. Clinical and radiographic risk factors for unsalvageable labral tear in femoroacetabular impingement (FAI) are not well established.

PURPOSE

To identify predictors of unsalvageable labral tear during initial hip arthroscopic management of FAI.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Patients were included who underwent primary hip arthroscopic treatment for FAI between March 2009 and March 2014. Patients were excluded who had <2-year follow-up, underwent bilateral surgery, or had a history of surgery, osteoarthritis (Tönnis grade 2 or 3), and other diagnoses, including lateral center-edge angle <25° diagnosed as developmental hip dysplasia. Patients were divided into 2 groups according to their labral condition: reconstruction and refixation. Unsalvageable labral tear was defined as any irreparable labral tear, including severe degenerative tear, frayed labrum, labral ossification, flattened labrum, and failed prior repair during surgery. Univariate and multivariate analyses identified risk factors for segmental labral reconstruction. Patient-reported outcome scores and postoperative revision rates were also assessed.

RESULTS

Twenty-five hips (18 male, 7 female) and 126 hips (65 male, 61 female) were included in the reconstruction and refixation groups, respectively. The mean ± SD ages were 52.6 ± 15.0 and 36.5 ± 16.1 years in the reconstruction and refixation groups, respectively. In the reconstruction group, the mean modified Harris Hip Score significantly improved from 67.3 ± 14.9 preoperatively to 95.0 ± 8.1 at final follow-up (P < .001), and the mean Nonarthritic Hip Score improved from 63.0 ± 18.3 preoperatively to 89.5 ± 10.1 at final follow-up (P < .001). In the refixation group, the mean modified Harris Hip Score significantly improved from 69.2 ± 18.6 preoperatively to 93.0 ± 11.2 at final follow-up (P < .001), and the mean Nonarthritic Hip Score improved from 60.7 ± 18.8 preoperatively to 88.6 ± 15.0 at final follow-up (P < .001). No significant difference was noted in patient-reported outcome scores and revision hip arthroscopy rates. The rate of conversion of total hip arthroplasty was higher in the reconstruction group than in the refixation group. Risk factors for unsalvageable labral tear were age ≥45 years (odds ratio [OR], 8.83; P < .007), body mass index ≥23.1 kg/m² (OR, 13.05; P < .001), and vertical center anterior angle ≥36° (OR, 19.03; P < .001). Furthermore, in this study, unsalvageable labral tears were present in cases with at least 2 of the 3 risk factors.

CONCLUSION

Age ≥45 years, body mass index ≥23.1 kg/m², and vertical center anterior angle ≥36° are risk factors for unsalvageable labral tear at initial hip arthroscopic surgery for patients with FAI.

Indications and Outcomes of Arthroscopic Labral Reconstruction of the Hip: A Systematic Review

PURPOSE

The primary purpose of this investigation was to systematically evaluate the literature for the current indications and outcomes of arthroscopic labral reconstruction of the hip. Our secondary purpose was to evaluate the role of arthroscopic labral reconstruction in the management of reparable labral tears.

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using a PRISMA checklist. Studies published between June 2009 and June 2018 that evaluated outcomes after arthroscopic labral reconstruction with a minimum of 1 year of follow-up were included.

RESULTS

Eleven studies met the inclusion and exclusion criteria. A total of 373 patients were identified. Of the 11 studies, 9 reported that an irreparable labrum was their indication for reconstruction, with 8 reporting that this was ultimately determined intraoperatively. Substantial variability in surgical technique, graft choice, and concurrent pathology was found. All 11 studies used at least 1 validated functional outcome metric to evaluate surgical outcomes, with all studies reporting improvement greater than the minimal clinically important difference. Donor-site pain was the most common complication, although it was reported in only 2 studies. Reported rates of revision surgery and conversion to arthroplasty were low (range, 0%-9.1% for both).

CONCLUSIONS

All 11 studies included in this systematic review reported clinically significant functional improvements after arthroscopic labral reconstruction and low rates of complications, revision surgery, and progression of arthritis, although graft types and concomitant procedures confound the results. The most common indication for reconstruction was a deficient labrum on intraoperative evaluation. The 6 studies that evaluated patient satisfaction reported favorable results, with a range of 6.73 to 8.7.

LEVEL OF EVIDENCE

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

Editorial Commentary: When Enough Is Enough-Orthopaedic Procedures With Long Learning Curves and the Case of Hip Arthroscopy

The incidence of hip arthroscopy is increasing over time, as is the rate of labral repairs performed by American Board of Orthopaedic Surgery candidates in general and by sports medicine fellowship-trained candidates in particular. However, both arthroscopic labral debridement and repair yield excellent minimum 10-year outcomes in well-selected femoroacetabular impingement patients. In my practice, most hip arthroscopy patients undergo labral repair, and labral reconstruction is performed in about 4%, so I view the rising use of labral repair as a step forward. But concerns remain. How many of these American Board of Orthopaedic Surgery candidates will be able to hone their arthroscopic skills (and clinical judgment) in anywhere near the number of cases needed to achieve demonstrably low reoperation rates? In addition, will these fledgling surgeons be able to perform labral reconstructions or augmentations when indicated, bearing in mind that only half of such cases could be predicted preoperatively? The definition of adequate hip arthroscopy training remains up for grabs.

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 gracilis tendon autograft is a safe choice for orthopedic reconstructive procedures: a consecutive case series studying the effects of tendon harvesting

Background

The gracilis tendon is commonly used as an autograft to reconstruct torn tendons or ligaments in many parts of the body. Little is known about the subjective and functional outcome after gracilis tendon harvest. The aim of this study was to evaluate the outcome of the donor leg in patients undergoing such surgery.

Methods

Patients with chronic acromioclavicular joint dislocations undergoing coracoclavicular ligament reconstructions using autogenous gracilis tendon grafts were eligible for this study. The graft harvesting procedure was carried out in a standard fashion using a tendon stripper. Knee injury and Osteoarthritis Outcome Score (KOOS) were collected preoperatively and after 12 months. The first 5 patients were included retrospectively and lacked preoperative data, for these patients age- and gender matched normative KOOS scores were used as baseline values. Isometric knee flexor strength in 60° and 90° degrees of flexion was measured at final follow up at a median of 26 (14–56) months postoperatively with the non-operated leg used as reference.

Results

Twenty four patients were eligible for the study and 2 were excluded. The 22 patients available for analysis had a mean age of 44 (22–62) years at the time of surgery and 4 were women. There was no statistically significant change in KOOS 12 months postoperatively compared to baseline values but the patients were weaker in knee flexion in the operated leg compared to the non-operated one.

Conclusions

Gracilis tendon harvesting results in a weakness of knee flexion but does not impair subjective knee function and is a procedure that can be recommended when an autogenous tendon graft is needed.