Is labral reattachment always needed in hip preservation?
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Reattachment should always be considered
The acetabular labrum plays a critical role in maintaining joint homeostasis by contributing to synovial fluid distribution, stability and the suction seal of the hip.
Loss of the suction seal can lead to microinstability, chondral injury and accelerated osteoarthritic progression. Early diagnosis and timely intervention for symptomatic labral tears are crucial in mitigating the evolution of hip arthritis.
Hip labral repair has emerged as the gold standard among surgical interventions due to its ability to restore the biomechanics of the hip to the native, uninjured state. It not only reinstates the suction seal of the hip, but also consistently provides superior functional outcomes compared with alternative surgical approaches.
In head-to-head comparisons with labral debridement, labral repair has demonstrated improved outcomes and lower revision rates across short-term, midterm and long-term follow-ups, underscoring its durability and efficacy. Although we agree that correcting the bony deformity is potentially the most important part of addressing femoroacetabular impingement syndrome, performing a labral repair when tissue quality allows should always be considered as it can be performed without additional surgical morbidity, does not prolong recovery time and improves outcomes as outlined before.
Despite its consistent improvement in outcomes, labral repair may not be suitable for all patient populations. Specific subsets, such as older patients (typically older than 40 to 50 years), those with moderate hip arthritis and patients requiring concurrent cartilage interventions (ie, microfracture), may derive greater benefit from other surgical approaches. These considerations highlight the importance of individualized treatment planning, as patient-specific factors heavily influence the surgical outcomes.
Nonetheless, while interpreting the available data, this author advocates for an attempt at labral repair in all patients whose labrum is amenable to repair. This approach is likely to maximize patient outcomes following hip arthroscopy, as well as potentially delay or prevent the need for arthroplasty in the future. As surgical techniques and technologies continue to evolve, labral repair remains a cornerstone in the preservation of hip joint function and the prevention of arthritic progression.
- References:
- Buzin S, et al. Orthop Res Rev. 2022;doi:10.2147/ORR.S253762.
- Greaves LL, et al. J Biomech. 2010;doi:10.1016/j.jbiomech.2009.11.016.
- Hurley ET, et al. Arthrosc Sports Med Rehabil. 2021;doi:10.1016/j.asmr.2021.06.008.
- Krych AJ, et al. Arthroscopy. 2013;doi:10.1016/j.arthro.2012.07.011.
- Kucharik MP, et al. Orthop J Sports Med. 2022;doi:10.1177/23259671221109012.
- Larson CM, et al. Am J Sports Med. 2022;doi:10.1177/03635465211067818.
- Woyski D, et al. Curr Rev Musculoskelet Med. 2019;doi:10.1007/s12178-019-09575-1.
Jorge Chahla, MD, PhD, is an orthopedic surgeon at Rush University Medical Center in Chicago.
Fix the relevant problem
While many labral tears require repair or reattachment to allow for stable fixation, for optimal healing and to enable immediate motion after hip arthroscopy, there may be several clinical scenarios in which labral reattachment is unnecessary to achieve good results. Every medical procedure has potential side effects so when repair is clinically unjustified, we should avoid it.
The primary goal of labral reattachment is mostly biomechanical in nature as surgeons aim to restore the suction seal of the hip joint by optimizing the contact between the labrum and the femoral head. The suction seal itself may still be present and competent in the setting of many labral tears. This preserved function, despite a discrete pathology observed on advanced imaging and intraoperatively, provides one of numerous likely explanations for why many labral tears are asymptomatic. It is easy to observe uncompromised suction seal in the presence of a clinically obvious labral tear. When diagnosing a labral tear arthroscopically before performing any repair, the joint can be taken off traction, the hip is relaxed by flexing the knee slightly and then traction is pulled again, slowly, after which an obvious vacuum phenomenon is observed corresponding with functional seal.
Our practice routinely forgoes labral reattachment when it is deemed intraoperatively as a superfluous step. For example, in a labral advancement procedure, the surgeon releases a portion of the labrum from its attachment to the acetabulum on the capsular side, enabling the released tissue to abut the femoral head and eliminating the gapping observed off-traction. Functionally, this untethers the labrum from its native attachment and maximizes its potential in yielding a greater suction seal or restoring a missing one. In some of these cases the released labral tissue is localized to 1 to 3 hours of the clockface and at the conclusion of the advancement deemed stable, hence required no refixation.
In addition, this rationale is also applicable in revision surgery in which robust capsulolabral adhesions tether the labrum and, thereby, render the primary surgical intervention obsolete. Simple lysis of adhesions is often sufficient to restore the suction seal. Because removing the adhesions between the capsule and labrum, if done meticulously, should not destabilize the labral tissue, reattachment in this setting is often unnecessary. During cases such as these, we dynamically evaluate the suction seal, and, if present, we will forgo this unnecessary step.
Finally, labral reattachment procedures are not completely benign. In addition to potential subchondral anchor placement, foreign body reaction, added surgical time, labral tissue damage with suture passing and so forth, labral repair generates localized bleeding which is known to mediate adhesion formation between the labrum and capsule. Forgoing unnecessary fixation can reduce the rates of symptomatic adhesions, which improves overall surgical outcomes.
- References:
- McCrum C, et al. Arthroscopy. 2024;doi:10.1016/j.arthro.2024.09.003.
- Girardi NG, et al. Am J Sports Med. 2024;doi:10.1177/03635465241237252.
- Vogel LA, et al. Arthroscopy. 2022;doi:10.1016/j.arthro.2021.04.038.
Omer Mei-Dan, MD, is the head of the Hip Preservation Service at the University of Colorado School of Medicine in Denver.
Jessica Lee, MD, is dual-fellowship trained in adult reconstruction and hip preservation surgery at the University of Colorado School of Medicine in Denver.
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