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Editorial Commentary: Labral Reconstruction: Some Early Positive Signals, and Now the Challenge Is Ours

      Abstract

      Adults between the ages of 40 and 49 with hip injuries can be challenging to treat, as they are often deemed “too young” for hip arthroplasty and yet have less predictable outcomes after hip arthroscopy. Moreover, in this population, hip arthroscopy with labral repair results in greater risk of treatment failure than labral reconstruction. Subclinical degenerative changes to the labral tissue may be responsible for this finding. In my practice, however, labral reconstruction is generally reserved for scenarios such as a failed labral repair in the setting of poor tissue, labral hypoplasia/calcification in the primary setting (<2 mm viable cuff of tissue), or complex irreparable tissue in the primary setting.
      The article, “Hip Arthroscopy in Patients Over 40: Greater Success With Labral Reconstruction Compared With Labral Repair,” by White, Patterson, Scoles, Lilo, and Herzog, reports a single-surgeon series on patients undergoing hip arthroscopic surgery for labral disease. Specifically, it evaluates patients aged 40 to 49 who underwent labral repair compared with a cohort of similar age who underwent labral reconstruction (as well as concomitant femoral acetabular impingement surgery). Their results show that there was a 3.29× higher likelihood of failure in the labral repair group than in the labral reconstruction group in this population.
      • White B.J.
      • Patterson J.
      • Scoles A.M.
      • Lilo A.T.
      • Herzog M.M.
      Hip arthroscopy in patients over 40: Greater success with labral reconstruction compared to labral repair.
      Further, the failure rate of labral reconstruction surgery in the 40- to 49-year age group was similar to the failure rate in the 30- to 39-year age group, which was used as a control group.
      For most hip arthroscopic and preservation surgeons, the population in the 40-to-49 age category can be a challenging one to manage. These patients are often considered too young for a total hip replacement but have been noted to have less than ideal outcomes after arthroscopic surgery compared with younger patients.
      • Horner N.S.
      • Ekhtiari S.
      • Simunovic N.
      • Safran M.R.
      • Philippon M.J.
      • Ayeni O.R.
      Hip arthroscopy in patients age 40 or older: A systematic review.
      ,
      • Sogbein O.A.
      • Shah A.
      • Kay J.
      • Memon M.
      • Simunovic N.
      • Belzile E.L.
      • Ayeni O.R.
      Predictors of outcomes after hip arthroscopic surgery for femoroacetabular impingement: A systematic review.
      The reasons for the increased failure rates in those 40 and older are not completely understood, but an underlying degenerative process in the entire joint may be taking place. After reading this article, one wonders whether subclinical degenerative changes in the articular cartilage are also associated with subclinical degenerative changes in soft tissues such as the labrum, capsule, and ligaments. The article is certainly helpful in providing insights about labral reconstruction in this setting, but longer-term follow-up is needed.
      One potential way to move this field forward is to challenge ourselves to seek more evidence. For example, histological analysis of the labral tissue stratified by age is one early step to help understand what is happening to the labrum in this population. In addition, we could solve the debate associated with labral reconstruction with a randomized controlled trial comparing labral repair versus labral reconstruction in the 40-plus age group. Finally, a trial comparing segmental (partial) reconstruction to complete labral reconstruction in the same group would help refine indications.
      At our institution, labral reconstruction is generally reserved for scenarios such as a failed labral repair in the setting of poor tissue, labral hypoplasia/calcification in the primary setting (<2 mm viable cuff of tissue), or complex irreparable tissue in the primary setting.
      • Al Mana L.
      • Coughlin R.P.
      • Desai V.
      • Simunovic N.
      • Duong A.
      • Ayeni O.R.
      The hip labrum reconstruction: Indications and outcomes—an updated systematic review.
      Nonetheless, White et al.
      • White B.J.
      • Patterson J.
      • Scoles A.M.
      • Lilo A.T.
      • Herzog M.M.
      Hip arthroscopy in patients over 40: Greater success with labral reconstruction compared to labral repair.
      should be commended for collecting precise data and shedding some light on a challenging population. Now the orthopaedic community should take the baton from this study and continue to race to obtain more clinical evidence on this topic.

      Supplementary Data

      References

        • White B.J.
        • Patterson J.
        • Scoles A.M.
        • Lilo A.T.
        • Herzog M.M.
        Hip arthroscopy in patients over 40: Greater success with labral reconstruction compared to labral repair.
        Arthroscopy. 2020; 36: 2137-2144
        • Horner N.S.
        • Ekhtiari S.
        • Simunovic N.
        • Safran M.R.
        • Philippon M.J.
        • Ayeni O.R.
        Hip arthroscopy in patients age 40 or older: A systematic review.
        Arthroscopy. 2017; 33: 464-475
        • Sogbein O.A.
        • Shah A.
        • Kay J.
        • Memon M.
        • Simunovic N.
        • Belzile E.L.
        • Ayeni O.R.
        Predictors of outcomes after hip arthroscopic surgery for femoroacetabular impingement: A systematic review.
        Orthop J Sports Med. 2019; 7 (2325967119848982)
        • Al Mana L.
        • Coughlin R.P.
        • Desai V.
        • Simunovic N.
        • Duong A.
        • Ayeni O.R.
        The hip labrum reconstruction: Indications and outcomes—an updated systematic review.
        Curr Rev Musculoskelet Med. 2019; 12: 156-165