Should refixation or acute reconstruction be used to treat a hypoplastic labral tear?
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Click here to read the Cover Story, "Surgeons weigh surgical options for primary hip labral tears."
Do not give up on refixation
The role for acute labral reconstruction continues to be defined.
Benjamin G. Domb, MD, and colleagues published a study that supports its use in the setting of irreparable tears and segmental defects or in the setting of deficiency secondary to an ossified labrum. That being said, I favor labral refixation whenever possible for reparable lesions. A hypoplastic labrum may still be a functional one, and refixation of preserved, native tissue with an intact transitional zone of cartilage is likely biologically and biomechanically favorable to allograft tissue. Edwin R. Cadet, MD, and colleagues have demonstrated the favorable biomechanics of refixation compared with reconstruction, although both fare better than debridement.
A variety of suture configurations have been described to help avoid eversion and preserve the suction seal even with hypoplastic labrums. In summary, do not give up on primary labral refixation, even in the setting of hypoplastic tissue. A careful rim recession can help to expose and preserve the transitional zone cartilage, which can be incorporated into the repair, resulting in a robust construct that avoids eversion and restores a strong suction seal.
In the end, however, responsible management of the labral tear is the key, and refixation, segmental reconstruction and circumferential reconstruction must all be in your armamentarium. Blake M. Bodendorfer, MD, Shane J. Nho, MD, MS, and colleagues showed equivalent 2-year patient-reported outcomes with all of these approaches when performed responsibly. Some lesions may not be reparable, particularly with compromised hypoplastic tissue, and you will need to be prepared for reconstruction.
- References:
- Bodendorfer BM, et al. Arthroscopy. 2022;doi:10.1016/j.arthro.2021.05.013.
- Cadet ER, et al. Am J Sports Med. 2012;doi:10.1177/0363546512457645.
- Maldonado DR, et al. Am J Sports Med. 2022;doi:10.1177/03635465221091192.
Asheesh Bedi, MD, director of Sports Medicine and Joint Preservation at NorthShore University Health System and clinical professor at University of Chicago, Skokie, Illinois is an Orthopedics Today Editorial Board Member.
Reconstruction is best for irreparable tears
A hypoplastic or small, 2-mm labrum poses a challenge to a hip arthroscopist who only repairs the labrum. It is well established that the labrum is critically important for acetabular volume enhancement, joint stability and creating a fluid seal with the femoral head. When the labrum is small, it is also likely to be everted from the edge of the acetabulum as a byproduct of the opposing cam or micro-instability. When everted and narrow, it is near impossible to both repair the labrum and mobilize it to re-establish a seal with the femoral head. Sometimes, attempting to do so can cause a radial tear in this fragile tissue. Even if the labrum is successfully repaired, it lacks the surface area to create a true bond and solid healing. Often, this leads to a disappointing result. At best, when it does heal, the patient is left with the same dysmorphic, dysfunctional labrum.
Circumferential labral reconstruction offers a perfect alternative. With this powerful operation, a new, properly sized labrum can be made. It will incorporate, as it is well fixed to a prepared acetabular rim and is constantly under compression, but it will not re-innervate, making it an ideal solution for a patient with a painful hip joint. Labral reconstruction offers the ability to make a properly sized labrum irrespective of the patient’s native labral anatomy.
I have two publications that offer a direct comparison between labral repair and labral reconstruction. The first is a bilateral study where a labral repair was performed on one hip and a labral reconstruction was performed on the other hip. None of the labral reconstructions failed, while 31% of the labral repairs failed and patients elected to have a third surgery to convert it to a labral reconstruction. The second study was written in response to several studies that showed a higher rate of failure in patients older than 40 years of age with labral repair. In some studies, this rate of failure was as high as 35%. In my “over 40” study of more than 300 patients, labral repair failed in 21% of patients and labral reconstruction failed in 7% of patients. In both studies, the labral reconstructions clearly outperformed the labral repairs.
Circumferential labral reconstruction is a well-validated and successful operation in situations where the labrum is deemed “irreparable.” This definition of “irreparable” has expanded over the years as our technique with labral reconstruction has improved and our experience has grown. Appropriately, the indications for primary labral reconstruction have expanded. The hypoplastic labrum clearly falls within the definition of “irreparable” and is better treated with circumferential labral reconstruction.
- References:
- Horner NS, et al. Arthroscopy. 2017;doi:10.1016/j.arthro.2016.06.044.
- White BJ, et al. Arthroscopy. 2018;doi:10.1016/j.arthro.2017.08.240.
- White BJ, et al. Arthroscopy. 2020;doi:10.1016/j.arthro.2020.04.031.
Brian J. White, MD, is an orthopedic surgeon at Western Orthopaedics in Denver.
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