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

Good Mid-Term Clinical Outcomes and Low Arthroplasty Conversion Rates After Hip Arthroscopy with Labral Debridement Without Refixation or Reconstruction

Introduction: The present study investigates the five-year outcomes of hip arthroscopy for cam or pincer-type femoroacetabular impingement (FAI) and associated labral tears in a defined patient population. Methods: Patients who underwent hip arthroscopy for cam or pincer-type arthroscopy femoroacetabular impingement (FAI) and labral tears at our hospital in the past five years were included. All patients who underwent revision-like a total hip arthroplasty (THA), a subsequent hip arthroscopy at another hospital, or had primary osseous diseases-were excluded. Patients were contacted via mail and asked to answer a clinical questionnaire called the "Hip Osteoarthritis Outcome Score" (HOOS) and to indicate whether there was a second surgery like a subsequent arthroscopy or THA. Results: There were 77 hip arthroscopies in 75 patients the last 5 years. A total of 29 patients responded. Those who did not respond were contacted via phone. All in all, we obtained the results of 49 patients (50 hips-29 right, 19 left, and 1 bilateral) who underwent hip arthroscopy over the past five years. The mean age at the time of operation was 41 years. Our results were as follows: 24 hips had an isolated labral tear, 49 hips a combined FAI pathology with cam and/or pincer-type impingement and labral tears, 3 patients had a posttraumatic FAI, and 1 patient suffered from hip chondromatosis, who was subsequently excluded; further, 22 patients (23 procedures) were lost to follow-up. HOOS contains various subscales; only the postoperative result of subscale 1 (symptoms) did not show a statistically significant improvement compared with the preoperative value. All other subscales showed a statistically significant improvement in comparison with the preoperative condition. Five patients (10.2%) still experienced symptoms, so we performed a total hip arthroplasty (THA) as a second surgical procedure. One patient was revised due to chondromatosis. One patient was revised at another center, and another was excluded because of chondromatosis. Conclusions: The five-year follow-up results of hip arthroscopy proved successful outcomes. Hip arthroscopy is an effective treatment for FAI in order to delay primary THA, regaining mobility and range of motion and reducing pain. Longer-term studies with a larger cohort are necessary.

Deep learning and conventional hip MRI for the detection of labral and cartilage abnormalities using arthroscopy as standard of reference

OBJECTIVES

To evaluate the performance of high-resolution deep learning-based hip MR imaging (CSAI) compared to standard-resolution compressed sense (CS) sequences using hip arthroscopy as standard of reference.

METHODS

Thirty-two patients (mean age, 37.5 years (± 11.7), 24 men) with femoroacetabular impingement syndrome underwent 3-T MR imaging prior to hip arthroscopy. Coronal and sagittal intermediate-weighted TSE sequences with fat saturation were obtained using CS (0.6 × 0.8 mm) and high-resolution CSAI (0.3 × 0.4 mm), with 3 mm slice thickness and similar acquisition times (3:55-4:12 min). MR scans were independently assessed by three radiologists and a hip arthroscopy specialist for labral and cartilage abnormalities. Sensitivity, specificity, and accuracy were calculated using arthroscopy as reference standard. Statistical comparisons between CS and CSAI were performed using McNemar's test.

RESULTS

Labral abnormality detection showed excellent sensitivity for radiologists (CS and CSAI: 97-100%) and the surgeon (CS: 81%, CSAI: 90%, p = 0.08), with 100% specificity. Overall cartilage lesion sensitivity was significantly higher with CSAI versus CS (42% vs. 37%, p < 0.001). Highest sensitivity was observed in superolateral acetabular cartilage (CS: 81%, CSAI: 88%, p < 0.001), while highest specificity was found for the anteroinferior acetabular cartilage (CS and CSAI: 99%). Sensitivity was lowest for the assessment of the anteroinferior and posterior acetabular zones, and inferior and posterior femoral zones (CS and CSAI < 6%).

CONCLUSION

CS and CSAI MR imaging showed excellent diagnostic performance for labral abnormalities. Despite CSAI's improved cartilage lesion detection, overall diagnostic performance for cartilage assessment remained suboptimal.

KEY POINTS

Question Accurate preoperative detection of labral and cartilage lesions in femoroacetabular impingement remains challenging, with current MRI protocols showing variable diagnostic performance. Findings High-resolution deep learning-based and standard-resolution compressed sense MRI demonstrate comparable diagnostic performance, with high accuracy for labral defects but limited sensitivity for cartilage lesions. Clinical relevance Current MRI protocols, regardless of resolution optimization, show persistent limitations in cartilage evaluation, indicating the need for further technical advancement to improve diagnostic confidence in presurgical planning.

Update on MR Imaging of the Acetabular Labrum

Acetabular labral tears are a mechanical cause of hip pain. Hip MR imaging should be performed on 3T magnets using small field of view and high-resolution imaging. If using a lower strength magnet, direct arthrography should be performed. The following should be used in the assessment for labral tear abnormalities on MR (or MR arthrography): labral morphology, abnormal T2 signal (or contrast) extension into the labral substance or chondrolabral junction. Description of the labral tear and extent of tear is useful for the hip preservation surgeon. Understanding the pitfalls around the acetabular labral complex will help avoid misinterpretation of labral tears.

Borderline Developmental Dysplasia of the Hip With Osseous Impingement as Distinct From Femoroacetabular Impingement and Developmental Dysplasia of the Hip

Background

Borderline developmental dysplasia of the hip (BDDH) accompanied by cam deformity and subspinous impingement has been found to benefit from arthroscopic surgery. However, the research comparing BDDH combined with osseous impingement to femoroacetabular impingement (FAI) without borderline dysplasia remains limited.

Purpose/Hypothesis

To compare the clinical symptoms, intraoperative findings, and outcomes of hip arthroscopy in patients with BDDH and osseous impingement versus cam-type FAI. It was hypothesized that BDDH with osseous impingement could be classified as a distinct entity between FAI and developmental dysplasia of the hip (DDH).

Study Design

Cohort study; Level of evidence, 3.

Methods

Data were collected from patients 18 to 50 years old who underwent primary hip arthroscopy between September 2016 and October 2020. Patients were divided based on preoperative lateral center-edge angle (LCEA) into 2 groups: (1) BDDH group (LCEA 18°-25°; n = 67); and (2) cam-type FAI group without BDDH (FAI group; LCEA 25°-40° and alpha angle >55°; n = 145). Disparities in symptoms, preoperative examination, intraoperative findings and procedures, and patient-reported outcome (PRO) scores were compared.

Results

Follow-up was available for 61 (91.0%) patients in the BDDH group and 125 (86.2%) patients in the FAI group. The incidence of cam deformity in BDDH patients was 91.8%. The preoperative characteristics and intraoperative findings were similar between the groups; however, preoperative internal and external hip rotation, Tönnis angle, femoroepiphyseal acetabular roof index, labral size, capsule thickness, and percentage of ligamentum teres tear were significantly higher in the BDDH group than the FAI group, and the percentage of pain aggravating factor, cam deformity, and anterior inferior iliac spine types 2 and 3 were also significantly different between groups (P < .05 for all). The percentage of intraoperative minimal acetabuloplasty, subspinous decompression, labral repair, ligamentum teres debridement, and capsular closure was significantly higher in the BDDH group than the FAI group, while the percentage of femoroplasty was higher in the FAI group (P < .05). Pre- to postoperative improvement on PRO scores was seen in both groups.

Conclusion

Given the differences in etiology and surgical procedures between the 2 conditions, it is suggested that BDDH with osseous impingement be classified as an entity distinct from FAI and DDH (and separate from BDDH without impingement) while excluding joint instability.

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.

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.

Patient-Reported Outcomes Improve at 2-Year Minimum Follow-Up After Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Systematic Review

PURPOSE

To provide an updated review of recent literature on postoperative outcomes following hip arthroscopy for femoroacetabular impingement syndrome (FAIS), focusing on larger-population studies with a minimum 2-year follow-up published within the last 5 years.

METHODS

A literature search of the PubMed, Ovid Medline, Web of Science, and Cochrane databases was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles were screened for clinical studies published from 2017 to 2022 with greater than 100 patients and minimum 2-year follow-up. Exclusion criteria included failure to report postoperative patient-reported outcomes (PROs), no preoperative radiographic measurements, and surgery for pathology other than FAIS. Data collection included study characteristics, patient demographics, radiographic findings, intraoperative findings, procedures performed, postoperative PROs, and subsequent surgeries.

RESULTS

Nine studies met inclusion criteria. Mean or median patient ages ranged from 32.3 to 41 years, with 4 studies reporting on greater than 50% female patients. Mean preoperative lateral center edge angles and alpha angles ranged from 30.2° to 37° and from 56.2° to 71°, respectively. Labral repairs (range 69.7%-100%) were performed more commonly than debridements (range 0%-26.3%). All studies demonstrated improved PROs at most recent follow-up. Seven studies reported mean or median modified Harris Hip Scores, with preoperative and postoperative values that ranged from 53.1 to 80 and from 67.4 to 100, respectively. Revision hip arthroscopies and conversions to hip arthroplasty ranged from 0.8% to 11.6% and from 0% to 34%, respectively.

CONCLUSIONS

All included studies found improvements in PROs after hip arthroscopy for FAIS at a minimum of 2-year follow-up. Conversion to total hip arthroplasty is most common in older patients at minimum 10-year follow-up.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through IV studies.

Midterm results after arthroscopic femoral neck osteoplasty combined with labral debridement for cam type femoroacetabular impingement in active adults

INTRODUCTION

Arthroscopic labral procedures are frequently undertaken in patients with femoroacetabular impingement (FAI). The role of arthroscopic femoral neck osteoplasty is well established, but less is known about labral procedures. This study evaluates the midterm efficacy and feasibility of arthroscopic osteoplasty with concomitant labral debridement for cam impingement in active adults.

METHODS

The present study was conducted according to the STROBE Statement. All 108 patients who underwent primary hip arthroscopy for cam type FAI combined with labral debridement were considered. Axial and anteroposterior plain radiographs of the pelvis were obtained preoperatively to identify the cam deformity and assess the presence of osteoarthritis, the lateral centre-edge angle, and the alpha angle. The ROM (flexion, extension, abduction, adduction, and intra/extra rotation) was evaluated. The following PROMs were administered: visual analogic scale (VAS), Tegner Activity Scale, non-arthritic hip score (NAHS), the international Hip Outcome Tool (iHOT-33) overall score, and related subscales: symptoms and functional limitations, sports and recreational activities, job-related concerns, and social, emotional, and lifestyle concerns.

RESULTS

At a mean of 2.0 ± 1.1 months, all 108 patients returned to their daily activities with no limitation. At a mean of 2.6 ± 1.4 months, all 108 patients were able to return to sport with no limitation. At 11.9 ± 2.1-month follow-up, no differences were reported in the range of motion compared to baseline: flexion (P = 0.3), extension (P = 0.09), abduction (P = 0.1), adduction (P = 0.3), internal rotation (P = 0.4), and external rotation (P = 0.6). At 72.8 ± 21.7-month follow-up, the mean VAS score was 1.7 ± 3.0, Tegner Activity Scale 3.5 ± 1.4, NAHS 92.1 ± 21.5, iHOT33 83.3 ± 27.2. At a mean of 21.7 ± 15.5 months following the index procedure, 14 of 108 patients had undergone total hip arthroplasty. No further revisions or complications were reported.

CONCLUSION

Arthroscopic femoral neck osteoplasty with concomitant labral debridement for cam type of FAI in active adults yields the reliable results, with a rate of progression to total hip arthroplasty of 13% (14 of 108) at 3-year follow-up. All patients returned to their daily activities with no limitation 2 months postoperatively. Within 3 months, all patients returned to sport with no limitations. No complication related to the index procedure was reported, and no further arthroscopic procedures were necessary.

Update on contribution of hip labral tears to hip pain: A narrative review

Hip labral tears are found in 22-55% of individuals with hip pain, but labral tears without cysts are usually not responsible for hip pain, which originates mostly from other structures than the torn labrum, like osteochondral, but also tendinous injuries (rectus femoris, gluteus minimus, iliopsoas) or capsulo-ligamentous tears (iliofemoral ligaments, ligament teres). Those lesions are mainly the consequences of underlying unrecognized functional acetabular dysplasia, and/or femoroacetabular impingements. Although the early repair of labral tears in young sportsmen induces a marked and lasting relief, and might delay the onset of osteoarthritis, the microinstability fostered by labral damages seems less important than underlying dysplasias/impingements. This narrative review details recent findings on: (i) the various mechanisms of pain associated with labral tears; (ii) few evidence for hip microinstability induced by isolated labral tears; (iii) how to best detect labral tears, both clinically (including through IROP test) and on imaging (MRI, MRA, computed tomography arthrography, ultrasound). Some authors suggested to use pull-out tests during surgery, but pulling of hips do not seem to increase much diagnostic performances of ultrasounds. Ultrasound-guided intra-articular and peri-articular injections may tell how often hip pain is exclusively induced by peri-capsular injuries secondary to the acetabular dysplasia/femoro-acetabular impingements already responsible for labral tears. Further works could tell whether labral repair, tendinous debridement, plication of capsule, and/or focal denervation, may induce lasting reliefs of pain induced by the chronic contraction of surrounding muscles (rectus femoris, gluteus minimus, psoas), whose deep aponeuroses mix with the superficial fibres of the thick hip capsule.

Editorial Commentary: Differences in Femoral Torsion Measurements Based on Axial Versus Axial-Oblique Magnetic Resonance Imaging Sequences-Let's Begin to Standardize Hip-Preservation Techniques to Improve Research and Clinical Outcomes

Femoral torsion is an important measure in patients with femoroacetabular impingement presenting with limited hip range of motion. However, femoral torsion may be measured using computed tomography or magnetic resonance imaging and on axial or axial-oblique sequences. Recent research shows that femoral torsion measurements differ based on the magnetic resonance imaging sequences on which this parameter is measured. In some cases, this may be clinically relevant in the sense that a derotational femoral osteotomy may be considered when otherwise it would not be. As more research is published within the specialized field of hip preservation surgery, we must begin to standardize our research and clinical techniques such that outcomes may be appropriately compared across studies.

Minimum 5-Year Outcomes After Primary Segmental Labral Reconstruction for Irreparable Labral Tears in the Hip With Hamstring Grafts: With a Subanalysis Comparing Autograft Versus Allograft

BACKGROUND

Comparable short-term outcomes have been obtained using hamstring allografts versus autografts after primary segmental labral reconstruction (SLR). Midterm results have not yet been determined.

PURPOSE

(1) To evaluate minimum 5-year patient-reported outcome (PRO) scores in patients who underwent primary SLR with hamstring grafts in the setting of femoroacetabular impingement syndrome (FAIS) and irreparable labral tears and (2) to compare the outcomes of hamstring autografts versus allografts in a subanalysis using propensity-matched groups.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Prospectively collected data were retrospectively reviewed for patients who underwent primary hip arthroscopy between September 2010 and November 2015. Patients were included if they underwent SLR using hamstring autografts or allografts and had preoperative and minimum 5-year PROs. The exclusion criteria were previous ipsilateral hip surgery or conditions, dysplasia, or Tönnis grade >1. Patients with autograft SLR were propensity matched 1 to 1 based on age, sex, and body mass index (BMI) to patients who underwent SLR using hamstring allografts. The minimal clinically important difference (MCID) and the Patient Acceptable Symptom State (PASS) were calculated.

RESULTS

Overall, 48 patients (N = hips 48) were eligible to be included in this study, and 41 patients (n = 41 hips [85.4%]) had a minimum 5-year follow-up reporting significant improvements in all PROs. Within the entire cohort, 9.8% required a secondary arthroscopy, with a mean time of 19 ± 1.8 months, and survivorship was 82.9%. Of the 41 included patients, 15 underwent an SLR with a hamstring autograft and were matched to 15 patients with labral reconstruction using a hamstring allograft. Groups were similar for sex (P > .999), age (P = .775), and BMI (P = .486). The mean follow-up times were 80.8 ± 25.5 and 66.1 ± 8.3 months (P = .223) for the autograft and allograft groups, respectively. Baseline PROs, preoperative radiographic measurements, surgical findings, and intraoperative procedures were similar. The groups achieved significant and comparable improvements for all PROs (P < .0001), satisfaction (P = .187), and the rate of achieving the MCID and the PASS. However, a tendency for higher postoperative PROs favoring allograft reconstruction was found.

CONCLUSION

At a minimum 5-year follow-up, patients who underwent primary arthroscopic SLR in the context of FAIS and irreparable labra, with either autograft or allograft hamstring tendons, reported significant improvements and comparable postoperative scores for all PROs, patient satisfaction, MCID, and PASS.

Can Non-Contrast 3T MRI scans predict the type of labral procedure in hip arthroscopy?

PURPOSE

The study proposed a simple classification system that aimed at predicting the labral procedure during hip arthroscopy using images from unenhanced 3T MRI scans.

PATENTS AND METHODS

Forty patients undergoing hip arthroscopy had their MRI scans reviewed pre-operatively by one of two senior radiologists and classified into: type 1: stable labrum with intra-substance degeneration (no labral repair required), type 2: unstable labrum, no intra-substance degeneration (labral repair required), or type 3: unstable labrum with intra-substance degeneration (Labral repair not feasible). Hip arthroscopy is carried out by one of two surgeons and classified accordingly while blinded to the radiologists' assessment.

RESULTS

The pre-operative radiological classification managed to predict the labral procedure in 29 cases out of 40 (72.5%). The gamma value was 0.83, and the kappa value was 0.46 denoting moderate agreement. The inter-class correlation coefficient was 0.52 indicating moderate reliability.

CONCLUSION

The proposed classification showed a moderate agreement between the radiological findings and arthroscopic findings. As we cannot accurately correlate the MRI findings with the type of surgical management, the surgeon should be prepared for all scenarios of labral procedures.

LEVEL OF EVIDENCE

Level IV (case series).