Arthroscopic hip labral repair preferred for young patients with repairable tears
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Hip arthroscopy for treatment of labral tears is common in hip preservation or sports medicine practices.
Historically, labral debridement was a common treatment for labral tears. In younger patients, this has been supplanted by labral repair as the preferred technique for repairable labral tears. While there has been some controversy about the type of labral repair that is preferable (wraparound/circumferentially affixing the labrum vs. vertical mattress configuration), outcomes thus far have been equivalent. The success of any hip labral repair also depends upon adequately treating underlying femoroacetabular impingement (FAI), if present. Before undertaking hip arthroscopy for a torn labrum, the patient should have first tried reasonable conservative treatment.
Source: Derek H. Ochiai, MD
Surgical technique
The patient is placed on a commercially available hip distractor table or a fracture table. While my preference is for supine positioning, lateral positioning can also be used. The amount of traction necessary to distract the hip 1 cm is recorded (Figure 1), and the traction is released until the start of surgery. This allows for saving traction time until it is necessary. Serial oblique radiographs are also obtained at the beginning of the case, so as surgical correction of FAI is performed, similar radiographic views may be obtained to dial in the appropriate amount of correction.
The hip is draped with an Ioban-impregnated drape (3M), which allows the hip to be repositioned throughout the procedure. Traction is reapplied, and the central compartment is accessed first through an anterolateral portal. A tip for this starting portal is tilting the C-arm 15°. Because most of my hip labral repairs utilize only an anterolateral and a mid-anterior portal, the anterolateral portal can be placed more over the greater trochanter, which allows easier access to the posterior aspect of the labrum. Under direct visualization, the mid-anterior portal is established, and a diagnostic arthroscopy is performed. An interportal capsulotomy can be helpful for atraumatic instrument passage and visualization; however, if performed, the transverse capsulotomy should be performed close to the femoral head to allow sufficient superior capsule for later closure, which is always performed. If there is associated pincer-type FAI, this is addressed before labral repair, taking care not to cause iatrogenic damage to the labrum. A curved burr can be useful, especially when using only two portals, as it allows safer access to the medial and posterior acetabulum. If there is no pincer impingement, the acetabulum adjacent to the labrum tear is roughened with a burr on the reverse setting to aid healing of the repair. The labrum is assessed for repair suitability. If the torn labrum is deemed repairable, the repair is done first working medially through the mid-anterior portal. Starting as far away from the scope (which is in the anterolateral portal) and progressively placing anchors closer to the scope decreases chances of suture tangling.
Many tears start at or medial to the iliopsoas notch, which can be a difficult area to seat an anchor when starting peripheral to the labrum. Therefore, in this location, I use all-suture anchors and start medial to the labrum, angling the curved guide in a superior and slightly lateral trajectory to ensure that the drill does not skive off the acetabulum (Figure 2). Once the anchor is seated, a low-profile “stab-and-grab” suture passer can be used to piece the labrum at the acetabular-labral interface, and then capture and retrieve the suture. A tip for this is to create a short limb (the post) and a long limb of suture and retrieve the short limb. This limits the amount of “Gigli-sawing” of the labrum with the high-tensile suture, as well as decrease the chance of inadvertently unloading the anchor. The sutures are then protected in a Suture Saver straw (ConMed), and the next anchor is placed. Typically, the more lateral anchors can be placed peripheral to the labrum and a stab-and-grab device wraps the non-post limb around the labrum and is also protected with straws. All necessary anchors and suture passage is done first (Figure 3). If anchors are required posterior to the 12 o’clock position, the arthroscope is placed through the mid-anterior portal, anchors are placed and sutures passed through the anterolateral portal. The knot tying starts with the most posterior suture anchor, and the surgeon’s preferred arthroscopic sliding knot is used to sew the labrum to the acetabulum. Working posterior to anterior to medial lessens the chance of suture entanglement. I prefer to pass all sutures prior to starting the knotted repair, as this lessens any chance of inadvertent tension force on the repair from suture passage on adjacent anchors, which can slightly loosen other parts of the labral repair. Once completed, the repair is probed and tested (Figure 4). A “wave sign,” or bubbling of the articular cartilage adjacent to the labrum, is part of the labral tear and the labral repair should be sufficient to stabilize the wave sign.
Once central compartment arthroscopy is completed, traction is removed and the labral repair is viewed from the peripheral compartment to ensure knot integrity, absence of any cam-type FAI and normal labral-femoral head/neck contact. The capsule is then closed with either nonabsorbable (my preference) or absorbable sutures.
Rehabilitation
Regardless of whether an FAI osteoplasty was required, all patients after labral repair are weight-bearing as tolerated, and patients can stop the use of crutches when they can walk without a noticeable limp. Passive circumduction exercises done with the patient supine for 10 minutes a day start the day after surgery. The patient may spin no resistance on an exercise bike the day after surgery, with formal physical therapy starting after suture removal in 10 to 12 days.
In general, core/gluteal strengthening is the hallmark of rehabilitation for functional recovery. Active hip flexor strengthening is limited for at least 6 weeks to decrease chances of hip flexor irritation. Usually by 4 to 6 weeks, patients can progress to an elliptical trainer for exercise. An interval running program may be started at 10 weeks postoperatively if the patient is pain-free with adequate hip range of motion and good gluteal strength. For athletes, sports-specific training may be initiated at this time. Many athletes may resume competition around 3 to 4 months after surgery. Overall recovery, when the patient feels he or she is at maximal improvement, may take 6 to 12 months after surgery.
- References:
- Beck EC, et al. Arthroscopy. 2021;doi:10.1016/j.arthro.2021.01.035.
- Sawyer GA, et al. Am J Sports Med. 2015;doi:10.1177/0363546515581469.
- Tang H, et al. Am J Sports Med. 2023;doi:10.1177/03635465231160179.
- For more information:
- Derek H. Ochiai, MD, is an orthopedic surgeon at the Nirschl Orthopaedic Center in Arlington, Virginia. He can be reached at teamsurgeon@gmail.com or @DrDerekOchiai.
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