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Editorial Commentary: Wanted Dead or Alive: Primary Allograft Labral Reconstruction of the Hip Is As Successful, if Not More Successful, Than Primary Labral Repair

      Abstract

      Primary repair of acetabular labral tears has been the gold standard treatment with excellent short to mid-term results. Autograft and allograft labral reconstruction has been described mostly in the revision labral surgery setting with good short-term results. A recent study has compared primary labral reconstruction to labral repair head-to-head in the same patient. Primary labral reconstruction may be a suitable alternative to labral repair in patients with symptomatic labral pathology. Concerns remain, however, about sacrificing living labral tissue for dead allograft tissue for the long term.
      Just when it seemed like we know how to best address labral tears and femoroacetabular impingement (FAI) with arthroscopic labral repair and cam and pincer resection, we are made to rethink what we thought at this point was fundamental and irrefutable. In “Bilateral Hip Arthroscopy: Direct Comparison of Primary Acetabular Labral Repair and Primary Acetabular Labral Reconstruction,”
      • White B.J.
      • Patterson J.
      • Herzog M.M.
      Bilateral Hip Arthroscopy: Direct Comparison of Primary Acetabular Labral Repair and Primary Acetabular Labral Reconstruction.
      the authors White, Patterson, and Herzog challenge us to rethink our traditional method of addressing a labral tear.
      In the last 10 years since hip arthroscopy has exploded on the orthopaedic scene, we first had to show that arthroscopic techniques could achieve equivalent results to open surgical dislocation of the hip for labral tears and FAI.
      • Nwachukwu B.U.
      • Rebolledo B.J.
      • McCormick F.
      • Rosas S.
      • Harris J.D.
      • Kelly B.T.
      Arthroscopic versus open treatment of femoroacetabular impingement: A systematic review of medium- to long-term outcomes.
      Then, we showed that arthroscopic labral repairs were superior to labral debridement.
      • Larson C.M.
      • Giveans M.R.
      Arthroscopic debridement versus refixation of the acetabular labrum associated with femoroacetabular impingement.
      Subsequently, we figured out how to make our labral repair results better. We know that the leading cause of failed arthroscopic labral repair is residual FAI.
      • Ross J.R.
      • Larson C.M.
      • Adeoye O.
      • Kelly B.T.
      • Bedi A.
      Residual deformity is the most common reason for revision hip arthroscopy: A three-dimensional CT study.
      Therefore, we got better at arthroscopically resecting hip impingement. We know there are some patients who develop labral tears from microinstability of the hip or mildly dysplastic hips that would have inferior results from a standard arthroscopic capsulotomy.
      • Larson C.M.
      • Ross J.R.
      • Stone R.M.
      • et al.
      Arthroscopic management of dysplastic hip deformities: predictors of success and failures with comparison to an arthroscopic FAI cohort.
      Therefore, we developed capsular plication techniques and expanded the spectrum of patients we could treat arthroscopically. We learned that patients with arthritis do not benefit from hip arthroscopy.
      • Skendzel J.G.
      • Philippon M.J.
      • Briggs K.K.
      • Goljan P.
      The effect of joint space on midterm outcomes after arthroscopic hip surgery for femoroacetabular impingement.
      Now, we send those patients to hip arthroplasty surgeons. We have delved into extra-articular sources of hip pain such as subspine impingement and ischiofemoral impingement with good success.
      • Nawabi D.H.
      • Degen R.M.
      • Fields K.G.
      • Wentzel C.S.
      • Adeoye O.
      • Kelly B.T.
      Anterior inferior iliac spine morphology and outcomes of hip arthroscopy in soccer athletes: A comparison to nonkicking athletes.
      We also know that hip arthroscopy is difficult, and when surgeons perform an extensive labral debridement instead of a labral repair, hip labral reconstruction is a satisfactory option in the revision setting.
      • White B.J.
      • Patterson J.
      • Herzog M.M.
      Revision arthroscopic acetabular labral treatment: Repair or reconstruct?.
      Dr. White's study potentially uproots what we have considered a fundamental tenet of arthroscopic management of hip labral tears: labral tears should be treated with labral repair whenever possible. Instead, we may have to start considering that when the labrum is torn or damaged, it may behoove you to remove or sacrifice it and replace it with dead allograft tissue!
      I know Dr. White personally and I have known him since he graduated from our residency program at NYU Hospital for Joint Diseases in 2007. He went on to train with Dr. Mark Philippon of Vail, Colorado, who is a pioneer in the field of hip arthroscopy. Dr. Philippon's hip arthroscopy techniques and research has firmly entrenched arthroscopic labral repair as the gold standard technique for hip labral tears. I view Dr. White as a champion and pioneer for hip labral reconstruction.
      His prior study comparing his patients who underwent revision hip arthroscopy with labral repair versus labral reconstruction influenced my personal practice.
      • White B.J.
      • Patterson J.
      • Herzog M.M.
      Revision arthroscopic acetabular labral treatment: Repair or reconstruct?.
      Because of his report of superior results of labral reconstruction, I view this as an important option that needs to be discussed with patients in the revision setting. We all have a few failures in our hip arthroscopy practice where we just cannot explain why the patient still has pain. The postoperative magnetic resonance image shows the repaired labrum to be intact. There is no evidence of residual FAI. There is no evidence of instability. There are no adhesions. The chondral surfaces are intact. Perhaps the labrum itself, though not detached, is degenerated and painful. It makes sense that in these cases, sacrificing the native labrum or pain generator and substituting it with allograft tissue that has no pain fibers can improve results.
      • These are my current indications for labral reconstruction:
        • 1.
          Prior failed labral debridement/resection with or without residual FAI (second surgery)
        • 2.
          Failed revision labral repair without residual FAI (third surgery)
        • 3.
          Primary labral reconstruction in a young patient with calcified/ossified labrum (first surgery)
        • 4.
          Nonrepairable, attenuated, or macerated labrum in a young patient (first surgery)
      The problem with indication no. 4, however, is that the repairability of the labrum is oftentimes not known until we are already inside the hip. Is it reasonable to start adding “possible labral reconstruction with allograft” to our consents for primary hip arthroscopy even in our young patients?
      What is revolutionary about Dr. White's current study is that we are not talking about labral reconstruction in the revision setting, or when there is calcified/ossified labrum, or nonrepairable labrum. He is advocating the routine sacrifice of viable labrum for allograft tissue in all patients (14 years and 9 months to 51 years and 6 months old in his study). And it is hard to argue with his results. He clearly found a higher failure rate with primary labral repairs compared with primary labral reconstruction and now has shifted his practice completely toward the latter.
      Dr. White retrospectively reviewed 30 hips between 2009 and 2014 who had a labral repair in one hip and a labral reconstruction with allograft in the contralateral hip. He states, “The choice of labral procedure among this cohort was generally made based on a shift in surgical practice over time.” This shift occurred because of an unacceptable failure rate of his labral repair and encouraging results with his labral reconstructions. All hips between 2009 and 2011 underwent hip labral repair, whereas all hips between 2013 and 2014 underwent labral reconstruction. The time between 2011 and 2013 was an overlap period where both procedures were performed. At first glance, the results are very surprising. Repair of viable tissue led to 5 failures (26%). Reconstruction with dead tissue (allograft) led to no failures. Among patients who did not fail both treatments, there was no difference in outcome scores.
      Dr. White admits in his study that in his first several years of practice, labral repair was his standard treatment for a torn labrum. He noticed over the ensuing years, as all of us who practice hip arthroscopy did, that results were somewhat disappointing. It has been well documented that hip arthroscopy has a difficult learning curve.
      • Hoppe D.J.
      • de Sa D.
      • Simunovic N.
      • et al.
      The learning curve for hip arthroscopy: A systematic review.
      In 2009, when Dr. White started collecting data for the patients in this study, our indications for arthroscopic labral repair were looser than they are now. With the rapidly expanding literature in the last 10 years, we have learned to choose patients more wisely. We avoid arthritis at all costs. We identify hypermobile patients and consider capsular plication techniques. We avoid labral debridement because we know repair is better. We are obsessive about impingement resection because we know this is at least as important, if not more important, than labral repair. We are more diligent about checking for femoral version and acetabular dysplasia and, as a result, more apt than ever before to refer these patients to open hip preservation surgeons. Basically, every year that we practice hip arthroscopy, our results get better.
      There is no doubt in my mind that Dr. White has outstanding results with his primary labral reconstructions. However, his 26% failure rate is much higher than what the literature reports for the arthroscopic labral repair technique.
      • Sawyer G.A.
      • Briggs K.K.
      • Dornan G.J.
      • Ommen N.D.
      • Philippon M.J.
      Clinical outcomes after arthroscopic hip labral repair using looped versus pierced suture techniques.
      Looking at my own experience with hip arthroscopy, I can safely state that patients who underwent labral repair in my first 3 years of practice did not do nearly as well as the patients I operated on in the last 3 years. I do wonder if Dr. White performed primary labral repair with our current knowledge base and surgical techniques, if his failure rate would be much less than 26%. Nevertheless, I understand why he has gone completely to labral reconstructions; with his stellar results—why would he look back?
      One of the limitations of any study on labral repair is the inability of the study to take into account the level of FAI, the difficulty of completely resecting the FAI, and the intuitive knowledge that every surgeon is better at resecting FAI every year they have under their belt. It is my estimation that the labrum and any repair or reconstruction is likely less important than comprehensively addressing FAI. Let us not forget that many labral repairs are not for displaced tears and are not truly “repairs.” In fact, they should more accurately be classified as labral “refixation” as we are destabilizing the labrum in many cases to expose rim impingement. Some labral tears are not labral tears at all, but subtle delamination injuries at the chondrolabral junction caused by FAI. In these cases, does it truly matter if the labrum is repaired or reconstructed as long as the FAI is addressed? Is it possible that Dr. White's technique of impingement resection improved each year in practice as it has in my practice?
      The goal with labral surgery is to restore the anatomy. That is why we do not debride. That is why we use a base refixation stitch if the labrum is hyperplastic. That is why we use suture anchors closer to the articular surface, so we do not medialize the labrum, and lose the “suction-seal” effect. When you cannot make your labral repair anatomic, then I think you should consider labral reconstruction. But I am not convinced you should sacrifice viable labrum for allograft reconstruction routinely.
      A circumferential labral reconstruction is not a surgery for the unskilled. In his figures, Dr. White shows a picture of a labral repair with 4 anchors and a labral reconstruction with 7 anchors. Twice as many anchors can lead to twice as many problems. The traction and surgical time involved in a labral reconstruction can be easily 2 to 3 times longer than a repair. This theoretically will lead to more neurapraxias. This also could result in greater fluid extravasation and possible compartment syndrome complications.
      Before jumping on the labral reconstruction bandwagon, please also consider the historical success of allografts in orthopaedic surgery. Allograft ACL reconstruction is a great option for the middle-age active patient, but we know there is a higher failure rate in young athletes and autografts are preferred in this population.
      • Steadman J.R.
      • Matheny L.M.
      • Hurst J.M.
      • Briggs K.K.
      Patient-centered outcomes and revision rate in patients undergoing ACL reconstruction using bone-patellar tendon-bone autograft compared with bone-patella tendon-bone allograft: A matched case-control study.
      In a young patient with a meniscus tear that is repairable, do we attempt to repair the meniscus first or jump straight to a meniscus allograft transplantation? Let's not forget that in nearly every joint, allografts are used only when repair is not possible and there is no potential of healing of native tissue. And even when allograft reconstruction is considered, autograft is usually preferred.
      I believe that Dr. White has validated primary allograft reconstruction of hip labral tears in the short to midterm. I also believe there are only a minority of hip arthroscopy surgeons who can achieve his results as this a very technically difficult procedure. Any reservations I had about labral reconstruction are diminishing in the revision setting. I am not quite there in the primary labral tear setting as it is still hard for me to imagine that dead tissue is better than living tissue. I do think that his 26% failure rate in primary labral repairs was much higher then than it would be now if he were still repairing labral tears. I also think his overall primary labral reconstruction rate over all of his years in practice is greater than 0% (but who knows?). Thank you Dr. White for making hip arthroscopy more exciting!

      Supplementary Data

      References

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