Revision Hip Arthroscopy With Labral Reconstruction for Irreparable Labral Tears in Athletes: Minimum 2-Year Outcomes With a Benchmark Control Group

Mid- to Long-Term Outcomes in Patients After Hip Arthroscopy With Labral Reconstruction: A Systematic Review

Background

There is a paucity of aggregate data documenting mid- to long-term outcomes of patients after hip arthroscopy with labral reconstruction.

Purpose

To report mid- to long-term outcomes in patients after undergoing either primary or revision hip arthroscopy with labral reconstruction for the treatment of irreparable labral tears.

Study Design

Systematic review; Level of evidence, 4.

Methods

A systematic review of the PubMed, Cochrane, and Scopus databases in May 2022 was conducted with the following keywords: "hip arthroscopy,""labral reconstruction,""irreparable,""labrum,""reconstruction,""five-year,""midterm,""5 year,""long-term,""10 year," ten-year," and "femoroacetabular impingement" using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. Midterm was defined as mean 5-year follow-up, and long-term was defined as mean 10-year or longer follow-up. For each included article, the demographic, radiographic, intraoperative, and surgical variables, as well as patient-reported outcomes (PROs), psychometric thresholds, and secondary surgeries were recorded. Forest plots were created for PROs that were reported in ≥3 studies; heterogeneity was assessed using I2 values.

Results

Out of 463 initial articles, 5 studies including 178 hips with primary and 41 hips with revision surgeries were included. One study had an average 5-year follow-up, three studies had a minimum 5-year follow-up and one study had a minimum 10-year follow-up. The most common indications for hip arthroscopy with labral reconstruction were irreparable labral tears. The most common PRO was the modified Harris Hip Score (mHHS), which was reported in all 5 studies. The mean preoperative mHHS ranged from 58.9 to 66, and the mean postoperative mHHS at minimum 5-year follow-up ranged from 80.2 to 89. The preoperative and postoperative mHHSs for the single long-term follow-up study were 60 and 82, respectively. All 5 studies demonstrated significant improvements in reported PROs. All 5 studies reported secondary surgery rates, with 1 study reporting rates at both 5- and 10-year follow-up. Conversion to total hip arthroplasty ranged from 0% to 27%, while overall secondary surgery rates ranged from 0% to 36%.

Conclusion

Findings demonstrated that patients undergoing primary and revision hip arthroscopy with labral reconstruction experienced favorable outcomes and high rates of clinical benefit and survivorship at mid- to long-term follow-up.

Patients Undergoing Revision Hip Arthroscopy With Labral Reconstruction or Augmentation Demonstrate Favorable Patient Reported Outcomes: A Systematic Review

PURPOSE

To review current literature evaluating patient-reported outcomes (PROs) and survivorship in patients undergoing revision hip arthroscopy with labral reconstruction or augmentation.

METHODS

A systematic review was performed with the following key words: (revision) AND (hip OR femoroacetabular impingement) AND (arthroscopy OR arthroscopic) AND (reconstruction OR augmentation OR irreparable). PubMed, Cochrane Trials, and Scopus were queried in October 2022 using the criteria established in the Preferred Reporting Items for Systematic Reviews and Meta-analyses. Studies were included if they involved patients undergoing revision hip arthroscopy with labral reconstruction or augmentation and reported preoperative and postoperative PROs at minimum 2-year follow-up. Only original research articles were included. Survivorship was defined as a nonconversion to total hip arthroplasty. Outcomes present in 3 or more studies underwent further statistical analysis with forest plots. Heterogeneity of studies was evaluated using the I2 statistic.

RESULTS

Five studies were reviewed, including 359 revision hip arthroscopies (335 with complete follow-up) with a follow-up that ranged from 2.2 to 5.2 years. Four studies reported on outcomes after revision labral reconstruction and 1 study reported on labral augmentation. Two out of 5 included studies evaluated for statistical significance between preoperative and postoperative outcomes. Three out of 5 studies reported a rate of at least 70% for achieving minimal clinically important difference in at least 1 PRO. At minimum 2-year follow-up, survivorship ranged from 93.5% to 100%.

CONCLUSIONS

Patients that underwent revision hip arthroscopy with labral reconstruction or augmentation demonstrated improvement in PROs with mixed rates of achieving clinical benefit and rates of survivorship at minimum 2-year follow-up ranging from 93.5% to 100%.

LEVEL OF EVIDENCE

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

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.

Modified Technique for Labral Reconstruction of Hip Joint Using Autologous Iliotibial Band (ITB)-Make Labral Reconstruction Stress-Free

Current treatments for labral tear include surgical debridement, arthroscopic repair, and labral reconstruction. Although labral debridement and labral suture repair are suitable for most patients, labral reconstruction is the first treatment option when there is extensive labral degeneration or defect. Often, however, the labral degeneration or defect is only detected intraoperatively; therefore, the surgeon should always have a backup plan. The current labral reconstruction technique has shortcomings such as long operation time, difficult autograft harvesting, cumbersome graft preparation, and the need for a large surgical incision and re-sterilization and draping. To address these problems, we developed a modified technique for draping and surgery. This technique ensures preparedness for labral reconstruction during each hip arthroscopic surgery. The method also simplifies the steps for autologous iliotibial band graft harvesting and shortens operative time. We have achieved satisfactory clinical results with use of this technique over the past 2 years. In this Technical Note, we describe our technique. This modified labral reconstruction technique greatly improves surgical efficiency and could be a promising surgical technique for hip labral reconstruction.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Descriptive laboratory study.

METHODS

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

RESULTS

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

CONCLUSION

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

CLINICAL RELEVANCE

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

Durable Outcomes After Hip Labral Reconstruction at Minimum 5-Year Follow-Up: A Systematic Review

PURPOSE

To systematically review and report the mid- to long-term patient reported outcomes (PROs) following hip labral reconstruction.

METHODS

A literature search of the Pubmed, Embase, and Cochrane Library databases was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for clinical studies reporting mid- to long-term PROs at minimum five year follow-up following arthroscopic hip labral reconstruction. A quality assessment was performed using the Methodological Index of Non-Randomized Studies (MINORS) grading system. Data collection included study characteristics, demographics, indications, radiographic metrics, perioperative findings, surgical technique, baseline and most recent PROs, and subsequent surgeries.

RESULTS

Four studies met inclusion criteria, with 182 hips (age range, 27.9 to 38.7 years) undergoing labral reconstruction in primary and revision hip surgery with minimum five year follow-up. There were three level III studies and one level IV study, with an average MINORS score of 16.6. All studies cited labral tissue characteristics as a factor for surgical indications, including the quality and/or size of the labrum. Three studies performed segmental labral reconstructions, while another study utilized a circumferential technique. Varying grafts were selected, including hamstring autograft/allograft, ligamentum teres autograft, iliotibial band autograft, and tensor fascia lata autograft. All studies demonstrated improved PROs from baseline to most recent follow-up, with four studies reporting modified Harris Hip Score (mHHS) values that increased from baseline (range, 58.9 to 66.8) to most recent follow-up (range, 80.1 to 86.3). After labral reconstruction, rates of revision arthroscopy ranged from 4.8% to 13.3% and conversion to total hip arthroplasty ranged from 1.6% to 27%.

CONCLUSION

Improved PROs were observed in all studies at minimum 5-year follow-up, suggesting that labral reconstruction can offer durable results beyond short-term follow-up. While surgical indications for all studies included labral tissue characteristics, differing graft selection and surgical techniques were utilized across studies, limiting the ability to determine an optimal treatment approach.

The Vascularization Course of Labral Autograft and Its Effect on Tissue Healing: Acetabular Labral Augmentation Versus Labral Reconstruction in a Porcine Model

BACKGROUND

The preservation of the native labral vascularization is assumed to be the potential advantage of acetabular labral augmentation, the effect of which remains unknown.

PURPOSE

To identify the vascular distribution within the labral autograft and its effect on the healing process between labral augmentation (AUG) and reconstruction (RECON) in a porcine model.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 36 pigs randomly underwent unilateral labral augmentation or reconstruction (AUG group, n = 18; RECON group, n = 18). The pigs were randomly sacrificed at 6, 12, and 24 weeks postoperatively. The labral autografts were harvested for macroscopic evaluation and histologic assessment. The labral autograft was zoned into 2 halves to observe the vascular distribution: the capsular half (zone I) and the articular half (zone II). Each zone was divided into 2 parts: the peripheral part (IA and IIA) and the part attached to the acetabulum (IB and IIB).

RESULTS

At 6 weeks, there existed more vascular ingrowth in zone I, whereas zone IIB appeared nearly avascular in both groups. At 12 weeks, the area with the greatest vascularity was zone II in the RECON group and zone IA in the AUG group. The vascularity was concentrated at zones IA and IIA in both groups at 24 weeks. The labral autografts were hypertrophic with sufficient filling of the labral defect in both groups at 6 weeks. At 12 weeks, an insufficient volume of the articular half was observed in 3 of 6 labral autografts in the RECON group, while all autografts remained well integrated with the chondrolabral junction in the AUG group. At 24 weeks, unsatisfactory merging of the labral autograft with the cartilage at the articular side was found in 2 of 6 labral autografts in the RECON group, which was not observed in the AUG group despite the sufficient volume of autografts labrum in both groups.

CONCLUSION

Slow vascular ingrowth within the articular half might account for the poor healing of the reconstructed labral autograft. Labral augmentation provides the possibility of better tissue healing because of the preservation of the original chondrolabral junction compared with labral reconstruction.

CLINICAL RELEVANCE

Labral augmentation might be a feasible alternative to labral reconstruction under the condition of viable labral remnants.