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

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.

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.

Endoscopic Tendon Compression Bridge Technique for Repair of Partial-Thickness Gluteus Medius Tears With Concomitant Arthroscopy for Labral Tears: Minimum 2-Year Outcomes With Benchmark Control Group

BACKGROUND

The transtendinous technique has been used to treat partial-thickness gluteus medius tears in the setting of concomitant arthroscopy for labral tears. The tendon compression bridge technique for gluteus medius repair has been developed as an alternative method, providing several advantages; however, comparative studies between the 2 techniques are lacking in the literature.

PURPOSE

(1) To evaluate the short-term patient-reported outcomes (PROs) of the tendon compression bridge technique and (2) to compare these findings with short-term PROs of the transtendinous technique.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected on patients who were followed for a minimum of 2 years after an endoscopic tendon compression bridge procedure for gluteus medius repair in the setting of concomitant hip arthroscopy for labral tears. The following PROs were collected preoperatively and postoperatively: modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, visual analog scale score for pain, and the International Hip Outcome Tool. Clinical outcomes were assessed using the Patient Acceptable Symptom State, minimal clinically important difference, and maximum outcome improvement satisfaction threshold. Patients were propensity matched 1:1 to a cohort that underwent gluteus medius repair using the endoscopic transtendinous technique with concomitant hip arthroscopy.

RESULTS

A total of 48 hips (48 patients) that met inclusion criteria (age, 53.3 ± 9.8 years; 92% female; body mass index, 26.7 ± 4.6), with a mean follow-up of 38.5 ± 15.7 months, were matched to 48 hips (46 patients) that underwent gluteus medius repair using the transtendinous technique. Both groups demonstrated significant improvement from preoperative scores to latest follow-up (P < .05). Mean magnitude of improvement and latest follow-up scores were not significantly different between the tendon compression bridge group and the transtendinous group, and the groups demonstrated similar favorable rates of achieving Minimal Clinically Important Difference (79% vs 79%, respectively), Patient Acceptable Symptom State (73% vs 73%, respectively), and Maximum Outcome Improvement Satisfaction threshold (65% vs 58%, respectively) for modified Harris Hip Score (P > .05). Patient satisfaction between groups was similar (8.1 ± 2.2 vs 7.7 ± 2.7, respectively) (P = .475).

CONCLUSION

At minimum 2-year follow-up, the endoscopic tendon compression bridge technique for partial-thickness gluteus medius tears, when performed with concomitant hip arthroscopy, was associated with significant improvement in functional outcomes. These postoperative results were comparable with those of a matched cohort that underwent the endoscopic transtendinous technique for partial-thickness gluteus medius tears, suggesting that the tendon compression bridge technique for gluteus medius repair is an effective treatment option for partial-thickness gluteus medius tears.

Ten-Year Survivorship, Outcomes, and Sports Participation in Athletes After Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome

BACKGROUND

Hip arthroscopy is an effective treatment tool for athletes with femoroacetabular impingement (FAI) syndrome. However, long-term data are scarce.

PURPOSE

To assess survivorship, minimum 10-year patient-reported outcome measures (PROMs), and sports participation after primary hip arthroscopy for FAI syndrome in athletes and to perform a propensity-matched comparison between patients undergoing labral debridement and labral repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Athletes who underwent hip arthroscopy for FAI syndrome between February 2008 and December 2010 were eligible. Exclusion criteria were other ipsilateral hip condition, Tönnis grade ≥2, or no baseline PROMs. Survivorship was defined as no conversion to total hip arthroplasty. The Patient Acceptable Symptom State (PASS), minimal clinically important difference (MCID), maximum outcome improvement (MOI) satisfaction threshold, and sports participation were reported. A propensity-matched comparison between labral debridement and labral repair was performed. Two additional propensity-matched subanalyses were performed for capsular management and cartilage damage.

RESULTS

In total, 189 hips (177 patients) were included. The mean ± SD follow-up was 127.2 ± 6.0 months. Survivorship was 85.7%. Significant improvement in all PROMs was reported (P < .001). A total of 46 athletes with labral repair were propensity matched to 46 athletes with labral debridement. This subanalysis demonstrated significant and comparable improvement in all PROMs at minimum 10-year follow-up (P < .001). For the labral repair group, the PASS achievement rates were 88.9% for the modified Harris Hip Score (mHHS) and 80% for the Hip Outcome Score-Sport Specific Subscale (HOS-SSS); the MCID achievement rates were 80.6% for the mHHS and 84% for HOS-SSS; and for the MOI satisfaction threshold, rates were 77.8%, 80.6%, and 55.6% for the mHHS, Nonarthritic Hip Score, and visual analog scale, respectively. For the labral debridement group, the PASS achievement rates were 85.3% for the mHHS and 70.4% for the HOS-SSS; the MCID achievement rates were 81.8% for the mHHS and 74.1% for HOS-SSS; and for the MOI satisfaction threshold, rates were 72.7%, 81.8%, and 66.7% for the mHHS, Nonarthritic Hip Score, and visual analog scale. Total hip arthroplasty conversions occurred significantly sooner with labral debridement than labral repair (P = .048). Age was identified as a significant predictor of achieving the PASS.

CONCLUSION

Primary hip arthroscopy for FAI syndrome in athletes results in 85.7% survivorship and sustained PROM improvement at a minimum 10-year follow-up. A significant time delay to total hip arthroplasty conversion at 10-year follow-up was reported with labral repair over debridement, although this should be interpreted with caution, as the total number of conversions was small.

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.

After Revision Hip Arthroscopy, Patients Having Either Circumferential or Segmental Labral Reconstructions for the Management of Irreparable Labra Show Clinical Improvement Based on Proper Indications

PURPOSE

To compare a minimum of two-year follow-up patient-reported outcome scores (PROs) in patients who underwent revision hip arthroscopy for acetabular circumferential labral reconstruction (CLR) and segmental labral reconstruction (SLR) using propensity-matched groups, in the setting of irreparable labral tear.

METHODS

Prospectively collected data were retrospectively reviewed for patients who underwent revision hip arthroscopy from April 2010 to September 2018. Patients were included if they underwent labral reconstruction and had preoperative and minimum 2-year PROs. Patients unwilling to participate, with Tönnis grade >1, or hip dysplasia were excluded. Patients in the CLR group were propensity-matched on the basis of age, sex, body mass index, and Tönnis grade to patients in the SLR group in a 1:1 ratio. The minimal clinically important difference (MCID) and the patient-acceptable symptomatic state (PASS) rates were calculated.

RESULTS

Twenty-six hips (25 patients) with CLR were propensity-matched to 26 hips (26 patients) with SRL. The mean follow-up time 25.92 and 27.78 months for the CLR and SLR, respectively (P = .845). Groups reported comparable findings for sex (P = .773), age (P = .197), body mass index (P = .124), preoperative Tönnis grade (P = .124), lateral-center edge angle (P = .144), and alpha angle (P = .264), and comparable improvement for all PROs at minimum 2-year follow-up. Patient satisfaction was similar (P = .612). Rates of achievement for the MCID and PASS were comparable.

CONCLUSION

Following revision hip arthroscopy, patients who underwent CLR or SLR for complete and segmental irreparable labral tears, respectively, reported significant and comparable postoperative improvement for all PROs and rate of achievement for the MCID and PASS at a minimum 2-year follow-up.

LEVEL OF EVIDENCE

III, retrospective comparative therapeutic trial.

Outcomes After Primary Hip Arthroscopy in Athletes Older Than 40 Years Compared With Nonathletes

BACKGROUND

Master athletes (MAs), or athletes older than 40 years, make up a patient population whose outcomes after primary arthroscopic hip surgery are largely unknown.

PURPOSE

To report minimum 2-year outcomes of MAs after primary hip arthroscopy and compare their results to a propensity-matched nonathlete (NA) control group.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected between February 2008 and April 2019 and retrospectively reviewed for all patients who underwent primary hip arthroscopy. Patients were included if they were older than 40 years and had preoperative data for the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, and visual analog scale score for pain. MAs reported participating in organized sports competition within 1 year before surgery and were propensity matched to a control group of patients who did not report participating in organized sports competition (NAs). Patient characteristics, radiographic and intraoperative findings, surgical procedures performed, and patient-reported outcome measures (PROMs) were reported and compared between the groups. The rates of achieving the minimal clinically important difference and maximum outcome improvement satisfaction threshold were recorded.

RESULTS

A total of 366 hips were eligible; 328 (89.6%) had adequate follow-up data. 328 patients met inclusion criteria but 88 were not included due to the restrictions of the propensity score match ratio. Of these, 80 hips (76 patients) were classified as MAs (mean age, 48.9 ± 6.2 years) and were propensity matched 1:2 to an NA control group. Groups were comparable for baseline demographic and radiographic parameters, intraoperative findings, and procedures performed. MAs had significantly better baseline and minimum 2-year PROM scores (P < .05), higher satisfaction (P = .01), and higher rates of achieving clinically meaningful improvement across all the outcome tools used (P < .05). MAs, when compared with NAs, had lower rates of secondary arthroscopy (0% vs 7.5%, respectively; P = .001) and conversion to total hip arthroplasty (12.5% vs 26.9%, respectively; P = .011).

CONCLUSION

MAs demonstrated favorable outcomes after primary hip arthroscopy. When compared with a propensity score-matched control group of NA patients, MAs demonstrated better preoperative and postoperative PROMs, higher rates of clinically meaningful improvement, and lower rates of secondary arthroscopy and conversion to total hip arthroplasty. Absolute improvements in PROM scores were similar between the groups.

Earlier Treatment Yields Superior Outcomes in Competitive Athletes Undergoing Primary Hip Arthroscopy

PURPOSE

To report minimum 2-year patient-reported outcome scores (PROs) and return to sport (RTS) for competitive athletes undergoing primary hip arthroscopy for femoroacetabular impingement syndrome within 1 year of symptom onset and to compare these results with a propensity-matched control group of competitive athletes with symptoms for over 1 year.

METHODS

Data on professional, collegiate, high-school, and organized amateur athletes who underwent primary hip arthroscopy within 1 year of symptom onset between April 2008 and November 2017 were collected. RTS and minimum 2-year PROs were collected for the modified Harris Hip Score (mHHS), Non-arthritic Hip Score (NAHS), Hip Outcome Score-Sport Specific Subscale (HOS-SSS), International Hip Outcome Tool (iHOT-12), and visual analog pain scale (VAS). Rates of achieving minimal clinically important difference (MCID) were also evaluated. These patients were propensity-matched to a control group of competitive athletes with symptoms for over one year for comparison.

RESULTS

Fifty competitive athletes (51 hips, 54.9% female) were included in the study group with a mean follow-up of 70.9 ± 29.1 months and age of 23.6 ± 11.3 years. They demonstrated significant improvement from preoperative to latest follow-up for all recorded PROs (P < .001) and RTS at a rate of 72.9%. When outcomes were compared to the control group, the study group demonstrated similar preoperative scores for all PROs but significantly better minimum 2-year postoperative scores for NAHS (93.8 vs 85.1, P = .0001), HOS-SSS (89.1 vs 77.2, P = .001), iHOT-12 (87.7 vs 76.4, P = 0.011), and VAS (1.5 vs 2.4, P = 0.027). Rates of achieving MCID for HOS-SSS and mHHS were comparable between groups. Further, RTS rates were similar between groups (P = .301).

CONCLUSION

Competitive athletes undergoing primary hip arthroscopy with symptoms for less than 1 year demonstrated superior 2-year PROs compared to a propensity-matched control group with symptoms for over 1 year, but the rates achieving MCID and RTS were similar between groups.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

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.

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.

Workers' Compensation Patients Improved After Hip Arthroscopy for Labral Tears: A 5-Year Outcome Propensity Score-Matched Study

BACKGROUND

The workers' compensation (WC) status has been associated with inferior outcomes in orthopaedic procedures and is usually excluded from clinical outcome studies. Therefore, comparative studies based on WC status are scarce.

PURPOSE

(1) To determine outcomes of patients with WC claims treated with hip arthroscopy for labral tears at a minimum 5-year follow-up and (2) to compare these findings with a propensity score-matched control group without WC claims.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients were propensity score matched to a control group without WC claims. Data were prospectively collected for all patients undergoing hip arthroscopy. Patients were included if they received primary hip arthroscopy for labral tears in the setting of femoroacetabular impingement, had a WC claim, and had preoperative and minimum 5-year follow-up patient-reported outcomes ([PROs]; 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). Clinical outcomes were measured using the Patient Acceptable Symptom State (PASS), minimal clinically important difference (MCID), and maximum outcome improvement satisfaction threshold (MOI).

RESULTS

A total of 111 from 132 (84.1%) eligible WC patients met the inclusion criteria with an average follow-up time of 80.3 ± 37.3 months. WC cases demonstrated significant improvement from preoperatively to a minimum 5-year follow-up for mHHS, NAHS, HOS-SSS, and VAS for pain (P < .05). WC patients returned to work at a 66% rate, with an average clearance time of 4.7 months to light duty and 9.5 months to heavy duty. When compared with the control group, the WC group demonstrated lower pre- and postoperative PROs (P < .05); however, WC cases had a greater magnitude of improvement (ΔmHHS [P = .0012], ΔNAHS [P < .001], and ΔHOS-SSS [P = .012]). Rates of achieving MCID and MOI were similar in both groups (P > .05). The WC group went on to receive a future arthroscopy in 19 cases (17.1%), while 10 cases (4.5%) in the control group required revision arthroscopy (P < .001). Patients in both the WC and the control groups converted to total hip arthroplasty at similar rates (13.3% and 15.4%, respectively; P > .05).

CONCLUSION

Patients with WC claims treated with hip arthroscopic surgery showed significant improvement and high rates of returning to work at a minimum 5-year follow-up. Although having lower scores in PROs and achieving PASS rates, no differences were found in MCID and MOI rates. Furthermore, WC patients had a greater magnitude of improvement from preoperatively to a minimum 5-year follow-up after hip arthroscopy. Therefore, even though more studies are needed to determine the causes of inconsistent outcomes in the WC population, hip arthroscopy can effectively treat labral tears in the setting of femoroacetabular impingement, regardless of the WC status.

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.

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

High Body Mass Index Does Not Adversely Affect Outcomes in High-Level Athletes Undergoing Primary Hip Arthroscopy: A Propensity-Matched Comparison With Minimum 2-Year Follow-up

BACKGROUND

The effect of high body mass index (BMI) on outcomes in athletes has not been established.

PURPOSE

(1) To report minimum 2-year patient-reported outcome (PRO) scores and return to sports (RTS) for high-level athletes with high BMI undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and (2) to compare results with a propensity-matched control group of high-level athletes with a normal BMI.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were collected on all professional, collegiate, and high school athletes who had a high BMI (>30) and who had undergone primary hip arthroscopy for FAIS between January 2010 and December 2018. RTS status and minimum 2-year PROs were collected 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. The percentage of patients achieving the minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) were also recorded. These patients were propensity matched in a 1:3 ratio to high-level athletes with a normal BMI for comparison.

RESULTS

A total of 30 high-level athletes with a high BMI were included with a mean follow-up of 49.4 ± 29.5 months. They demonstrated significant improvement from preoperatively to latest follow-up for mHHS, NAHS, HOS-SSS, and VAS (P < .001). When outcomes were compared with a propensity-matched control group of 90 athletes with a normal BMI, athletes with a high BMI had worse acetabular cartilage injury and were more likely to undergo acetabular microfracture (P < .001). Athletes with a high BMI demonstrated lower postoperative scores for NAHS when compared with athletes with a normal BMI (88.06 ± 9.37 [range, 60-100] and 90.25 ± 10.79 [range, 48.75-100], respectively; P = .049). Athletes with a high BMI also demonstrated worse postoperative scores for HOS-SSS when compared with athletes with a normal BMI (77.22 ± 18.31 [range, 22.22-100] and 82.38 ± 22.79 [range, 2.78-100], respectively; P = .038). Rates of achieving MCID for the high-BMI and normal-BMI groups were comparable in mHHS (90.0% and 77.8%, respectively; P = .185) and HOS-SSS (90.0% and 82.2%, respectively; P = .397). PASS rates were also comparable between the high- and normal-BMI groups for mHHS (90.0% and 87.8%, respectively; P > .999) and HOS-SSS (70.0% and 71.1%, respectively; P = .908). Athletes with a high BMI also returned to sports at a lower rate compared with athletes with a normal BMI, but this did not reach statistical significance (P = .479).

CONCLUSION

Athletes with a high BMI undergoing primary hip arthroscopy for FAIS demonstrated significant improvement in PROs and favorable rates achieving clinically meaningful improvement. When compared with a control group of high-level athletes with a normal BMI, they exhibited similar rates of achieving psychometric thresholds and RTS rates. At short-term follow-up, high BMI did not adversely affect outcomes of high-level athletes undergoing primary hip arthroscopy.

Clinical Outcomes and Reoperation Rates After Hip Arthroscopy in Female Athletes With Low Versus Normal Body Mass Index: A Propensity-Matched Comparison With Minimum 2-Year Follow-up

BACKGROUND

The effect of low body mass index (BMI) on outcomes in female athletes is unknown.

PURPOSE

(1) To report minimum 2-year patient-reported outcomes and return to sports for high-level female athletes with low BMI undergoing hip arthroscopy for femoroacetabular impingement syndrome and (2) to compare results with those of a propensity-matched control group of high-level female athletes with a normal BMI.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were collected on all professional, collegiate, and high school female athletes who had a low BMI and underwent primary hip arthroscopy between September 2009 and March 2017 at our institute. Return-to-sports status and minimum 2-year patient-reported outcomes were collected for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score, Hip Outcome Score-Sport Specific Subscale, and visual analog scale (VAS) for pain. The percentage of patients achieving the minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), and maximum outcome improvement satisfaction threshold (MOIST) was also recorded. These patients were propensity matched to high-level female athletes with a normal BMI for comparison.

RESULTS

A total of 21 high-level female athletes (25 hips) with a mean ± SD follow-up of 58.9 ± 31.5 months were included. They demonstrated significant improvement from preoperatively to latest follow-up for the mHHS, Nonarthritic Hip Score, Hip Outcome Score-Sport Specific Subscale, and VAS (P < .001). When outcomes were compared with those of the control group, female athletes with low BMI demonstrated lower rates of achieving the MCID for the mHHS (54.5% vs 77.4%; P = .041), PASS for the International Hip Outcome Tool-12 (45.5% vs 72.6%; P = .022), and MOIST for the VAS (31.8% vs 56.5%; P = .047). There were no other significant differences in the rate of achieving the MCID, PASS, or MOIST between the groups (P > .05). Female athletes with low BMI also had higher rates of revision when compared with the control group (27.2% vs 10.6%; P = .049), but there were comparable return-to-sports rates (75.0% vs 74.5%; P > .05).

CONCLUSION

High-level female athletes with low BMI undergoing primary hip arthroscopy for femoroacetabular impingement syndrome demonstrated significant improvement in patient-reported outcomes and acceptable rates of return to play. When compared with a control group with normal BMI, they exhibited higher rates of revision and lower rates of achieving the MCID for the mHHS, PASS for the International Hip Outcome Tool-12, and MOIST for the VAS.

Labral Tear Management in Patients Aged 40 Years and Older Undergoing Primary Hip Arthroscopy: A Propensity-Matched Case-Control Study With Minimum 2-Year Follow-up

BACKGROUND

Previous literature has suggested that primary acetabular labral reconstruction leads to lower secondary surgery rates than does labral repair for patients aged ≥40 years.

PURPOSE

To report minimum 2-year patient-reported outcome (PRO) scores, survivorship, and secondary surgeries in patients aged ≥40 years who underwent primary hip arthroscopy with labral reconstruction compared with a propensity-matched primary labral repair group.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed for patients who underwent a primary hip arthroscopy for femoroacetabular impingement syndrome between January 2014 and June 2018. Patients aged ≥40 years who underwent a labral reconstruction or a labral repair and had preoperative and minimum 2-year PROs for the modified Harris Hip Score, Nonarthritic Hip Score, and visual analog scale (VAS) for pain were included. Patients with previous ipsilateral hip conditions and surgery, Tönnis grade >1, hip dysplasia, or workers' compensation status were excluded. Patients in the reconstruction group were propensity matched 1:2 to patients in the repair group based on age, sex, and body mass index. Secondary surgeries and achievement of the minimal clinically important difference (MCID), patient acceptable symptom state (PASS), and maximum outcome improvement (MOI) were recorded.

RESULTS

A total of 53 and 106 hips were included in the labral reconstruction and repair groups, respectively. The average follow-up time was 37.6 months. The average ages for the reconstruction and repair groups were 48.01 ± 5.4 years and 48.61 ± 6.0 years, respectively. Both groups achieved significant improvements in all PROs at a minimum of 2 years, with similar achievements of MCID, PASS, and MOI, and comparable secondary surgery rates.

CONCLUSION

Patients aged ≥40 years who received primary labral repair and primary labral reconstruction achieved similar significant improvements in all PROs, VAS pain, and patient satisfaction at the minimum 2-year follow-up, with comparable rates of secondary surgeries and achieving MCID, PASS, and MOI. Based on these findings, labral repair remains the gold standard treatment for viable labrum in this population group, while reconstruction is a useful alternative for irreparable labrum.

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.].

Hip Labral Reconstruction: Techniques and Outcomes

PURPOSE OF REVIEW

With increased understanding of the biomechanical function of the acetabular labrum, more attention has been directed towards surgical techniques that preserve or restore normal joint anatomy. While labral repair has been shown to produce superior outcomes to labral debridement, repair is not always possible in the setting of severe labral intrasubstance tearing or deficiency. These patients were previously left without suitable arthroscopic treatment options.

RECENT FINDINGS

Labral reconstruction is an emerging procedure that has been shown to offer promising outcomes for traditionally difficult-to-treat hip pathology. Short- and mid-term follow-up studies have consistently demonstrated significant improvement in patient-reported outcomes, function, and patient satisfaction postoperatively, often despite less favorable preoperative characteristics. Labral reconstruction is a viable arthroscopic treatment option that has been shown to reliably produce clinically meaningful results in patients with severe labral pathology that is not amenable to repair/refixation or augmentation.

Revision Hip Arthroscopy in High-Level Athletes: Minimum 2-Year Outcomes Comparison to a Propensity-Matched Primary Hip Arthroscopy Control Group

BACKGROUND

Outcomes of revision hip arthroscopy in the athletic population have not been well established.

PURPOSE

(1) To report clinical outcomes for high-level athletes undergoing revision hip arthroscopy in the setting of femoroacetabular impingement syndrome (FAIS) or labral tears and (2) to compare these outcomes against a propensity-matched group of high-level athletes undergoing primary hip arthroscopy.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data for professional, college, and high school athletes were prospectively collected and retrospectively reviewed between January 2012 and October 2018. Patients were included if they underwent revision or primary hip arthroscopy and had preoperative and minimum 2-year patient-reported outcome (PRO) scores for 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. The findings and outcomes of revision athletes were compared with a propensity-matched control group of high-level athletes undergoing primary hip arthroscopy.

RESULTS

A total of 32 hips (29 patients) undergoing revision hip arthroscopy and 92 hips (88 patients) undergoing primary hip arthroscopy were included in our final analysis with a median follow-up time of 29.5 months (95% CI, 27.2-32.1 months) and 36.5 months (95% CI, 33.5-37.7 months), respectively. Athletes undergoing revision surgery showed significant improvement in all recorded PRO measurements and achieved patient acceptable symptomatic state (PASS) and minimal clinically important difference (MCID) for mHHS at high rates (80.6% and 83.9%, respectively). When compared with a propensity-matched primary control group, patients undergoing revision surgery demonstrated lower preoperative and postoperative scores for mHHS, NAHS, and HOS-SSS, but the magnitude of improvement in functional scores was similar between groups. Athletes undergoing revision surgery achieved PASS for HOS-SSS at lower rates than the control group (P = .005), and they were less likely to attempt to return to sport compared with the control group (62.5% vs 87.0%; P < .01).

CONCLUSION

Revision hip arthroscopy is a viable treatment option to improve PROs in high-level athletes at minimum 2-year follow-up. The study group showed significant improvement in functional scores and a high rate of successful outcomes. They experienced similar magnitude of improvement as that of a propensity-matched control group; however, they achieved lower postoperative PRO scores and attempted to return to sport at lower rates.

In search of labral restoration function with hip arthroscopy: outcomes of hip labral reconstruction versus labral repair: a systematic review

PURPOSE

To perform a systematic review comparing patient-reported outcomes (PROs) in patients who underwent hip arthroscopy with labral repair versus labral reconstruction in the setting of femoroacetabular impingement syndrome (FAIS) and labral tears.

METHODS

A systematic review of the PubMed, Embase, and Cochrane databases was performed in May 2020 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and checklist. Articles were included in the analysis if they compared PROs between a labral repair and labral reconstruction cohort. For all PROs, the standardised mean difference (SMD) was calculated to compare the effect size of labral repair and labral reconstruction.

RESULTS

10 comparative studies, with 582 reconstruction cases and 631 repair cases, were included in this analysis. The mean age for the reconstruction and the repair groups ranged from 27.0 years to 52.6 years and 27.5 years to 47.0 years, respectively. The mean follow-up for the reconstruction and the repair groups ranged from 24.0 months to 66.0 months and 24.0 months to 71.0 months, respectively. The modified Harris Hip Scores (mHHS) was favourable in 8 reconstruction studies (range 80.4-95.0) and 9 repair studies (range 84.1-93.0). Average NAHS scores for the repair and reconstruction cohorts ranged from 77.9-88.6 and 73.9-92.4, respectively. Additionally, the effect sizes regarding NAHS and mHHS scores were large (SMD > 0.8) in both the reconstruction and repair groups for the majority of studies. Finally, reconstruction patients underwent a subsequent total hip arthroplasty (THA) at a slightly higher rate.

CONCLUSIONS

In the setting of FAIS and labral tears, patients who underwent hip arthroscopy may expect significant improvement in PROs at short-term follow-up with either labral repair or labral reconstruction. Although, not statistically significant, the repair group trended towards higher scores and exhibited a lower risk of conversion to THA.

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.

Limited lumbopelvic mobility does not influence short-term outcomes after primary hip arthroscopy: a propensity-matched controlled study

There is a paucity of literature investigating the effect of lumbopelvic mobility on patient-reported outcome scores (PROs) after primary hip arthroscopy. The purpose of this study was (i) to report minimum 1-year PROs in patients with limited lumbopelvic mobility (LM) who underwent primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and (ii) to compare clinical results with a propensity-matched control group of patients with normal lumbopelvic mobility (NM). Data were reviewed for surgeries performed between November 2019 and March 2020. Patients were considered eligible if they received a primary hip arthroscopy for FAIS in the setting of LM (seated to standing change in sacral slope ≤ 10°). LM patients were propensity-matched to a control group of patients with normal lumbopelvic motion (seated to standing change in sacral slope > 10°) for comparison. A total of 17 LM and 34 propensity-matched NM patients were included in the study. LM patients showed significant improvement in all outcome measures and achieved the minimum clinically important difference (MCID) and patient acceptable symptomatic state (PASS) at high rates for modified Harris Hip Score (MCID: 94% and PASS: 82%) and International Hip Outcome Tool-12 (iHOT-12; MCID: 94% and iHOT-12: 76%). When LM patients were compared to a propensity-matched control group of NM patients, they demonstrated similar postoperative PROs and rates of achieving MCID/PASS. LM patients who undergo primary hip arthroscopy may expect favorable short-term PROs at minimum 1-year follow-up. These results were comparable to a control group of NM patients.

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.

Achieving Successful Outcomes in High-Level Athletes With Borderline Hip Dysplasia Undergoing Hip Arthroscopy With Capsular Plication and Labral Preservation: A Propensity-Matched Controlled Study

BACKGROUND

Return to sports (RTS) rates and patient-reported outcomes (PROs) after hip arthroscopy in athletes with borderline dysplasia (BD) have not been established.

PURPOSE

(1) To report minimum 2-year PROs and RTS rates in high-level athletes with BD who underwent hip arthroscopy for labral pathology in the setting of microinstability and (2) to compare clinical results with those of a matched control group of athletes with normal acetabular coverage.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were reviewed for surgery performed between January 2012 and July 2018. Patients were considered eligible if they received a primary hip arthroscopy in the setting of BD (lateral center-edge angle, 18°-25°) and competed in professional, collegiate, or high school sports. Inclusion criteria included preoperative and minimum 2-year follow-up scores for the modified Harris Hip Score, Non-arthritic Hip Score, Hip Outcome Score-Sport Specific Subscale, and visual analog scale for pain. Athletes with BD were matched to a control group of athletes with normal acetabular coverage (lateral center-edge angle, 25°-40°).

RESULTS

A total of 65 patients with BD were included in the study with a mean ± standard deviation follow-up of 47.5 ± 20.4 months. Athletes with BD showed significant improvement in all outcome measures recorded, demonstrated high RTS rates (80.7%), and achieved the minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) for the Hip Outcome Score-Sport Specific Subscale at high rates (MCID, 90.8%; PASS, 75.4%). When compared with a propensity-matched control group with normal acetabular coverage, capsular plication was performed more commonly in the BD group (93.8% vs 82.7%; P = .037). PROs and RTS, PASS, and MCID rates were similar between the BD and control groups (P > .05).

CONCLUSION

High-level athletes with BD who undergo primary hip arthroscopy for labral pathology in the setting of microinstability may expect favorable PROs and RTS rates at minimum 2-year follow-up. These results were comparable with those of a control group of athletes with normal coverage.

Labral reconstruction with polyurethane implant

Surgical treatment of labral injuries has shifted from debridement to preservation over the past decades. Primary repair and secondary augmentation or reconstruction techniques are aimed at restoring the labral seal and preserving or improving contact mechanics. Currently, the standard of care for non-repairable tears favours the use of auto- or allografts. As an alternative, we present our initial experience using a synthetic, off-the-shelf polyurethane scaffold for augmentation and reconstruction of segmental labral tissue loss or irreparable labral damage. Three patients aged 37–44 (two male, one female) with femoroacetabular impingement without associated dysplasia (Wiberg > 25°) or osteoarthritis (Tönnis <2) were included in this series. Labral reconstruction (one case) and augmentation (two cases) were performed using a synthetic polyurethane scaffold developed for meniscal substitution (Actifit^®, Orteq Ltd, London, UK) and adapted to the hip. Clinical results were analysed with patient-reported outcomes (PROMs) using non-arthritic hip score (NAHS) and daily live activities hip outcome score (DLA HOS) and magnetic resonance images (MRI) at 2- and 4-year follow-up. Clinically improvement was seen in all PROMs at 4 years. The NAHS scores improved from 57.7 to 82.3 (50.9% improvement) and HOS from 59 to 79.3 (35.3% improvement). Last follow-up MRIs confirmed the presence of the scaffold; however, the scaffold signal was still hyperintense compared to native labrum. There was no shrinkage in any scaffold and no progression to hip osteoarthritis seen. Reconstruction or augmentation of segmental labral defects with a polyurethane scaffold may be an effective procedure. At 4 years after implantation, our small cases series resulted in improved hip joint function, reduced pain and scaffold preservation on follow-up imaging.

Arthroscopic Circumferential Acetabular Labral Reconstruction for Irreparable Labra in the Revision Setting: Patient-Reported Outcome Scores and Rate of Achieving the Minimal Clinically Important Difference at a Minimum 2-Year Follow-up

BACKGROUND

There is a paucity in the literature reporting patient-reported outcome (PRO) scores and the minimal clinically important difference (MCID) after revision hip arthroscopic surgery with circumferential labral reconstruction.

PURPOSE

To report minimum 2-year PRO scores and the rate of achieving the MCID in patients who underwent revision hip arthroscopic surgery with circumferential labral reconstruction in the setting of irreparable labral tears.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Data were retrospectively reviewed for all patients who underwent revision hip arthroscopic surgery between February 2016 and November 2017. Patients were included if they had undergone circumferential labral reconstruction and had preoperative and postoperative scores for the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score Sport-Specific Subscale (HOS-SSS), International Hip Outcome Tool (iHOT-12), 12-Item Short Form Health Survey physical and mental components (SF-12 P and SF-12 M, respectively), Veterans RAND 12-Item Health Survey physical and mental components (VR-12 P and VR-12 M, respectively), and visual analog scale (VAS) for pain. Exclusion criteria were Tönnis grade >1, Legg-Calve-Perthes disease, slipped capital femoral epiphysis, fractures, hip dysplasia, or revision labral treatment different from circumferential labral reconstruction. The MCID was calculated. Secondary surgical procedures were documented.

RESULTS

A total of 26 hips (26 patients; 61.5% female) were included. The mean age and body mass index were 33.2 ± 10.4 years and 25.5 ± 4.9, respectively. Significant improvements were reported for the mHHS (17.0 ± 19.5; P = .0002), NAHS (17.9 ± 16.7; P < .0001), HOS-SSS (21.7 ± 23.1; P = .0005), VAS (-2.2 ± 3.0; P = .006), iHOT-12 (25.8 ± 32.5; P = .0007), SF-12 P (8.5 ± 11.2; P = .001), and VR-12 P (8.9 ± 11.6; P = .001). Rates of meeting the MCID for the mHHS, NAHS, HOS-SSS, iHOT-12, and VAS were 76.9%, 80.0%, 65.0%, 62.5%, and 69.2%, respectively. No case of re-revision arthroscopic surgery was documented, but 1 case of conversion to total hip arthroplasty was documented at 38.6 months.

CONCLUSION

In the setting of revision hip arthroscopic surgery and irreparable labral tears, circumferential labral reconstruction resulted in significant improvements in all PRO and VAS scores at a minimum 2-year follow-up with a high rate of achieving the MCID.

Characterizing irreparable: a retrospective machine learning analysis of patients who undergo primary labral reconstruction during hip arthroscopy

Hip labrum reconstruction has been demonstrated to be a viable option for patients with irreparable labral tears. However, there is a lack of data analyzing patient and labral characteristics in those undergoing primary hip labral reconstruction. To use a machine learning technique to subcategorize patients who underwent labral reconstruction during primary hip arthroscopy and to determine if there may be varying pathology resulting in severe labral damage. Patients who underwent primary labral reconstruction between 2015 and 2018 were included. Patients with a prior ipsilateral hip surgery, who were unwilling to participate, or had incomplete preoperative data were excluded. Agglomerative hierarchical clustering analysis was conducted to identify the subgroups of patients. A comparison was performed for preoperative characteristics, intraoperative findings and procedures. Of the 191 patients who underwent primary labral reconstruction and were eligible, 174 were included in the clustering analysis. Two distinct groups were identified (Group 1: 112 patients, 64.4%; Group 2: 62 patients, 35.6%). Group 1 had a significantly higher proportion of females (61.6% versus 43.5%; P &lt; 0.05), combined Seldes I and II labral tears (94.6% versus 54.8%; P &lt; 0.05), and larger tears. Group 2 had a significantly higher rate of labral calcification (82.3% versus 3.6%; P &lt; 0.05). The results of this study demonstrate two distinct groups of patients who underwent primary hip labral reconstruction: those with severe labral damage, and those with a calcified labrum. Approximately two-thirds were placed in the group with severe labral damage, while the other third had diminished quality secondary to calcific changes. Retrospective comparative trial; Level of Evidence, 3.

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.

Femoroacetabular Impingement and Management of Labral Tears in the Athlete

Femoroacetabular impingement and associated labral tearing is a common source of hip pain in athletes. This article reviews the hip joint anatomy and complex interplay between alterations on the femoral and acetabular sides, in addition to evaluation of soft tissue stabilizers and spinopelvic parameters. Symptom management with a focus on arthroscopic treatment of abnormal bony morphology and labral repair or reconstruction is discussed. In select patients with persistent pain who have failed conservative measures, hip arthroscopy with correction of bony impingement and labral repair or reconstruction has yielded good to excellent results in recreational and professional athletes.

Arthroscopic acetabular labral reconstruction: a review

The function and importance of the acetabular labrum in hip biomechanics have been determined. A labral tear is one of the most common findings in the hip preservation field, commonly associated with femoroacetabular impingement (FAI) syndrome. It has been established that the restoration of labral anatomy and function are key factors to improve patient-reported outcome measurements (PROMs) and psychometric tools following arthroscopic hip arthroscopy in the context of FAI syndrome. Labral repair or refixation is currently the gold-standard surgical option when facing labral tears, with clinical mid to long-term data supporting its use. Labral selective debridement has proven to be a valid alternative in selective patients. Acetabular labral reconstruction has risen as an alternative to labral excision or resection when repair is not an option due to labral tissue deficiency. Restoring the labral sealing mechanism is the goal behind the acetabular labral reconstruction. It has been proven that labral reconstruction leads to superior PROMs when compared with resection. This review presents an analysis of the indications, techniques, and outcomes for arthroscopic acetabular labral reconstruction.

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.

Circumferential Labral Reconstruction for Irreparable Labral Tears in the Primary Setting: Minimum 2-Year Outcomes With a Nested Matched-Pair Labral Repair Control Group

PURPOSE

(1) To report minimum 2-year patient-reported outcome (PRO) scores of primary circumferential acetabular labral reconstruction using anterior tibialis allograft and the knotless pull-through technique in the setting of femoroacetabular impingement syndrome (FAIS) and irreparable labral tears and (2) to compare these PROs with a matched-pair primary labral repair group.

METHODS

Data were prospectively collected and retrospectively reviewed. Patients were included if they underwent primary circumferential labral reconstruction with anterior tibialis tendon allograft during February 2016 to April 2017 for irreparable labral tears and FAIS and had preoperative and minimum 2-year follow-up for modified Harris Hip Score (mHHS), Hip Outcome Score-Sport-Specific Subscale, Non-arthritic Hip Score, International Hip Outcome Tool 12 (iHOT-12), 12-Item Short Form Health Survey physical component and mental component, Veterans RAND 12-Item Health Survey physical component and mental component, and visual analog scale for pain. The exclusion criteria were previous ipsilateral hip conditions or surgical procedures, Tönnis grade 2 or higher, or dysplasia (lateral center-edge angle ≤ 18°). Labral tears were considered irreparable if the labrum appeared (1) to be mostly or completely calcified and (2) to be inadequate (nonviable) and not amenable for labral repair. The reconstruction group was matched 1:3 based on age, sex, and body mass index to a benchmark control group of hips undergoing labral repair from the same period. The minimal clinically important difference and patient acceptable symptomatic state for the mHHS and iHOT-12 score were calculated.

RESULTS

A total of 37 hips (37 patients) underwent circumferential labral reconstruction. There were 19 female patients (51.4%) and 18 male patients (48.6%). The mean age was 45.6 ± 11.6 years, and the average body mass index was 27.1 ± 5. At minimum 2-year follow-up, the circumferential labral reconstruction group showed statistically significant improvements in the mHHS, Non-arthritic Hip Score, Hip Outcome Score-Sport-Specific Subscale, iHOT-12 score, and visual analog scale score. All hips in the reconstruction group were successfully matched to 111 labral repair hips. At latest follow-up, improvements in all PROs between the 2 groups were comparable. The revision rates were 0% and 3.6% in the reconstruction and repair groups, respectively.

CONCLUSIONS

After primary hip arthroscopy, primary circumferential labral reconstruction using anterior tibialis allograft and the knotless pull-through technique in the setting of FAIS and irreparable labral tears resulted in significant improvements in several PROs at minimum 2-year follow-up and high patient satisfaction. Primary circumferential labral reconstruction reached comparable functional outcomes to those of a benchmark matched-pair primary labral repair control group.

LEVEL OF EVIDENCE

Level III, case-control study.

Radiographic and Demographic Factors Can Predict the Need for Primary Labral Reconstruction in Hip Arthroscopic Surgery: A Predictive Model Using 1398 Hips

BACKGROUND

Labral tears are the most common findings in patients with symptomatic femoroacetabular impingement (FAI). The restoration of labral function is critical, and labral reconstruction has been proposed as an alternative for irreparable tears.

PURPOSE

To compare preoperative radiographic measurements and demographics of patients who underwent primary arthroscopic labral reconstruction versus primary labral repair and to identify factors that are predictive of the need for reconstruction.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Patients who underwent their index hip arthroscopic procedure between October 2010 and November 2018 and underwent either labral reconstruction or repair were included in the study. A total of 18 variables (14 radiographic and 4 demographic) were assessed in a bivariate comparison and analyzed in a multivariate logistic model.

RESULTS

A total of 251 primary reconstruction and 1147 primary repair procedures were included. The logistic model selected age, body mass index (BMI), Tönnis grade, lateral center-edge angle (LCEA), and alpha angle. The odds of reconstruction were 2.52 times higher in patients with Tönnis grade 1 than 0 (odds ratio [OR], 2.52 [95% CI, 1.82-3.49]). Each additional degree in the LCEA was associated with a 6% increase in the odds of reconstruction (OR, 1.06 [95% CI, 1.04-1.09]) and 4% for each additional degree in the alpha angle (OR, 1.04 [95% CI, 1.03-1.05]). Higher age (per log 10 unit) and BMI also increased the likelihood of reconstruction (OR, 11.29 [95% CI, 4.23-30.10] and OR, 1.03 [95% CI, 1.00-1.06], respectively).

CONCLUSION

In a multivariate analysis, factors identified as preoperative predictors for primary arthroscopic labral reconstruction in the setting of FAI and labral tears were Tönnis grade, LCEA, age, and BMI. These predictive factors may be useful for the clinician in determining the preoperative likelihood of primary labral reconstruction.

Primary labral reconstruction in patients with femoroacetabular impingement, irreparable labral tears and severe acetabular chondral defects decreases the risk of conversion to total hip arthroplasty: a pair-matched study

In the presence of severe acetabular cartilage defects, the benefits of labral reconstruction (RECON) versus labral resection (RESEC) have not been determined. Prospectively collected data between October 2008 and December 2016 were retrospectively reviewed. Inclusion criteria were hip arthroscopy, acetabular Outerbridge grade III/IV, irreparable labral tears that underwent RECON or RESEC, and minimum 2-year postoperative measures for the modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, International Hip Outcome Tool, Patient Satisfaction and Visual Analogue Scale for pain. Exclusion criteria included Tönnis grade >1, previous hip conditions or previous ipsilateral hip surgeries. A 1:1 matched-pair analysis was performed based on age ±5 years, sex, body mass index ±5 kg/m², Tönnis grade, acetabular microfracture, femoral Outerbridge grade (0 or I compared with II, III or IV). Relative risk (RR) and conversion rate to total hip arthroplasty (THA) were calculated. A total of 38 RECON hips were successfully matched. Both groups demonstrated significant improvements in patient-reported outcomes (PROs). THA conversion was 5.3% and 21.1% for the RECON and RESEC groups, respectively (P = 0.04). RECON was four times less likely to require THA conversion than the RESEC group (RR=4.0; 95% CI 0.91-17.63). In the setting of primary arthroscopic management of femoroacetabular impingement, irreparable labral tears and acetabular chondral lesions of Outerbridge III/IV, patients that underwent RECON and RESEC experienced significant improvement in PROs at minimum 2-year follow-up, and these functional scores were comparable when groups were matched. However, RR and rate to THA conversion were significantly higher in the RESEC group.