Labral Degeneration Predicts Inferior Mid-Term Outcomes in Hip Labral Repair: A Multicenter Comparative Analysis

Evaluation of Outcomes Following Arthroscopic Treatment of Femoroacetabular Impingement Syndrome Across Different Surgeons, Surgical Techniques, and Postoperative Protocols: A Multi-institutional Study

Background

Femoroacetabular impingement syndrome (FAIS) is frequently treated arthroscopically with osteoplasty and labral repair. Surgical preferences vary in terms of equipment, technique, and postoperative protocol. Patient-reported outcome measures (PROMs) are valuable tools to assess outcomes across different institutions.

Purpose

To compare PROMs after FAIS arthroscopy and evaluate the impact on postoperative outcomes with independent surgeons utilizing different surgical techniques and postoperative protocols.

Study Design

Cohort study; Level of evidence, 2.

Methods

Prospective data were collected from patients with a 2-year follow-up after arthroscopic FAIS treatment by 2 orthopaedic surgeons from different states, each attending different sports medicine fellowships. Patients were matched according to age, sex, and body mass index. Data included patient characteristics, surgical findings, and the Hip disability and Osteoarthritis Outcome Score (HOOS) preoperatively and 2 years postoperatively. Patients with revision surgery, concomitant procedures, or incomplete pre- and postoperative data were excluded. Surgeon A utilized interportal capsulotomy, capsular repair, all-suture anchors, and a postoperative hip brace. Surgeon B employed periportal capsulotomy without repair, polyether ether ketone suture anchors, and no brace. The 2 high-volume arthroscopists (>100 hips/year) performed osteoplasty and labral repair and used a large perineal post. Cohorts were analyzed with appropriate t tests, with significance set at P < .05. The percentage of patients achieving minimal clinically important difference (MCID) was calculated using Pearson chi-square tests.

Results

A total of 176 hips (100 women, 76 men) were included, with 88 matched patients from each institution. The mean age was 33.7 years and the body mass index was 26.3 kg/m2. Both cohorts significantly improved in all 5 HOOS subscales 2 years after surgery. When comparing the mean change in PROMs and the percentage of patients achieving the MCID, differences were only observed in the HOOS-Sports subscale (cohort A: 25.3 ± 29.7 vs cohort B: 34.3 ± 29.7; P = .048; MCID achieved in 57% of patients vs 76%; P = .01).

Conclusion

This prospective cohort study on arthroscopic FAIS treatment indicates that matched patient cohorts from different institutions show similarly improved PROMs at 2 years. This study suggests consistent patient outcomes across sites despite geography, surgeon, training, surgical technique, implants, and postoperative protocol.

Editorial Commentary: Diminished Hip Hypoplastic Labrum Predicts Poor Patient Outcomes After Non-augmented Primary Repair

Diminished hip labral size and tissue quality may be a predictor of poor patient outcomes when a non-augmented primary labral repair is performed. Labral augmentation is an option for patients with hypoplastic or degenerative labral tissue. The optimal graft for augmentation has yet to be identified, and biomechanical research shows no difference in force to suction-seal disruption between dermal allograft and iliotibial band allograft when used to augment the labrum. However, time-zero biomechanical studies do not reflect the biological ability of the graft to heal to surrounding structures, revascularization of the graft, durability of the graft, hip capsular status, and response to functional demands of the patient.

Editorial Commentary: Older Patients Without Degenerative Joint Disease Can Have Excellent Outcomes After Hip Arthroscopy

Early research on hip arthroscopy for femoroacetabular impingement syndrome identified patient age as a risk factor for poor outcomes and heightened revision rates. However, more recent research challenges this dogma. Disparities between chronologic and physiologic age exist among patients. In addition, orthopaedic pathology (such as degenerative chondral or labral pathology) can correlate with age, so the use of age, and using age as a predictor of outcome, may be biased by this confounding effect. Older patients without degenerative joint disease can have excellent outcomes after hip arthroscopy. Recent research shows that patients older than the age of 40 years undergoing hip arthroscopy for femoroacetabular impingement syndrome demonstrate outcomes comparable with younger patients at 10-year follow-up. However, older patients were at greater risk for conversion to total hip arthroplasty. In our experience, in the absence of joint degeneration, patients older than the age of 40 years experience predictable and durable relief following arthroscopic management of femoroacetabular impingement syndrome. These outcomes result from sound surgical indications, appropriate preoperative counseling, and meticulous surgical technique. We ought not replace joints we can preserve, and age is not the most determinative factor regarding outcome of otherwise well-indicated and performed hip arthroscopy.

Patient Factors Influencing Outcomes at 12-Year Follow-up of Hip Arthroscopy for Femoroacetabular Impingement

BACKGROUND

Arthroscopic treatment of femoroacetabular impingement has increased in popularity since the early 2000s when it was first described, although only a few midterm follow-up studies have been published.

PURPOSE

To describe the outcomes of patients undergoing hip arthroscopy for femoroacetabular impingement at a mean 12-year follow-up and to determine the risk factors for failure.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

The Non-Arthritic Hip Score (NAHS) and a radiographic evaluation were completed preoperatively and at midterm follow-up. Participants were divided into 2 groups according to their clinical evolution. The success group consisted of patients whose NAHS at the final follow-up was above the established Patient Acceptable Symptom State (PASS) threshold of 81.9, whereas patients who underwent a second surgical intervention or did not reach the PASS threshold at final follow-up were assigned to the failure group. These groups were compared to identify preoperative differences in demographic, pathological, and surgical factors.

RESULTS

A total of 95 hips were included, after 23 were lost to follow-up (80.5% follow-up). At a mean follow-up of 12.1 years (range, 9.2-16.0 years), 9 hips required total hip arthroplasty (9.5%), 5 required revision hip arthroscopy (5.3%), 29 did not achieve the NAHS PASS threshold (30.5%), and 52 achieved the NAHS PASS threshold (54.7%). The mean NAHS was 82.4 at final follow-up compared with 66.9 preoperatively (mean difference = 15.5; P < .001). Higher mean body mass index (24.9 vs 23.0; P = .030), older age (30.0 vs 27.2; P = .035), and inferior preoperative lateral joint space width (3.9 vs 4.4; P = .019) were associated with inferior prognosis in the failure group versus success group. Osteoarthritis progression was observed in 69.2% of the failure group and in 34.8% of the success group (P = .082). Labral ossification was observed in 78.3% of all patients, and its lateral projection length was statistically associated with failure (P = .015).

CONCLUSION

At a mean 12-year follow-up, hip arthroscopy for femoroacetabular impingement led to significant clinical improvement, with 55% PASS achievement. In total, 31% of patients were below the PASS threshold, 5% had revision arthroscopy, and only 9% had conversion to total hip arthroplasty for a 45% global failure rate. Increased body mass index, older age, and smaller preoperative lateral joint space width were significant negative prognostic factors. Postoperative degenerative changes were highly prevalent and demonstrated association with failure.

Editorial Commentary: Primary Treatment of Hip Labral, Osseous, Chondral, Capsular, and Extra-Articular Pathology Is Essential: Outcomes Following Revision Are Less Predictable

Appropriate labral management is one of many procedures during hip arthroscopy that affects postoperative outcomes and revision rates. Both primary labral repair and reconstruction have been shown to have superior clinical and functional outcomes compared with labral debridement when treating unstable labral tears. Arthroscopic labral reconstruction is one of the most powerful techniques in the arsenal of complex hip-preservation surgeons, and although often reserved for the revision setting, when the native labrum is irreparable, a primary reconstruction may be indicated when the only alternatives are selective labral debridement or a suboptimal repair. Labral reconstruction, either in primary or revision procedures, is indicated when the existing labrum is deemed irreparable based on an intraoperative evaluation. Current indications for primary labral reconstruction, either in the primary or revision setting, include a calcified labrum, an irreparable mixed Seldes type 1 and 2 tear, or a hypoplastic labrum with less than 3 mm of viable tissue. Primary hip arthroscopy has been shown to have superior outcomes compared with revision hip arthroscopy, whether with labral repair or reconstruction. Finally, appropriate labral management is necessary but not always sufficient. Hip arthroscopy requires management of osseous deformities, with care taken to avoid under- and over-resection during both femoroplasty and acetabuloplasty; management of chondral injury; and management of the hip capsule with repair or plication. Consideration also must be given to potential extra-articular pain generators, such as abductor insufficiency, ischiofemoral impingement, lumbar spine disease, as well as deformities requiring open surgical correction such as acetabular dysplasia or pathologic femoral version. The primary goal is getting it right the first time.

Secondary Hip Labral Reconstruction Yields Inferior Minimum 2-Year Functional Outcomes to Primary Reconstruction Despite Comparable Intraoperative Labral Characteristics

PURPOSE

To compare intraoperative labral characteristics and minimum 2-year functional outcomes of allograft labral reconstruction in primary versus revision hip arthroscopy across multiple orthopaedic centers.

METHODS

A retrospective multicenter hip arthroscopy registry was queried for patients with completed labral reconstruction surgeries from January 2014 to March 2023 with completed 2-year international Hip Outcome Tool-12 (iHOT-12) reports. Age, sex, and major intraoperative variables also were collected. Patients were placed in cohorts based on whether their arthroscopic allograft labral reconstruction was a primary procedure or secondary procedure (reconstruction following failed hip arthroscopy). One-way analysis of variance was performed on continuous variables. χ2 test was performed on categorical variables. Achievement of minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), and Substantial Clinical Benefit (SCB) also was assessed.

RESULTS

In total, 77 patients met the inclusion and exclusion criteria and had complete information. The primary reconstruction group (n = 50) was significantly older than the secondary reconstruction group (n = 27) (47.5 ± 10.5 vs 39.1 ± 8.8 years; P = .001). In both cohorts, most patients had labral bruising, advanced labral degeneration, and/or grade III complexity of labral tearing. There was no difference in any recorded intraoperative findings (P = .160, P = .783, P = .357, respectively). Each cohort experienced significant improvement in iHOT-12 scores (P < .0001). However, patients undergoing secondary labral reconstruction reported inferior iHOT-12 scores (60.1 ± 29.2 vs 74.8 ± 27.0; P = .030). Patients undergoing primary reconstruction were more likely to reach MCID, PASS, and nearly normal SCB (92 vs 66.7%, P = .024; 68.0 vs 40.7%, P = .021; 76.0 vs 48.1%, P = .014, respectively).

CONCLUSIONS

Primary and secondary allograft labral reconstruction show clinical improvement, but primary reconstruction demonstrates better outcomes and greater percentage of patients reaching MCID, PASS, and nearly normal SCB than reconstruction in the revision setting.

LEVEL OF EVIDENCE

Level III, retrospective comparative prognostic case-control study.

Decreased Hip Labral Width Measured on Preoperative Magnetic Resonance Imaging Is Associated With Greater Revision Rate After Primary Arthroscopic Labral Repair for Femoroacetabular Impingement Syndrome at 5-Year Follow-Up

PURPOSE

To examine the associations between hip labral width and patient-reported outcomes, clinical threshold achievement rates, and rate of reoperation among patients with femoroacetabular impingement syndrome (FAIS) who underwent hip arthroscopy and labral repair at minimum 5-year follow-up.

METHODS

Patients were identified from a prospective database who underwent primary hip arthroscopy for treatment of labral tears and FAIS. Modified Harris Hip Score (mHHS) and Nonarthritic Hip Score (NAHS) were recorded preoperatively and at 5-year follow-up. Achievement of the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptom state (PASS) was determined using previously established values. Labral width magnetic resonance imaging measurements were performed by 2 independent readers at standardized "clockface" locations. Patients were stratified into 3 groups at each position: lower-width (<½ SD below mean), middle-width (within ½ SD of mean), and upper-width (>½ SD above mean). Multivariable regression was used to evaluate associations of labral width with patient-reported outcomes and reoperation rate.

RESULTS

Seventy-three patients (age: 41.0 ± 12.0 years; 68.5% female) were included. Inter-rater reliability for labral width measurements was high at all positions (intraclass correlation coefficient 0.94-0.96). There were no significant intergroup differences in mHHS/NAHS improvement (P > .05) or in achievement rates of MCID/SCB/PASS at each clockface position (P > .05). Eleven patients (15.1%) underwent arthroscopic revision and 4 patients (5.5%) converted to total hip arthroplasty. Multivariable analysis found lower-width groups at 11:30 (odds ratio 1.75, P = .02) and 3:00 (odds ratio 1.59, P = .04) positions to have increased odds of revision within 5 years; however, labral width was not associated with 5-year improvement in mHHS/NAHS, achievement of MCID/PASS/SCB, or conversion to total hip arthroplasty (P > .05).

CONCLUSIONS

Hip labral width <½ SD below the mean measured on preoperative magnetic resonance imaging at 11:30- and 3:00-clockface positions was associated with increased odds of reoperation after arthroscopic labral repair and treatment of FAIS. Labral width was not associated with 5-year improvement of mHHS, NAHS, achievement of clinical thresholds, or conversion to arthroplasty.

LEVEL OF EVIDENCE

Level IV, case series.

Modified Technique for Labral Reconstruction of Hip Joint Using Autologous Iliotibial Band (ITB)-Make Labral Reconstruction Stress-Free

Current treatments for labral tear include surgical debridement, arthroscopic repair, and labral reconstruction. Although labral debridement and labral suture repair are suitable for most patients, labral reconstruction is the first treatment option when there is extensive labral degeneration or defect. Often, however, the labral degeneration or defect is only detected intraoperatively; therefore, the surgeon should always have a backup plan. The current labral reconstruction technique has shortcomings such as long operation time, difficult autograft harvesting, cumbersome graft preparation, and the need for a large surgical incision and re-sterilization and draping. To address these problems, we developed a modified technique for draping and surgery. This technique ensures preparedness for labral reconstruction during each hip arthroscopic surgery. The method also simplifies the steps for autologous iliotibial band graft harvesting and shortens operative time. We have achieved satisfactory clinical results with use of this technique over the past 2 years. In this Technical Note, we describe our technique. This modified labral reconstruction technique greatly improves surgical efficiency and could be a promising surgical technique for hip labral reconstruction.

Editorial Commentary: Surgeons Planning Hip Labral Arthroscopic Repair Should Have a Backup Plan of Labral Reconstruction or Augmentation Based on Intraoperative Labral Degeneration, Hypoplasia, or Ossification

The arena of hip arthroscopy has seen leaps in practices over the past decade, evolving from surgical debridement of the labrum to improvements in techniques which now allow repair, augmentation, and circumferential reconstruction. But as the operating theater continues to change its act, so too must the preoperative choreography. Recent advancements in the understanding of preoperative risk factors for failure of primary labral repair have identified the diminutive or hypoplastic labra on prescreening magnetic resonance imaging as a negative predictor of success. While this quantitative assessment predicts the anatomical coverage of the labrum, we are still limited in our ability to qualify the latter's tissue substance preoperatively. Ossified or degenerative labra may not have the inherent functional capacity to restore the suction seal of the hip in a primary repair setting. If the applause from the audience fails to reach a significant threshold, we must rethink our act, and that begins with the choreography. The next step in hip arthroscopy is determining if a primary augmentation or reconstruction, in lieu of primary repair, warrants further consideration. Until we develop reliable methods of quantifying and qualifying the labral tissue, both preoperatively and optimally, we should establish backup for surprises encountered while on the "stage."