Acetabular labral reconstruction using the indirect head of the rectus femoris tendon significantly improves patient reported outcomes

Mid- to Long-Term Outcomes in Patients After Hip Arthroscopy With Labral Reconstruction: A Systematic Review

Background

There is a paucity of aggregate data documenting mid- to long-term outcomes of patients after hip arthroscopy with labral reconstruction.

Purpose

To report mid- to long-term outcomes in patients after undergoing either primary or revision hip arthroscopy with labral reconstruction for the treatment of irreparable labral tears.

Study Design

Systematic review; Level of evidence, 4.

Methods

A systematic review of the PubMed, Cochrane, and Scopus databases in May 2022 was conducted with the following keywords: "hip arthroscopy,""labral reconstruction,""irreparable,""labrum,""reconstruction,""five-year,""midterm,""5 year,""long-term,""10 year," ten-year," and "femoroacetabular impingement" using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. Midterm was defined as mean 5-year follow-up, and long-term was defined as mean 10-year or longer follow-up. For each included article, the demographic, radiographic, intraoperative, and surgical variables, as well as patient-reported outcomes (PROs), psychometric thresholds, and secondary surgeries were recorded. Forest plots were created for PROs that were reported in ≥3 studies; heterogeneity was assessed using I2 values.

Results

Out of 463 initial articles, 5 studies including 178 hips with primary and 41 hips with revision surgeries were included. One study had an average 5-year follow-up, three studies had a minimum 5-year follow-up and one study had a minimum 10-year follow-up. The most common indications for hip arthroscopy with labral reconstruction were irreparable labral tears. The most common PRO was the modified Harris Hip Score (mHHS), which was reported in all 5 studies. The mean preoperative mHHS ranged from 58.9 to 66, and the mean postoperative mHHS at minimum 5-year follow-up ranged from 80.2 to 89. The preoperative and postoperative mHHSs for the single long-term follow-up study were 60 and 82, respectively. All 5 studies demonstrated significant improvements in reported PROs. All 5 studies reported secondary surgery rates, with 1 study reporting rates at both 5- and 10-year follow-up. Conversion to total hip arthroplasty ranged from 0% to 27%, while overall secondary surgery rates ranged from 0% to 36%.

Conclusion

Findings demonstrated that patients undergoing primary and revision hip arthroscopy with labral reconstruction experienced favorable outcomes and high rates of clinical benefit and survivorship at mid- to long-term follow-up.

Patients Undergoing Revision Hip Arthroscopy With Labral Reconstruction or Augmentation Demonstrate Favorable Patient Reported Outcomes: A Systematic Review

PURPOSE

To review current literature evaluating patient-reported outcomes (PROs) and survivorship in patients undergoing revision hip arthroscopy with labral reconstruction or augmentation.

METHODS

A systematic review was performed with the following key words: (revision) AND (hip OR femoroacetabular impingement) AND (arthroscopy OR arthroscopic) AND (reconstruction OR augmentation OR irreparable). PubMed, Cochrane Trials, and Scopus were queried in October 2022 using the criteria established in the Preferred Reporting Items for Systematic Reviews and Meta-analyses. Studies were included if they involved patients undergoing revision hip arthroscopy with labral reconstruction or augmentation and reported preoperative and postoperative PROs at minimum 2-year follow-up. Only original research articles were included. Survivorship was defined as a nonconversion to total hip arthroplasty. Outcomes present in 3 or more studies underwent further statistical analysis with forest plots. Heterogeneity of studies was evaluated using the I2 statistic.

RESULTS

Five studies were reviewed, including 359 revision hip arthroscopies (335 with complete follow-up) with a follow-up that ranged from 2.2 to 5.2 years. Four studies reported on outcomes after revision labral reconstruction and 1 study reported on labral augmentation. Two out of 5 included studies evaluated for statistical significance between preoperative and postoperative outcomes. Three out of 5 studies reported a rate of at least 70% for achieving minimal clinically important difference in at least 1 PRO. At minimum 2-year follow-up, survivorship ranged from 93.5% to 100%.

CONCLUSIONS

Patients that underwent revision hip arthroscopy with labral reconstruction or augmentation demonstrated improvement in PROs with mixed rates of achieving clinical benefit and rates of survivorship at minimum 2-year follow-up ranging from 93.5% to 100%.

LEVEL OF EVIDENCE

Level IV, systematic review of level III to IV studies.

Indirect Head of the Rectus Femoris Tendon as a Graft for Segmental Hip Labral Reconstruction: An Anatomic, Radiographical, and Biomechanical Study in Comparison With Iliotibial Labral Reconstruction

BACKGROUND

The indirect head of the rectus femoris (IHRF) tendon has been used as an autograft for segmental labral reconstruction. However, the biomechanical properties and anatomic characteristics of the IHRF, as they relate to surgical applications, have yet to be investigated.

PURPOSE

To (1) quantitatively and qualitatively describe the anatomy of IHRF and its relationship with surrounding arthroscopically relevant landmarks; (2) detail radiographic findings pertinent to IHRF; (3) biomechanically assess segmental labral reconstruction with IHRF, including restoration of the suction seal and contact pressures in comparison with iliotibial band (ITB) reconstruction; and (4) assess potential donor-site morbidity caused by graft harvesting.

STUDY DESIGN

Descriptive laboratory study.

METHODS

A cadaveric study was performed using 8 fresh-frozen human cadaveric full pelvises and 7 hemipelvises. Three-dimensional anatomic measurements were collected using a 3-dimensional coordinate digitizer. Radiographic analysis was accomplished by securing radiopaque markers of different sizes to the evaluated anatomic structures of the assigned hip.Suction seal and contact pressure testing were performed over 3 trials on 6 pelvises under 4 different testing conditions for each specimen: intact, labral tear, segmental labral reconstruction with ITB, and segmental labral reconstruction with IHRF. After IHRF tendon harvest, each full pelvis had both the intact and contralateral hip tested under tension along its anatomic direction to assess potential site morbidity, such as tendon failure or bony avulsion.

RESULTS

The centroid and posterior apex of the indirect rectus femoris attachment are respectively located 10.3 ± 2.6 mm and 21.0 ± 6.5 mm posteriorly, 2.5 ± 7.8 mm and 0.7 ± 8.0 mm superiorly, and 5.0 ± 2.8 mm and 22.2 ± 4.4 mm laterally to the 12:30 labral position. Radiographically, the mean distance of the IHRF to the following landmarks was determined as follows: anterior inferior iliac spine (8.8 ± 2.5 mm), direct head of the rectus femoris (8.0 ± 3.9 mm), 12-o'clock labral position (14.1 ± 2.8 mm), and 3-o'clock labral position (36.5 ± 4.4 mm). During suction seal testing, both the ITB and the IHRF reconstruction groups had significantly lower peak loads and lower energy to peak loads compared with both intact and tear groups (P = .01 to .02 for all comparisons). There were no significant differences between the reconstruction groups for peak loads, energy, and displacement at peak load. In 60° of flexion, there were no differences in normalized contact pressure and contact area between ITB or IHRF reconstruction groups (P > .99). There were no significant differences between intact and harvested specimen groups in donor-site morbidity testing.

CONCLUSION

The IHRF tendon is within close anatomic proximity to arthroscopic acetabular landmarks. In the cadaveric model, harvesting of the IHRF tendon as an autograft does not lead to significant donor-site morbidity in the remaining tendon. Segmental labral reconstruction performed with the IHRF tendon exhibits similar biomechanical outcomes compared with that performed with ITB.

CLINICAL RELEVANCE

This study demonstrates the viability of segmental labral reconstruction with an IHRF tendon and provides a detailed anatomic description of the tendon in the context of an arthroscopic labral reconstruction. Clinicians can use this information during the selection of a graft and as a guide during an arthroscopic graft harvest.

Similar Clinical Outcomes for Arthroscopic Labral Reconstruction in Irreparable Cases Using the Indirect Head of the Rectus Femoris Tendon With an All-Inside Technique for Small Defects and the Iliotibial Band for Large Defects

PURPOSE

To evaluate the clinical outcomes and satisfaction rate of patients who underwent arthroscopic labral reconstruction for an irreparable labral tear with a minimum follow-up period of 2 years. Additionally, this study aimed to compare 2 different reconstructive techniques for small and large labral defects: the indirect head of the rectus femoris tendon (IHRFT) autograft with an all-inside technique used to repair small defects (≤3 hours) and the iliotibial band (ITB) autograft for large defects (>3 hours).

METHODS

A total of 24 hips treated with the IHRFT were compared with 24 hips treated with the ITB. All patients underwent clinical evaluation before surgery and during the most recent follow-up (42 ± 18 months). The evaluation included patient satisfaction, the modified Harris Hip Score, the Non-Arthritic Hip Score, the Hip Outcome Score, the Hip Outcome Score-sport subscale, the 12-item International Hip Outcome Tool, and the visual analog scale pain score.

RESULTS

All clinical scores were significantly improved (P < .001) at the latest follow-up in both groups. The final satisfaction was 7.1 ± 2.8 and 8.8 ± 1.6 for the IHRFT and ITB groups, respectively (P = .006). There was a significant difference in age (41.2 ± 6.0 years for the IHRFT group and 33 ± 8.5 for the ITB group; P = .004) and in surgery time (147.3 ± 39.4 minutes for the ITB group and 105.3 ± 25.7 for the IHRFT group; P < .001). One patient (4.2%) in the IHRFT group underwent total hip arthroplasty after 21.3 months (P = .999).

CONCLUSIONS

At the 2-year follow-up, treating small defects using IHRFT and larger defects using ITB resulted in good patient-reported outcome measures with a low rate of complications and failures. The ITB group reported a higher level of satisfaction at the final follow-up.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Labral repair, reconstruction, and augmentation improve postoperative outcomes in patients with irreparable or hypoplastic labra: A systematic review

PURPOSE

To review the postoperative outcomes of arthroscopic surgical options in treating irreparable and hypoplastic labrum of the hip.

METHODS

Three online databases (PubMed, MEDLINE, and EMBASE) were searched from database inception to June 27, 2023 to identify literature on treatment strategies for hypoplastic/irreparable acetabular labrum. Data pertaining to classification of irreparable tears or labral hypoplasia, indication for surgery, description of treatment, radiographic findings, and clinical outcomes were recorded and described. The methodological quality of included studies was assessed by the Methodological Index for Non-Randomized Studies (MINORS) criteria.

RESULTS

Seven level IV case series, eleven level III retrospective cohort studies, and two level II prospective cohort studies comprising 1937 patients were included for analysis. Studies were divided into an irreparable labral group comprising 1002 patients and a hypoplastic labral group comprising 935 patients. Treatments included repair, augmentation, or reconstruction. In the irreparable group, 12 studies recorded improvement of modified Harris Hip Score (mHHS) with preoperative scores ranging from 50.3 to 67.3 and postoperative scores ranging from 76.2 to 95.0. The rate of conversion to total hip arthroplasty (THA) and rate of revision arthroscopy were 6.6% and 5.9%, respectively across all studies. In the hypoplastic group, two studies that focused on repair noted no statistical difference in mHHS for repair in hypoplastic labrum vs repair in non-hypoplastic labrum. One study showed that there was a difference in post-operative mHHS for labral repair for hypoplastic vs non-hypoplastic labrum, with repair in non-hypoplastic labrum showing superior mHHS (p ​< ​0.001).

CONCLUSION

The findings of this review suggest that treatment of irreparable labra with reconstruction or augmentation results in improved patient-reported outcome measures (PROMs). For the hypoplastic labrum, primary repair also results in improvement in PROMs. Future studies focusing on the hypoplastic labra alone with an appropriate control group, rather than irreparable labral tears, are needed to properly assess patient outcomes and guide surgical indications.

No Difference in Most Reported Outcome Measures for Allograft Versus Autograft for Hip Labral Reconstruction: A Systematic Review of Comparative Studies

PURPOSE

To systematically review studies comparing outcomes of allograft versus autograft for hip labral reconstruction.

METHODS

A systematic review following guidelines established by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) was performed in 3 databases using the terms "labrum," "hip," "acetabulum," "reconstruction," "augmentation," "allograft," and "autograft." Data on study characteristics, patient demographic characteristics, follow-up time, patient-reported outcomes (PROs), rates of revision surgery, and rates of conversion to total hip arthroplasty (THA) were collected.

RESULTS

Three studies were included, with Methodological Index for Non-randomized Studies (MINORS) scores ranging from 17 to 23. Among 92 patients receiving allografts, the mean ages ranged from 30.6 to 34.8 years; mean follow-up times, from 34.6 to 66.1 months; revision rates, from 0% to 23.6%; and conversion-to-THA rates, from 0% to 20%. Among 185 patients receiving autografts, the mean ages ranged from 34.6 to 35.9 years; mean follow-up times, from 32.7 to 80.8 months; revision rates, from 0% to 7.3%; and conversion-to-THA rates, from 0% to 6.7%. One study reported significantly higher revision rates in the allograft group. All studies reported no statistically significant differences in postoperative PROs, and all postoperative PROs significantly improved compared with preoperative PROs. Rates of achievement of the minimal clinically important difference and patient acceptable symptomatic state, reported by 1 study, were statistically similar between the 2 groups and ranged from 55.6% to 100% for the allograft group and from 53.8% to 84.6% for the autograft group.

CONCLUSIONS

There were no significant differences between allograft and autograft patients in terms of postoperative PROs; however, all PRO measures were slightly higher in allograft patients. Both revision and conversion-to-THA rates were higher in allograft patients in 2 studies, with the level of significance being reached in terms of revision in 1 study. The third study reported zero revisions and conversions to THA in allograft and autograft patients.

LEVEL OF EVIDENCE

Level III, systematic review of Level II and III studies.

Labral Reconstruction via Capsular Augmentation Maintains Perfusion to the Acetabular Labrum and Locally Transferred Autograft: An in Vivo Laser Doppler Flowmetry Analysis

Background

The purpose of the present study was to examine the effects of arthroscopic labral repair with capsular augmentation on blood flow in vivo with use of laser Doppler flowmetry (LDF) to measure microvascular perfusion of the labrum and autograft tissue.

Methods

The present prospective case series included patients ≥18 years old who underwent arthroscopic acetabular labral repair with capsular augmentation; all procedures were performed by a single surgeon between 2018 and 2022. The LDF probe measured microvascular blood flow flux within 1 mm3 of the surrounding labral and capsular tissue of interest. Mean baseline measurements of flux were compared with readings immediately following capsular elevation and after completing labral augmentation. Blood flux changes were expressed as the percent change from the baseline measurements.

Results

The present study included 41 patients (24 men [58.5%] and 17 women [41.5%]) with a mean age (and standard deviation) of 31.3 ± 8.4 years, a mean BMI of 24.6 ± 3.4 kg/m2, a mean lateral center-edge of angle 35.3° ± 4.9°, a mean Tönnis angle of 5.8° ± 5.8°, and a mean arterial pressure of 93.7 ± 10.9 mm Hg. Following capsular elevation, the mean percent change in capsular blood flow flux was significantly different from baseline (-9.24% [95% confidence interval (CI), -18.1% to -0.04%]; p < 0.001). Following labral augmentation, the mean percent change in labral blood flow flux was significantly different from baseline both medially (-22.3% [95% CI, -32.7% to -11.9%]; p < 0.001) and laterally (-32.5% [95% CI, -41.5% to -23.6%]; p = 0.041). There was no significant difference between the changes in medial and lateral perfusion following repair (p = 0.136).

Conclusions

Labral repair with capsular augmentation sustains a reduced blood flow to the native labrum and capsular tissue at the time of fixation. The biological importance of this reduction is unknown, but these findings may serve as a benchmark for other labral preservation techniques and support future correlations with clinical outcomes.

Level of Evidence

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Treatment of Severe Pincer-Type Femoroacetabular Impingement With Arthroscopic Significant Acetabular Rim Correction and Circumferential Labral Reconstruction Improves Patient-Reported Outcome Measures

PURPOSE

To validate an arthroscopic approach for performing significant acetabular rim correction and circumferential labral reconstruction required to treat severe pincer-type femoroacetabular impingement.

METHODS

Using a minimum of 2-year follow-up, data from 48 hips, including 47 patients (11 male, 36 female; mean age of 42 years) having undergone significant arthroscopic acetabuloplasty for severe pincer impingement (center edge angle >45°) with concomitant circumferential allograft labral reconstruction were analyzed to determine improvements in patient-reported outcomes and degree of radiographic correction.

RESULTS

Findings demonstrated a 98% success rate, including substantial improvements on all radiographic measurements and patient-reported outcomes. Minimal clinically important differences were met with extremely strong measures of effect. The mean center edge angle improved from 49° to 36° (MΔ = 13.96, P ≤ .001, standard deviation [SD] = 55.97, confidence interval [CI] 12.17- 15.62, d = 2.33) and the mean Tönnis angle improved from -6° to 0° (MΔ = 6.2, P ≤ .001, SD = 2.76 CI -7.1 to -5.39, d = 2.29). Modified Hip Harris Scores improved by a mean of 34.45 points (P ≤ .001, SD = 20.64, 95% CI 28.45-40.44, d = 1.66). Lower extremity functional scale scores improved by a mean of 27.35 points (P ≤ .001, SD = 18.37, 95% CI 22.02-32.69, d =1.48). No complications were reported. One case converted to a total hip arthroplasty (2%).

CONCLUSIONS

Findings validated that the significant acetabular rim correction required to treat severe pincer morphology is safe and feasible via an arthroscopic approach. This, in addition to concomitant circumferential allograft labral reconstruction, resulted in improvement in patient-reported outcomes and radiographic measurements.

LEVEL OF EVIDENCE

Level IV, therapeutic case-series.

Graft Options for Hip Labral Reconstruction

➢

Arthroscopic hip labral reconstruction is a complex procedure which is growing in use as indications, techniques, and surgical expertise advance.

➢

Graft selection is an important component of labral reconstruction based on relative advantages and disadvantages of available types of autografts and allografts.

➢

The ideal graft should mimic the native acetabular labrum form and function while also being affordable, readily available, and associated with low morbidity.

➢

High rates of patient satisfaction and positive patient-reported outcomes have been reported after labral reconstruction using several graft types.

Pre- and intraoperative decision-making challenges in hip arthroscopy for femoroacetabular impingement

There has been a marked increase in the number of hip arthroscopies performed over the past 16 years, primarily in the management of femoroacetabular impingement (FAI). Insights into the pathoanatomy of FAI, and high-level evidence supporting the clinical effectiveness of arthroscopy in the management of FAI, have fuelled this trend. Arthroscopic management of labral tears with repair may have superior results compared with debridement, and there is now emerging evidence to support reconstructive options where repair is not possible. In situations where an interportal capsulotomy is performed to facilitate access, data now support closure of the capsule in selective cases where there is an increased risk of postoperative instability. Preoperative planning is an integral component of bony corrective surgery in FAI, and this has evolved to include computer-planned resection. However, the benefit of this remains controversial. Hip instability is now widely accepted, and diagnostic criteria and treatment are becoming increasingly refined. Instability can also be present with FAI or develop as a result of FAI treatment. In this annotation, we outline major current controversies relating to decision-making in hip arthroscopy for FAI. Cite this article: Bone Joint J 2022;104-B(5):532-540.

Segmental and Circumferential Acetabular Labral Reconstruction Have Comparable Outcomes in the Treatment of Irreparable or Unsalvageable Labral Pathology: A Systematic Review

PURPOSE

To perform a systematic review comparing outcomes of segmental versus circumferential arthroscopic labral reconstruction as a treatment for symptomatic irreparable or unsalvageable acetabular labral pathology.

METHODS

A systematic review was conducted according to PRISMA guidelines using defined inclusion and exclusion criteria. The study groups were divided into segmental and circumferential labral reconstructions. Studies with <2 years follow up, overlapping patient populations, or indications for labral reconstruction other than irreparable or unsalvageable pathology were excluded.

RESULTS

The literature search resulted in nine included publications. Five studies presented data on segmental labral reconstruction (166 hips in 164 patients), and seven studies presented data on circumferential labral reconstruction (261 hips in 253 patients). All circumferential reconstruction studies used allograft only, while segmental studies used a combination of autograft and allograft. The range of conversion to total hip arthroplasty was 9.1% to 26.8% in the segmental studies and 3.1% to 9.9% in the circumferential studies. The modified Harris Hip Score (mHHS) was the only patient-reported outcome measure reported in three or more studies in both groups. The mean change from preoperative to postoperative mHHS ranged from 17.8 to 29 in the segmental group and from 20.4 to 31.7 in the circumferential group. Weighted estimates were not calculated due to significant heterogeneity for both the segmental and circumferential groups (I² = 63.9% and 72.9%, respectively).

CONCLUSIONS

Segmental and circumferential reconstructions are both reasonable options for arthroscopic treatment of irreparable or unsalvageable labral pathology. Articles in both groups demonstrated improvement in patient-reported outcomes (mHHS). Because of study heterogeneity, low level of evidence, and high risk of bias, the scores were unable to be directly compared. Although there are theoretical biomechanical and technical advantages of one technique over another, this systematic review did not demonstrate clinical superiority of either technique.

LEVEL OF EVIDENCE

Level IV, systematic review of level III and IV studies.

Comparison of Acetabular Labral Reconstruction With 7-mm Tibialis Anterior Allograft and 5-mm Iliotibial Band Autograft at Minimum 2-Year Follow-up

BACKGROUND

Labral reconstruction has been described as a treatment option for irreparable labral tear. Labral graft size ranges from 5 to 7 mm² for reconstruction. A thicker labral graft could support mechanical stability and protect cartilage better. No study has compared the effect of graft thickness on clinical outcomes.

PURPOSE/HYPOTHESIS

The purpose of this study was to compare patient-reported outcomes between hips reconstructed with an autologous iliotibial band (AUITB; 5 mm²) graft and with an allogenic tibialis anterior (ALTA; 7 mm²) tendon graft. Our hypothesis was that hips reconstructed with a thicker allograft (7 mm²) would have better clinical outcomes than those with a smaller autograft (5 mm²).

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A total of 42 patients (aged 21 to 54 years) underwent arthroscopic hip segmental labral reconstruction during the study period of January 2016 to November 2018. Twenty patients had reconstruction with AUITB grafts (5 mm²) and 22 with ALTA grafts (7 mm²). Both groups had minimum 2 year follow-up. Patients were evaluated with patient-related outcome scores: modified Harris Hip Score, Nonarthritic Hip Score, and Hip Outcome Score-Sports Specific. Pain evaluation was performed using a visual analog scale.

RESULTS

There were significant differences in all studied variables when comparing pre- and postoperative scores. Yet, there were no differences in terms of patient-related outcome scores between the groups postoperatively. Postoperative visual analog scale scores averaged 2.1 for the AUITB group vs 1.9 for the ALTA group (P = .89); modified Harris Hip Score, 82.7 vs 83.3 (P = .77); Nonarthritic Hip Score, 81.1 vs 82.2 (P = .81); and Hip Outcome Score-Sports Specific, 81.6 vs 82.5 (P = .67).

CONCLUSION

No differences were found in terms of clinical outcomes between the 7-mm² ALTA graft and the 5-mm² AUITB graft. Both graft types and thicknesses might be considered comparable choices for primary reconstruction. Although a thicker-graft labral reconstruction seemed to have more ability to cover joint surface, clinical results did not show any superiority of a thicker graft whether it is autologous or allogenic.

Does labral treatment technique influence the outcome of FAI surgery? A matched-pair study of labral reconstruction versus repair and debridement with a follow-up of 10 years

The aim of this study was to analyze the long-term clinical outcomes of labral reconstruction in patients undergoing femoro-acetabular impingement (FAI) surgery and compare them with labral repair and debridement. This is a single-center, single-surgeon, retrospective match-paired study from a prospectively collected hip preservation database. All patients underwent a hip surgical dislocation for FAI surgery. Eight patients underwent labral reconstruction with the ligamentum teres and were matched on sex, age and body mass index with 24 labral repair and 24 labral debridement (1:3). Failure was defined as conversion to total hip replacement (THR) and patient-reported outcome measures (PROMs) were collected. Mean follow-up was 9.8 years ±2.6 (5.2–13.9). There was a significant improvement in postoperative PROMs in the three groups regarding the WOMAC total, WOMAC function, HOOS-QoL, HOOS-ADL and HOOS-SRA (P < 0.05). There was no statistical difference between the three groups regarding postoperative PROMs and change in PROMs (P > 0.05). A total of 10 hips underwent joint replacement surgery at a mean time of 7.9 ± 3.5 years (2.4–12). There was no statistically significant difference between the three groups regarding the conversion rate to THR (P = 0.64) or time between surgery and conversion to THR (P = 0.15). Compared to a match-pair group of labral repair and debridement, labral reconstruction with ligamentum teres provides similar survival with conversion to a THR as an endpoint, as well as similar improvement in PROMs. Labral treatment can be safely adapted at the nature of the labral lesion with a treatment ‘à la carte’.

Allograft Labral Reconstruction of the Hip: Expanding Evidence Supporting Greater Utilization in Hip Arthroscopy

Purpose of Review

The current review investigates outcomes and failure rates associated with arthroscopic circumferential allograft labral reconstruction of the hip, both as a revision and primary procedure in treating femoroacetabular hip impingement and labral-related pathology.

Recent Findings

Numerous studies within the last decade have demonstrated excellent patient-reported outcomes, high rates of return-to-play in athletes, and low failure rates in patients having undergone arthroscopic circumferential allograft labral reconstruction of the hip. Removal of chronically diseased and injured labral tissue can eliminate a significant pain-generator from the hip joint. Additionally, circumferential reconstruction of the labrum restores the hoop fiber strength and fluid seal akin to what would be seen with native, healthy labral tissue. Recent research has shown that arthroscopic circumferential allograft labral reconstruction may be used not only in the revision setting, but as a primary procedure. Circumferential labral reconstruction should be considered when a surgeon feels that the labrum is irreparable or has failed previous repair.

Summary

Arthroscopic circumferential allograft labral reconstruction of the hip can be utilized as treatment option not only in revision settings, but also in primary treatment for femoroacetabular impingement and labral pathology

Multicenter Outcomes After Primary Hip Arthroscopy: A Comparative Analysis of Two-Year Outcomes After Labral Repair, Segmental Labral Reconstruction, or Circumferential Labral Reconstruction

PURPOSE

(1) To report minimum 2-year follow-up patient-reported outcome measures in patients undergoing labral repair (LR), segmental labral reconstruction (SLR), or circumferential labral reconstruction (CLR) in the primary setting; and (2) to compare minimum 2-year follow-up patient-reported outcome measures among these groups.

METHODS

A retrospective review of a prospectively maintained multicenter database of patients undergoing hip arthroscopy was performed. Inclusion criteria were patients undergoing hip arthroscopy for treatment of labral tear and femoroacetabular impingement syndrome between January 2014 and October 2017, and completion of minimum 2-year postoperative outcome scores. Exclusion criteria were patients undergoing revision hip surgery, labral treatment limited to debridement, lateral center-edge angle <20°, osteoarthritis (Tönnis grade > 1), slipped capital femoral epiphysis, workers compensation status, and patients undergoing concomitant gluteus medius and/or minimus repair. Labral reconstruction patients were matched (1:3) with labral repair patients on age, sex, and body mass index. The labral reconstruction group was further stratified into SLR, and CLR groups. Patient demographic characteristics and clinical outcomes including Hip Outcome Score - Activities of Daily Living, Hip Outcome Score - Sport Subscale, modified Harris Hip Score, international Hip Outcome Tool, and visual analog scale for pain were analyzed, as well as achievement of the minimal clinical improvement difference (MCID). A P-value less than .05 indicated statistical significance.

RESULTS

A total of 416 patients were included (LR, n = 312; SLR, n = 53; CLR, n = 51). The age, body mass index, and sex of the matched cohort were 42.3 ± 11.2 years, 24.7 ± 3.7, and 55.0% female. At a minimum of 2-year after hip arthroscopic surgery, no differences were found in preoperative, postoperative, or the delta visual analog scale for pain, modified Harris Hip Score, Hip Outcome Score - Activities of Daily Living, Hip Outcome Score - Sport Subscale, or international Hip Outcome Tool. Subsequently, the proportion of patients achieving the MCID and the PASS at latest follow-up were analyzed. This analysis revealed that no significant differences in the rate of MCID or PASS achievement for any outcome measure existed based on labral treatment.

CONCLUSIONS

In this multicenter study on labral treatment in the primary setting, patients undergoing LR, SLR, and CLR demonstrated no difference in preoperative or postoperative scores, nor the proportion of patients achieving clinically significant outcome improvement.

LEVEL OF EVIDENCE

III; therapeutic outcome study with controls.

Age-Adjusted Normative Values for Hip Patient-Reported Outcome Measures

BACKGROUND

Patient-reported outcome measures (PROMs) are essential clinical instruments used for assessing patient function, assisting in clinical decision making, and quantifying outcomes of surgical and nonsurgical management. However, PROMs are often designed using patients with preexisting pathology and typically assume that a patient without the pathology would have a perfect or near perfect score. This may result in unrealistic expectations or falsely underestimate how well a patient is doing after treatment. The influence of age on PROMs about the hip of healthy individuals has not been studied.

HYPOTHESIS

We hypothesize that in asymptomatic individuals hip-specific PROM scores will decrease in an age-dependent manor.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

In this multicenter survey study, volunteers who denied preexisting hip pathology and previous hip surgery completed 3 PROMs online or as traditional paper questionnaires. The International Hip Outcome Tool (iHOT), the modified Harris Hip Score (mHHS), and the Hip Outcome Score-Activities of Daily Living (HOS-ADL) and HOS-Sport were completed. Analysis of variance with a Tukey post hoc test was used to analyze differences in PROMs among subgroups. An independent-samples Student t test and a χ² test were used to analyze differences in continuous and categorical data, respectively.

RESULTS

In total 496, 571, 534, and 532 responses were collected for the iHOT, mHHS, HOS-ADL, and HOS-Sport, respectively. Respondents' PROMs were scored and arranged into 3 groups by age: <40 years, 40 to 60 years, and >60 years. The iHOT, mHHS, HOS-ADL, and HOS-Sport of these asymptomatic respondents all decreased in an age-dependent manner: iHOT (<40, 94.1; 40-60, 92.4; >60, 87.0), mHHS (<40, 94.8; 40-60, 91.3; >60, 89.1), HOS-ADL (<40, 98.4; 40-60, 95.0; >60, 90.9), and HOS-Sport (<40, 95.7; 40-60, 82.9; >60, 72.9) (analysis of variance between-group differences, P < .05).

CONCLUSION

This study demonstrated that the iHOT, mHHS, and HOS-ADL and HOS-Sport scores in asymptomatic people decrease in an age-dependent manner. It is important to compare a patient's outcome scores with the age-normalized scores to establish an accurate reference frame with which to interpret outcomes.

Circumferential and Segmental Labral Reconstruction: A Systematic Review

The purposes of this study were to synthesize, report, and compare patient-reported outcomes (PROs) between arthroscopic segmental and circumferential labral reconstruction. A systematic review was performed in February 2019 using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) method. Inclusion criteria were levels I to IV evidence, articles in English, arthroscopic labral reconstruction, and PROs data. Exclusion criteria were labral treatment without reconstruction, open surgery, and less than 6-month follow-up. Eleven studies were identified. Nine studies (212 hips) reported outcomes of segmental reconstruction. Two studies (194 hips) reported outcomes of circumferential reconstruction. Significant improvement in PROs at short-term with either segmental or circumferential reconstruction was found. [Orthopedics. 2021;44(6):361-366.].

Autograft Versus Allograft: The Evidence in Hip Labral Reconstruction and Augmentation

BACKGROUND

Labral augmentation and labral reconstruction have emerged as essential procedures for restoring the anatomic and functional characteristics of the hip joint in patients with a deficient hip labrum or irreparable labral tear.

HYPOTHESIS/PURPOSE

The purpose of this study was to compare allograft and autograft hip labral reconstruction and augmentation. We hypothesized that autografts would entail fewer revision arthroscopic procedures.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients were identified who underwent labral reconstruction or labral augmentation using iliotibial band (ITB) allograft or ITB autograft performed by a single surgeon between 2011 and 2017. Patient-reported outcome measures collected before surgery and at minimum 2-year follow-up included the following: Hip Outcome Score Activities of Daily Living and Hip Outcome Score Sports-Specific Subscale and, at follow-up, patient satisfaction (range, 1-10, with 10 being very satisfied). Patients followed a standardized rehabilitation protocol after surgery with relative individualization to address each patient's needs. For continuous variables, comparisons between allografts and autografts were made using Student t tests or Mann-Whitney tests. Categorical comparisons were assessed using chi-square or Fisher exact test. Multiple logistic regression was performed to determine the influence of graft choice on risk of revision or THA.

RESULTS

A total of 205 hips met 2-year inclusion criteria. ITB allografts were used for 55 patients (37 augmentations, 18 reconstructions) and ITB autografts for 150 patients (34 augmentations, 116 reconstructions). Females represented a greater proportion of allograft versus autograft patients (71% vs 46%, respectively; P = .001). Overall, autograft patients had larger alpha angles (66.6° vs 59.1°; P = .001) and longer grafts (46 vs 41 mm; P = .03) compared with allograft patients. A total of 13 (23.6%) patients required revision surgery in the allograft group compared with 11 (7.3%) in the autograft group (P < .001). After controlling for sex, procedure (reconstruction vs augmentation), and previous surgery, the odds of revision were higher for allograft patients (OR, 4.1; 95% CI, 1.5-11.6). No significant differences in conversion to THA were observed between groups (allograft = 9%; autograft = 6%; P = .50), even after adjustment for the above covariates (OR, 2.3; 95% CI, 0.6-7.9). No differences in postoperative patient-reported outcome measures or patient satisfaction were observed between groups.

CONCLUSION

Labral augmentation or reconstruction with autograft has a significantly lower revision rate than labral augmentation or reconstruction with allograft.

Minimum 2-Year Functional Outcomes of Patients Undergoing Capsular Autograft Hip Labral Reconstruction

BACKGROUND

There is a paucity of literature on arthroscopic capsular autograft labral reconstruction.

PURPOSE

To report midterm functional outcomes for patients undergoing acetabular labral repair with capsular autograft labral reconstruction.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This is a retrospective case series of prospectively collected data on patients who underwent arthroscopic acetabular labral repair by the senior surgeon between March 2013 and August 2018. The inclusion criteria for this study were adult patients aged 18 years or older who underwent primary hip arthroscopy for arthroscopic capsular autograft labral reconstruction. Exclusion criteria were <2 years of postoperative follow-up, elective disenrollment from study before 2-year follow-up, or repeat ipsilateral hip surgery before 2-year follow-up. Intraoperatively, patients underwent capsular autograft hip labral reconstruction if they were found to have a labrum with hypoplastic tissue (width <5 mm), complex tearing, or frank degeneration of native tissue. Clinical outcome data consisted of patient-reported outcome measures.

RESULTS

A total of 97 hips (94 patients) met the inclusion criteria with a mean final follow-up of 28.2 months (95% CI, 26.0-30.4). Patients had a mean age of 39.0 years (95% CI, 36.8-41.2) with a mean body mass index of 25.8 (95% CI, 24.9-26.7). When compared with baseline (40.4 [95% CI, 36.7-44.2]), the mean international Hip-Outcome Tool-33 (iHOT-33) scores were significantly greater at 3-month (60.9 [95% CI, 56.8-64.9]; P < .001), 6-month (68.8 [95% CI, 64.7-72.9]; P < .001), 12-month (73.2 [95% CI, 68.9-77.5]; P < .001), and final (76.6 [95% CI, 72.4-80.8]; P < .001) follow-up. At 2-year follow-up, 76.3%, 65.5%, and 60.8% of patients' iHOT-33 scores exceeded clinically meaningful outcome thresholds for minimally clinically important difference (MCID), patient-acceptable symptomatic state, and substantial clinical benefit, respectively.

CONCLUSIONS

In this study of 97 hips undergoing arthroscopic labral repair with capsular autograft labral reconstruction, we found favorable outcomes that exceeded the MCID thresholds in the majority of patients at a mean 28.2 months' follow-up. Future studies should compare outcomes between this technique and other methods of autograft and allograft reconstruction to determine differences in patient-reported outcomes, donor-site morbidity, and complications.

Consensus-based classification system for intra-operative management of labral tears during hip arthroscopy-aggregate recommendations from high-volume hip preservation surgeons

The purpose of this study was to survey high-volume hip preservation surgeons regarding their perspectives on intra-operative management of labral tears to improve decision-making and produce an effective classification system. A cross-sectional survey of high-volume hip preservation surgeons was conducted in person and anonymously, using a questionnaire that is repeated for indications of labral debridement, repair and reconstruction given the torn labra are stable, unstable, viable or non-viable. Twenty-six high-volume arthroscopic hip surgeons participated in this survey. Provided the labrum was viable (torn tissue that is likely to heal) and stable, labral debridement would be performed by 76.92% of respondents for patients >40 years of age and by >84% of respondents for stable intra-substance labral tears in patients without dysplasia. If the labrum was viable but unstable, labral repair would be performed by >80% of respondents for patients ≤40 years of age and > 80% of respondents if the labral size was >3 mm and located anteriorly. Presence of calcified labra or the Os acetabuli mattered while deciding whether to repair a labrum. In non-viable (torn tissue that is unlikely to heal) and unstable labra, labral reconstruction would be performed by 84.62% of respondents if labral size was <3 mm. The majority of respondents would reconstruct calcified and non-viable, unstable labra that no longer maintained a suction seal. Surgeons performing arthroscopic hip labral treatment may utilize this comprehensive classification system, which takes into consideration patient age, labral characteristics (viability and stability) and bony morphology of the hip joint. When choosing between labral debridement, repair or reconstruction, consensus recommendations from high-volume hip preservation surgeons can enhance decision-making.

The Efficacy of Labral Reconstruction: A Systematic Review

Background:

With a greater understanding of the importance of the acetabular labrum in the function of the hip, labral repair is preferred over debridement. However, in some scenarios, preservation or repair of the labrum is not possible, and labral reconstruction procedures have been growing in popularity as an alternative to labral resection.

Purpose:

To provide an up-to-date analysis of the literature to determine the overall efficacy of labral reconstruction when compared with labral repair or resection.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

PubMed, Embase, and MEDLINE databases were searched for literature regarding labral reconstruction in the hip before July 21, 2020. The results were screened and evaluated by 2 reviewers, and a third reviewer resolved any discrepancies. The final studies were evaluated using the MINORS (Methodological Index for Non-randomized Studies) score.

Results:

There were 7 comparative studies that fit the inclusion criteria, with 228 hips from 197 patients. The mean follow-up was 34.6 months, and the mean age of all patients was 38.34 years. There were slightly more female patients than male patients (105 vs 92). Arthroscopic reconstruction was performed in 86% of studies (6/7); open surgical techniques, in 14% (1/7). A variety of grafts was used in the reconstructions. The indications for labral reconstruction and outcome measures varied in these publications. Nine patients were lost follow-up, and 6 patients converted to total hip replacement postlabral reconstruction. The assessment of these comparative studies illustrated statistically equivalent results between labral reconstruction and labral repair. Comparisons of labral reconstruction with labral resection also showed statistically equivalent postoperative patient-reported outcome scores; however, the rates of conversion to total hip arthroplasty were significantly higher in the population undergoing resection.

Conclusion:

The review of current available comparative literature, which consists entirely of level 3 studies, suggests that labral reconstruction does improve postoperative outcomes but does not demonstrate superiority over repair. There may, however, be benefit to performing labral reconstruction over resection owing to the higher rate of conversion to total hip arthroplasty in the labral resection group.

Graft Options in Hip Labral Reconstruction

PURPOSE OF REVIEW

The last decade has seen a boom in hip arthroscopy with refined indications. Improved understanding of pathoanatomy and disease progression has allowed for the development of advanced techniques. Labral reconstruction has been developed to substitute a non-functional or absent labrum. It has become an important technique in the armamentarium of high-volume arthroscopic hip surgeons.

RECENT FINDINGS

Basic science studies have improved understanding of hip biomechanics in the presence and absence of a labrum with a labral reconstruction allowing for reconstitution of normalcy. Current techniques have shown success with autograft and allograft tissue options. While autograft tissue allows for easy access intra-operatively and maintains patient biology, donor site morbidity is possible. Allografts negate donor site morbidity and allow for an abundance of tissue but can be resource-intensive and face availability concerns. Recent studies support outcomes of labral reconstructions using both autograft and allograft. Promising results have also allowed for performing labral reconstruction in a primary setting. Labral reconstruction can be successfully performed using both autograft and allograft. Patient biology should be respected, and native hip biomechanics restored. The literature is plentiful for appropriate surgical decision-making allowing the surgeon with multiple graft choices depending on training, experience, and resources.

Indications and Outcomes for Arthroscopic Hip Labral Reconstruction With Autografts: A Systematic Review

Background: The acetabular labrum plays a major role in hip function and stability. The gold standard treatment for labral tears is labral repair, but in cases where tissue is not amenable to repair, reconstruction has been demonstrated to provide superior outcomes compared to debridement. Many types of grafts have been used for reconstruction with good to excellent outcomes. Autograft options include iliotibial band (ITB), semitendinosus, and indirect head of the rectus femoris tendon, while allografts have included fascia lata and gracilis tendon allografts.

Questions/Purposes: As allografts are not always readily available and have some inherent disadvantages, the aims of this systematic review were to assess (1) indications for labral reconstruction and (2) summarize outcomes, complications, and reoperation rates after arthroscopic labral reconstruction with autografts.

Methods: A systematic review of the literature was performed using six databases (PubMed, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Scopus, and Google Scholar) to identify studies reporting outcomes for arthroscopic labral reconstruction utilizing autografts, with a minimum follow-up of 1 year. Study design, patient demographics, autograft choice, complications, donor site morbidity, reoperation rates, conversion to arthroplasty, and patient reported outcomes were extracted and reported.

Results: Seven studies were identified for inclusion with a total of 402 patients (173 females, age range 16–72, follow-up range 12–120 months). The most commonly reported functional outcome score was the modified Harris Hip Score (mHHS), which was reported in six of seven studies. Preoperative mHHS ranged from 56 to 67.3 and improved postoperatively to a range of 81.4–97.8. Conversion to total hip arthroplasty and reoperation rates ranged from 0 to 13.2% and 0 to 11%, respectively. The most common indication for labral reconstruction was an irreparable labrum. Autografts utilized included ITB, hamstring tendons, indirect head of rectus femoris, and capsular tissue.

Conclusions: Arthroscopic autograft reconstruction of the acetabular labrum results in significant improvement in the short- and mid-term patient reported outcomes, for properly selected patients presenting with pain and functional limitation in the hip due to an irreparable labral injury.

Outcomes After Arthroscopic Hip Labral Reconstruction: A Systematic Review and Meta-analysis

BACKGROUND

The acetabular labrum is critical to maintenance of hip stability and has been found to play a key role in preservation of the hip fluid seal. For irreparable labral damage, arthroscopic labral reconstruction is an evolving technique that has been shown to decrease hip pain and restore function.

PURPOSE

To provide a comprehensive review of current literature for arthroscopic hip labral reconstruction, with a focus on determining if outcomes differ between autograft or allograft tissue.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

PubMed and Scopus online databases were searched with the key terms "hip,""labrum,""reconstruction," and "graft" in varying combinations. Procedures performed, complications, failures, and functional outcome measures were included in this analysis. The inverse variance method was used to calculate pooled estimates and 95% CIs.

RESULTS

Eight studies with 537 hips were included. Mean age was 37.4 years (95% CI, 34.5-40.4 years), and mean follow-up time was 29 months (95% CI, 26-33 months). Survivorship after autograft reconstruction ranged from 75.7% to 100%, as compared with 86.3% to 90.0% in the allograft cohort. In the autograft cohort, failures included 0% to 13.2% conversion to total hip arthroplasty and 0% to 11.0% revision hip arthroscopy. Failures in the allograft cohort included 0% to 12.9% total hip arthroplasty conversion, 0% to 10.0% revision arthroscopy, and 0% to 0.8% open revision surgery. Based on 6 studies, the modified Harris Hip Score improved by a mean 29.0 points after labral reconstruction (P < .0001).

CONCLUSION

Arthroscopic hip labral reconstruction results in clinically significant improvements in patient-reported outcomes. Our analysis indicates that there are no significant differences in outcomes based on graft type alone. A number of factors may determine graft choice, including patient preference, surgeon experience, operative time, morbidity, and cost. Proper patient selection based on age and severity of degenerative joint disease will also optimize outcomes after labral reconstruction.

The anatomical properties of the indirect head of the rectus femoris tendon: a cadaveric study with clinical significance for labral reconstruction surgery

BACKGROUND

Acetabular labral tear is a common pathology. In some clinical situations, primary labral repair may not be possible and labral reconstruction is indicated.

PURPOSE AND CLINICAL RELEVANCE

Describe the anatomy of the indirect head of the rectus femoris (IHRF) tendon with clinical application in arthroscopic labral reconstruction surgery.

METHODS

Twenty-six cadaver hips were dissected. Thirteen measurements, each with clinical relevance to arthroscopic labral reconstruction using an IHRF tendon graft were taken on each hip. All measurements were taken in triplicate. Mean values, standard deviations and intra-observer reliability were calculated.

RESULTS

The mean footprint of the direct head of the rectus femoris tendon was 10.6 mm × 19.6 mm. The width and thickness at the confluence of both heads were 10.9 mm and 6.9 mm, respectively. The mean total length of the footprint and "free portion" of the IHRF was 55.3 mm, the mean cranial to caudal footprint measured at the 12 o'clock, 1 o'clock, and 2 o'clock positions were 22.3 mm. The mean length of the Indirect Head footprint alone was 38.1 mm. The mean length of IHRF tendon suitable for grafting was 46.1 mm and the mean number of clock face sectors covered by this graft was 3.3 clock face sectors. Intra-observer reliability was ≥ 0.90 for all recorded measurements. The origin of the IHRF on the acetabulum fans out posteriorly, becoming thinner and wider as the origin travels posteriorly. The tendon footprint is firmly attached on the lateral wall of the ilium and becomes a free tendon overlying the acetabular bone as it travels anteriorly and distally towards its muscular attachment.

CONCLUSION

The IHRF tendon is in an ideal location for harvesting and contains the appropriate thickness, length and triangular architecture to serve as a safe and local graft source for acetabular labral reconstruction surgery.

Indications and Outcomes of Arthroscopic Labral Reconstruction of the Hip: A Systematic Review

PURPOSE

The primary purpose of this investigation was to systematically evaluate the literature for the current indications and outcomes of arthroscopic labral reconstruction of the hip. Our secondary purpose was to evaluate the role of arthroscopic labral reconstruction in the management of reparable labral tears.

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using a PRISMA checklist. Studies published between June 2009 and June 2018 that evaluated outcomes after arthroscopic labral reconstruction with a minimum of 1 year of follow-up were included.

RESULTS

Eleven studies met the inclusion and exclusion criteria. A total of 373 patients were identified. Of the 11 studies, 9 reported that an irreparable labrum was their indication for reconstruction, with 8 reporting that this was ultimately determined intraoperatively. Substantial variability in surgical technique, graft choice, and concurrent pathology was found. All 11 studies used at least 1 validated functional outcome metric to evaluate surgical outcomes, with all studies reporting improvement greater than the minimal clinically important difference. Donor-site pain was the most common complication, although it was reported in only 2 studies. Reported rates of revision surgery and conversion to arthroplasty were low (range, 0%-9.1% for both).

CONCLUSIONS

All 11 studies included in this systematic review reported clinically significant functional improvements after arthroscopic labral reconstruction and low rates of complications, revision surgery, and progression of arthritis, although graft types and concomitant procedures confound the results. The most common indication for reconstruction was a deficient labrum on intraoperative evaluation. The 6 studies that evaluated patient satisfaction reported favorable results, with a range of 6.73 to 8.7.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Diagnosis and treatment of labral tear

Objective:

To review the literature regarding diagnosis and treatment of labral tear.

Data sources:

A systematic search was performed in PubMed using various search terms and their combinations including hip, labrum, acetabular labral tear, arthroscopy, diagnosis, and anatomy.

Study selection:

For each included study, information regarding anatomy, function, etiology, diagnosis, and management of acetabular labral tear was extracted.

Results:

Five hundred and sixty abstracts about anatomy, function, etiology, diagnosis, and management of acetabular labral tear were reviewed and 66 selected for full-text review. The mechanism of labral tear has been well explained while the long-term outcomes of various treatment remains unknown.

Conclusions:

Labral tear is generally secondary to femoroacetabular impingement, trauma, dysplasia, capsular laxity, and degeneration. Patients with labral tear complain about anterior hip or groin pain most commonly with a most consistent physical examination called positive anterior hip impingement test. Magnetic resonance arthrography is a reliable radiographic examination with arthroscopy being the gold standard. Conservative treatment consists of rest, non-steroidal anti-inflammatory medication, pain medications, modification of activities, physical therapy, and intra-articular injection. When fail to respond to conservative treatment, surgical treatment including labral debridement, labral repair, and labral reconstruction is often indicated.

Primary Hip Arthroscopic Surgery With Labral Reconstruction: Is There a Difference Between an Autograft and Allograft?

Background:

Labral reconstruction has been described as a solution for the irreparable labrum. Initial techniques employed autografts, while more recent procedures have utilized allografts. No study, to our knowledge, has compared graft types.

Purpose:

To compare outcomes between patients who underwent primary labral reconstruction with a hamstring allograft versus hamstring autograft.

Hypothesis:

No significant differences in outcomes will be found between patients who underwent primary labral reconstruction with an allograft versus autograft.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Data from September 2010 to March 2015 were reviewed. Inclusion criteria were primary hip arthroscopic surgery with labral reconstruction using either a hamstring allograft (ALLO group) or autograft (AUTO group), with minimum 2-year follow-up scores for the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score–Sports-Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain. Exclusion criteria were previous ipsilateral hip surgery, previous hip conditions, preoperative Tönnis osteoarthritis grade >1, and workers’ compensation claims. Significance was set at P = .05.

Results:

Twenty-nine patients (29 hips) were included (85.3% follow-up). There were 17 patients (17 hips) in the ALLO group and 12 patients (12 hips) in the AUTO group. All patient-reported outcome scores demonstrated significant improvements at latest follow-up except for the mHHS for the AUTO group (P = .064). Comparisons between the ALLO and AUTO groups at the preoperative and latest follow-up time points showed no significant differences (preoperative mean [range]: mHHS, 67.5 [33.0-100.0] and 65.8 [29.0-96.0], respectively [P = .826]; NAHS, 65.6 [26.3-92.5] and 58.5 [35.0-79.0], respectively [P = .322]; HOS-SSS, 43.7 [12.5-100.0] and 40.1 [19.0-78.0], respectively [P = .707]) (latest follow-up mean [range]: mHHS, 86.4 [56.0-100.0] and 81.4 [57.0-100.0], respectively [P = .46]; NAHS, 87.7 [60.0-100.0] and 82.4 [56.3-100.0], respectively [P = .396]; HOS-SSS, 81.7 [0.0-100.0] and 70.9 [27.8-100.0], respectively [P = .423]).

Conclusion:

Primary arthroscopic hip labral reconstruction yielded improvements in patient-reported outcome scores and high patient satisfaction. In this small series, no differences were found in clinical outcomes between hamstring allografts and autografts. Based on these results, hamstring allografts and autografts may be considered comparable graft choices for primary reconstruction. Because of the avoidance of donor site morbidity and the possible increase in patient satisfaction, allografts may be the preferred choice in a surgical setting when they are accessible.

Hip labral reconstruction: consensus study on indications, graft type and technique among high-volume surgeons

To survey high-volume hip arthroscopists regarding their current indications for labral reconstruction, graft preference and technique. In May 2018, a cross-sectional based survey was conducted on high-volume hip arthroscopists. A high-volume surgeon was defined as an orthopaedist who had case experience ranging from 50 to 5000 hip arthroscopies performed annually. The survey included their current indications for labral reconstruction, graft preference and technique. Twelve high-volume surgeons successfully completed the questionnaire. The mean arthroscopic procedures performed by the surgeons annually was 188.7 (range 60–350). Four surgeons (33.3%) performed <5 labral reconstruction cases per year, three (25.0%) 5–10 cases per year, two (16.7%) 11–15 cases per year and three (25.0%) over 20 cases per year. Of the 12 surgeons, 11 (91.6%) would reconstruct in certain primary settings and 100% would reconstruct in revision settings. In the primary setting, the main indications for reconstruction were poor quality labral tissue, calcified labrum and hypoplastic labrum. None of the surgeons recommended labral reconstruction for reparable labral tears in primary cases. In primary cases of irreparable labra, 58.3% of the surgeons favoured reconstruction over debridement. In revisions, 100% of the surgeon favoured reconstruction over debridement; 91.7% chose an allograft option versus an autograft alternative. Amongst high-volume arthroscopists, labral reconstruction was considered a valuable technique to restore labral function. Labral reconstruction was more often advocated in revision than in primary settings. Allograft was the preferred choice for reconstruction. Excision of the labral tissue prior to reconstruction was favoured over augmentation. Fewer surgeons performed circumferential reconstruction than segmental reconstruction.

Graft choices for acetabular labral reconstruction

The acetabular labrum plays a key role in maintaining hip function and minimizing hip degeneration. Once thought to be a rare pathology, advances in imaging have led to an increase in the number of diagnosed labral tears. While still a relatively new field, labral reconstruction surgery is an option for tears that are irreparable or require revision after primary repair. Various autograft and allograft options exist when considering labral reconstruction. The first labral reconstruction surgery was described using the ligamentum teres capitis, and has since evolved, incorporating more graft sources and reconstructive techniques. The purpose of this review is to assess and describe the different graft sources and technique currently implemented by hip surgeons. Moreover, this review attempts to determine whether a single labral reconstructive graft type is superior to the others. Techniques using the Ligamentum teres capitis autograft, ITB autograft, gracilis autograft, quadriceps tendon autograft, capsular autograft, semitendinosus allograft, indirect head of the rectus femoris autograft, peroneus brevis tendon allograft and Tensor fascia lata allograft were found. Scoring was available on 5 out of the 9 graft types. The advantages and disadvantages of each graft source is described as a comparative tool. No single graft type has shown increased benefit in acetabular labral reconstruction. The lack of uniform outcome measurements hinders comparison of reported outcomes. Surgeons should make an informed decision based on their experience as well as the patient's history and needs when choosing which graft type would be best suited for their patients.

Arthroscopic labral reconstruction using fascia lata allograft: shuttle technique and minimum two-year results

The purpose of this study was to describe the shuttle technique of acetabular labral reconstruction using allograft fascia lata and report minimum two-year clinical outcomes in a prospective patient cohort. We present a shuttle technique to introduce and fixate the allograft, by which the need to fix the free end of the graft from inside the joint is avoided. Between October 2010 and March 2014, 693 hip arthroscopic surgeries were performed by the senior author. Of these 693 patients, 34 patients underwent a labral reconstruction procedure using allograft fascia lata and the shuttle technique and met inclusion criteria. Outcome measures were collected at minimum two years postoperatively. 91.2% (31) of reconstruction patients were available for follow-up at minimum two years after surgery with 12.9% (4) of these patients converting to total hip arthroplasty at average time 27.9 months post-surgery. For the remaining reconstruction patients, mean mHHS increased from 64.0 preoperatively to 84.6 postoperatively (P = 0.0015), SF-12 Physical from 38.9 to 49.0 (P = 0.0004), SF-12 Mental from 49.5 to 55.6 (P = 0.0095), iHOT-12 from 36.4 to 68.1 (P = 0.0017), HOS-ADL from 62.6 to 81.6 (P = 0.0032) and HOS-SS from 32.9 to 65.7 (P < 0.0001). Arthroscopic acetabular labral reconstruction using fascia lata allograft and a shuttle technique appears to be an effective procedure for the treatment of labral pathology through minimum two-year follow-up. While it is difficult to discern the direct influence of the labral reconstructive procedure given the treatment of often concomitant intra-articular pathology, this patient cohort has fared similarly to other cohorts of labral reconstruction patients. No major adverse events are reported.