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At Issue: Hip labral reconstruction
Is the optimal method of hip labral reconstruction segmental or circumferential?
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Segmental reconstruction enables augmentation
I perform arthroscopic labral repair when possible. The real question is whether the entire labrum, even intact sections, should be replaced by a labral graft in the common scenario of focal anterosuperior labral insufficiency typically observed in patients with femoroacetabular impingement (FAI).
In the setting of irreparable and/or poor quality tissue, I perform limited labral resection, often from 12 o’clock to 2 o’clock or 3 o’clock, followed by primary segmental labral reconstruction using semitendinosus allograft with techniques we originally described in 2012. Key concepts introduced were overlapped junctional positioning of gracilis autograft with native labrum and graft tensioning. In cases of insufficient labral quantity, but sufficient quality, labral retention with segmental labral augmentation is performed (Figure).
Compared with total labral reconstruction, segmental labral reconstruction is simpler, faster, cheaper, retains proprioception, enables labral augmentation and has more evidence-based support. In my hands, compared to labral repair, segmental reconstruction adds about 15 minutes of surgical time, typically using four knotless suture anchors, with simple external graft preparation. Hip arthroscopy, in general, is difficult enough, and segmental labral reconstruction, while challenging, is easier to perform than total labral reconstruction. Traction times, which correlated with complications, are significantly less compared with total labral reconstruction.
Graft tensioning with compression at the overlapped graft-native labrum junctions avoids side-to-side junctional gaps that could compromise the desired fluid seal effect. Other advantages are seamless labral augmentation if the surgeon opts to retain labral tissue, partially retaining hoop stresses. From a cost perspective, fewer suture anchors and shorter surgery time also favor segmental labral reconstruction. Moreover, not all facilities have the financial or storage resources for allografts; shorter autografts (eg, iliotibial band [ITB], gracilis, semitendinosus) are readily available for segmental reconstructions, but longer autografts, such as a 10-cm ITB, used in total reconstructions may have more consequential harvest morbidity.
Image: Dean K. Matsuda, MD
Although compromised hoop stresses are a potential downside of segmental labral reconstruction, this has not been established and is at least partially averted via labral augmentation. That argument should be counterbalanced with the loss of proprioception that occurs when replacing an entire native labrum with denervated graft with unknown consequences.
Total labral reconstruction is newer, so it understandably has less evidence-based support. Studies suggest promising benefits with both options. Emerging evidence suggests labral augmentation may yield even better patient-reported outcomes. Segmental labral reconstruction techniques may be more feasible than total labral reconstruction techniques in this setting of retained labral tissue. If further studies confirm better outcomes with labral augmentation, I fear that patients indicated for labral augmentation using segmental techniques will potentially lose that option if surgeons only perform total labral reconstruction.
A well-done, simpler, faster, less expensive procedure that meets the desired treatment goal and has more evidence-based support beats a longer, more complex and more expensive procedure with less evidence-based support, in my opinion. However, I believe there is a role for total labral reconstruction in select cases; just, respectfully, not in the common scenario of focal labral insufficiency.
- References:
- Domb BG, et al. Am J Sports Med. 2019;doi:10.1177/0363546518825259.
- Lee S, et al. Am J Sports Med. 2015; doi: 10.1177/0363546514553089.
- Maldonado DR, et al. J Hip Preserv Surg. 2019;doi:10.1093/jhps/hnz008.
- Matsuda DK. Arthrosc Tech. 2012;doi:10.1016/j.eats.2011.12.001.
- Matsuda DK, et al. Am J Sports Med. 2013; doi:10.1177/0363546513482884.
- Philippon MJ, et al. Arthroscopy. 2018;doi:10.1016/j.arthro.2018.04.021.
- For more information:
- Dean K. Matsuda, MD, can be reached at Premier Hip Arthroscopy, 13160 Mindanao Way, #300, Marina Del Rey, CA 90292; email: saltandlight777@hotmail.com.
Disclosure: Matsuda reports he is a paid consultant for Zimmer Biomet and receives royalties from Smith & Nephew, ArthroCare and Zimmer Biomet.
Complete hip labral reconstruction offers advantages over labral repair
Most debates on this issue in which I have participated have focused on labral reconstruction vs. repair or debridement. Therefore, I see this opportunity to discuss the advantages of complete labral reconstruction vs. segmental grafting as a sign of progress. Labral reconstruction, in general, offers clear advantages over repair. In the presence of chronic FAI, the torn labrum is inherently degenerative and damaged. The conventional repair technique involves exposure of the acetabular rim for anchor placement and compromises its vital blood supply. These factors make it challenging for the repaired labrum to truly heal, maintain its seal function and not be painful. Labral reconstruction offers obvious advantages. The painful labral tissue is removed, the acetabulum can be optimally shaped and the new labral graft can confer all of the biomechanical advantages of the native labrum, but remains aneural as it incorporates. In this way, labral reconstruction provides more consistent pain relief.
Segmental grafting is typically performed in the anterosuperior (AS) quadrant of the acetabulum where the labrum is typically the most significantly damaged. This area is also in the thickest aspect of the acetabular rim where anchor placement is easier. Clearly, it is a simpler procedure to perform than complete reconstruction, but it is fundamentally limited. Its most significant limitation is that the native labrum that remains is rendered weaker as it has lost its circular structure and thereby its hoop fiber strength. There is no effective way to fix adjacent native labral tissue to the graft, and the tissue is therefore weakened and more vulnerable to any future tearing. Many of my early segmental grafts failed as a consequence of tearing of the antero-inferior native labral remnant.
Source: Brian J. White, MD.
The longer graft is more complete and creates a stronger construct to re-establish a seal with the femoral head and reproduce normal hip biomechanics. Complete reconstructions span from the origin of the anterior transverse acetabular ligament to the postero-inferior acetabulum. These allow for a more thorough correction of the pincer and for a more effective treatment of all posterior labral pathology. A longer graft more closely represents a circle and, although it is not complete in this regard, it is stronger than a shorter graft. Its length more closely re-establishes the normal hoop fibers of the native labrum. The construct of a complete labral reconstruction is like a suspension bridge in that graft material is positioned both in front of and behind the AS quadrant of the acetabulum, giving added strength to the graft in this high stress region. In contrast, the segmental graft placed exclusively in this zone is not afforded any surrounding strength and support of its construct. Complete allograft labral reconstructions have been well validated in the literature. Within my 2016 revision study, we sub-analyzed longer grafts vs. segmental grafts and found a statistically lower failure rate with the longer grafts.
Segmental grafting is part of an evolutionary process. As surgeons gain experience and the ability to comfortably work around the entire acetabulum, it is only logical that graft length will increase just as it did in my hands. Anyone who is interested in expanding his or her zone of labral reconstruction is welcome to visit me and learn more.
- References:
- Scanaliato JP, et al. Am J Sports Med. 2018;doi: 10.1177/0363546518775425.
- White BJ, et al. Arthroscopy. 2016;doi: 10.1016/j.arthro.2015.07.016.
- White BJ, et al. Arthroscopy. 2016;doi:10.1016/j.arthro.2016.07.024.
- White BJ, et al. Arthroscopy. 2018;doi:10.1016/j.arthro.2017.08.240.
- For more information:
- Brian J. White, MD, can be reached at Western Orthopaedics, 1830 Franklin St., Suite 450, Denver, CO 80218; email: whitebj2@gmail.com.
Disclosure: White reports he is an education and product development consultant for AlloSource, Zimmer Biomet, Conmed Linvatec and Smith & Nephew.