Advertisement

Editorial Commentary: Meet Your Newest Tool in the Hip Labral Preservation Toolbox: Labral Augmentation

      Abstract

      Chondrolabral dysfunction in the hip is becoming increasingly recognized in clinical practice as a source of pain and dysfunction in young patients. In a short period of time, there have been substantial advances in the treatment of hip labral tears. Over the past 15 years, the field of hip medicine has rapidly moved from open labral resection to minimally invasive arthroscopic labral preservation techniques with repair and reconstruction. A new method of hip labral preservation, labral augmentation, provides the next advance in treating appropriately selected patients with chondrolabral dysfunction.
      In treating young patients with hip pain, it really is all about the labrum. As we clinicians have come to realize, a functioning labrum is essential to a fit and healthy hip joint. Of course, it is rare that the labrum is the beginning and end of the story. We often find that the labrum is the “canary in the coal mine” in that a pathologic labrum is often indicative of a larger lurking structural issue, such as dysplasia or femoroacetabular impingement, especially in a young hip. Given the range of pathology in which the hip labrum suffers, considerable effort and focus have been dedicated to treatment of this area. While treatment of the background structural issues is paramount in these hips, hip labral preservation techniques have also advanced rapidly during the last decade. Ten to 15 years ago, a labral tear was commonly treated with complete excision or resection. As techniques and instrumentation improved, adoption of arthroscopic labral repair was rapidly incorporated,
      • Larson C.
      • Giveans M.
      Arthroscopic debridement versus refixation of the acetabular labrum associated with femoroacetabular impingement.
      fueled by the first randomized controlled trial in hip arthroscopy clearly demonstrating superior results for labral repair over debridement.
      • Krych A.J.
      • Thompson M.
      • Knutson Z.
      • Scoon J.
      • Coleman S.H.
      Arthroscopic labral repair versus selective labral debridement in female patients with femoroacetabular impingement: A prospective randomized study.
      As familiarity with labral repair techniques grew, Dr. Marc Philippon pioneered labral reconstruction procedures for segmental labral defects, largely following failed primary hip arthroscopy.
      • Philippon M.J.
      • Briggs K.K.
      • Hay C.J.
      • Kuppersmith D.A.
      • Dewing C.B.
      • Huang M.J.
      Arthroscopic labral reconstruction in the hip using iliotibial band autograft: Technique and early outcomes.
      Early results for reconstruction were encouraging, and the dilemma became whether to repair or reconstruct the labrum when labral tissue was diminutive and of questionable quality.
      • White B.J.
      • Patterson J.
      • Herzog M.M.
      Revision arthroscopic acetabular labral treatment: Repair or reconstruct?.
      For me, this remains a challenging question at the time of difficult revision hip arthroscopy, when I must decide between removing the remaining native labrum and reconstructing or trying to repair the native suboptimal tissue.
      The current study by Philippon, Bolia, Locks, and Briggs, “Labral Preservation: Outcomes Following Labral Augmentation Versus Labrum Reconstruction,”
      • Philippon M.J.
      • Bolia I.K.
      • Locks R.
      • Briggs K.K.
      Labral preservation: Outcomes following labrum augmentation vs. labrum reconstruction.
      marks another defining moment in the brief history of arthroscopic hip labral preservation techniques. We are now granted another hopeful option to treat labral deficiency in challenging cases: labral augmentation. The concept of labral augmentation was mentioned as a technical note in Arthroscopy Techniques in 2015.
      • McConkey M.O.
      • Moreira B.
      • Mei-Dan O.
      Arthroscopic hip labral reconstruction and augmentation using knotless anchors.
      Labral augmentation was conceived as an innovation to meet a critical clinical need—what to do with increasing numbers of hips that were noted to have a diminutive labrum and insufficiency of the labral seal, but with some remaining native labral fibers. It is said that necessity is the mother of invention, and this is clearly an instance where that sentiment rings true. A short time later, we now have comparative clinical data for labral reconstruction, in the setting of challenging revision hip arthroscopy cases.
      In the current study by Philippon et al., the introduction is particularly eloquent and deserves praise for exquisitely articulating the seal mechanism of the hip labrum. The entire goal of treating chondrolabral dysfunction with hip arthroscopy is to reestablish this important seal mechanism. We know that this seal mechanism is vital for reducing hip contact pressures, improving stability, and deepening the acetabulum and femoral head coverage, especially in cases of structural abnormality such as dysplasia.
      • Ferguson S.J.
      • Bryant J.T.
      • Ganz R.
      • Ito K.
      An in vitro investigation of the acetabular labral seal in hip joint mechanics.
      When this seal mechanism is disrupted, the hip can rapidly deteriorate due to altered synovial fluid dynamics and negative effects on the maintenance and nourishment of chondral surfaces.
      • Philippon M.J.
      • Nepple J.J.
      • Campbell K.J.
      • et al.
      The hip fluid seal—Part II: The effect of an acetabular labral tear, repair, resection, and reconstruction on hip stability to distraction.
      I would also like to emphasize that the current study included a very challenging cohort of patients. In this series, all patients had previous failed hip arthroscopy procedures. In addition, many had cartilage defects. In these salvage cases, labral augmentation had very good results as a revision procedure. However, in this setting of multiple surgeries and cartilage defects, we know that labral augmentation and revision hip arthroscopy procedures likely represent a bridging, rather than permanent, solution. This is evidenced by 21% of these patients requiring further surgery, with 1 total hip replacement and 6 revision arthroscopies.
      • Philippon M.J.
      • Nepple J.J.
      • Campbell K.J.
      • et al.
      The hip fluid seal—Part II: The effect of an acetabular labral tear, repair, resection, and reconstruction on hip stability to distraction.
      As we learn more about labral augmentation, future study is needed to appropriately select patients, optimize surgical technique and healing, and refine rehabilitation protocols. However, in indicating patients with a challenging problem, the authors highlight the brilliance in developing solutions for patients for whom we otherwise do not have a good option.
      With these promising early results in a very challenging patient cohort, I submit that labral augmentation should be included in the armamentarium for labral preservation, with consideration in the setting of primary hip arthroscopy. Your first surgery should be your best surgery, and in a primary operation where cartilage status may be most optimal, labral augmentation represents an opportunity to restore the labral seal and thereby improve hip biomechanics and function. In cases of suspected labral deficiency or poor tissue quality preoperatively, surgeons must have a detailed discussion with patients regarding reconstruction and the possibility of labral augmentation. In weighing reconstruction versus augmentation, it is important to understand that both are tools are in our labral repair “toolboxes,” and each is best suited to a different intraoperative scenario. The benefit of complete removal of the native tissue, as in a labral reconstruction, is that it affords better access to any full-thickness cartilage lesions of the acetabulum in the transition zone. This approach also allows good access for removal of any remaining unstable chondrolabral tissue. The advantage of labral augmentation is that the native tissues may have superior nociceptive function and vascularization properties to a reconstructed collagen graft. It is important to note that the decision to proceed with labral augmentation versus reconstruction is a judgment call, primarily dictated by the remaining quality and fibers of the native labrum, rather than by surgeon “choice.”
      Overall, the current study contributes greatly to the concept of hip labral preservation. It demonstrates a significant and viable surgical option in challenging hip revision arthroscopic cases. It reinforces the need to advocate for labral function and the seal mechanism. And, last but not at all least, Philippon et al. show us the value of being bold but not cavalier in pioneering new solutions for patients who would otherwise have limited options.

      Supplementary Data

      References

        • Larson C.
        • Giveans M.
        Arthroscopic debridement versus refixation of the acetabular labrum associated with femoroacetabular impingement.
        Arthroscopy. 2009; 25: 369-376
        • Krych A.J.
        • Thompson M.
        • Knutson Z.
        • Scoon J.
        • Coleman S.H.
        Arthroscopic labral repair versus selective labral debridement in female patients with femoroacetabular impingement: A prospective randomized study.
        Arthroscopy. 2013; 29: 46-53
        • Philippon M.J.
        • Briggs K.K.
        • Hay C.J.
        • Kuppersmith D.A.
        • Dewing C.B.
        • Huang M.J.
        Arthroscopic labral reconstruction in the hip using iliotibial band autograft: Technique and early outcomes.
        Arthroscopy. 2010; 26: 750-756
        • White B.J.
        • Patterson J.
        • Herzog M.M.
        Revision arthroscopic acetabular labral treatment: Repair or reconstruct?.
        Arthroscopy. 2016; 32: 2513-2520
        • Philippon M.J.
        • Bolia I.K.
        • Locks R.
        • Briggs K.K.
        Labral preservation: Outcomes following labrum augmentation vs. labrum reconstruction.
        Arthroscopy. 2018; 34: 2604-2611
        • McConkey M.O.
        • Moreira B.
        • Mei-Dan O.
        Arthroscopic hip labral reconstruction and augmentation using knotless anchors.
        Arthrosc Tech. 2015; 4: e701-e705
        • Ferguson S.J.
        • Bryant J.T.
        • Ganz R.
        • Ito K.
        An in vitro investigation of the acetabular labral seal in hip joint mechanics.
        J Biomech. 2003; 36: 171-178
        • Philippon M.J.
        • Nepple J.J.
        • Campbell K.J.
        • et al.
        The hip fluid seal—Part II: The effect of an acetabular labral tear, repair, resection, and reconstruction on hip stability to distraction.
        Knee Surg Sports Traumatol Arthrosc. 2014; 22: 730-736

      Linked Article