Surgeons weigh surgical options for primary hip labral tears
Click Here to Manage Email Alerts
Among patients with labral tears, hip arthroscopy with primary labral repair is the gold standard treatment, which published literature has shown to have high success rates.
A study published in 2022 in the American Journal of Sports Medicine by Christopher M. Larson, MD, and colleagues showed 86% of patients who underwent labral repair reported excellent results compared with 48% of patients who underwent labral debridement at 7-year follow-up. Larson and colleagues noted a failure rate of 13% vs. 30% in the repair group and debridement group, respectively.
Source: Kayla Seiffert
“We feel confident that we want to preserve the labrum,” Larson, an orthopedic surgeon at Twin Cities Orthopedics, told Healio/Orthopedics Today. “[In] my opinion, and I think in [the opinions of] most hip arthroscopists, a labral repair is performed in just about every primary case. So for me, probably 95% to 99% of the time, I am going to repair the labrum if it is repairable.”
When a patient’s labrum is calcified or too shredded or diseased to repair or is too small to form a seal against the femoral head, the trend has been to remove portions of the labrum and reconstruct it, sources told Healio/Orthopedics Today.
“For many years, it has been our approach that repair is the gold standard, and when a labrum has viable tissue, then our go-to approach is to repair it,” Benjamin G. Domb, MD, FAAOS, FAOA, medical director of the American Hip Institute and fellowship director of the American Hip Institute Research Foundation, said. “When there is compromise of the labral tissue and/or that labral tissue is not going to produce a viable repair, then a labral reconstruction offers us an excellent alternative.”
Repair vs. reconstruction
However, Derek H. Ochiai, MD, of the National Hip Center at the Nirschl Orthopaedic Center, said there is a “spectrum of thought” on performing primary labral reconstruction, with some surgeons choosing to perform reconstruction in only a few patients and others choosing to perform it in almost every patient.
“My threshold is if I can make a repair look, feel and function as good as a labral reconstruction, then I will do a repair,” Ochiai said. “If I think I can make the reconstruction look, feel and function better than repairing what is in front of me, then I am going to do a reconstruction. But others have different thresholds.”
Dean K. Matsuda, MD, FAAOS, FAANA, of Premier Hip Arthroscopy, said the idea of performing labral reconstruction in all primary cases may be due to research that has shown similar or even better outcomes between labral reconstruction compared with repair.
“Another advantage that rarely gets mentioned is that, in patients with rim chondral loss meriting microfracture or other cartilage/fibrocartilage regrowth procedures, labral reconstruction restores a peripheral border to contain the super clot,” Matsuda, who is an Orthopedics Today Editorial Board Member, said.
But Matsuda added, “For me, labral repair is plan A and labral reconstruction, which I perform with semitendinosus allograft in approximately 15 minutes, is plan B in about 5% of these hips.”
Advantages of reconstruction
Because most labral tears are due to femoroacetabular impingement, Ochiai said, by performing a labral repair, the surgeon is repairing a labrum that already has degeneration from the impingement.
“During the surgery, you normalize the biomechanics of the hip, so that would make it more likely that the labrum would heal when you sew it back, but maybe the labrum was already too degenerative to heal or maybe it partially heals, but not completely because of intrasubstance labral degeneration, which cannot be addressed with doing a repair,” he said. “So, then there would be a chance the patient would need a revision surgery and labral reconstruction.”
Labral reconstruction also allows surgeons to remove diseased tissue of the labrum, remove structurally compromised tissue and replace it with graft tissue and make a more robust labrum in cases of native hypoplastic labrum, according to Domb.
“Reconstruction can restore the biomechanics and native suction seal in cases when labral repair cannot, such as when there is calcification or excessive damage to the native labrum. As an ancillary benefit, removal of the native labrum will remove with it any nociceptive pain-sensing nerve fibers that supply the native labrum, so that when we replace it with a graft, the patient may feel less pain right from the start,” Domb said.
Advantages of repair
Despite these advantages, Ochiai said being able to restore normal anatomy with the patient’s own tissue is attractive from a sports medicine standpoint because the aim is to repair and restore function to as close to normal as possible.
“If you can get a normal labrum to heal and function normally, then that is probably going to work better from a proprioception standpoint than having a donated tendon graft in place,” Ochiai said. “So, I think in best case scenarios, if the labrum heals and functions normally, then that patient would have a higher chance of having a normal function to their hip throughout their life.”
In addition, Larson said there is a larger expense associated with labral reconstruction as the procedure takes more time to perform and surgeons usually use an allograft, as well as more anchors.
“The longer time that surgeons take also involves potentially more traction time and we know from studies that the greater length of time in traction, the potential greater risk for complications like nerve-related complications,” Larson, who is an Orthopedics Today Editorial Board Member, said.
Technically advanced procedure
Domb said labral reconstruction is a technically advanced procedure, especially when it comes to larger and circumferential labral reconstructions. The knotless pull-through technique for segmental and circumferential labral reconstruction has been used as a way to simplify labral reconstruction, he said.
“The technique obviates the need for measurement of the graft length and allows us to complete the labral reconstruction using pre-placed anchors. The graft is pulled through the joint and then sequentially anchored from anterior to posterior. In the final step, we amputate the unused remnant of the graft so that the graft will be perfectly sized in every case,” Domb said. “The steps delineated in this technique have made the procedure simpler, more reproducible and faster, and I hope more accessible to more surgeons.”
However, even with this simplified technique, Domb said that labral reconstruction still remains “a more technically advanced procedure than a labral repair and does require a significant amount of training.”
Similarly, Matsuda said he developed a knotless anchor technique for segmental labral reconstruction using hamstring tendon autograft or allograft which he believes is technically easier, quicker, needs fewer anchors and enables graft tensioning and intentional graft overlap at the margins of the native labrum to optimize a fluid seal.
Long-term results needed
Although primary labral reconstruction has shown good results in the short-term, John J. Christoforetti, MD, FAAOS, second vice president of the International Society for Hip Arthroscopy, said surgeons and researchers are only on the verge of understanding the long-term implications of choosing repair or reconstruction for primary hip labral tears.
“I think further research needs to be done into how important various techniques may be to help impact improving outcomes, as well as preserving the joint, both in the setting of how we choose to reconstruct the labrum, how difficult or easy it is to reproducibly reconstruct the labrum in various settings of hip structure and, of course, in the area of labral repair, how we continue to work toward making repairs improve the native mechanics,” Christoforetti said.
To better identify whether repair or reconstruction would benefit patients more in the primary setting, Larson said better designed studies, such as randomized controlled trials that compare labral repair and reconstruction in a similar setting with short- and long-term follow-up, are still needed.
“That is the only way we are going to know if a reconstruction would be ideal,” Larson said. “I do not know if that study is ever going to take place, but almost all of our studies have biases and flaws, so we cannot prove that one [procedure] is better than the other.”
When performing primary labral reconstruction, Ochiai said it is still unclear whether it is more beneficial to only reconstruct the part of the labrum that has macroscopic damage or to remove and insert the tendon graft throughout the entire labrum. He said future research should focus on identifying why some labral repairs fail and how surgeons can identify those factors prior to or during surgery to know which patients would be better served with a labral reconstruction.
“We know some labral repairs fail even if they are technically well done. The question is why,” Ochiai said.
He continued, “There are multiple factors [of why labral repairs fail], but it would be nice to know which patients would not do well with a repair before a repair was performed. Then, the surgeon could go straight to a labral reconstruction or augmentation.”
Education on both approaches
Surgeons who perform hip arthroscopy should be comfortable and competent in performing labral reconstruction as a go-to option if functional labral repair in not possible. That way they do not “force an ill-advised repair that could contribute to interval hip degeneration,” according to Matsuda.
“My opinion is for surgeons on the learning curve to gain the arthroscopic skills to perform a reliable labral reconstruction technique based on one’s experience, comfort level and resources, including graft type, harvest morbidity if not using allograft, surgical time and traction time,” Matsuda said.
Currently, orthopedic surgery residents do not receive adequate instruction to be able to perform labral repair or labral reconstruction, according to Christoforetti. Although residents in sports medicine-accredited fellowships are required to be exposed to 2 months of athletic hip management instruction, including arthroscopic hip surgery, Christoforetti said the education currently provided on labral repair and reconstruction is not consistent across programs.
“At present, advanced fellowship training in hip arthroscopic surgery or hip preservation is a more typical road for a surgeon to gain adequate training on both of these techniques inside organized training programs,” Christoforetti said.
He said there are various opportunities for continuing education beyond a fellowship and often these are mandatory for surgeons, including industry-sponsored or medical society-sponsored educational programs.
Source: Derek H. Ochiai, MD
In addition, Domb said orthopedic surgeons also have the option to practice labral repair and reconstruction in the cadaver lab.
“Practice in the cadaver lab is a wonderful opportunity for us that orthopedic surgeons 50 years ago did not have. Today we have the opportunity to practice almost endlessly in cadaver labs,” Domb said. “So, we ought not to be practicing in patients, but rather practicing in a lab.”
Patient consent
Because some published research has shown that only half of preoperative MRIs were predictive of hips that would require labral reconstruction, Matsuda said it is important to counsel and consent patients for possible labral reconstruction preoperatively. That way surgeons can “seamlessly transition from repair to primary reconstruction or augmentation” intraoperatively, if necessary.
“If a surgeon only knows how to perform primary repairs, there will be a tendency to repair every labral tear regardless of condition, which is ill-advised. Or they may need to reschedule or refer that patient for labral reconstruction,” he said. “I always discuss the possibility of labral reconstruction with patients preoperatively to obtain their consent in case I determine the [reconstruction] is indicated.”
However, Domb said he believes not every surgeon who does hip arthroscopy needs to know how to perform a labral reconstruction.
“Labral reconstruction, at least for the foreseeable future, will probably remain something that is reserved for a tertiary referral setting where the surgeon and center are highly specialized in hip preservation,” Domb said. “At least at present, it is appropriate for surgeons who do hip preservation and also [focus on] other areas of sports medicine or orthopedics to consider a labral repair to be the first line of treatment. In the minority of cases where labral repair is not enough, referring a patient out for a labral reconstruction is totally fine and appropriate.”
- References:
- Domb BG, et al. Am J Sports Med. 2019;doi:10.1177/0363546518825259.
- Harris JD, et al. Curr Rev Musculoskelet Med. 2016;doi:10.1007/s12178-016-9360-9.
- Kwon HM, et al. Knee Surg Sports Traumatol Arthrosc. 2022;doi:10.1007/s00167-002-06881-z.
- Larson CM, et al. Am J Sports Med. 2022;doi:10.1177/03635465211067818.
- Maldonado DR, et al. J Hip Preserv Surg. 2021;doi:10.1093/jhps/hnab003.
- Matsuda DK, et al. Am J Sports Med. 2013;doi:10.1177/0363546513482884.
- Perets I, et al. Arthrosc Tech. 2017;doi:10.1016/j.eats.2017.01.014.
- Philippon MJ, et al. Arthroscopy. 2018;doi:10.1016/j.arthro.2018.04.021.
- Sabetian PW, et al. Arthrosc Tech. 2021;doi:10.1016/j.eats.2021.05.029.
- Safran N, et al. Orthop J Sports Med. 2021;doi:10.1177/2325967120977088.
- Scanaliato JP, et al. Am J Sports Med. 2022;doi:10.1177/03635465221109237.
- Tresch F, et al. J Magn Reason Imaging. 2017;doi:10.1002/jmri.25565.
- Westermann RW, et al. Arthroscopy. 2019;doi:10.1016/j.arthro.2018.11.016.
- White BJ, et al. Curr Rev Musculoskeletal Med. 2022;doi:10.1007/s12178-022-09741-y.
- For more information:
- John J. Christoforetti, MD, FAAOS, of Texas Health Orthopedic Specialists, can be reached at info@drchristo.com.
- Benjamin G. Domb, MD, FAAOS, FAOA, of American Hip Institute, can be reached at bendombpersonal@drdomb.com; www.americanhipinstitute.com; www.americanhipinstituteresearchfoundation.org.
- Christopher M. Larson, MD, of Twin Cities Orthopedics, can be reached at chrislarson@tcomn.com.
- Dean K. Matsuda, MD, FAAOS, FAANA, of Premier Hip Arthroscopy, can be reached at saltandlight777@hotmail.com.
- Derek H. Ochiai, MD, of the National Hip Center at the Nirschl Orthopaedic Center, can be reached at teamsurgeon@gmail.com.
Click here to read the Point/Counter to this Cover Story.
Collapse
Read more about
Click Here to Manage Email Alerts